TAP CHi Y HOC VlgT NAM TAP 459 - THANG 10 • SO 2 - 2017
HIEU QUA TREN TRAO DOI KHI CIJA THONG KHI DAO DONG TAN S6 CAO (y BENH NHAN SUY HO HAP CAP TIEN TRIEN NANG
Trinh The Anh', Nguyen Cong Tan^
Dang Quoc T u a n ' , Dao Xuan Cff^
chet [1]. Thong khi bao ve phoi la bien phap quan trpng trong dieu tri [2]. Tuy nhien, ti le t d vong ciia benh nhan ARDS eon cao26 - 58% [3].
Thd may dao dong tan so cao - HFOV la phu'dng thifc thd mdi dddc ki vong giai quyet dddc cac van de thong klii d benh nhan ARDS nang khdng dap dng vdi chien Iddc thdng khi bao ve phoi.
Tuy nhien d Viet Nam, HFOV van chda dddc ap dung rdng rai. Vi vay, ehung toi tien hanh de tai nghien ciru vdi muc tieu danh gia hieu qua cua phddng thirc thd may HFO d benh nhan ARDS nang.
II. o6\ TU'DNG VA PHU'aNG PHAP NGHIEN CU'U 2 . 1 . Doi tu'dng nghien cu'u
2.1.1. Tieu chuan Ida chpn dot tu'dng nghien ciiu: Doi tddng nghien cdu la cac benh nhan dieu trj tai khoa hoi sire tieh cdc va cap cdu dddc chan doan ARDS nang, that bai vdi thd may thddng quy:
Tieu chuan ARDS:
l.Khdi phat cap tinh trong 7 ngay 2.Ton thddng phoi md lan tda 2 ben 3.P/F < 300 vdi PEEP toi thieu la 5 cmHaO 4. Khong the giai thich bang suy tim hay thii^ dich 77eu ehuan that bai vdi thd may thddng guy:
CO 1 trong 3 tieu chuan sau l.P/F < 100 vdi PEEP >10 cmHjO 2.P/F >100 nhdng tang C02 mau khdng giai quyet ddric vdi tan so may thd > 35 lan/phiit
3.Co tran khi mang phoi va/hoac trung t h a t (trdde va trong thd may thddng quy)
2.1.2. Tiiu chui'n loai trtt
l.Benh nhan ed benh phoi man tinh tru'dc do 2.Tang ap Idc ndi so
2.2. PhUdng phap nghien cii'u 2.2.1. Thiet ke nghien cii'u
-Nghien ciru can thiep t d d o i chirng trdde sau -Lay mau thuan tien, ed mau 16 benh nhan -Dia diem: Khoa hoi sdc tieh cdc va Khoa cap ciru - Benh Vien Bach Mai
-Thdi gian: 01/2016 - 08/2017
2.2.2. Quy trinh nghien ah/: Benh nhan dddc ehuyen thd bang may HFO 3100B eiia hang Carefusion theo quy trinh ciia bp y te.
Mue tieu thong khi: Pa02 55 - SOmmHg, SpO;
88 - 95%, pH 7,2 - 7,5 TOM TAT
Muc tieu: Danh gia hieu qua trao doi oxy va carbonic d benh nhan suy ho hap cap tien trien nang (ARDS) Wii diong khi dao dong tan sd cao (HFO).
Phu'dng phap: Nghien cdu can thiep lam sang tu"
chirng trdde sau tren 16 benh nhan tai khoa Hoi siTc tich cdc va Cap cdu, Benh vien Bach Mai tir thang 1 nam 2016 den thang 8 nam 2017. Cac benh nhan ARDS nSng khong dap iTng vdi may thd thirdng quy du'dc chuyen sang thd may HFO. Ket qua: Pa02 sau ket HFO 111 ± 42 so vdi ban ^ u 75 ± 22, p = 0,02.
pH mau sau ket HFO 7,38 ± 0,13, PaCOj sau ket HFO 45 ± 12, Ket luan: Phu'dng thirc thd HFO cho thay hieu qua lam tang PaO; va ti le Pa03/Fi02 va khong gay toan ho hap.
Tir khoa: suy hd hap cap tien trien, ARDS, Thong khi dao dong tan so cao, HFO
SUMMARY
EFFECTS OF HIGH-FREQUENCY OSaLLATION VENHUVnON ON GAS EXCHANGE I N PATIENT
WITH SEVERE ACUTE RESPIRATORY DISTRESS SYNDROME Background: Hiqh-freauency oscillatory ventilation (HFO\0 IS a novel method that can support gas exchange in the severely hypoxemic patient without contributing addibonal venblator-mduced lung iniurv.
We investigated the effects of HFOV in severe ARDS.
Methods: the uncontrolled clinical trial. Sixteen patients with severe ARDS undergo HFOV if they had a ratio of the partial pressure of arterial oxygen (Pao2) to the fraction of inspired oxygen (Ro2) of 100 mm Hg or refractory respiratory acidosis, or pneumothorax.
Results: There was significant difference in Pa02 and the Pao2: Fio2 ratio in patients undenwent HFO and initial PaOz the PaoZ; Fio2 ratio, p=0,02 and p=0,004, respectively. After HFO, PaCOzof 45 ± 12, pH of 7,38
± 0,13. Conclusion: HFOV improves dearly oxygenation in patients with severe ARDS.
I. OAT VAN OE
Hpi chirng suy ho hap cap tien trien (Acute Respiratory Distress Syndrome - ARDS) dddc dac trdng bdi tdn thu'dng lan tda hai ben phdi gay giam oxy mau nang va tang thdng khi khoang
' Tn/dng dai hoc Y Ha Noi 'Benh vien Bach Mai
Chiu trach nhiem chinh: Trinh The Anh Email: [email protected] Ngay nhan bai: 21.8.2017 Ngay phan bien khoa hoc: 3.10.2017 Ngay duyet bai: 9.10.2017
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 Tieu chuan eai may HFO: Benh nhan dat dddc mue
tieu thong khi vdi R02< 40%, MAP 20 - 22 onHaO.
Cac chi tieu nghiin cii'u:
TO: thdi diem vao nghien ciru
-Tuoi, gidl, tien sir benh, diem APACHE I I , SOFA, Chi so van mach, thdi gian khdi benh, thdi gian thd may thddng quy
-Dae diem ed hpc phdi va khi mau trdde HFO:
Pplateau, Compliance tTnh, tan so thd, PaOz, PaCOj, P/F, pH
Bing 1: Die dli'm mau nghien cu'u
Tn: khi mau ngay t h d n
2.2.3.Dao du'c nghien cu'u: quy trinh nghien cdu da dddc hdi dong dao dii'e benh vien Bach Mai thdng qua.
III. KET QUA
3.1 Dac di^m mau nghien cu'u: Chiing toi nghien cdu 16 benh nhan trong dd ed 10 benh nhan nam va 6 benh nhan nu'
Cac thong so Trung binh
Tuoi
48,5 ± 18,0
Diem APACHEII
21,6 ± 4,9
Chi sd van mach
17,4 ± 28,7
So ngay khdi benh trdde khi vao ICU So gid thd may thddng quy trdde HFO
4,6 ± 2,6 65,6 ± 53,2
PEEP trdde HFO
13,9 ± 2,7
Pplateau trdde HFO 30,4 ± 4,3
Tan sdcai dat tru'dc HFO FiOj trdde HFO
27,6 ± 6,6 90 ±17
Nhin xet: Cac benh nhan tai thdi diem nhap vao nghien cdu cd tinh trang suy tang nang, chi so van mach cao. Cae tliong sd cai dat khi thd may thddng quy d ngddng gidi han.Bang 2: Bac dli'm khi miu tru'dc HFO
Compliance trifdc HFO PaO, tru'tfc HFO
P/Ftri/dc HFO PaCO; trifflc HFO
pH tru'cfc HFO FiOj tri/Sc HFO
Nhom giam O2 ( n = 1 0 ) 20,8 ± 4,9 75 ± 2 6 86 ± 2 8 50 ± 12 7,36 ± 0,06
93 ± 3,9
Nhom tang CO2
Cn=2l
23,5 ± 0,766 ± 5 82 ± 2 8 82 ± 3 0 7,10 ± 0,13
80 ± 2 0
Nhom tran khi Cn=4) 31 ±3,8 80 ± 1 8 97 ± 3 3 48 ± 11 7,33 ± 0,05 87,5 ± 12,5 Nhin xet: nhdm ehi dinh HFO vi tran khi cd Compliance tinh, Pa02, ti le Pa02/Fi02 tdt hdn eac nhdm khac.
1.2 Danh gia hieu qua thd HFO
Bang 3: Thay doi ve trao doi khi khi thd may HFO Tru'dc HFO
X ± SPCn=16)
Ngay thu-1 X ± S D ( n = 1 6 )
Ngay thu" 2 X ± S P ( n = 1 3 )
Sau ket HFO X ± SD(ii=10) PaOa
PaCO;
53 ± 17 50 ± 1 5
_ ^ H _
7,32 ± 0,11 7,32 ± 0,15 7,3 ± 0,18 7,38 ± 0,13
Cd 2 benh nhan dddc chi djnh HFO vi tang COz. Benh nhan thir nhat, PaCO? giam tir 104 mmHg xuong 47mmHg sau 24h chay HFO, nhu'ng benh nhan toan chuyen hoa nang va tir vong Vi soc nhiem khuan. Benh nhan thd hai, PaCO; giam t d 61mmHg xudng 44mmHg sau 24 gid chay HFO. Benh nhan eai may thanh cdng, PaCO; khi ket HFO la 37mmHg
*: so sanh \^i thdi diem trudc HFO v&p <0,05
**: so sanh \^ tiididi&n tn/rk HFO vdi P<0,01 Nhin xet: Sd cai thien ve oxy mau va tl sd PaO;/Fl02 xuat hien tir ngay thir nhat va duy tri
tdi ngay ket thuc thd may HFO. PaCO; va pH mau thay do'i khong ed y nghTa.
Bang 4: Ket qua thd may HFO
Thanh eong Chuyen thd may thddng
quy vi tang CO;
Thoi thd may vi ly do khac
So benh I T i l |
nhan I (%)
J7j5_
Nhan xet: cd 8 trddng hdp eai may thcf HFO thanh cong, khong cd trddng hdp nao that bai vi giam oxy mau.
TAP CHi Y HOC VIET NAM TAP 459 - THAHG 10 - 802 - 2017 Bang S; Thdlgian dieu tri
Thdi qian nam vien (nqay) Th6i qian nam ICU (nqay) Thdi qian thd may HFO (qid) Tiidi qian thd may sau HFO (nqay)
Nho nhat 3 2 14 0
Ldn nhat 79 65 188
53
Trung binh 22.6 ±19 16,7 ± 15,5 78,2 ± 51,6 7,6 ± 13,1 IV. BAN LUiBkN
Nghien cu'u gom 16 benh nhan, 10 nam, 6 nQ', CO tuoi trung binh la 48,5. Cac benh nhan ed b'nh trang benh ly nang, suy da tang, diem APACHE I I 21,6 ± 4,9, SOFA 8,5 ± 2,9 {bang 1).
Mire do nang ciia tienh nhan trong nghien cu'u cua chiing tdi tddng tu" vdi cac nghien cdu eiia Derdak [5], Young [6], Bollen [7] vdi diem APACHE I I lan Iddt la 2 2 , 1 9 , 20,7.
Benh nhan ARDS trong nghien cdu ciia chung toi dddc thd may theo chien Iddc bao ve phoi trung binh 65,6 gid trdde khi ehuyen thd may HFO. Tai thdi diem chuyen thd may HFO, cae thong so eai dat d d ngddng gidi han eao: PEEP 13,9 cmHzO, Pplateau 30,4 cmH;0, tan so thd 27 l/p, FiO; 90% (bang 2). Cae thdng so eai dat nay tddng t d vdi cac nghien ciru eiia Derdak [5], Young [6], Bollen [7]. Cd 10 benh nhan dddc chi djnh HFO vi giam oxy mau dai dang, mac dii PaO; van trong gidi han nhdng FiO; trung binh b-ddc HFO ia 97%. Cd 2 benh nhan chi dinh HFO vi tang CO; mau, pH mau trung binh 7,10 mac dii tan sd thd eai dat len den 35l/p. Co 4 benh nhan chi djnh HFO vi tran khi mang pho'i, mac dii cac chi so khi mau deu tdt hdn 2 nhdm con lai, nhdng nguy cd tran khf tang len, khd duy tri tinh trang thong khf bang may thd thddng quy.
Sd cai thien ve oxy mau trong nhdm nghien cud xuat hien d tir ngay t h d 1 chda ed y nghTa thong ke vdi p= 0,08. Sd khac biet ve PaO; d ngay thif 2 so vdi trdde thd HFO cd y nghTa thdng ke vdi p=0,02 va keo dai tdi khi ket thuc tiid HFO vdi P=0.02. Sd cai thien ve ti sd PaO;/Fi02 so vdi trdde thd HFO xuat hien t d ngay thd 1, t h d 2 tdi khi ket thiic HFO vdi p lan Iddt la 0,001, <0,aa01 va 0,004 (Bang 3). Ket qua nay cung tddng t d vdi nghien cdu ciia Young [6], Derdak [ 5 ] , Bollen [7]. Trong nghien cull cua Bollen, PaO; thdi diem ban dau la 80,8
± 24,1, Pa02 ngay t h d nhat, ngay thir 2 lan Iddt la 126 ± 79.2, 96 ± 2 1 . Trong nghien cdu ciia Young, 398 benh nhan dddc thd may HFO cung cho thay sd c^i thien ro ret ti le PaO;/Fi02 trong cae ngay thif nhat (192±77), thd 2 (212±69) so vdi trdde thd HFO (113±37).
Trong 2 benh nhan chi djnh HFO vi tang CO;
mau, benh nhan thir 1, PaCO; giam t d 104mmHg xuong 47 mmHg sau 24h; benh nhan t h d 2,
PaCO; giam t d 61 mmHg xudng 44 mmHg sau 24h va 37 mmHg sau khi ket Khdng thay su"
khac biet cd y nghTa eiia PaCO; va pH mau d cac ngay thd nhat, t h d 2 va sau ket so vdi trdde thd HFO. Tuy nhien, ehi so PaCO; va pH mau deu duy tri trong gidi han cho phep. Nhdm benh nhan tran khf mang phoi eung duy tri dddc mue tieu thong khi va trao doi oxy mau.
Ket qua nghien eifu, cd 8 benh nhan cai may thanh cdng, 2 benh nhan that bai do tang CO;
dai dang, 6 benh nhan ngdng nghien cdu vi t d vong va xin ve (bang 4). Ti le that bai do tang CO; trong nghien cdu cua ehimg tdi cao hdn so vdi nghien cdu eiia Furguson [4] 3%, nghien eifu cua Derdak [5] 5%. Ca 2 benh nhan that bai vi tang CO; dddc chi dmh vi tran khi mang phoi va giam 0 ; mau. Trong dd, 1 tru'dng hdp that bai vi tac ddm gay xep phoi, 1 trddng hdp dddc ghi nhan la do true trac kl thuat ve may.
t h d i gian nam ICU trong ket qua nghien cdu eiia chiing toi la 16,7 ± 15,5 ngay (bang 5), ket qua nay la tddng t d vdi nghien cii'u ciia Young [6] la 17,6 ± 16,6 ngay va 15 ngay d nghien ciru ciia Furguson [4]
V. KET LUAN
Ket qua nghien cdu ciia chiing tot eho thay phddng thdc thd may dao dong tan so cao d benh nhan ARDS nang giiip cai thien ro ret ve trao ddi O; mau. HFO khong gay toan hd hap qua ngudng gidi han.
Can tien hanh nghien cdu tiep vdi cd mau idn hdn, cd nhdm chdng, dat biet nghien cdu ve cac bien chifng khi thd may dao dong tan so eao.
TAI Ll|U T H A M KHAO
1. Lemaire F, Harf A, Teisseire BP. Oxygen exchange acrossthe acutelyinjured lung. In: Zapol WM, Falke KJ eds. AcuteRespiratory Failure. New York 1985: Marcel Dekker; 521. 2
2. The Acute Respiratory Distress Syndrome Network. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injurv and the Acute Resoiratorv Distress Syndrome. N Engl J Med 2000; 342:1301-1308 4 3. Rubenfeld GD, Caldwell E, Peabody E, et
a\.Incidence and outcomes ofacute lung injury. N Engl J Med 2005; 353:1685. 5
4. Niall D. Ferguson, M.D. High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome. N Engl J Med 2013;368:795-805. 6
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 . Stephen Derdak. High-Frequency Oscillatory
Ventilation fyr AcuteRespiratory Distress Syndmme in Adults. Am J Respir Grit Care Med Vol 166. pp 801-808, 2002. 7
. Duncan Young, D.M. High-Frequency Oseiiiadon for Acute Respiratory Distress Syndrome. N Engl J
Med 2013;368:806-13. 8
, Bo1len.C.W. High frequency osdilatory venfflahxi compared with conventional mechankal ventBafion r adult respiratury distress syndnDme: a randomizeit oantrolled trial. Critical Care 2005,9:R430-R439 9
DANH GIA CHI SO DO DAY GIAC MAC VA KHUC XA GIAC MAC TREN MAT CAN T H | O LU'A TUOI THANH NIEN
Nguyen Thi Thanh Dung*, Nguyen Thi Thu Hien**, Dang Thi Nhv Quynb***
T O M TAT
Muc tieu: Oanh gia chi so dp day giac mac, khuc xa giac mac va tnm hieu mdi lien quan giuS cac chi so dp day giac mac, khiic xa giac mac, miTc do can thi d lira tuoi thanh men. Doi tu'dng va phu'dng phap nghien curtj: nghien eiru mo ta, nghien cdu du'dc thi/c hien 6 209 benh nhan (418 mat), tuoi tir 18 den 30 dUOe chan doan la tat can thi tai khoa khuc xa benh vien Mat Quoc te DND. Ket qua: Khong co su' khac biet ve ty le can thi giiJa nam va nff. Do can trung binh la -4,85 ± 1,99D. Op day giac mac trung binh la 539,78± 32,665|jm. Khuc xa giac mac trung binh la 43,16 ± 1,359D. Do day giac mac va can thj co moi tu'dng quan tuyen tinh (r=0,107, P=0,029). Khuc xa giac mac va can thi co tu'dng quan tuyen tinh (r=- 0,123, p=0,012). Hai chi so khiic xa giac mac va do day giac mac co tu'dng quan tuyen tinh v6i nhau v6i (r=-0,265, p<0,Q01). Ket luan: 06 day giac mac va khuc xa giac mac c6 tu'dng quan tuyen b'nh vdi nhau va tu'dng quan tuyen b'nh vdi mdc do can thj. Oo do day giac mac va khuc xa giac mac tren benh nhan can thi la quan trong giiip cho chan doan va dieu tn can thi.
Tz/AAcB/can thj, dp day giac mac, khuc xa giac mac.
SUMMARY
ASSESSMENT OF CORNEAL THICKNESS, CORNEAL REFRACTION POWER ON
MYOPIC EYE AT ADOLESCENCE Objective: Assessment of corneal thickness, corneal refraction power and finding relabonships between corneal thickness, corneal refraction power, myopia in adolescence. Research methods: descriptive study, the study was conducted in 209 patients (418 eyes) were diagnosed myopia in international eye hospital DND. Results: The rate of
*Trddng Dal hoc Y Dddc Thai Nguyen
**Benh vien Mat Trung i/dng
***Benh vien Mat Quoc teDND Chiu trach nhiem chinh: Nguyen Thi Thanh Dung Email: [email protected] Ngay nhan bai: 1.8.2017 Ngay phan bien khoa hoc: 3.10.2017 Ngay duyet bai: 9.10.2017
myopia is not different between males and females.
The average myopia was -4.85 ± 1.990. The average corneal thickness was 539.78 ± 32.665pm. The average corneal refraction power was 43.16 ± 1.369D.
Corneal thickness and myopia are a statistically significant association (r=0.107; p=0.029). Corneal refraction power and myopia are a statistically significant association (r=-0.123; p=0.012). Corneal thickness and corneal refraction power are a statistically significant association{r=-0.265; p<0.001), Conclusion: Corneal thickness and corneal refraction power are Itneady correlated and linearly correlated with myopia. Measuring corneal thickness and corneal refraction on patients with myopia is impodsntforthe diagnosis and treatment of myopia.
Key words: myopia, cornea! thickness, corneal refraction power.
I. DAT VAN OE
Tat khuc xa la mot trong nhOtig nguyen nhan chinh gay giam thj li/c d nhieu nddc tren the gidi ciing nhd d Viet Nam. Can thi la loai tat khuc xa hay gap nhat, chiem khoang 25% tong dan so tren the^gidi. Theo nghien cirtj eiia tae gia Du'dng Hoang An va epng s d nam 2014 tren nhom doi tddng sinh vien nam t h d nhat tai trddng Dai hoc
"Hiang Long cho thay ty le can thi len tdi 61,52%
[1]. Ty le can thj cao d nhdm tudi tir 18 den 30 hien dang la van de dang lo ngai bdi se anh hddng ldn den qua trinh hpc tap, lao dong va tao thanh ganh nang eho ban than ngu'di can thj, gia dinh va cho xa hpi. Vi vay viec can thiep, dieu tn can thj can dddc quan tam thich dang.
Hien nay ed rat nhieu phu'dng phap dieu tri can thj: deo kinh (kinh gpna kinh tiep xuc, ortho-k...) va phau_thuat (phau thuat tren te mat giac mac va p h l u thuat noi nhan). Dac biet d Ida tuoi thanh nien khi dp can thj da 6n_dinh, CO the Ida chon phddng phap phlu thuat de dieu trj vTnh vien tat can thi. Oe Ida chon 6d(iz phddng phap dieu tri toi u'u nhat eho tirng dw tu'dng, bac sT nhan khoa se phai can nhae cac yeu to: tuoi, mdc dp can thi, mot so chi so cua mat nhd dp day giac mac, khiic xa giac mac,
