| Objectives To analyze the changes of early airway function after tracheotomy by establishing a rat tracheotomy model,to reveal the effect of different osmotic saline on airway function and to analyze the effect difference of hypertonic,isotonic and hypertonic saline,and to discuss the suitable osmolality of saline fluid for nebulization,which may provide reference for the solution selection of clinical nebulization.Methods The study is separated into two parts Part 1: Animal experiments 1.42 SD rats undergoing tracheotomy without any nursing intervention were sacrificed at 24 h,48h,72 h,4d,5d,6d and 7d(6 rats / group)respectively.Compared with normal rats,the changes of sputum viscosity,tracheal tissue structure,airway mucosa and cilia function,AQP4 and TNF-α expression in the lungs were analyzed by HE staining,scanning electron microscopy and Western blot.2.We set the Sham and experimental groups.Sham group: 6 rats without any nursing intervention after tracheotomy,the experimental group: 36 SD rats with tracheotomy were divided into 0.1%,0.45%,0.9% 3%,5% and 7% saline nebulization group,with 6 rats in each group,and the rats were sacrificed at 7 days long nebuliztion(10ml / kg saline solution).The differences of sputum viscosity,tracheal tissue structure,airway mucosa / cilia function,AQP4 / TNF-α expression in the lungs were analyzed by viscosity measurement,HE staining,scanning electron microscopy and Western blot.Part 2: Clinical study The tracheotomy patients admitted to the three ICU of neurosurgery department from June to October 2016 were selected and divided into 0.45%(every 2 h/time,12 times/day in total),0.45% + 0.9%(every 2 h/time,every two 0.45%(8 times/day in total)followed one 0.9%(4 times/day in total)),0.45% + 3%(every 2 h/time,every two 0.45%(8 times/day in total)followed one 3%(4 times/day in total))saline nebulization group,and each ICU corresponded to an atomization intervention by lot drawing.The amount of saline fluids were 8ml/times,and the driving oxygen flow for nebulization was 6L/min.After a week-long nebulization intervention,we observed and analyzed the patient’s sputum viscosity and the amount of sputum,VAP incidence,ICU stay days,length of hospital stay and mortality.Results Part 1: Animal experiments 1.The survival rate of each group was 100%.Compared with normal rats,the sputum viscosity and the levels of AQP4 and TNF-α in rats with tracheotomy were significantly increased and increased with the passage of time(p <0.05);After tracheotomy,the airway mucosa epithelium was irregularly arranged,and the neutrophil infiltration and the number of white blood cells were significantly increased(P <0.01).The mucosal and cilia on the airway were decreased and the area of injury increased,and the area of injury increased with the passage of time(P <0.001)2.Two rats in 0.45%,5% saline group respectively were dead during the intervention period,the other groups of rats were all alive.Compared with Sham group,the sputum viscosity of every experimental group was significantly decreased(P <0.05).The sputum viscosity of 3% saline group was significantly lower than that of 0.1% and 7% saline(P <0.05),there was no significant difference in sputum viscosity between the other groups(P> 0.05).Compared with Sham group,the expression of TNF-α in the lungs of each experimental group was significantly decreased(P <0.05).The TNF-α expression levels of 0.1% and 0.9%,0.1% and 3%,0.45% and 0.9%,0.45% and 3%,0.9% and 7%,3% and 5%,3% and 7% saline group were significantly different(P <0.05),and the expression level of TNF-α in the 3% saline group was the lowest;Compared with Sham group,the expression level of AQP4 in the lungs of each experimental group was significantly decreased(P <0.001),but there was no significant difference in the expression level of AQP4 between the experimental groups(P> 0.05).Compared with Sham group,the white blood cell count of each atomization group was significantly decreased(P <0.001),but there was no significant difference in white blood cell count between the experimental groups(P> 0.05).Compared with Sham group,the area of airway mucosa and cilia injury in each nebulization group was significantly decreased(P <0.001).The area of mucosal and cilia injury in 3% saline group was significantly lower than that in 0.1%,5% and 7% saline(P <0.05),there was no significant difference in airway mucosa and cilia injury area between the other experimental groups(P> 0.05).Part 2: Clinical study A total of 76 patients with tracheotomy were enrolled,with 27 patients for 0.45% nebulization,25 patients for 0.45% + 0.9% nebulization,and 24 patients for 0.45% + 3% nebulization.There was no significant difference on the baseline data of the patients included in each group(P> 0.05).There was no significant difference in the degree I of sputum viscosity between the three groups after one week of nebulizaton intervention(P> 0.05),there were significant differences in the degree II of sputum viscosity between 0.45% and 0.45% + 3%,0.45% + 0.9% and 0.45% + 3% groups(P <0.05),and significant differences were found in between every groups(P <0.05).The average sputum volume in 0.45% + 3% groups was significantly more than that of 0.45% and 0.45% + 0.9% group,yet no significant difference has been found between the 0.45% and 0.45% + 0.9% group(P> 0.05).There was no significant difference in the incidence of VAP,ICU residence time,hospitalization time and mortality rate among the three groups(p> 0.05).Conclusions 1.The tracheostomy can lead to mucosal and cilia injury of airway,increase the sputum viscosity and elevate the level of inflammation in the lungs.2.Saline nebulization after tracheostomy can significantly reduce the viscosity of sputum,reduce mucosal and cilia damage,and control airway inflammation level,it is an effective intervention for airway management after tracheostomy.3.Nebulization with saline fluids of different osmolality acts different role,hypertonic saline nebulization seem to be superior to hypotonic and isotonic saline nebulization,and taking into account the various indicators,the use of 3% saline for nebulization after tracheostomy may be the better choice.4.Combined use of 0.45% and 3% saline nebulization for airway management after tracheostomy appears can significantly reduce the patient’s sputum viscosity,increase the amount of induced sputum with high patient’s tolerance,it should be recommended for clinical use after further validation. |
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