Objective:To observe the application effect of respiratory stepwise management in patients with septic shock combined with acute lung injury (ALI).Methods:100 patients with septic shock combined with ALI were selected as the research objects in Haikou Hospital Affiliated to Xiangya Medical College of Central South University from January 2018 to June 2020. Fifty patients were given endotracheal intubation or invasive ventilation on the basis of conventional treatment (conventional treatment group). According to the respiratory situation and blood gas, 50 patients were given systematic respiratory support step-by-step treatment according to the principle of simple to complex, and appropriate and scientific respiratory support was given according to the sequence from unarmed to mechanical (respiratory stepwise management group). The differences of cardiac index (CI), central venous pressure (CVP), mean arterial pressure (MAP), extravascular lung water index (EVLWI), arterial partial pressure of carbon dioxide (PaCO 2), arterial partial pressure of oxygen (PaO 2), oxygenation index (PaO 2/FiO 2) before and after treatment were compared between the two groups, the therapeutic effects of the two groups were evaluated, and the resuscitation effect, postoperative complications rate, tracheotomy rate, utilization rate of invasive ventilator of the two groups were recorded. Results:After treatment, CI, CVP, EVLWI, PaO 2, PaO 2/FiO 2 levels of the two groups were significantly higher than before treatment, MAP and PaCO 2 levels were significantly lower than before treatment; MAP and PaCO 2 levels after treatment of the respiratory stepwise management group were significantly lower than those of the conventional treatment group [MAP (mmHg, 1 mmHg = 0.133 kPa): 68.2±7.0 vs. 74.4±6.8, PaCO 2 (mmHg): 37.82±4.05 vs. 41.76±4.59], the levels of EVLWI, PaO 2 and PaO 2/FiO 2 in the respiratory stepwise management group were significantly higher than those in the conventional treatment group [EVLWI (mL/kg): 15.34±3.03 vs. 13.64±3.32, PaO 2 (mmHg): 84.44±4.83 vs. 79.03±5.54, PaO 2/FiO 2 (mmHg): 452.42±51.32 vs. 431.73±50.03, all P < 0.05]. There was no significant difference in CI or CVP after treatment between respiratory stepwise management group and conventional treatment group [CI (mL·s -1·m -2): 70.01±21.67 vs. 66.68±18.34, CVP (mmHg): 11.1±3.2 vs. 12.3±3.2, both P > 0.05]. Compared with the conventional treatment group, the average recovery time of the respiratory stepwise management group was earlier (hours: 2.04±0.54 vs. 4.29±0.20, P < 0.05), the stable breathing time was shorter (hours: 3.07±0.22 vs. 5.36±0.35, P < 0.05), the total effective rate and the success rate of recovery were significantly improved [86.0% (43/50) vs. 60.0% (30/50), 94.0% (47/50) vs. 74.0% (37/50), both P < 0.05], the incidence of ventilator associated pneumonia (VAP) and airway complications were significantly reduced [14.0% (7/50) vs. 32.0% (16/50), 12.0% (6/50) vs. 40.0% (20/50), both P < 0.05], and the tracheotomy rate and the utilization rate of invasive ventilator were significantly reduced [8.0% (4/50) vs. 28.0% (14/50), 30.0% (15/50) vs. 60.0% (30/50), both P < 0.05]. Conclusion:Respiratory stepwise management can effectively improve the resuscitation effect of septic shock patients with ALI, improve cardiopulmonary function, blood gas index and the treatment efficiency, effectively reduce the incidence of iatrogenic trauma and complications.

Objective:To explore the application of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score in the timing and nursing of noninvasive ventilation for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods:106 AECOPD patients admitted to Haikou People's Hospital from January 2018 to October 2019 were selected as the study objects. According to the method of random number table, the patients were divided into observation group and control group, with 53 patients in each group. The control group selected the timing of noninvasive ventilation treatment according to the standards of Mechanical ventilation (second edition), weaned according to Clinical practice of mechanical ventilation, and received routine nursing in intensive care unit (ICU), including creating comfortable indoor environment, reasonable diet, condition monitoring, psychological nursing and complications nursing. On the basis of the control group, the patients in the observation group were given noninvasive ventilation when APACHE Ⅱ score was more than 10, and were weaned when APACHE Ⅱ score was less than or equal to 10. According to APACHE Ⅱ score < 10, 10-14, 15-19 and ≥ 20, the patients were given level-3 care, level-2 care, level-1 care and intensive care. The pulmonary function before and 3 days after the noninvasive ventilation treatment was monitored, and the duration of mechanical ventilation, the length of ICU stay, endotracheal intubation rate, incidence of complication [ventilator associated pneumonia (VAP)] and ICU mortality were recorded. The self-designed questionnaire of nursing satisfaction was used to evaluate the patients' nursing satisfaction. Results:There was no significant difference in general data such as gender or age between the two groups. After 3 days of noninvasive ventilation, the forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio of the two groups were increased significantly as compared with those before treatment, especially in the observation group, with statistical significances as compared with the control group [FEV1 (L): 3.02±0.22 vs. 2.54±0.19, FVC (L): 3.01±0.32 vs. 2.13±0.28, FEV1/FVC ratio: 0.89±0.08 vs. 0.79±0.08, all P < 0.05]. Compared with the control group, the duration of mechanical ventilation and length of ICU stay in the observation group were significantly shortened [duration of mechanical ventilation (days): 4.32±0.73 vs. 8.42±1.94, length of ICU stay (hours): 32.23±10.22 vs. 38.52±9.85, both P < 0.01]. The intubation rate, incidence of VAP and ICU mortality in the observation group were significantly lower than those in the control group [intubation rate: 1.9% (1/53) vs. 13.2% (7/53), incidence of VAP: 1.9% (1/53) vs. 15.1% (8/53), ICU mortality: 1.9% (1/53) vs. 13.2% (7/53), all P < 0.05]. The nursing satisfaction of patients in the observation group was significantly higher than that in the control group [96.2% (51/53) vs. 75.5% (40/53), P < 0.01]. Conclusions:APACHE Ⅱ score can be used to guide the choice of noninvasive ventilation treatment opportunity and nursing intervention measures for AECOPD patients. It can significantly improve the pulmonary function of patients, improve the treatment effect, reduce the incidence of complications, and improve the satisfaction of patients with nursing, which is effective in clinical application.

目的：探讨苍术素（ATR）通过调节受体相互作用蛋白激酶（RIPK）1/RIPK3/混合谱系激酶结构域样（MLKL）信号通路对非小细胞肺癌（NSCLC）A549细胞程序性死亡及裸鼠移植瘤生长的影响。方法：使用0~160 μmol/L的ATR处理A549细胞，MTT法检测细胞存活率以确定后续实验给药浓度。使用ATR和/或RIPK1抑制剂Nec-1（necrostatin-1）、caspase抑制剂Z-VAD-FMK处理A549细胞，验证ATR是否诱导A549细胞发生程序性坏死。将A549细胞分为对照组、ATR-L组、ATR-M组、ATR-H组（分别用0、10、20、40 μmol/L ATR处理）、ATR+Nec-1组（40 μmol/L ATR+50 μmol/L Nec-1处理），处理24 h后，采用PI单染及Hoechst33342/PI双染法检测细胞死亡情况、透射电镜观察细胞死亡形态、DCFH-DA荧光探针法检测细胞内ROS水平、JC-1染色法检测线粒体膜电位、WB法检测细胞中RIPK1/RIPK3/MLKL信号通路相关蛋白质的表达水平。构建A549细胞裸鼠移植瘤模型，用10 mg/kg ATR（溶于玉米油中）对裸鼠灌胃给药5周，观察ATR对移植瘤生长的影响，WB法检测移植瘤组织中RIPK1/RIPK3/MLKL信号通路相关蛋白质的表达水平。结果：10~160 μmol/L的ATR可显著抑制A549细胞增殖，选择10、20、40 μmol/L的ATR进行后续实验。ATR组A549细胞存活率显著低于对照组（P<0.01）和ATR+Nec-1组（P<0.01），而ATR+z-VAD组细胞存活率显著低于z-VAD组（P<0.01），说明ATR可诱导A549细胞发生程序性坏死而非凋亡。与对照组比较，ATR处理组A549细胞发生肿胀，线粒体内脊消失呈空泡化，细胞内容物向外泄漏，细胞核聚集，表现为坏死特征，ATR-L组、ATR-M组、ATR-H组A549细胞死亡率、ROS水平及p-RIPK1、p-RIPK3、p-MLKL表达水平均显著升高，线粒体膜电位显著降低（均P<0.01），且呈药物浓度依赖性；与ATR-H组比较，ATR+Nec-1组细胞死亡率、ROS及p-RIPK1、p-RIPK3、p-MLKL表达水平降低，线粒体膜电位显著升高（均P<0.01）。裸鼠移植瘤实验结果显示，与对照组比较，ATR组裸鼠移植瘤体积、移植瘤质量均降低（P<0.05，或P<0.01），而与瘤组织中p-RIPK1、p-RIPK3、p-MLKL蛋白表达水平均显著升高（均P<0.01）。结论：ATR可能通过激活RIPK1/RIPK3/MLKL信号通路诱导A549细胞发生程序性坏死，抑制A549细胞及其裸鼠移植瘤的生长。