无创正压通气在急性呼吸衰竭中的应用学案

1、无创正压通气在急性呼吸衰竭中的应用学案急性呼吸衰竭：具有很高的病死率有创通气的AECOPD：17-46%急性低氧性呼吸衰竭：40%国外ALI/ARDS：49.4/57.9国内上海ARDS：68.5%重症院外获得性肺炎（CAP）：22-54%院内获得性肺炎（HAP）：33-70%接受有创通气免疫抑制患者：50-90%呼吸衰竭高病死率疾病的病因和发病机制复杂有效的治疗手段有限原发病治疗呼吸支持技术常规呼吸支持手段的局限性普通氧疗不能提供正压支持有创正压通气（IPPV）成本高：对通气设备及监护条件要求高操作技术复杂无法早期干预并发症：VAP无创正压通气(NPPV)弥补传统手段之不足容易推广应用：成本

2、低，操作简单提供早期正压呼吸支持减少/避免有创通气并发症无创正压通气(NPPV)应运而生80年代:CPAP治疗OSAS89年:Meduri应用BiPAP治疗急性呼吸衰竭90-92年:陈荣昌/钮善福治疗重症AECOPD97年:王辰提出序贯通气的概念2000年:国内开始第一个多中心RCT2001年:学会推出NPPV操作意见2009年:学会推出NPPV操作意见（第2版）NPPV临床应用科室ICU普通病房急诊室家庭手术室NPPV临床应用价值不宜以有创通气治疗的轻型呼吸功能不全早期干预：拓展了机械通气的内涵解决部分原需有创通气的呼吸衰竭替代治疗：减少了IPPV的应用NPPV在呼吸支持技术中的定位普通氧疗

3、IPPVNPPV早期干预替代治疗如何成功应用NPPV应用指征的把握：当用则用对禁忌证的认识宜早不宜晚规范操作技术：物应其用NPPV禁忌证/相对禁忌证心跳或呼吸停止自主呼吸微弱、昏迷老年/一般情况差误吸危险性高及气道保护能力差气道分泌物多且排除障碍严重器官功能障碍面颈部和口咽腔创伤、烧伤、畸形或近期手术上呼吸道梗阻NPPV应用指征与范围早期应用AECOPD，心源性肺水肿，免疫力低下其他：ALI/ARDS，术后预防呼衰序贯通气其他：辅助气管镜，DNI（DO NOT INTUBATE）NPPV治疗AECOPD所致重症呼吸衰竭NPPV及IPPV病人一般情况对比例数年龄 pH PaO2/FiO2PaCO

4、2NPPV23738 7.200.05 16838 8516 IPPV26718 7.200.05 17138 8714P值-0.250.91 0.49 0.38主要结果对比（NPPV vs IPPV）NPPV失败率： 52%机械通气时间：1619 d vs 1521 d p=0.30 住ICU时间 ： 2219 d vs 2120 d p=0.21致死性并发症：5 vs 4 p=0.41存活率： 74% vs 54% p=0.43NPPV治疗AECOPD所致重症呼吸衰竭NPPV及IPPV病人一般情况对比例数年龄 pH PaO2PaCO2NPPV64696 7.18 439 10014 IPP

5、V64705 7.18 448 10013P值-0.510.91 0.37 0.06主要结果对比（NPPV vs IPPV）NPPV失败率： 40/64机械通气时间：108 d vs 123 d p=0.39住ICU时间： 138 d vs 153 d p=0.43并发症： 26 vs 42 p=0.01病死率： 8% vs 17% p=0.14Scala对153例COPD患者进行的病例对照研究发现，对于严重意识障碍（评分大于分）患者，应用NPPV的死亡率则高达50%Chest，2005;128;1657-1666NPPV治疗AECOPD对于出现轻中度呼吸性酸中毒（7.25pH7.35）及明显

6、呼吸困难（辅助呼吸肌参与、呼吸频率25次/分）的AECOPD患者，推荐应用NPPV。推荐级别：A级对于病情较轻（动脉血pH7.35，PaCO245mmHg）的AECOPD患者宜早期应用NPPV。 推荐级别：C级对于出现严重呼吸性酸中毒（pH7.25）的AECOPD患者，在严密观察的前提下可短时间（1-2h）试用NPPV。 推荐级别：C级对于伴有严重意识障碍的AECOPD患者不宜行NPPV。推荐级别：D级急性心力衰竭（AHF）发生呼吸衰竭的机制I型（轻）及II型呼吸衰竭（重）换气功能障碍肺水肿，肺泡萎陷V/Q失调，弥散通气功能障碍限制性通气：肺顺应性下降，肺不张， 肥胖，呼吸肌氧供下降阻塞性通气

7、：气道水肿氧耗增加无创正压通气治疗AHF的机制改善换气：改善氧合提高吸氧浓度PEEP：减少肺水肿，萎陷肺泡复张V/Q改善改善通气：降低PaCO2肺顺应性改善呼吸肌氧供改善减少呼吸做功：降低氧耗无创正压通气治疗AHF的机制降低后负荷：心室后负荷与室壁张力正相关T：室壁张力，Ptm：跨心室壁压，R：心室腔半径，H：室壁厚度PIC：心腔内压，Ppl胸腔内压无创正压通气治疗AHF改善心脏工作环境氧合及通气改善降低心脏前负荷降低心脏后负荷为吗啡、安定等药物的使用保驾Mehta S, et al. Respir Care, 2009, 54(2):186 195.Mehta S, et al. Respi

8、r Care, 2009, 54(2):186 195.Mwbazaa A, et al. Crit Care Med, 2008, 36 :S129S139无创正压通气应为AHF的一线治疗手段!无创正压通气治疗AHF指证：应用时机无禁忌证尽早应用较明显呼吸困难或/和缺氧表现而常规氧疗效果不佳对伴有CO2潴留者应不失时机男性，45岁,肾移植术后3月，PCP9-69-79-20男性，45岁, PCP，肾移植术后3月04-9-2804-9-27最终死于VAP以及气压伤文献复习：免疫抑制患者行有创通气的存活率 有创通气病死率高系统回顾（System review)干细胞移植术后接受IPPV的患者病死

9、可能性： 82%-96%若合并肝脏及肾脏功能不全，病死的可能性增高为： 98%-100% Blood.2001;98:3234-3240有创通气病死率高 “在迄今为止完成的两项针对免疫抑制患者应用机械通气的RCT中均发现，一旦发生VAP，ICU病死率将高达100%” Hillbert G, et al. Clin Pulm Med 2004;11: 175182. Antonelli M,et al. JAMA. 2000;283(2):235-41. Hilbert G, N Engl J Med, 2001, 344:481-487.关于VAP呼吸机相关肺炎？ 还是人工气道相关肺炎？ Kr

10、amer B. Ann Inter Med, 1999,130:1027-1028.男性，50岁,肾移植术后2月，CMV感染,MOF1-81-9NPPV治疗NPPV:FiO2 1.0,IPAP 16cmH2O, EPAP10cmH2O血气：pH 7.338, PO2 62mmHg, PCO2 33mmHg患者预后2-22NPPV:50天转出ICU好转出院男性,41岁,肾移植术后3月Venturi mask:FiO2 50pH 7.45，PCO2 34，PO2 47NPPV for 9days4-5NPPV失败4-154-14in 200 non-HIV immunocompromised pa

11、tients：delay (5 days) in establishing a specific diagnosis were associated with higher mortality (OR, 3.4) Ana Rano, CHEST 2002; 122:253261.经有创通气行气管镜检查病例女，61岁,干燥综合征，系统红斑狼疮，间质性肺炎因“发热、咳嗽咯痰4天”于2006-8-11入住风湿免疫科长期口服激素（美卓乐25mg/d）及免疫抑制剂（骁悉 0.5 tid）8月18日呼吸困难加重，发热，体温39 ABG（FiO2 50）: pH 7.56 PO2 35.8 PCO2 30.

12、3 2006-8-182006-8-212006-8-222006-8-242006-8-21拔管前情况HRRR模式PSPEEPPaO2PaO2/FiO22006-8-24-2PM(拔管前)9139PSV181265.81102006-8-24-4PM(拔管后)10445CPAP0974.41002006-8-259038CPAP01071.61102006-8-268832CPAP01069.81162006-8-2810029CPAP01091.81532006-9-110531CPAP07711582006-9-610428CPAP0683.51862006-9-910026CPAP05

13、78200拔管前后变化HRRR模式PSPEEPPaO2PaO2/FiO22006-8-24-2PM(拔管前)9139PSV181265.81102006-8-24-4PM(拔管后)10445CPAP0974.41002006-8-259038CPAP01071.61102006-8-268832CPAP01069.81162006-8-2810029CPAP01091.81532006-9-110531CPAP07711582006-9-610428CPAP0683.51862006-9-910026CPAP05782009.15转至综合科病房，9.29日出院免疫抑制合并呼吸衰竭的呼吸支持策略

14、灵活选择NPPV与IPPVNPPV：避免气管插管的一线治疗，辅助早期拔管 IPPV：NPPV的补救手段，保障气管镜检查的安全Rocker GM,et al.Chest 1999;115:173177Success rate ：66%Survival (ICU and hospital) for the 10 patients was 70%NPPV for ALI/ARDSObservational cohort study,2 ICU54/79 ALI/ARDS initially treated with NPPV70.3% failed NPPVNPPV failure predicte

15、d by:Shock: all 19 pats with shock failed to NPPVMetabolic acidosis:7.37 (7.267.43) vs 7.39 (7.327.45)Severe hypoxemia:112 (70157) vs 147 (118209)critical care,2006;10:R79Design: Prospective, multiple-center cohort studySetting: 3 European ICU having expertise with NPPVPatients: Between March 2002 a

16、nd April 2004479 patients with ARDS were admitted to the ICU332 ARDS patients were already intubated147 were eligible for the studyCrit Care Med 2007; 35:1825Avoided intubation in 79 patients (54%) Less VAP: 2% vs 20%, p 0.001 Lower ICU mortality rate: 6% vs 53%, p34 PaO2/FIO2 50 mmHg 1 case refused

17、 NPPV19 completed19 Included in analysis21 completed21 Included in analysis40 Patients Randomized21 Randomized to NPPV group21 Received intervention as randomized 19 Randomized to control group 19 Received intervention as randomizedNPPV group (n=21)Control group (n=19)PAge, mean (SD), years43.813.74

18、9.113.70.234Male, n (%)16 (76.2)8 (42.1)0.028Smoking, n (%)5(23.8)7(36.8)0.369Height, mean (SD), cm169616780.211Body mass index, mean (SD), kg/m223.82.822.94.00.391Ideal body weight, mean (SD), kg64.17.260.68.40.169Days since onset of acute lung injury, median (IQR)2.0 (1.0-3.5)3.0 (1.0-6.0)0.377APA

19、CHE II score, mean (SD)*11.86.313.45.70.389White blood cell count, 109/L, mean (SD)15.67.915.015.10.890Neutrophil, 109/L, mean (SD)82.88.583.66.40.747Hemoglobin, g/L, mean (SD)125.227.5113.631.20.219Aspartate aminotransferase,IU/L, median(IQR)60.0(28.0-111.0)34.0 (25.0-65.0)0.255Creatinine, mg/dl, m

20、ean (SD)1.160.931.100.650.833C-reactive protein, mg/L ,median(IQR)118.0 (54.3-147.0)77.3 (19.0-174.8)0.82Demographic and baseline physiologic dataRespiratory Rate between groupsPaO2/FiO2 between groupsClinical outcomes 40 ALI patientsNPPV: 21Control:191 intubation: 1died20 Discharged7 intubation:5di

21、ed2 discharged12 DischargedNeed for intubationNPPVVenturiTotalEndotracheal intubation+178-201232total211940P=0.015Actual intubation rateNPPVVenturiTotalEndotracheal intubation+145-201535total211940P=0.042Kaplan-Mierer estimates of probability of the need for EILog Rank P=0.030Age-sex adjusted Relati

22、ve Risk(95% CI) =0.04 (0.00-0.23) Mortality in ICU/hospitalNPPVVenturiTotalDied in ICU/hospital+156-201434total211940P=0.085Kaplan-Mierer estimates of probability of mortality Age-sex adjusted Relative Risk(95% CI) =0.03 (0.00-0.58) Organ failureOrgan failureNPPV (n=21)Control (n=19)PAge-sex adjuste

23、dRelative risk(95% CI )Renal failure, n (%)1(4.8)2(10.5)0.4890.17 (0.01-3.13)Cardiovascular failure, n (%)2(9.5)6(31.6)0.1200.11 (0.01-0.93)Hepatic failure, n (%)0(0.0)2(10.5)0.127-Hematological failure, n (%)0(0.0)3(15.8)0.058-Centrial nervous systemfailure, n (%)0(0.0)1(5.2)0.287-Total, n (%)3(14.3)14(73.7)0.0000.09 (0.01-0.74) P0.05 主要研究结果:NPPV干预ARDSDemographic and baseline physiologic dataMeasurementNPPV GroupIPPV Groupp N/grou