ERS／ATS急性呼吸衰竭无创通气治疗

1、 ERS/ATS急性呼吸衰竭无创通气指南解读第1页欧洲呼吸学会（ERS）与美国胸科学会（ATS）在欧洲呼吸杂志上联合发表了ARF患者无创通气指南。该指南采取PICO(populationinterventioncomparisonoutcome)范式对11个临床相关问题进行了解答。推荐意见整理以下：第2页Question 1: Should NIV be used in COPD exacerbation?问题1：NIV是否应用于AECOPD？第3页Question 1a: Should NIV be used in ARF due to a COPD exacerbation to prev

2、ent the development of respiratory acidosis?RecommendationWe suggest NIV not be used in patients with hypercapnia who are not acidotic in the setting of a COPD exacerbation. (Conditional recommendation, low certainty of evidence.)第4页问题1a：NIV是否应用于COPD急性加重造成急性呼吸衰竭（ARF）以预防发展为呼吸性酸中毒？推荐意见：提议NIV不适合用于COPD急

3、性加重患者中无酸中毒高碳酸血症患者（条件性推荐，低质量证据）。第5页See forest plots and the evidence profile in the supplementary material for further details regarding included evidence. Pooled analysis was very imprecise but demonstrated that bilevel NIV does not reduce mortality (RR 1.46, 95% CI 0.643.35) and decrease the need f

4、or intubation (RR 0.41, 95% CI 0.180.72).Given the lack of consistent evidence demonstrating be-nefit in those without acidosis and the potential for harm, the committee decided on a conditional recommendation against bilevel NIV in this setting.最近几项研究表明双相气道正压NIV不降低死亡率（RR 1.46,95CI 0.64-3.35），不降低对插管

5、需要（RR 0.41,95CI 0.18-0.72）。鉴于缺乏证据证实对没有酸中毒患者益处和潜在危害，委员会决定在这一环境中对 bilevel NIV提出反对意见。第6页Question 1b: Should NIV be used in es-tablished acute hypercapnic respiratory failure due to a COPD exacerbation?Recommendations We recommend bilevel NIV for patients with ARF leading to acute or acute-on-chronic re

6、spiratory acidosis (pH 7.35) due to COPD exacerbation. (Strong recommendation, high certainty of evidence.) We recommend a trial of bilevel NIV in patients con-sidered to require endotracheal intubation and mechanical ventilation, unless the patient is immediately deteriorating. (Strong recommendati

7、on, moderatecertainty of evidence.)第7页问题1b：NIV是否应用于因为COPD急性加重而造成急性高碳酸血症呼吸衰竭？推荐意见：我们推荐双相气道正压NIV用于因为COPD急性加重造成急性呼吸衰竭引发急性或慢性急性加重呼吸性酸中毒（pH7.35）（强烈推荐，高质量证据）。第8页我们提议在认为需要气管内插管患者中进行试验性双相气道正压NIV机械通气，除非患者马上恶化（强烈推荐，中等质量证据）。实施考虑：当pH值7.35，PaCO245mmHg，呼吸频率 20-24次/min时，应考虑双相气道正压NIV， 尽管采取标准药品治疗。双相气道正压NIV依然是住院期间COP

8、D患者发生呼吸性酸中毒首选。第9页There is no lower limit of pH below which a trial of NIV isinappropriate; however, the lower the pH, the greater risk of failure, and patients must be very closelymonitored with rapid access to endotracheal intubation and invasive ventilation if not improving.对于试验性NIV没有pH下限是不适当; 然而，

9、pH越低失败风险越大，患者必须非常亲密监测，假如没有改进，能够快速取得气管内插管和有创通气。第10页问题2a：应该在因为心源性肺水肿引发急性呼吸衰竭中使用NIV吗？推荐意见：我们提议对心源性肺水肿引发呼吸衰竭患者提供双气道正压NIV或CPAP。（强烈推荐，中等质量证据）。第11页In , GRAYet al.43 published the largest multicentre trial from 26 emergency departments, in which1069 patients were randomised to CPAP, bilevel NIV or standard

10、oxygen therapy. This trial found physiological improvement in the CPAP and bilevel NIP groups compared with the standard group, but no difference in intubation rate or mortality at 7 and 30 days.这项试验发觉CPAP及Bilevel NIP组与标准组相比，有生理上改进， 但插管率和死亡率在7天和30天内没有差异。 第12页five systematic reviews 4448 that have in

11、corporated the data from GRAYet al.43, as well as other new trials, have been published. They consistently conclude that: 1) NIV decreases the need for intubation, 2) NIV is associated with a reduction in hospital mortality, 3) NIV isnot associated with increased myocardial infarction (a concern rai

12、sed by the first study comparing NIVand CPAP 49),4) CPAP and NIV have similar effects on these outcomes. Recommendation We recommend either bilevel NIV or CPAP for patients with ARF due to cardiogenic pulmonary oedema.(Strong recommendation, moderate certainty of evidence.)1）降低气管插管需要， 2）与降低住院死亡率相关，

13、3）和合不增加心肌梗死相关4）CPAP和Bilevel NIV治疗对这些结果有相同影响。第13页Question 2b: Should a trial of CPAP prior to hospitalisation be used to prevent deterioration in patients with ARF due to cardiogenic pulmonary oedema? Pooled analysis demonstrated that NIV decreased mortality (RR 0.88, 95% CI 0.451.70; moderate certai

14、nty) decreased the need for intubation (RR 0.31, 95% CI 0.170.55; low certainty)We suggest that CPAP or bilevel NIV be used for patients with ARF due to cardiogenic pulmonaryoedema in the pre-hospital setting. (Conditional recommendation, low certainty of evidence.) 第14页问题2b：在院前是否应使用CPAP进行以预防心源性肺水肿引

15、发ARF患者恶化？推荐意见：提议在院前对心源性肺水肿引发ARF患者使用CPAP或双相气道正压NIV（条件性推荐，低质量证据）。汇总分析表明 NIV 降低死亡率（RR 0.88，95% CI 0.45 - 1.70；适度确定性） 降低了插管需要（RR 0.31，95% CI 0.17 - 0.55；低确定性）。 第15页Question 3: Should NIV be used in ARF due to acute asthma? Recommendation Given the uncertainty of evidence we are unable to offer a recomme

16、ndation on the use of NIV for ARF due to asthma. NIV has an unclear effect on mortality, intubation(RR 4.48, 95% CI 0.2389.23; very low certainty) or ICU length of stay (mean difference 0.3 higher, 95%CI 0.63 lower to 1.23 higher) in this population. 第16页问题3：NIV是否用于因为急性哮喘引发ARF？推荐意见：鉴于证据不确定性，我们无法就因为哮

17、喘引发ARF使用NIV提出提议。似乎有利于改进1 s用力呼气量。 （平均差值高14.02，95% CI 7.73 - 20.32；低确定性） 和呼气峰流量（平均差值高19.97，95% CI 15.01 - 24.93；低确定性）。 第17页Question 4: Should NIV be used for ARF in immunocompromised patients? Recommendation We suggest early NIV for immunocompromised patients with ARF. (Conditional recommendation,mode

18、rate certainty of evidence.)第18页问题4：NIV是否用于免疫缺点患者ARF？推荐意见：我们提议免疫功效低下ARF患者早期使用NIV（条件性推荐，中等质量证据）。第19页 one recent RCT 67 showed benefits of high-flow nasal cannula oxygen therapy over bilevel NIV with regard to intubation and mortality. 高流量鼻套管氧疗在插管率和死亡率改进上高于 Bilevel NIV。 and more study is required to d

19、etermine whether this modality has advantages over NIV in immunocompromised patients with ARF.第20页Question 5: Should NIV be used in de novo ARF? RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for de novo ARF. 第21页问题5：NIV是否用于新发急性呼吸衰竭？推荐意见：鉴于证

20、据不确定性，无法就因为新发ARF使用NIV提出提议。第22页Question 6: Should NIV be used in ARF in the post-operative setting? RecommendationWe suggest NIV for patients with post-operative ARF. (Conditional recommendation, moderate certainty of evidence.) 第23页问题6：NIV是否用于手术后ARF患者中？ 推荐意见： 提议在手术后ARF患者使用NIV（条件性推荐，中等质量证据）。第24页Quest

21、ion 7: Should NIV be used in patients with ARF receiving palliative care? RecommendationWe suggest offering NIV to dyspnoeic patients for palliation in the setting of terminal cancer or other terminal conditions. (Conditional recommendation, moderate certainty of evidence.) 第25页问题7：NIV是否用于接收姑息治疗ARF患

22、者？推荐意见：提议将NIV提供给癌症终末期或其它疾病终末期呼吸困难患者（条件性推荐，中等质量证据）。第26页Question 8: Should NIV be used in ARF due to chest trauma? RecommendationWe suggest NIV for chest trauma patients with ARF. (Conditional recommendation, moderate certainty of evidence.) 第27页问题8：NIV是否用于因为胸部创伤造成ARF？推荐意见：提议胸部创伤引发ARF患者中使用NIV。 （条件性推荐，

23、中等质量证据）。第28页Question 9: Should NIV be used in ARF due to pandemic viral illness? RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation for this question 第29页问题9：NIV是否用于因为流行性病毒性疾病引发ARF？推荐意见：鉴于证据不确定性，无法就此提出提议。第30页Question 10: Should NIV be used in ARF following extuba

24、tion from invasive mechanical ventilation?问题10：NIV是否用于有创机械通气拔管后ARF？第31页Question 10a: Should NIV be used to prevent respiratory failure post-extubation? RecommendationsWe suggest that NIV be used to prevent post-extubation respiratory failure in high-risk patientspost-extubation. (Conditional recomme

25、ndation, low certainty of evidence.)We suggest that NIV should not be used to prevent post-extubation respiratory failure in non-high-riskpatients. (Conditional recommendation, very low certainty of evidence.) 第32页问题10a：NIV是否用于预防拔管后呼吸衰竭？推荐意见：提议NIV用于预防拔管后有呼吸衰竭高风险患者呼吸衰竭 （条件性推荐，低质量证据）。提议NIV不应用于预防非呼吸衰竭高风险拔管后患者 （条件性推荐，低质量证据）。第33页Question 10