无创正压通气临床应用

无创正压通气临床应用1正压机械通气的目的正压机械通气能够解决肺的通气和部分换气功能能够有效改善和维持最适氧合和促进二氧化碳排出，维持生命支持的氧的需要，为疾病的恢复赢得时机在进行正压机械通气的同时，应采取有效的措施尽量减小机械通气相关副作用2Preface对无创通气应用的把握在

与

非

机

械

通

气

治

疗

的

对

比

中

动

态

把

握

应

用

指

征在

与

有

创

通

气

的

对

比

中

动

态

把

握

应

用

指

征——

关键词：

对比

动态——

孰更有效/好用？——

代价、副作用更小？无创通气有创通气非机械通气35Interfaceof

NIVLancet2009;374:

250–5956Interfaceof

NIVDesirableCharacteristicsofanInterfaceforNoninvasive

VentilationRespirCare.2013;58(6):950-97167Interfaceof

NIVJAerosolMed.

27007;20(1):S85–S99.8Ventilator

selectionConsiderationsintheSelectionofaVentilatorfor

NIVRespirCare.2013;58(6):950-9718理论上讲,

具有完善监测与报警功能的大型多功能呼吸机(critical

care

ventilator)

以及专用无创呼吸机均可用于NPPV对于应用密闭性能较好的全面罩和头罩可尝试应用传统的有创多功能呼吸机进行NPPV而应用密闭性能较差的鼻罩和口鼻面罩简易应用漏气补偿效果较好的专用无创呼吸机进行NPPV治疗Ventilator

selection9IndicationsandcontraindicationsforNIVinacute

careLancet2009;374:

250–5910RiskFactorsofNIV

Failure1011RespirCare.2013;58(6):950-971RiskFactorsofNIV

Failure1111RespirCare.2013;58(6):950-97113PrefaceFailureriskchartsfor

NPPVRespirCare2007;521(53):568

–578.WhentoTransfertothe

ICU---Huddleformand

checklist13RespirCare.2013;58(6):950-971WhentoTransfertothe

ICU14RespirCare.2013;58(6):950-971---Huddleformand

checklist临床应用1516急性低氧性呼吸衰竭161618AcuteHypoxemicRespiratory

FailureCausesofacutehypoxemicrespiratoryfailureandfrequencyof

NIVfailureEurJInternMed.

2012;23(5):420-428ARDSARDS是临床最为常见的重症呼吸衰竭疾患，病情发展快，病死率较高，也是临床研究的热点和难点问题由于ARDS是以顽固性进行性低氧血症为主要表现，机械通气治疗通过促进肺泡复张和维持肺泡和周围毛细血管的氧降梯度从而改善氧合为针对疾病的病因治疗争取宝贵的时间1820无创通气的时代来临了----NavaS.IntensiveCareMed

,2006,32:361–3701920对ARDS患者应用NIV应非常慎重----NavaS.Lancet,2009,374:

250–259由于NIV治疗ARDS的高失败率，因此对ARDS患者来说选择NIV应给外慎重----NavaS.RespirCare

,2011,56(10):1583–1588ARDSARDS的定义20201994年欧美会议共识（AECC）ARDS诊断标准：病程：急性起病低氧血症：PaO2/FiO2≤200mmHg胸片：双肺弥漫性浸润没有左心房高压的证据，PAWP≤18mmHgALI诊断标准:PaO2/FiO2≤300mmHg.AmJRespirCritCareMed.1994;149(3pt

1):818-824.ARDS的定义AECC标准AECC局限性病程：急性起病无具体时间ALIPaO2/FiO2≤300mmHg容易混淆201-300mmHg为ALI氧合指数PaO2/FiO2≤200mmHg，未考虑PEEP水平不同的PEEP及FiO2，PaO2/FiO2也不同胸片双肺弥漫性浸润缺乏客观评价指标PAWPPAWP≤18mmHg,无左心房高压ARDS及高水平PAWP可同时存在，PAWP有不确定性危险因素无未考虑22ARDS的定义：柏林标准JAMA.

2012;307(23):2526-323.急性呼吸窘迫综合征发病时间1周以内起病、或新发、或恶化的呼吸症状胸部影像学双肺模糊影—不能完全由渗出、肺塌陷或结节来解释肺水肿起因不能完全由心力衰竭或容量过负荷解释的呼吸衰竭.没有发现危险因素时可行超声心动图等检查排除流体静力性肺水肿氧合指数轻度200mmHg<PaO2/FiO2≤300mmHgwith

PPEP≥5cmH2O中度100mmHg<PaO2/FiO2≤200mmHgwith

PPEP≥5cmH2O重度PaO2/FiO2≤100mmHgwithPPEP≥

5cmH2O24ARDSWesuggestthatnoninvasivemaskventilation(NIV)beusedinthat

minorityofsepsis-inducedARDSpatients

inwhomthebenefitsofNIVhavebeencarefullyconsideredandarethoughttooutweightherisks(grade

2B).SurvivingSepsis----2012

UpdateCritCareMed2013;

41:580–637ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryZhanQY,etal.CritCareMed.

2012;40(2):455-6025ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryZhanQY,etal.CritCareMed.

2012;40(2):455-602526ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryZhanQY,etal.CritCareMed.

2012;40(2):455-602626ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryKaplan-Meierestimatesoftheprobabilityoftheneedforendotracheal

intubationZhanQY,etal.CritCareMed.

20122;480(2):455-60286028ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryKaplan-Meierestimatesoftheprobabilityof

mortalityZhanQY,etal.CritCareMed.

20122;480(2):455-6029602930ARDSEarlyuseofnoninvasivepositivepressureventilationforacutelung

injuryZhan

QY,

et

al.

Crit

Care

Med.2011

Oct

20.

[Epub

ahead

ofprint]Conclusions:Noninvasivepositivepressureventilationissafeforselected

patientswithacutelung

injuryHowever,alargerrandomizedtrialwithneedforintubationandmortalityastheoutcomesofinterestis

required.30ARDSAmultiple-centersurveyontheuse

inclinicalpracticeofNPPVasafirst-lineinterventionforARDSNPPV:79Intubation：68CritCare3M1ed.2007;35(1):18

–321532ARDS

(cont)CritCareMed.

2007;35(1):18

–25Inexpertcenters,NPPVappliedasfirst-lineinterventioninARDSavoidedintubationin54%oftreated

patients.InpatientswithSAPS34,thosewithaPaO2/FIO2175after1hrofNPPV

willlikelybenefitfromcontinuationof

NPPV3233ARDS

(cont)Failureofnon-invasiveventilationinpatientswithacutelunginjury:observationalcohort

studyCriticalCare2006,

10:R793334ARDS

(cont)CriticalCare2006,

10:R79Failureofnon-invasiveventilationinpatientswithacutelunginjury:observationalcohort

study在对没有合并休克的的ALI患者就氧合指数、代谢性酸碱指数和APACHEIII进行多元逐步回归分析，其中代谢性酸中毒（OR:1.27）和严重低氧血症（OR:1.03）是预测NPPV失败的主要决定因素NIPPV治疗失败的患者其病死率远高于APACHEIII预测的病死率（68%vs.39%，p<

0.01）但是NPPV成功的患者无一例死亡3435ARDS

(cont)IntensiveCareMed(2006)

32:1756–1765Benefitsandrisksofsuccessorfailureof

NIVdenovo：withoutpreviouscardiacorrespiratory

diseaseDenovo:mainlyALI/ARDSpatients3536ARDS

(cont)IntensiveCareMed(2006)

32:1756–1765Benefitsandrisksofsuccessorfailureof

NIVNIVfailurewasassociatedwithICUmortalityinthedenovogroup(OR3.24,

CI1.61–6.53)36ARDSRoleofNIVin

ARDSPracticalApproachtotheUseofNIVinPatientsWith

ARDSRespirCare

2010;55(3172):1653–1660377ARDSRoleofNIVin

ARDSPracticalApproachtotheUseofNIVinPatientsWith

ARDSRespirCare

2010;55(3172):1653–166038739ARDSHigherseverityscore(SAPSII

35>34)Olderage(>40

years)PresenceofARDSor

CAPFailuretoimproveafter1hoftreatment(PaO2:

FiO2≤146≤175Predictorsoffailureofnoninvasive

ventilationCurrOpinCritCare2012,

18:54–603940ARDSFailure

to

maintain

a

PaO2

>65mmHg

with

an

FIO2:

0.6DevelopmentofconditionsnecessitatingETItoprotecttheairways(coma

or

seizure

disorders)

or

to

manage

copious

tracheal

secretionsPersistentdyspnea,tachypnea,oruseofaccessoryrespiratory

musclesAppearanceofhemodynamicorelectrocardiographic

instabilityInabilitytotoleratethe

interfaceCriteriausedforNIVdiscontinuationandendotracheal

intubationCurrOpinCritCare201420,

18:54–6041Severe

PneumoniaClinicalfeaturesandriskfactorsforsevereandcriticalpregnantwomenwith2009pandemicH1N1influenzainfectionin

ChinaBMCInfectiousDiseases2012,

12:2941Severe

PneumoniaNIVinCAPandsevere

ARFdenovo：withoutpreviouscardiacorrespiratory

diseaseIntensiveCareMed

(2012)4328:458–46641Severe

PneumoniaNIVinCAPandsevere

ARFIntensiveCareMed

(2012)4328:458–4664244Severe

PneumoniaNIVinCAPandsevere

ARFIntensiveCareMed(2012)38:458–466Bycontrast,norelationshipwasfound

betweendurationofNIVbeforeintubationandmortalityinpatientswithpreviouscardiacorrespiratory

disease4Severe

PneumoniaNIVinCAPandsevere

ARFIntensiveCareMed

(2012)4358:458–46644Conclusions:SuccessfulNIVwasstronglyassociatedwithbetter

survivalIfpredictorsforNIVfailurearepresent,avoidingdelayedintubationofpatientswith‘‘denovo’’ARFwouldpotentiallyminimise

mortalitySevere

PneumoniaNIVinCAPandsevere

ARFIntensiveCareMed

(2012)4358:458–46645重症肺炎NIV的应用适应证应参照ARDS如果患者既往没有心肺基础疾病，NIV失败、延迟有创机械通气的时间会明显增加患者的病死率因此把握好NIV的应用时机至关重要AcuteCardiogenicpulmonary

edema(ACPE)Heart.

2013;0:35497:1-6.47AcuteCardiogenicpulmonary

edema(ACPE)Heart.

2013;0:35498:1-6.48AcuteCardiogenicpulmonary

edema(ACPE)Heart.

2013;0:35499:1-6.49AcuteCardiogenicpulmonary

edema(ACPE)现有的研究已经证明单纯CPAP即对多数合并有低氧血症的因左心功能不全（主要是左室舒张功能不全）继发心源性肺水肿患者具有明显的疗效，即使CPAP无效转而应用BiPAP还会使患者病情所有好转（GradeB）Thorax.2002;

57:192-211因为NIPPV不仅能改善气体交换,而且通过促进左心室后负荷下降从而具有改善心功能的作用。左心功能不全时,胸腔负压可显著升高,从而使跨壁压升高，适当持续正压通气(CPAP)

/PEEP

使胸腔负压下降,左心室跨壁压和后负荷相应下降，促进心功能改善Lancet.200560;367:1155-116350NIVin

ACPEMeta-analysis:NIVinACPE(limited

evidence)Comparedwithstandardtherapy,

CPAPreducedmortality(RR:0.64)andneed

forintubation(RR:0.44)butnotincidenceofnewMI(RR:1.07

)TheeffectwasmoreprominentintrialsinwhichmyocardialischemiaorinfarctioncausedACPEinhigherproportionsofpatients

(RR:0.92)Bilevelventilationreducedtheneedforintubation(RR,0.54)butdidnotreduce

mortalityornew

MINodifferencesweredetectedbetweenCPAPandbilevelventilationonanyclinicaloutcomesforwhichtheyweredirectly

comparedWengCL,etal.AnnInternMed.521010;152:590-56100.NIVin

ACPEJCardiacFail

2011;17:850e859Meta-analysis:NIVinACPE

(2011)Results:Attotalof34studies(3,041patients)wereincluded.Indirectcomparisons,bothCPAPandNIPPVreducedtheriskofdeath(RR0.64,95%CI0.44-0.93;RR0.80,95%CI0.58-1.10;respectively)comparedwithST,althoughonlyCPAPhadasignificanteffect.TherewerenosignificantdifferencesbetweenNIPPVandCPAP.ComparedwithST,

bothCPAPandNIPPVsignificantlyreducedmortality

(RR0.63,95%

CI

0.44-0.89;

RR0.73,

95%

CI

0.55-0.97;

respectively).Conclusions:OurfindingssuggestthatamongACPEpatients,NIVdeliveredthrougheitherNIPPVorCPAPreduced

mortality.52Cardiogenicpulmonaryedema

(cont)如果患者合并有呼吸肌疲劳通过应用BiPAP给患者吸气时有效的压力支持增加肺泡有效通气量会使病情进一步好转但也应注意因BiPAP的人机同步问题和胸腔压力的变化可能对患者带来不良的影响因此在保守治疗效果不佳的情况下心源性肺水肿患者应首选NIPPV治疗，但是如果病情加重或NIPPV疗效不佳时应积极采取有创机械通气方式Lancet.

2006;367:1155-1163CritCareMed.2007;

35(10):2402–240753Cardiogenicpulmonaryedema

(cont)NoninvasiveVentilationinPulmonaryEdemaComplicatingAcuteMyocardial

Infarction53CircJ.2012;76:2586–

2591Cardiogenicpulmonaryedema

(cont)NoninvasiveVentilationinPulmonaryEdemaComplicatingAcuteMyocardial

Infarction54CircJ.2012;76:2586–

2591Cardiogenicpulmonaryedema

(cont)NoninvasiveVentilationinPulmonaryEdemaComplicatingAcuteMyocardial

InfarctionConclusions:NIVeffectivelyimprovedvitalsignsandoxygenationandloweredtheintubationrateinpatientswithcardiogenicpulmonaryedemaofalletiologies,including

AMITheoutcomeinpatientswithAMItreatedwithNIVdependsprimarilyontheseverityofthecourseofAMIandnotontheseverityofacuterespiratory

failure55CircJ.2012;76:2586–

2591Cardiogenicpulmonaryedema

(cont)Heart.

2013;0:35597:1-6.NIV

可以作为急性心源性肺水肿的一线治疗手段，可以降低气管插管率和病死率NIV可以试用于急性心肌梗塞、合并有轻度心源性休克、应用血管活性药物和IABP能够维持有效灌注的患者，但一定要严密观察病情变化对原发病的救治是治疗的关键所在58Cardiogenicpulmonaryedema

(cont)NIVforPulmonaryFibrosis

PatientsWhyDoPatientsWithILDFailinthe

ICU?58RespirCare

2013;58(3):525–531.NIVforPulmonaryFibrosis

PatientsWhyDoPatientsWithILDFailinthe

ICU?病死率：59RespirCare

2013;58(3):525–531.81.5%95.2%NIVforPulmonaryFibrosis

PatientsWhyDoPatientsWithILDFailinthe

ICU?60RespirCare

2013;58(3):525–531.NIVforPulmonaryFibrosis

Patients61RespirCare

2013;58(3):525–531.WhyDoPatientsWithILDFailinthe

ICU?RiskfactorsforNIVfailureofILDinthe

ICU:APACHEIIscore>20(hazardratio2.77,95%CI1.19–6.45,P<0.02)continuousNIVdemand(hazardratio5.12,95%CI

1.44–18.19,

P<0.01)Predominantlyimmunocompetent

patientsCurrOpinCritCare2012,

18:54–6063Predictorsoffailureofnoninvasiveventilationinhypoxemic

patients64CurrOpinCritCare

20126,418:54–60Criteriausedfornoninvasiveventilationdiscontinuationandendotrachealintubationinhypoxemic

patientsPredominantlyimmunocompetent

patients65Definition什么是免疫功能低下：Denotingapersonwithanimmunologicmechanismdeficienteitherbecauseofanimmunodeficiencydisorderorbecauseithasbeensorenderedbyimmunosuppressive

agents免疫功能低下分类：先天性：先天性胸腺缺如，CVID，……..后天获得性：HIV感染医源性：脏器移植、造血干细胞移植、免疫抑制剂应用（肿瘤化疗、自身免疫性疾病免疫抑制治疗）6566移植后感染的致病原（包括骨髓移植和器官移植）移植术后时间（月）66PTLD:Post-transplantlymphoproliferativediseaseNoninfectious

ComplicationsCurrOpinOncol20086；7

20:227–23368Idiopathicpneumonia

syndromeEngraftment

syndromeDiffusealveolar

hemorrhageAJR

2005;18648:629–637Noninfectious

ComplicationsImmunosuppressed

diseases近年来国外对免疫抑制合并低氧血症患者（脏器移植和造血干细胞移植）应用NIPPV治疗取得了较为理想的疗效现有的前瞻随机对照研究结果提示与常规治疗比较NIPPV可有效降低免疫抑制合并低氧血症患者的病死率、气管插管率和ICU住院时间，具有良好的应用前景EurRespirJ.2003;22:Suppl47,31s–37s

IntensiveCareMed.260906;

32:361–37069Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignanciesCritCareMed

2011;39:2232–22397070Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignancies71CritCareMed2011;

39:2232–223971Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignanciesCritCare

Med2011;39:2232–22397272Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignanciesSeveresepsisandsepticshockoccurringafterintensivecareunitadmission7373CritCareMed2011;

39:2232–2239Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignancies7474CritCareMed2011;

39:2232–2239Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignancies7475CritCareMed2011;

39:2232–2239Immunosuppressed

diseasesNIVversusIMVforARF

inpatientswithhematologicmalignancies7575CritCareMed2011;

39:2232–2239Conclusions:Inpatientswithhematologicmalignancies,

acuterespiratory

failureshouldprobablybemanagedinitiallywithnoninvasive

mechanical

ventilationFurtherstudyisneededtodeterminewhetherimmediateinvasivemechanicalventilationmightoffersomebenefitsforthosewithacutelunginjury/adultrespiratorydistress

syndromeImmunosuppressed

diseasesNIVinimmunosuppressedpatientswithpneumoniaandextrapulmonary

sepsis76RespirMed.2012;106(11)

1509-151677Immunosuppressed

diseasesNIVinimmunosuppressedpatientswithpneumoniaandextrapulmonary

sepsis77RespirMed.2012;106(11)

1509-151677Immunosuppressed

diseasesNIVinimmunosuppressedpatientswithpneumoniaandextrapulmonary

sepsis78RespirMed.2012;106(11)

1509-15167780Immunosuppressed

diseasesCurrOpinCritCare2012,

18:54–6080Predictorsoffailureofnoninvasiveventilationinhypoxemic

patients81Immunosuppressed

diseasesCurrOpinCritCare

20128,118:54–60Criteriausedfornoninvasiveventilationdiscontinuationandendotrachealintubationinhypoxemic

patients82合并高碳酸血症的急性呼吸衰竭82Isit

Right?NoninvasiveVentilationforAcuteExacerbationsof

ChronicObstructivePulmonary

Disease:“Don’tThinkTwice,It’s

Alright!”------Elliott

MW.AmJRespirCritCareMed.2012.

15;185(2):121-3.8384AECOPDUseofNoninvasiveVentilationinPatientswithARF,

2000–2009AnnAmThoracSoc.2013;

10(1):10–17NIVpopulationduringahospitalizationwithanARFclaimincreasedinpatientswithCOPDfrom8.6to39per100,000UnitedStatesresidents(360%increase),andNIVuseinpatientswithoutCOPDincreasedfrom6to39

patientsper100,000

UnitedStatesresidentsduringtheyears2000to2009(560%

increase);84AECOPD对AECOPD合并呼吸衰竭和康复期对部分中重度COPD患者有效的呼吸支持治疗是及时挽救患者生命、提高患者生活质量的最主要手段自20世纪90年代初NIPPV应用于临床治疗COPD以来，已有大量的临床研究证实NIPPV对AECOPD的确切疗效，与传统的治疗措施比较，NIPPV可以有效降低病死率、减少气管插管率（GradeA）85 GOLD

201086AECOPDp=0.002Invasiveventilationrate

(%)Intubationrate–EarlyuseNIPPVvs.

ControlChinMedJ.2005;11886(24):2034-40.AECOPDContemporaryManagementofAECOPD:Ameta

analysisEffectsofNPPVontheriskof

intubation8687Chest2008;133;756-766Inthe12controlledrandomizedtrials(959patients),NPPVreducedthe

needforintubation

by65%AECOPDContemporaryManagementofAECOPD:Ameta

analysisInthe11controlledrandomizedtrials(940patients),

NPPVreducedthe

in-hospitalmortalityrateby

55%EffectsofNPPVontheriskofin-hospital

mortality8787Chest2008;133;756-766AECOPD8889NPPV是AECOPD的常规治疗手段。[推荐级别：A级]对于病情较轻（动脉血pH＞7.35，PaCO2＞45mmHg）的AECOPD患者宜早期应用NPPV。[推荐级别：C级]对于出现轻中度呼吸性酸中毒（7.25＜pH＜7.35）及明显呼吸困难（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]对于出现严重呼吸性酸中毒（pH＜7.25）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]中华医学会重症医学分会AECOPDCOPD患者长期处于呼吸肌疲劳和慢性营养不良状态，IMV治疗若不能及时拔管有可能继发呼吸机相关肺炎（VAP）而致使病情而化、导致脱机困难甚至造成呼吸机依赖，在此情况下采取有创无创序贯机械通气治疗具有积极的意义国外多根据呼吸生理参数选择拔管时机，而国内王辰等提出肺部感染窗概念（PIC），即患者病情有所好转、呼吸道感染得到有效控制而在VAP出现以前（一般在气管插管后4-6天）及时拔管采用NIPPV治疗以进一步缓解呼吸肌疲劳，临床应用证明可操作性更强8989AECOPD

(cont)GroupCasesIMVstays(Days)IMV+NIVStays

(days)VAP

casesDead

casesICUstays(Days)IMV-NIV476.4±4.413.3±7.63112±8Control4311.3±6.211.3±6.212716±11p

value0.0000.1010.0060.0190.047Sequentialinvasivetononinvasiveventilationin

COPDPulmonaryinfectioncontrol

window中华结核和呼吸杂志9.

21006;

29:

14-18.

91AECOPD

(cont)UseofNIVtoweancriticallyilladultsoffinvasiveventilation:meta-analysisandsystematic

review9192BMJ.2009May

21;338:b1574AECOPD

(cont)9292BMJ.2009May

21;338:b1574UseofNIVtoweancriticallyilladultsoffinvasiveventilation:meta-analysisandsystematic

reviewConclusions:Currenttrialsincriticallyilladultsshowaconsistentpositiveeffectofnon-invasiveweaningonmortalityandventilatorassociatedpneumonia,thoughthenetclinicalbenefitsremaintobefully

elucidated.Non-invasiveventilationshouldpreferentiallybeusedinpatientswith

chronicobstructivepulmonarydisease

inahighlymonitoredenvironment.中华急诊医学杂志.2007;16(4

):350-3579395AECOPD对接受有创正压通气的AECOPD患者应尽早选用辅助通气模式。[推荐级别：D级]无创正压通气是AECOPD患者早期拔管的有效手段。

[推荐级别：B级]对于支气管-肺部感染为诱发加重因素的AECOPD患者,可以肺部感染控制窗作为有创通气与无创通气的切换点。

[推荐级别：B级]中华医学会呼吸病分会推荐意见：9495NPPV是AECOPD的常规治疗手段（A级）对存在NPPV应用指征，而没有NPPV禁忌证的AECOPD患者，早期应用NPPV治疗可改善症状和动脉血气，降低气管插管的使用率和病死率，缩短住院或住ICU的时间（A级）对于病情较轻（动脉血pH>7.35,

PaCO2>45mmHg）的AECOPD患者是否应用NPPV存在争议，需要综合考虑人力资源和患者对治疗的耐受性中华结核和呼吸杂志.

2009;

32(2):

86-98AECOPD对于出现严重呼吸性酸中毒的AECOPD患者，NPPV治疗的成功率相对较低，可以在严密观察的前提下短时间（1~2h）试用，有改善者继续应用，无改善者及时改为有创通气对于伴有严重意识障碍或有气管插管指征的AECOPD患者，不推荐常规使用NPPV只有在患者及其家属明确拒绝气管插管时，在一对一密切监护的条件下，将NPPV作为一种替代治疗的措施（C级）中华医学会呼吸病分会推荐意见：中华结核和呼吸杂志.

2009;

32(2):

86-98AECOPD96GOLD2014AECOPD96GOLD2014AECOPD97GOLD2014AECOPD98AsthmaChangingetiologiesofacuterespiratoryfailureamongpatientsreceivingnoninvasiveventilation,2000versus

200999AnnAmThoracSoc.2013;

10(1):10–17AsthmaFailureofNIVamongpatientswithoutCOPDcomparedwithpatientswithCOPD100AnnAmThoracSoc.2013;

10(1):10–17Asthma对部分以单纯以低氧血症为主的重症哮喘患者单纯应用CPAP即可以有效缓解呼吸肌疲劳、改善氧合，而应用BiPAP治疗可以迅速缓解呼吸窘迫状况，促进二氧化碳排出、改善呼吸功能但是由于缺乏大样本的研究，尚无证据证明NIPPV能够降低重症哮喘的气管插管率和病死率，应用NIPPV需严密监测患者生命体征变化，必要时立即行气管插管CochraneDatabaseSystRev.2005;

25(1):CD004360.102NPPV在哮喘严重急性发作中的应用存在争论，在没有禁忌证的前提下可以尝试应用（C级）治疗过程中应同时给与雾化吸入支气管舒张剂等药物治疗如果NPPV治疗后无改善，应及时气管插管进行有创机械通气102中华医学会呼吸病分会推荐意见：中华结核和呼吸杂志.

2009;

32(2):

86-98AsthmaAsthmaTheuseofNIVforlife-threateningasthmaattacks:ChangesintheneedforintubationRespirology(2010)15,

714–720103105AsthmaTheuseofNIVforlife-threateningasthmaattacks:ChangesintheneedforintubationRespirology(2010)15,

714–720105AsthmaTheuseofNIVforlife-threateningasthmaattacks:Changesinth