无创正压通气与经鼻高流量氧疗对新型冠状病毒肺炎并发ARDS患者临床疗效的影响  

Effect of noninvasive positive pressure ventilation and high-flow nasal cannula oxygen therapy on the clinical efficacy of coronavirus disease 2019 patients with acute respiratory distress syndrome

作　　者：赵志伶[1] 曹红 程秦 李楠[4] 张水生 葛庆岗[1] 沈宁[3] 杨林承[6] 史尉利 白洁[8] 孟庆阳[7] 吴超[9] 王奔 李秋钰 么改琦[1] Zhao Zhiling;Cao Hong;Cheng Qin;Li Nan;Zhang Shuisheng;Ge Qinggang;Shen Ning;Yang Lincheng;Shi Weili;Bai Jie;Meng Qingyang;Wu Chao;Wang Ben;Li Qiuyu;Yao Gaiqi(Department of Intensive Care Unit,Peking University Third Hospital,Beijing 100191,China;Department of Geriatrics,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology,Wuhan 430030,Hubei,China;Department of Respiratory and Critical Care Medicine,Peking University Third Hospital,Beijing 100191,China;Department of Research Center of Clinical Epidemiology,Peking University Third Hospital,Beijing 100191,China;Department of General Surgery,Peking University Third Hospital,Beijing 100191,China;Department of Cardiology,Peking University Third Hospital,Beijing 100191,China;Department of Institute of Sports Medicine,Peking University Third Hospital,Beijing 100191,China;Department of Thoracic Surgery,Peking University Third Hospital,Beijing 100191,China;Department of Neurosurgery,Peking University Third Hospital,Beijing 100191,China;Department of Orthopedics,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院危重医学科,北京100191 [2]华中科技大学同济医学院附属同济医院综合科,湖北武汉430030 [3]北京大学第三医院呼吸与危重症医学科,北京100191 [4]北京大学第三医院临床流行病学研究中心,北京100191 [5]北京大学第三医院普通外科,北京100191 [6]北京大学第三医院心内科,北京100191 [7]北京大学第三医院运动医学研究所,北京100191 [8]北京大学第三医院胸外科,北京100191 [9]北京大学第三医院神经外科,北京100191 [10]北京大学第三医院骨科,北京100191

出　　处：《中华危重病急救医学》2021年第6期708-713,共6页Chinese Critical Care Medicine

基　　金：北京大学医学部交叉种子基金项目(BMU2021MX020)。

摘　　要：目的观察无创正压通气(NIPPV)和经鼻高流量氧疗(HFNC)对新型冠状病毒肺炎(新冠肺炎)并发急性呼吸窘迫综合征(ARDS)患者预后的影响。方法采用回顾性研究方法,选择2020年2月至4月作者援鄂期间在华中科技大学同济医学院附属同济医院收治的脉搏血氧饱和度/吸入氧浓度比值(SpO_(2)/FiO_(2),S/F)<235〔利用S/F比值代替氧合指数(PaO_(2)/FiO_(2))诊断ARDS〕的新冠肺炎患者。按氧疗模式不同将患者分为NIPPV组和HFNC组。收集患者的临床资料,包括:一般特征、呼吸频率(RR)、FiO_(2)、SpO_(2)、心率(HR)、平均动脉压(MAP),最初72 h S/F比值、入院/出院前/死亡前淋巴细胞计数(LYM)、淋巴细胞比例(LYM%)、白细胞计数(WBC)、通气前呼吸困难病程、发病至入院时间等,比较不同氧疗模式患者需要插管率、全因病死率、S/F比值和RR改善情况的差异。采用单因素分析和广义估计方程(GEE)方法分析影响S/F比值的危险因素。结果41例患者中男性比例较高(占68.3%,28例),中位年龄68(58-74)岁,28例有合并症(占68.3%),发生多器官功能障碍综合征(MODS)34例(占82.9%)。与HFNC组比较,NIPPV组合并症更多〔87.5%(21/24)比41.2%(7/17),P<0.05〕,LYM%更低〔5.3%(3.4%-7.8%)比10.0%(3.9%-19.7%),P<0.05〕,血液净化治疗率也更低〔0%(0/24)比29.4%(5/17),P<0.05〕。随时间延长,NIPPV组治疗2 h后S/F比值逐渐升高,RR逐渐下降;HFNC组S/F比值较基线有下降趋势,两组各时间点S/F比值比较差异均无统计学意义,而RR则较基线有上升趋势,治疗2 h NIPPV组RR明显高于HFNC组〔次/min:30(27-33)比24(21-27),P<0.05〕。NIPPV组与HFNC组需要插管率和病死率比较差异均无统计学意义〔66.7%(16/24)比70.6%(12/17),58.3%(14/24)比52.9%(9/17),均P>0.05〕。分析影响氧疗过程中S/F比值的因素显示:氧疗方式和入院时病程是影响患者S/F比值的因素〔β值分别为-15.827、1.202,95%可信区间(95%CI)分别为-29.102--2.552和0.247-2.15Objective To observe the effect of noninvasive positive pressure ventilation(NIPPV)and high-flow nasal cannula oxygen therapy(HFNC)on the prognosis of patients with coronavirus disease 2019(COVID-19)accompanied with acute respiratory distress syndrome(ARDS).Methods A retrospective study was conducted in Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology when authors worked as medical team members for treating COVID-19.COVID-19 patients with pulse oxygen saturation/fraction of inspiration oxygen(SpO_(2)/FiO_(2),S/F)ratio<235,managed by medical teams[using S/F ratio instead of oxygenation index(PaO_(2)/FiO_(2))to diagnose ARDS]from February to April 2020 were included.The patients were divided into NIPPV group and HFNC group according to their oxygen therapy modes.Clinical data of patients were collected,including general characteristics,respiratory rate(RR),fraction of FiO_(2),SpO_(2),heart rate(HR),mean arterial pressure(MAP),S/F ratio in the first 72 hours,lymphocyte count(LYM),percentage of lymphocyte(LYM%)and white blood cell count(WBC)at admission and discharge or death,the duration of dyspnea before NIPPV and HFNC,and the length from onset to admission.The differences of intubation rate,all-cause mortality,S/F ratio and RR were analyzed,and single factor analysis and generalized estimation equation(GEE)were used to analyze the risk factors affecting S/F ratio.Results Among the 41 patients,the proportion of males was high(68.3%,28 cases),the median age was 68(58-74)years old,28 cases had complications(68.3%),and 34 cases had multiple organ dysfunction syndrome(MODS,82.9%).Compared with HFNC group,the proportion of complications in NIPPV group was higher[87.5%(21/24)vs.41.2%(7/17),P<0.05],and the value of LYM%was lower[5.3%(3.4%-7.8%)vs.10.0%(3.9%-19.7%),P<0.05],the need of blood purification was also significantly lower[0%(0/24)vs.29.4%(5/17),P<0.05].The S/F ratio of NIPPV group gradually increased after 2 hours treatment and RR gradually decreased with over time,S/F ratio de

关 键 词：无创正压通气 经鼻高流量氧疗 新型冠状病毒肺炎 急性呼吸窘迫综合征 

分 类 号：R563.8[医药卫生—呼吸系统] R563.1[医药卫生—内科学]