AECOPD致严重呼吸衰竭患者早期拔管后序贯经鼻高流量湿化氧疗与无创正压通气的优劣比较  

Comparative study on pros and cons of sequential high-flow nasal cannula and non-invasive positive pressure ventilation immediately following early extubated patients with severe respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease

作　　者：方国强 万秋风 田雅洁 贾文婷 罗茜 杨婷[1] 史玉娇 谷兴丽 徐思成[1] Fang Guoqiang;Wan Qiufeng;Tian Yajie;Jia Wenting;Luo Xi;Yang Ting;Shi Yujiao;Gu Xingli;Xu Sicheng(RICU,Respiratory and Critical Care Medical Center,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,Xinjiang Uygur Autonomous Region,China)

机构地区：[1]新疆医科大学第一附属医院呼吸与危重症医学中心RICU,乌鲁木齐830054

出　　处：《中华危重病急救医学》2021年第10期1215-1220,共6页Chinese Critical Care Medicine

基　　金：国家自然科学基金(81660005)。

摘　　要：目的比较经鼻高流量湿化氧疗(HFNC)与无创正压通气(NIPPV)在慢性阻塞性肺疾病急性加重(AECOPD)致严重呼吸衰竭(SRF)患者早期拔管后序贯治疗中的优劣,为临床选择优化方案提供依据。方法选择2019年1月至2020年9月新疆医科大学第一附属医院呼吸重症监护病房(RICU)连续入院的年龄40~85岁、以支气管肺部感染为急性加重原因且初始呼吸支持方式为气管插管机械通气(ETI-MV)的AECOPD致SRF患者作为研究对象。通气模式为同步间歇指令通气(SIMV),参数设置为潮气量(VT)8 mL/kg、支持压力10~15 cmH_(2)O(1 cmH_(2)O=0.098 kPa)、呼气末正压(PEEP)4~6 cmH_(2)O、吸气与呼气时间比为1.5~2.5∶1、平台压(Pplat)<30 cmH_(2)O,使用最小吸入氧浓度,保持脉搏血氧饱和度≥0.92。当患者肺部感染控制窗(PIC窗)出现后拔管,并随机分为两组,一组序贯HFNC治疗(HFNC组),另一组序贯NIPPV治疗(NIPPV组)。序贯HFNC或NIPPV失败的患者接受再次气管插管(ETI)。比较两组出窗后拔管7 d内再插管率、并发症(鼻面部压伤、胃胀气等)发生率、住院病死率、出窗时ETI时间、RICU住院时间及总住院时间等。结果最终有44例患者纳入研究,其中HFNC组20例,NIPPV组24例。HFNC组与NIPPV组出窗时ETI时间差异无统计学意义(h:95.9±13.1比91.8±20.4,P>0.05)。HFNC组患者7 d内再插管率显著高于NIPPV组〔35.0%(7/20)比4.2%(1/24),P<0.05〕,但并发症发生率明显低于NIPPV组〔0%(0/20)比25.0%(6/24),P<0.05〕。与NIPPV组比较,HFNC组患者住院病死率稍高〔5.0%(1/20)比4.2%(1/24)〕,RICU住院时间稍长(d:19.5±10.8比15.5±7.2),总住院时间也稍长(d:27.4±12.2比23.3±10.9),但差异均无统计学意义(均P>0.05)。结论AECOPD致SRF患者早期拔管后序贯HFNC治疗的依从性增高,并发症明显减少,但是最终疗效可能劣于NIPPV。Objective To explore the pros and cons of sequential high-flow nasal cannula(HFNC)and non-invasive positive pressure ventilation(NIPPV)immediately following early extubated patients with severe respiratory failure(SRF)due to acute exacerbations of chronic obstructive pulmonary disease(AECOPD),so as to provide evidence for clinical selection of optimal scheme.Methods Consecutive AECOPD patients admitted to the respiratory intensive care unit(RICU)of the First Affiliated Hospital of Xinjiang Medical University from January 2019 to September 2020 were screened for enrollment.Patients were between 40 years old and 85 years old with acute exacerbation of bronchial-pulmonary infection,who received endotracheal intubation mechanical ventilation(ETI-MV)as the initial respiratory support method.The pattern of synchronous intermittent mandatory ventilation(SIMV)was used in the study.The parameters were set as follows:tidal volume(VT)8 mL/kg,support pressure 10-15 cmH_(2)O(1 cmH_(2)O=0.098 kPa),positive end-expiratory pressure(PEEP)4-6 cmH_(2)O and the ratio of inspiratory to expiratory time 1.5-2.5∶1.Under these conditions,the plateau pressure(Pplat)was maintained less than 30 cmH_(2)O.The minimum fraction of inspired oxygen was adjusted to keep the pulse oxygen saturation no less than 0.92.When the pulmonary infection control window(PIC window)occurred,the subjects were extubated immediately and randomly divided into two groups,with one group receiving HFNC(called HFNC group),the other group receiving NIPPV(called NIPPV group).Patients with failed sequential HFNC or NIPPV underwent tracheal re-intubation.The rate of tracheal re-intubation within 7 days of extubation,complications(such as nose and face crush injury and gastric distension),in-hospital mortality,duration of ETI before PIC window,length of RICU stay and length of hospital stay were compared,respectively.Results Forty-four patients were enrolled in the study,20 in the HFNC group and 24 in the NIPPV group.There was no significant difference in the duration of

关 键 词：慢性阻塞性肺疾病 呼吸衰竭 拔管后 经鼻高流量湿化氧疗 无创正压通气 

分 类 号：R563.9[医药卫生—呼吸系统]