有创无创正压通气的区别与联系

Transcription

1 无创正压通气临床应用 全军呼吸病研究所解放军总医院呼吸科解立新 1

2 Preface 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 2

3 对无创通气应用的把握 非机械通气 无创通气 有创通气 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? 3

4 Interface of NIV 4 Lancet 2009; 374:

5 Interface of NIV Desirable Characteristics of an Interface for Noninvasive Ventilation Respir Care.2013;58(6):

6 Interface of NIV J Aerosol Med. 2007;20(1):S85 S99. 6

7 Ventilator selection Considerations in the Selection of a Ventilator for NIV Respir Care.2013;58(6):

8 Ventilator selection 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 8

9 Indications and contraindications for NIV in acute care 9 Lancet 2009; 374:

10 Risk Factors of NIV Failure 10 Respir Care.2013;58(6):

11 Risk Factors of NIV Failure 11 Respir Care.2013;58(6):

12 Preface Failure risk charts for NPPV Respir Care 2007;52(5):

13 When to Transfer to the ICU ---Huddle form and checklist 13 Respir Care.2013;58(6):

14 When to Transfer to the ICU ---Huddle form and checklist Respir Care.2013;58(6):

15 临床应用 15

16 急性低氧性呼吸衰竭 16

17 Acute Hypoxemic Respiratory Failure Causes of acute hypoxemic respiratory failure and frequency of NIV failure Eur J Intern Med. 2012;23(5):

18 ARDS ARDS 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 18

19 ARDS 无创通气的时代来临了 ----Nava S. Intensive Care Med,2006,32: 对 ARDS 患者应用 NIV 应非常慎重 ----Nava S. Lancet, 2009, 374: 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 ----Nava S. Respir Care,2011,56(10):

20 ARDS 的定义 1994 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 18mmHg ALI 诊断标准 : PaO2/FiO2 300mmHg.Am J Respir Crit Care Med. 1994; 149(3 pt 1):

21 ARDS 的定义 AECC 标准 AECC 局限性 病程 : 急性起病无具体时间 ALI PaO2/FiO2 300mmHg 容易混淆 mmHg 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 PAWP PAWP 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 21

22 ARDS 的定义 : 柏林标准 急性呼吸窘迫综合征 发病时间 胸部影像学 肺水肿起因 1 周以内起病 或新发 或恶化的呼吸症状 双肺模糊影 不能完全由渗出 肺塌陷或结节来解释 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 中度 重度 200 mmhg <PaO2/FiO2 300mmHg with PPEP 5cmH2O 100 mmhg <PaO2/FiO2 200mmHg with PPEP 5cmH2O PaO2/FiO2 100mmHg with PPEP 5cmH2O JAMA. 2012;307(23):

23 ARDS Surviving Sepsis Update We suggest that noninvasive mask ventilation (NIV) be used in that minority of sepsis-induced ARDS patients in whom the benefits of NIV have been carefully considered and are thought to outweigh the risks (grade 2B). Crit Care Med 2013; 41:

24 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury 24 Zhan QY, et al. Crit Care Med. 2012;40(2):455-60

25 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury Zhan QY, et al. Crit Care Med. 2012;40(2):

26 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury Zhan QY, et al. Crit Care Med. 2012;40(2):

27 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury Kaplan-Meier estimates of the probability of the need for endotracheal intubation Zhan QY, et al. Crit Care Med. 2012;40(2):

28 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury Kaplan-Meier estimates of the probability of mortality Zhan QY, et al. Crit Care Med. 2012;40(2):

29 ARDS Early use of noninvasive positive pressure ventilation for acute lung injury Conclusions: Noninvasive positive pressure ventilation is safe for selected patients with acute lung injury However, a larger randomized trial with need for intubation and mortality as the outcomes of interest is required. Zhan QY, et al. Crit Care Med Oct 20. [Epub ahead of 29

30 ARDS A multiple-center survey on the use in clinical practice of NPPV as a first-line intervention for ARDS NPPV:79 Intubation:68 Crit Care Med. 2007; 35(1):

31 ARDS (cont) Crit Care Med. 2007; 35(1):18 25 In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients. In patients with SAPS 34, those with a PaO2/FIO2 175 after 1 hr of NPPV will likely benefit from continuation of NPPV 31

32 ARDS (cont) Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study 32 Critical Care 2006, 10:R79

33 ARDS (cont) Failure of non-invasive ventilation in patients with acute lung injury: observational cohort 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 Critical Care 2006, 10:R79 33

34 ARDS (cont) Benefits and risks of success or failure of NIV De novo: mainly ALI/ARDS patients de novo:without previous cardiac or respiratory disease Intensive Care Med (2006) 32:

35 ARDS (cont) Benefits and risks of success or failure of NIV NIV failure was associated with ICU mortality in the de novo group (OR 3.24, CI ) Intensive Care Med (2006) 32:

36 ARDS Role of NIV in ARDS Practical Approach to the Use of NIV in Patients With ARDS Respir Care 2010;55(12):

37 ARDS Role of NIV in ARDS Practical Approach to the Use of NIV in Patients With ARDS Respir Care 2010;55(12):

38 ARDS Predictors of failure of noninvasive ventilation Higher severity score (SAPS II 35>34) Older age (>40 years) Presence of ARDS or CAP Failure to improve after 1 h of treatment(pao2 : FiO Curr Opin Crit Care 2012, 18:

39 ARDS Criteria used for NIV discontinuation and endotracheal intubation Failure to maintain a PaO 2 >65mmHg with an FIO 2 : 0.6 Development of conditions necessitating ETI to protect the airways (coma or seizure disorders) or to manage copious tracheal secretions Persistent dyspnea, tachypnea, or use of accessory respiratory muscles Appearance of hemodynamic or electrocardiographic instability Inability to tolerate the interface Curr Opin Crit Care 2012, 18:

40 Severe Pneumonia Clinical features and risk factors for severe and critical pregnant women with 2009 pandemic H1N1 influenza infection in China BMC Infectious Diseases 2012, 12:29 40

41 Severe Pneumonia NIV in CAP and severe ARF de novo:without previous cardiac or respiratory disease Intensive Care Med (2012) 38:

42 Severe Pneumonia NIV in CAP and severe ARF Intensive Care Med (2012) 38:

43 Severe Pneumonia NIV in CAP and severe ARF By contrast, no relationship was found between duration of NIV before intubation and mortality in patients with previous cardiac or respiratory disease Intensive Care Med (2012) 38:

44 Severe Pneumonia NIV in CAP and severe ARF Conclusions: Successful NIV was strongly associated with better survival If predictors for NIV failure are present, avoiding delayed intubation of patients with de novo ARF would potentially minimise mortality Intensive Care Med (2012) 38:

45 Severe Pneumonia NIV in CAP and severe ARF 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 Intensive Care Med (2012) 38:

46 Acute Cardiogenic pulmonary edema(acpe) Heart. 2013;0:359:

47 Acute Cardiogenic pulmonary edema(acpe) Heart. 2013;0:359:

48 Acute Cardiogenic pulmonary edema(acpe) Heart. 2013;0:359:

49 Acute Cardiogenic pulmonary 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 (Grade B) 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. 2006;367: Thorax. 2002; 57:

50 NIV in ACPE Meta-analysis: NIV in ACPE (limited evidence) Compared with standard therapy, CPAP reduced mortality (RR:0.64) and need for intubation (RR:0.44 ) but not incidence of new MI (RR:1.07 ) The effect was more prominent in trials in which myocardial ischemia or infarction caused ACPE in higher proportions of patients (RR:0.92) Bilevel ventilation reduced the need for intubation (RR, 0.54) but did not reduce mortality or new MI No differences were detected between CPAP and bilevel ventilation on any clinical outcomes for which they were directly compared Weng CL, et al. Ann Intern Med. 2010;152:

51 NIV in ACPE Meta-analysis: NIV in ACPE (2011) Results: At total of 34 studies (3,041 patients) were included. In direct comparisons, both CPAP and NIPPV reduced the risk of death (RR 0.64, 95%CI ; RR 0.80, 95%CI ; respectively) compared with ST, although only CPAP had a significant effect. There were no significant differences between NIPPV and CPAP. Compared with ST, both CPAP and NIPPV significantly reduced mortality (RR 0.63, 95% CI ; RR 0.73, 95% CI ; respectively). Conclusions: Our findings suggest that among ACPE patients, NIV delivered through either NIPPV or CPAP reduced mortality. 51 J Cardiac Fail 2011;17:850e859

52 Cardiogenic pulmonary edema (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: Crit Care Med.2007; 35(10):

53 Cardiogenic pulmonary edema (cont) Noninvasive Ventilation in Pulmonary Edema Complicating Acute Myocardial Infarction Circ J. 2012; 76:

54 Cardiogenic pulmonary edema (cont) Noninvasive Ventilation in Pulmonary Edema Complicating Acute Myocardial Infarction Circ J. 2012; 76:

55 Cardiogenic pulmonary edema (cont) Noninvasive Ventilation in Pulmonary Edema Complicating Acute Myocardial Infarction Conclusions: NIV effectively improved vital signs and oxygenation and lowered the intubation rate in patients with cardiogenic pulmonary edema of all etiologies, including AMI The outcome in patients with AMI treated with NIV depends primarily on the severity of the course of AMI and not on the severity of acute respiratory failure Circ J. 2012; 76:

56 Cardiogenic pulmonary edema (cont) Heart. 2013;0:359:

57 Cardiogenic pulmonary edema (cont) 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 57

58 NIV for Pulmonary Fibrosis Patients Why Do Patients With ILD Fail in the ICU? Respir Care 2013;58(3):

59 NIV for Pulmonary Fibrosis Patients Why Do Patients With ILD Fail in the ICU? 病死率 : 81.5% 95.2% Respir Care 2013;58(3):

60 NIV for Pulmonary Fibrosis Patients Why Do Patients With ILD Fail in the ICU? Respir Care 2013;58(3):

61 NIV for Pulmonary Fibrosis Patients Why Do Patients With ILD Fail in the ICU? Risk factors for NIV failure of ILD in the ICU: APACHE II score>20 (hazard ratio 2.77, 95% CI , P<0.02) continuous NIV demand (hazard ratio 5.12, 95% CI , P<0.01) Respir Care 2013;58(3):

62 Predominantly immunocompetent patients Predictors of failure of noninvasive ventilation in hypoxemic patients Curr Opin Crit Care 2012, 18:

63 Predominantly immunocompetent patients Criteria used for noninvasive ventilation discontinuation and endotracheal intubation in hypoxemic patients Curr Opin Crit Care 2012, 18:

64 Definition 什么是免疫功能低下 : Denoting a person with an immunologic mechanism deficient either because of an immunodeficiency disorder or because it has been so rendered by immunosuppressive 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 ) 64

65 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 ) PTLD:Post-transplant lymphoproliferative disease 65

66 Noninfectious Complications Curr Opin Oncol 2008;20:

67 Noninfectious Complications Engraftment syndrome Idiopathic pneumonia syndrome Diffuse alveolar hemorrhage AJR 2005;184:

68 Immunosuppressed 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 Eur Respir J. 2003; 22: Suppl 47, 31s 37s Intensive Care Med. 2006; 32:

69 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies Crit Care Med 2011; 39:

70 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies Crit Care Med 2011; 39:

71 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies Crit Care Med 2011; 39:

72 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies Severe sepsis and septic shock occurring after intensive care unit admission 72 Crit Care Med 2011; 39:

73 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies 73 Crit Care Med 2011; 39:

74 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies 74 Crit Care Med 2011; 39:

75 Immunosuppressed diseases NIV versus IMV for ARF in patients with hematologic malignancies Conclusions: In patients with hematologic malignancies, acute respiratory failure should probably be managed initially with noninvasive mechanical ventilation Further study is needed to determine whether immediate invasive mechanical ventilation might offer some benefits for those with acute lung injury/adult respiratory distress syndrome 75 Crit Care Med 2011; 39:

76 Immunosuppressed diseases NIV in immunosuppressed patients with pneumonia and extrapulmonary sepsis Respir Med. 2012; 106(11)

77 Immunosuppressed diseases NIV in immunosuppressed patients with pneumonia and extrapulmonary sepsis Respir Med. 2012; 106(11)

78 Immunosuppressed diseases NIV in immunosuppressed patients with pneumonia and extrapulmonary sepsis Respir Med. 2012; 106(11)

79 Immunosuppressed diseases Predictors of failure of noninvasive ventilation in hypoxemic patients Curr Opin Crit Care 2012, 18:

80 Immunosuppressed diseases Criteria used for noninvasive ventilation discontinuation and endotracheal intubation in hypoxemic patients Curr Opin Crit Care 2012, 18:

81 合并高碳酸血症的 急性呼吸衰竭 81

82 Is it Right? Noninvasive Ventilation for Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Don t Think Twice, It s Alright! Elliott MW. Am J Respir Crit Care Med ;185(2):

83 AECOPD Use of Noninvasive Ventilation in Patients with ARF, NIV population during a hospitalization with an ARF claim increased in patients with COPD from 8.6 to 39 per 100,000 United States residents (360% increase), and NIV use in patients without COPD increased from 6 to 39 patients per 100,000 United States residents during the years 2000 to 2009 (560% increase); 83 Ann Am Thorac Soc. 2013; 10(1):10 17

84 AECOPD 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 (Grade A) 84 GOLD 2010

85 Invasive ventilation rate (%) AECOPD Intubation rate Early use NIPPV vs. Control % p= % 5 0 NIPPV Control Chin Med J. 2005;118(24):

86 AECOPD Contemporary Management of AECOPD: A meta analysis In the 12 controlled randomized trials (959 patients), NPPV reduced the need for intubation by 65% Effects of NPPV on the risk of intubation 86 Chest 2008;133;

87 AECOPD Contemporary Management of AECOPD: A meta analysis In the 11 controlled randomized trials (940 patients), NPPV reduced the in-hospital mortality rate by 55% Effects of NPPV on the risk of in-hospital mortality 87 Chest 2008;133;

88 AECOPD NPPV 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 88

89 AECOPD COPD 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 89

90 AECOPD (cont) Sequential invasive to noninvasive ventilation in COPD Group Cases IMV stays (Days) IMV+NIV Stays (days) VAP cases Dead cases ICU stays (Days) IMV-NIV ± ± ±8 Control ± ± ±11 p value Pulmonary infection control window 中华结核和呼吸杂志. 2006; 29:

91 AECOPD (cont) Use of NIV to wean critically ill adults off invasive ventilation: meta-analysis and systematic review 91 BMJ May 21;338:b1574

92 AECOPD (cont) Use of NIV to wean critically ill adults off invasive ventilation: meta-analysis and systematic review Conclusions: Current trials in critically ill adults show a consistent positive effect of non-invasive weaning on mortality and ventilator associated pneumonia, though the net clinical benefits remain to be fully elucidated. Non-invasive ventilation should preferentially be used in patients with chronic obstructive pulmonary disease in a highly monitored environment. 92 BMJ May 21;338:b1574

93 AECOPD 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 ] 中华急诊医学杂志.2007;16 (4 ):

94 AECOPD 中华医学会呼吸病分会推荐意见 : NPPV 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, PaCO 2 >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):

95 AECOPD 中华医学会呼吸病分会推荐意见 : 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 ) 95 中华结核和呼吸杂志. 2009; 32(2): 86-98

96 AECOPD GOLD

97 AECOPD GOLD

98 AECOPD GOLD

99 Asthma Changing etiologies of acute respiratory failure among patientsreceiving noninvasive ventilation, 2000 versus Ann Am Thorac Soc. 2013; 10(1):10 17

100 Asthma Failure of NIV among patients without COPD compared with patients with COPD 100 Ann Am Thorac Soc. 2013; 10(1):10 17

101 Asthma 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 Cochrane Database Syst Rev. 2005; 25(1):CD

102 Asthma 中华医学会呼吸病分会推荐意见 : NPPV 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 中华结核和呼吸杂志. 2009; 32(2):

103 Asthma The use of NIV for life-threatening asthma attacks: Changes in the need for intubation Respirology (2010) 15,

104 Asthma The use of NIV for life-threatening asthma attacks: Changes in the need for intubation 104 Respirology (2010) 15,

105 Asthma The use of NIV for life-threatening asthma attacks: Changes in the need for intubation Conclusions: The need for ETI in patients with severe attacks of asthma was decreased after introduction of NIV. The ready availability of NIV enabled the rapid commencement of MV and may decrease the need for ETI. NIV is an acceptable and useful method of stabilizing patients experiencing severe attacks of asthma. 105 Respirology (2010) 15,

106 Asthma The use of NIV for life-threatening asthma attacks: Changes in the need for intubation Conclusions: The need for ETI in patients with severe attacks of asthma was decreased after introduction of NIV The ready availability of NIV enabled the rapid commencement of MV and may decrease the need for ETI NIV is an acceptable and useful method of stabilizing patients experiencing severe attacks of asthma 106 Respirology (2010) 15,

107 Asthma 重症支气管哮喘应用有创的标准与 COPD 比较应从严 ph<7.25, Glsgow<11, PaO2/FiO2<150 应作为应用有创机械通气的标准 呼吸频数 不适用面罩 情绪波动 矛盾呼吸 咳痰无力等应考虑 IMV 如果 NIV 治疗 2 小时没有明显缓解, 或有加重, 建议有创机械通气 应用 NIV 期间应严密监测, 如有病情恶化应及时气管插管 IMV 107 Respirology (2010) 15,

108 A Question Hypercapnic encephalopathy syndrome: A new frontier for non-invasive ventilation? -----Scala R. Respiratory Medicine (2011) 105,

109 NIV for Hypercapnic Encephalopathy Syndrome Hypercapnic encephalopathy syndrome (HES) is a heterogeneous and potentially reversible wide spectrum of neurological alterations (from cognitive defects, psychomotor agitation and confusion with asterixis to soporous status, delirium and coma) occurring in the presence of acute respiratory failure (ARF) with severe decompensated respiratory hypercapnic acidosis Respir Med. (2011) 105, 1109e

110 NIV for Hypercapnic Encephalopathy Syndrome Respir Med. (2011) 105, 1109e

111 NIV for Hypercapnic Encephalopathy Syndrome Respir Med. (2011) 105, 1109e

112 NIV for Hypercapnic Encephalopathy Syndrome Respir Med. (2011) 105, 1109e

113 Conclusion 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):

114 Conclusion NPPV 是治疗呼吸衰竭的重要有效手段 在 NPPV 治疗中应严密监测患者的生命体征, 如病情恶化应立即气管插管进行有创机械通气 NPPV 的实施应需要 : 有一个训练有素和富有临床经验的专业团队 对适应证的选择应慎重, 有丰富应用经验的可适当放宽 NPPV 的最终目的是应能促进患者病情的好转 114 Crit Care Med.2007; 35(10):

115 115

116 THANK YOU 116