无创正压通气（蔡洪流.ppt

浙江大学医学院附属第一医院 ICU 蔡洪流,无创正压通气,Noninvasive Positive Pressure Ventilation NPPV,无创正压通气,NPPV概述 NPPV的优势与不足 NPPV适应证、禁忌证及并发症 NPPV的实施,机械通气,正压通气 负压通气,机械通气,机械通气,有创机械通气 无创机械通气 正压通气 负压通气 高频通气,无创正压通气,定义 采用非气管插管或气管切开方法而提供正压通气支持的技术。,International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Organized Jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Socit de Ranimation de Langue Franaise, and approved by the ATS Board of Directors, December 2000,Am. J. Respir. Crit. Care Med. 2001; 163: 283-291,NPPV,NPPV,NPPV was defined as any form of ventilatory support applied without the use of an endotracheal tube, and was considered to include continuous positive airway pressure (CPAP), with or without inspiratory pressure support; volume- and pressure-cycled systems, propotional assist ventilation (PAV), and adjuncts such as the use of helium-oxygen (heliox) gas mixture.,Am. J. Respir. Crit. Care Med. 2001; 163: 283-291,NPPV,正压通气的主要目的,改善氧合和肺泡通气 降低呼吸作功，缓解呼吸困难,适当选择适应证，上述目标通过NPPV同样可以达到，而且NPPV可以有效避免与气管插管/气管切开相关的并发症。,NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是,NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是 相互补充,NPPV的优点（1）,病人痛苦小，易接受,NPPV的优点（2）,减少气管插管/气管切开相关并发症 上呼吸道正常屏障功能的破坏 上呼吸道损伤 院内感染（VAP）,NPPV的优点（3）,镇静剂用量减少 保持病人清醒、增加活动和交流、减少心理问题。 增加自主吸气努力，促进静脉回流 保持咳嗽能力，促进排痰，减少肺不张，改善通气/血流比。 减少对其他脏器功能的影响，避免镇静剂掩盖其他并发症。,NPPV的优点（4）,保持气道防御反应，允许咳嗽、咳痰,NPPV的优点（5）,允许讲话及吞咽,NPPV的优点（6）,使用方便、灵活,NPPV的不足,需要病人清醒配合 不利于气道分泌物的引流 不能完全替代气管插管/气管切 开，通气效果不十分确切 NPPV相关并发症,NPPV与有创正压通气的比较,NPPV的适应证,急性呼吸功能衰竭 慢性呼吸功能衰竭,Acute applications of noninvasive positive pressure ventilation,Chest. 2003 Aug;124(2):699-713,Acute applications of NPPV,Chest. 2003 Aug;124(2):699-713,Acute applications of NPPV,Type of Evidence Strong ( multiple controlled trials ) Less strong (single controlled trial or multiple case series) Weak (few case series or case reports),Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型 强（多个对照研究） 次强（单个对照研究或多个病例系列） 弱（病例系列或病例报告）,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：强 COPD急性加重,Chest. 2003 Aug;124(2):699-713,COPD急性加重时NPPV应用指征 中重度气促伴有使用辅助呼吸肌或反常呼吸 轻中度酸中毒（PH7.307.35）和高碳酸血症（PaCO24560mmHg) RR25次/分,COPD国际防治指南,BTS GUIDELINE Non-invasive ventilation in acute respiratory failure British Thoracic Society Standards of Care Committee,Thorax. 2002 Mar;57(3):192-211,NIV has been shown to be an effective treatment for acute hypercapnic respiratory failure (AHRF), particularly in chronic obstructive pulmonary disease (COPD). Facilities for NIV should be available 24 hours per day in all hospitals likely to admit such patients. A,Thorax. 2002 Mar;57(3):192-211,NIV should be considered in patients with an acute exacerbation of COPD in whom a respiratory acidosis (pH 45 nmol/l) persists despite maximum medical treatment on controlled oxygen therapy. A,Thorax. 2002 Mar;57(3):192-211,Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature,Ann Intern Med. 2003 Jun 3;138(11):861-70,DATA SOURCES: MEDLINE (1966 to 2002) EMBASE (1990 to 2002).,Ann Intern Med. 2003 Jun 3;138(11):861-70,Additional data sources included Cochrane Library personal files abstract proceedings reference lists of selected articles expert contact,Ann Intern Med. 2003 Jun 3;138(11):861-70,Ann Intern Med. 2003 Jun 3;138(11):861-70,结果显示COPD急性发作患者在标准治疗基础上加用NPPV： 气管插管风险下降28% ，95%可信区间1540% 住院时间下降4.57天，95%可信区间2.306.83天 住院死亡率下降10%，95%可信区间515%,Ann Intern Med. 2003 Jun 3;138(11):861-70,severe COPD exacerbations Baseline PH7.30 or An in-hospital mortality rate of greater than 10% in the control group,分组结果显示COPD严重急性发作患者在标准治疗基础上加用NPPV： 气管插管风险下降34% ，95%可信区间2246% 住院时间下降5.59天，95%可信区间3.667.52天 住院死亡率下降12%，95%可信区间618%,Ann Intern Med. 2003 Jun 3;138(11):861-70,分组结果显示COPD非严重急性发作患者在标准治疗基础上加用NPPV： 气管插管风险下降0% ，95%可信区间1111% 住院时间下降0.82天，95%可信区间0.121.77天 住院死亡率下降2%，95%可信区间812%,Ann Intern Med. 2003 Jun 3;138(11):861-70,CONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.,Ann Intern Med. 2003 Jun 3;138(11):861-70,NPPV在急性呼衰中的应用,证据类型：强 急性心原性肺水肿,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,Pending further studies, the most sensible recommendation is to use CPAP(10 cm H2O) initially and to consider switching to NPPV if the patient is found to have substantial hypercapnia or unrelenting dyspnea.,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,This recommendation is in line with the conclusion of a meta-analysis that found insufficient evidence to support the use of NPPV in preference to CPAP to treat patients with acute pulmonary edema.,Chest. 2003 Aug;124(2):699-713,Continuous positive airway pressure (CPAP) has been shown to be effective in patients with cardiogenic pulmonary oedema who remain hypoxic despite maximal medical treatment. NIV should be reserved for patients in whom CPAP is unsuccessful. B,Thorax. 2002 Mar;57(3):192-211,NPPV在急性呼衰中的应用,证据类型：强 免疫抑制病人,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,Thus, the avoidance of intubation in this patient population is a desirable outcome, and the use of NPPV is, therefore, justifiable in selected patients with immunocompromised states.,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,It is important to note, however, that the authors of these studies stress the importance of early initiation of therapy before progression to severe compromise.,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：强 帮助COPD病人撤机,Chest. 2003 Aug;124(2):699-713,Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure,Cochrane Database Syst Rev. 2003;(4):CD004127,随机对照研究： Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 2, 2003) MEDLINE (January 1966 to July 2003) EMBASE (January 1980 to July 2003),Cochrane Database Syst Rev. 2003;(4):CD004127,入选5个研究，包括171名患者。以COPD患者为主 NPPV strategy IPPV strategy,Cochrane Database Syst Rev. 2003;(4):CD004127,NPPV组较IPPV组 降低死亡率 RR 0.41, 95% CI 0.22 to 0.76 降低VAP发生率 RR 0.28, 95% CI 0.09 to 0.85,Cochrane Database Syst Rev. 2003;(4):CD004127,NPPV组较IPPV组 缩短住ICU时间 - 6.88 days, 95% CI -12.60 to -1.15 缩短住院时间 - 7.33 days, 95%CI -14.05 to -0.61,Cochrane Database Syst Rev. 2003;(4):CD004127,NPPV组较IPPV组 缩短总机械通气时间 -7.33 days, 95% CI -11.45 to -3.22 缩短气管插管时间 -6.79 days, 95% CI -11.70 to -1.87,Cochrane Database Syst Rev. 2003;(4):CD004127,NPPV在急性呼衰中的应用,证据类型：次强 哮喘,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：次强 囊性纤维化,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：次强 术后呼吸衰竭,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：次强 避免拔管失败,Chest. 2003 Aug;124(2):699-713,Noninvasive positive-pressure ventilation for respiratory failure after extubation,N Engl J Med. 2004 Jun 10;350(24):2452-60,8个国家 :阿根廷、巴西、哥伦比亚、沙特阿拉伯、西班牙、美国、委内瑞拉等 37个医疗中心,N Engl J Med. 2004 Jun 10;350(24):2452-60,上机48小时以上，选择性拔管后48小时内发生呼吸衰竭的221名患者随机分为 经面罩NPPV组 （n=114 ） 常规内科治疗组（n=107 ）,N Engl J Med. 2004 Jun 10;350(24):2452-60,N Engl J Med. 2004 Jun 10;350(24):2452-60,N Engl J Med. 2004 Jun 10;350(24):2452-60,再插管比例 经面罩NPPV组 55/114（48%） 常规内科治疗组 51/107（48%） relative risk 0.99 95%可信区间 0.751.30,N Engl J Med. 2004 Jun 10;350(24):2452-60,ICU死亡率 经面罩NPPV组 28/114（25%） 常规内科治疗组 15/107（14%） relative risk 1.78 95%可信区间 1.033.20；P = 0.048,N Engl J Med. 2004 Jun 10;350(24):2452-60,CONCLUSIONS: Noninvasive positive-pressure ventilation does not prevent the need for reintubation or reduce mortality in unselected patients who have respiratory failure after extubation,N Engl J Med. 2004 Jun 10;350(24):2452-60,NPPV在急性呼衰中的应用,证据类型：次强 DNI（Do-Not-Intubate）患者,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：弱 上呼吸道堵塞,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：弱 ARDS,Chest. 2003 Aug;124(2):699-713,Mechanical ventilation in sepsis-induced acute lung injury/acute respiratory distress syndrome: an evidence-based review,Crit Care Med. 2004 Nov;32(11 Suppl):S548-53,Role of noninvasive positive-pressure ventilation in acute lung injury/ARDS is undefined,Crit Care Med. 2004 Nov;32(11 Suppl):S548-53,NPPV在急性呼衰中的应用,证据类型：弱 外伤,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：弱 阻塞性睡眠呼吸暂停，肥胖性低通气,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,SARS（Severe Acute Respiratory Syndrome ）,NPPV在急性呼衰中的应用,证据类型：强 COPD急性加重 急性心原性肺水肿 免疫抑制病人 帮助COPD病人撤机,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：次强 哮喘 囊性纤维化 术后呼吸衰竭 避免拔管失败 DNI（Do-Not-Intubate）患者,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型：弱 上呼吸道堵塞 ARDS 外伤 阻塞性睡眠呼吸暂停，肥胖性低通气,Chest. 2003 Aug;124(2):699-713,NPPV在急性呼吸衰竭中应用的病理生理指征（1）,急性呼吸窘迫的症状和体征 中重度呼吸困难或呼吸困难程度较平时严重 和 RR24次/分，使用辅助呼吸肌，出现矛盾呼吸,Mehta S. Am J Respir Crit Care Med 2001;163(2):540-77,气体交换异常 PaCO245mmHg，PH7.35 或 PaO2/FiO2 200 无NPPV禁忌证,NPPV在急性呼吸衰竭中应用的病理生理指征（2）,Mehta S. Am J Respir Crit Care Med 2001;163(2):540-77,NPPV治疗成功的急性呼吸衰竭患者的临床特点（1）,年龄较小 病情较轻（APACHE评分低） 能配合治疗，神志较好 自主呼吸能与呼吸机配合 面罩漏气少，牙齿完整,Mehta S. Am J Respir Crit Care Med 2001;163(2):540-77,不十分严重的CO2潴留（PaCO2 4592mmHg） 不十分严重的酸中毒（PH 7.107.35） 通气后最初2小时内气体交换、心率、呼吸频率改善,NPPV治疗成功的急性呼吸衰竭患者的临床特点（2）,Mehta S. Am J Respir Crit Care Med 2001;163(2):540-77,NPPV在慢性呼吸功能衰竭的适应证,胸廓限制性疾病 神经肌肉疾病 慢性阻塞性肺部疾病 夜间低通气综合征,Chest. 1999;116:521-534,A meta-analysis of nocturnal noninvasive positive pressure ventilation in patients with stable COPD,Chest. 2003 Jul;124(1):337-43,Conclusions: This meta-analysis of 3 months of NIPPV in patients with stable COPD showed that ventilatory support did not improve lung function, gas exchange, or sleep efficiency.,Chest. 2003 Jul;124(1):337-43,The high upper limit of the confidence interval for the 6MWD suggested that some people do improve their walking distance. The small overall sample size precluded a clear clinical direction regarding the effects of NIPPV in patients with COPD.,Chest. 2003 Jul;124(1):337-43,缓慢进展的呼吸衰竭 上呼吸道功能完整 气道分泌物少 清醒合作病人,慢性呼衰使用NPPV的入选标准,NPPV的禁忌症,绝对禁忌症 相对禁忌症,中华结核和呼吸杂志.2002,25(3):130-134,心跳呼吸停止 自主呼吸微弱、昏迷 误吸可能性高,中华结核和呼吸杂志.2002,25(3):130-134,NPPV的绝对禁忌症 （1）,合并其它脏器功能衰竭（血流动力学不稳定、消化道大出血/穿孔、严重脑部疾病等） 面部创伤/术后/畸形 不合作,中华结核和呼吸杂志.2002,25(3):130-134,NPPV的绝对禁忌症 （2）,NPPV的相对禁忌证（1）,气道分泌物多/排痰障碍 严重感染 极度紧张 严重低氧血症(PaO245mmHg)/严重酸中毒(pH7.20),中华结核和呼吸杂志.2002,25(3):130-134,NPPV的相对禁忌证（2）,近期上腹部手术后（尤其是需要严格胃肠减压者） 严重肥胖 上气道机械性阻塞,中华结核和呼吸杂志.2002,25(3):130-134,Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failure,Chest. 2005 Mar;127(3):952-60,RESULTS: A total of 76 coma patients (80%) responded to NPPV therapy, and 605 patients with GCS scores 8 responded to therapy (70%; p = 0.04). A total of 25 coma patients died in the hospital (26.3%), and 287 noncoma patients died in the hospital (33.2%; p = 0.17).,Chest. 2005 Mar;127(3):952-60,The variables related to the success of NPPV therapy were GCS score 1 h posttherapy (odds ratio OR, 2.32; 95% confidence interval CI, 1.53 to 3.53) and higher levels of multiorgan dysfunction, as measured by the maximum sequential organ failure assessment index score reached during NPPV therapy (OR, 0.72; 95% CI, 0.55 to 0.92).,Chest. 2005 Mar;127(3):952-60,CONCLUSIONS: We concluded that selected patients with hypercapnic coma secondary to ARF can be treated as successfully with NPPV as awake patients with ARF,Chest. 2005 Mar;127(3):952-60,NPPV的并发症,面/鼻罩相关并发症 正压通气相关并发症,面/鼻罩相关并发症（1）,面/鼻罩周围漏气,局部压迫皮肤损伤,面/鼻罩相关并发症（2）,吞气症，引起胃肠胀气并可引起呕吐、误吸 排痰障碍 鼻腔、口咽部 、眼部干燥刺激,面/鼻罩相关并发症（3）,面/鼻罩相关并发症（4）,恐惧（幽闭恐怖症） 睡眠性上呼吸道阻塞,正压通气相关并发症,通气机所致肺损伤（VILI） 肺泡外气体 系统性气体栓塞 弥漫性肺水肿 氧中毒 静脉回流障碍、影响心输出量,病人选择,选择需要通气支持的病人（排除可以单独采用常规治疗的病人） 排除不适合 NPPV治疗和需立即气管插管的病人 病人具有上呼吸道防御功能是重要条件之一,NPPV临床应用策略,有效,积极的常规治疗,NPPV,有创正压通气,常规撤机,NPPV辅助撤机,继续使用,无效,12h后如无改善 （PaCO2下降16%，pH 7.30，PaO240mmHg）,NPPV疗效评价（1）,气促改善 辅助呼吸肌肉动用减轻和反常呼吸消失 呼吸频率减慢 SaO2增加 心率减慢,Mehta S. Am J Respir Crit Care Med 2001;163(2):540-77,NPPV疗效评价（2）,初始治疗有效 12h后临床情况改善 血气分析 PaCO2下降16% pH 7.30 PaO240mmHg,Am. J. Respir. Crit. Care Med. 2001; 163: 283-291,NPPV不易成功的因素（1）,严重的呼吸衰竭 严重的肺炎 气道分泌物多 排痰能力差,中华结核和呼吸杂志.2002,25(3):130-134,NPPV不易成功的因素（2）,患者不合作 严重酸血症（pH7.20） 急性生理学慢性健康（APACHE）评分15 治疗12 h后效果不明显,中华结核和呼吸杂志.2002,25(3):130-134,NPPV临床应用策略,无创-有创-无创序贯治疗,NPPV通气机的选择,ICU通气机 NPPV专用通气机,氧浓度精确可调 吸气管和呼气管分开，减少管路死腔，减少 CO2重吸收 吸气流速加速快 监测报警功能完善,ICU通气机用于NPPV的优点,体积小，重量轻，操作简单，价格便宜 不需高压空气，可用低压供氧,NPPV专用通气机的优点(1),NPPV专用通气机的优点(2),识别并精确补偿可能存在的漏气 维持触发灵敏度，保持理想的同步状态 在有大量漏气的情况下保持预设压力,NPPV专用通气机的优点(3),特殊设计的智能灵敏度控制系统,BiPAP通气机主要模式,S 同步 S/T 同步/时间 T 时间控制,BiPAP （Bi-level Positive Airway Pressure）,IPAP （Inspiratory Positive Airway Pressure） 与PS类似 EPAP （Expiratory Positive Airway Pressure） 与CPAP类似,IPAP的作用,降低吸气作功 增大潮气量,EPAP的作用（1）,减少肺内分流，改善通气/血流比 增加功能残气量 改善顽固性低氧,EPAP的作用（2）,对抗 AutoPEEP,EPAP的作用（）,改善肺顺应性 降低气道阻力 保护肺组织,BiPAP的设置,改善氧合 降低PaCO2,降低 PaCO2的措施,BiPAP的设置,降低 PaCO2的措施 降低 PaCO2产量 增加 Vt ，减少Vd 增加 RR,BiPAP的设置,BiPAP的设置,增加潮气量的措施 IPAPEPAP 顺应性 气道阻力 患者吸气努力,BiPAP的设置,IPAP初始设置为48cmH2O EPAP初始设置为23cmH2O 潮气量主要取决于 IPAPEPAP 增大EPAP和/或IPAP值均可改善氧合,NPPV常用的通气参数的参考值,中华结