ERS／ATS急性呼吸衰竭无创通气治疗PPT参考幻灯片

2017ERS/ATS急性呼吸衰竭无创通气指南解读,1,欧洲呼吸学会（ERS）与美国胸科学会（ATS）在欧洲呼吸杂志上联合发表了ARF患者无创通气指南。该指南采用PICO(populationinterventioncomparisonoutcome)范式对11个临床相关问题进行了解答。推荐意见整理如下：,2,Question1:ShouldNIVbeusedinCOPDexacerbation?,问题1：NIV是否应用于AECOPD？,3,Question1a:ShouldNIVbeusedinARFduetoaCOPDexacerbationtopreventthedevelopmentofrespiratoryacidosis?,RecommendationWesuggestNIVnotbeusedinpatientswithhypercapniawhoarenotacidoticinthesettingofaCOPDexacerbation.(Conditionalrecommendation,lowcertaintyofevidence.),4,问题1a：NIV是否应用于COPD急性加重导致的急性呼吸衰竭（ARF）以防止发展为呼吸性酸中毒？,推荐意见：建议NIV不适用于COPD急性加重患者中无酸中毒的高碳酸血症患者（条件性推荐，低质量证据）。,5,Seeforestplotsandtheevidenceprofileinthesupplementarymaterialforfurtherdetailsregardingincludedevidence.PooledanalysiswasveryimprecisebutdemonstratedthatbilevelNIVdoesnotreducemortality(RR1.46,95%CI0.643.35)anddecreasetheneedforintubation(RR0.41,95%CI0.180.72).Giventhelackofconsistentevidencedemonstratingbe-nefitinthosewithoutacidosisandthepotentialforharm,thecommitteedecidedonaconditionalrecommendationagainstbilevelNIVinthissetting.,最近的几项研究表明双相气道正压NIV不减少死亡率（RR1.46,95CI0.64-3.35），不减少对插管的需要（RR0.41,95CI0.18-0.72）。鉴于缺乏证据证明对没有酸中毒患者的益处和潜在的危害，委员会决定在这一环境中对bilevelNIV提出反对意见。,6,Question1b:ShouldNIVbeusedines-tablishedacutehypercapnicrespiratoryfailureduetoaCOPDexacerbation?,RecommendationsWerecommendbilevelNIVforpatientswithARFleadingtoacuteoracute-on-chronicrespiratoryacidosis(pH7.35)duetoCOPDexacerbation.(Strongrecommendation,highcertaintyofevidence.)WerecommendatrialofbilevelNIVinpatientscon-sideredtorequireendotrachealintubationandmechanicalventilation,unlessthepatientisimmediatelydeteriorating.(Strongrecommendation,moderatecertaintyofevidence.),7,问题1b：NIV是否应用于由于COPD急性加重而导致的急性高碳酸血症呼吸衰竭？,推荐意见：我们推荐双相气道正压NIV用于由于COPD急性加重导致急性呼吸衰竭引起的急性或慢性急性加重呼吸性酸中毒（pH7.35）（强烈推荐，高质量证据）。,8,我们建议在认为需要气管内插管的患者中进行试验性双相气道正压NIV机械通气，除非患者立即恶化（强烈推荐，中等质量证据）。实施考虑：当pH值7.35，PaCO245mmHg，呼吸频率20-24次/min时，应考虑双相气道正压NIV，尽管采用标准药物治疗。双相气道正压NIV仍然是住院期间COPD患者发生呼吸性酸中毒的首选。,9,ThereisnolowerlimitofpHbelowwhichatrialofNIVisinappropriate;however,thelowerthepH,thegreaterriskoffailure,andpatientsmustbeverycloselymonitoredwithrapidaccesstoendotrachealintubationandinvasiveventilationifnotimproving.对于试验性NIV没有pH的下限是不适当的;然而，pH越低失败的风险越大，患者必须非常密切监测，如果没有改善，可以快速获得气管内插管和有创通气。,10,问题2a：应该在由于心源性肺水肿引起的急性呼吸衰竭中使用NIV吗？推荐意见：我们建议对心源性肺水肿引起的呼吸衰竭患者提供双气道正压NIV或CPAP。（强烈推荐，中等质量证据）。,11,In2008,GRAYetal.43publishedthelargestmulticentretrialfrom26emergencydepartments,inwhich1069patientswererandomisedtoCPAP,bilevelNIVorstandardoxygentherapy.ThistrialfoundphysiologicalimprovementintheCPAPandbilevelNIPgroupscomparedwiththestandardgroup,butnodifferenceinintubationrateormortalityat7and30days.这项试验发现CPAP及BilevelNIP组与标准组相比，有生理上的改善，但插管率和死亡率在7天和30天内没有差别。,12,fivesystematicreviews4448thathaveincorporatedthedatafromGRAYetal.43,aswellasothernewtrials,havebeenpublished.Theyconsistentlyconcludethat:1)NIVdecreasestheneedforintubation,2)NIVisassociatedwithareductioninhospitalmortality,3)NIVisnotassociatedwithincreasedmyocardialinfarction(aconcernraisedbythefirststudycomparingNIVandCPAP49),4)CPAPandNIVhavesimilareffectsontheseoutcomes.RecommendationWerecommendeitherbilevelNIVorCPAPforpatientswithARFduetocardiogenicpulmonaryoedema.(Strongrecommendation,moderatecertaintyofevidence.)1）减少气管插管的需要，2）与减少住院死亡率有关，3）和合不增加心肌梗死相关的4）CPAP和BilevelNIV治疗对这些结果有相似的影响。,13,Question2b:ShouldatrialofCPAPpriortohospitalisationbeusedtopreventdeteriorationinpatientswithARFduetocardiogenicpulmonaryoedema?,PooledanalysisdemonstratedthatNIVdecreasedmortality(RR0.88,95%CI0.451.70;moderatecertainty)decreasedtheneedforintubation(RR0.31,95%CI0.170.55;lowcertainty)WesuggestthatCPAPorbilevelNIVbeusedforpatientswithARFduetocardiogenicpulmonaryoedemainthepre-hospitalsetting.(Conditionalrecommendation,lowcertaintyofevidence.),14,问题2b：在院前是否应使用CPAP进行以防止心源性肺水肿引起的ARF患者恶化？,推荐意见：建议在院前对心源性肺水肿引起的ARF患者使用CPAP或双相气道正压NIV（条件性推荐，低质量证据）。汇总分析表明NIV降低死亡率（RR0.88，95%CI0.45-1.70；适度确定性）减少了插管的需要（RR0.31，95%CI0.17-0.55；低确定性）。,15,Question3:ShouldNIVbeusedinARFduetoacuteasthma?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationontheuseofNIVforARFduetoasthma.NIVhasanuncleareffectonmortality,intubation(RR4.48,95%CI0.2389.23;verylowcertainty)orICUlengthofstay(meandifference0.3higher,95%CI0.63lowerto1.23higher)inthispopulation.,16,问题3：NIV是否用于由于急性哮喘引起的ARF？,推荐意见：鉴于证据的不确定性，我们无法就由于哮喘引起的ARF使用NIV提出建议。似乎有助于改善1s用力呼气量。（平均差值高14.02，95%CI7.73-20.32；低确定性）和呼气峰流量（平均差值高19.97，95%CI15.01-24.93；低确定性）。,17,Question4:ShouldNIVbeusedforARFinimmunocompromisedpatients?,RecommendationWesuggestearlyNIVforimmunocompromisedpatientswithARF.(Conditionalrecommendation,moderatecertaintyofevidence.),18,问题4：NIV是否用于免疫缺陷患者的ARF？,推荐意见：我们建议免疫功能低下的ARF患者早期使用NIV（条件性推荐，中等质量证据）。,19,onerecentRCT67showedbenefitsofhigh-flownasalcannulaoxygentherapyoverbilevelNIVwithregardtointubationandmortality.高流量鼻套管氧疗在插管率和死亡率的改善上高于BilevelNIV。andmorestudyisrequiredtodeterminewhetherthismodalityhasadvantagesoverNIVinimmunocompromisedpatientswithARF.,20,Question5:ShouldNIVbeusedindenovoARF?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationontheuseofNIVfordenovoARF.,21,问题5：NIV是否用于新发的急性呼吸衰竭？,推荐意见：鉴于证据的不确定性，无法就由于新发的ARF使用NIV提出建议。,22,Question6:ShouldNIVbeusedinARFinthepost-operativesetting?,RecommendationWesuggestNIVforpatientswithpost-operativeARF.(Conditionalrecommendation,moderatecertaintyofevidence.),23,问题6：NIV是否用于手术后ARF的患者中？,推荐意见：建议在手术后ARF患者使用NIV（条件性推荐，中等质量证据）。,24,Question7:ShouldNIVbeusedinpatientswithARFreceivingpalliativecare?,RecommendationWesuggestofferingNIVtodyspnoeicpatientsforpalliationinthesettingofterminalcancerorotherterminalconditions.(Conditionalrecommendation,moderatecertaintyofevidence.),25,问题7：NIV是否用于接受姑息治疗的ARF患者？,推荐意见：建议将NIV提供给癌症终末期或其他疾病终末期的呼吸困难患者（条件性推荐，中等质量证据）。,26,Question8:ShouldNIVbeusedinARFduetochesttrauma?,RecommendationWesuggestNIVforchesttraumapatientswithARF.(Conditionalrecommendation,moderatecertaintyofevidence.),27,问题8：NIV是否用于由于胸部创伤导致的ARF？,推荐意见：建议胸部创伤引起的ARF患者中使用NIV。（条件性推荐，中等质量证据）。,28,Question9:ShouldNIVbeusedinARFduetopandemicviralillness?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationforthisquestion,29,问题9：NIV是否用于由于流行性病毒性疾病引起的ARF？,推荐意见：鉴于证据的不确定性，无法就此提出建议。,30,Question10:ShouldNIVbeusedinARFfollowingextubationfrominvasivemechanicalventilation?问题10：NIV是否用于有创机械通气拔管后的ARF？,31,Question10a:ShouldNIVbeusedtopreventrespiratoryfailurepost-extubation?,RecommendationsWesuggestthatNIVbeusedtopreventpost-extubationrespiratoryfailureinhigh-riskpatientspost-extubation.(Conditionalrecommendation,lowcertaintyofevidence.)WesuggestthatNIVshouldnotbeusedtopreventpost-extubationrespiratoryfailureinnon-high-riskpatients.(Conditionalrecommendation,verylowcertaintyofevidence.),32,问题10a：NIV是否用于预防拔管后的呼吸衰竭？,推荐意见：建议NIV用于预防拔管后有呼吸衰竭高风险的患者呼吸衰竭（条件性推荐，低质量证据）。建议NIV不应用于防止非呼吸衰竭高风险的拔管后患者（条件性推荐，低质量证据）。,33,Question10b:ShouldNIV