无创正压通气在AECOPD的应用

NoninvasivePositivePressureVentilationinAcuteExacerbationofCOPD

无创正压通气在AECOPD的应用YounsuckKoh,M.D.

DepartmentofPulmonaryandCriticalCareMedicine,AsanMedicalCenter,UniversityofUlsanCollegeofMedicine,Seoul,KoreaTongjiMechanicalVentilationForumNoninvasivePressureVentilation无创正压通气Anyformofventilatorysupportappliedwithouttheuseofanendotrachealtube

任何形式的无气管插管的机械通气支持Negative/Positivepressureventilation

负压/正压通气Mode:CPAPwithorwithoutpressuresupport,volume-andpressure-cycledsystems.proportionalassistventilation(PAV).

模式：有或无压力支持的CPAP

容量控制/压力控制支持通气HillNS.Lancet2009;374:250-259InterfacesforNPPVEarly1960s:IPPVwithmouthpiece/facialmaskLate1960s:MVwithETI1989:NPPVwithPSVinCOPDpatients(MeduriGU,etal.Chest1991:100;445)BrandNew?

Eur

RespirJ2008;31:874Timecourseofpublishedreferencesonnoninvasive(NIV)

mechanicalventilation(■),andNIVmechanicalventilationandacuterespiratory

failure(■).Source:PubMed.Update:December,2007.关于无创机械通气及其与急性呼吸衰竭的文章逐年增多HillNS.RespCare2009;54:62-70院前家庭治疗病房长期急救后续治疗科室急诊室NoIntubationTube不插管-Communication

交流-VAPincidence呼吸机相关性肺炎:14-28%

AdvantageofNPPV

NPPV的优点Easytoperform

易操作Easymonitoring

易监护

sedation

镇静

Comfortness

舒适

Easytowean

易脱机Lessnosocomialinfections

减少院内感染

AdvantageofNPPV(2)

NPPV的优点FrequencyofNosocomialInfectionsinthe2Groups两组患者院内感染的发生率Girou,E.etal.JAMA2000;284:2361-2367Subjects:ThepatientswithacuteexacerbationofCOPDorsevereCPE对象：AECOPD或严重肺气肿NPPVisnotreplacingintubation.

NPPV无需更换气管插管First2hmonitoringiscriticalafterinitiationofNPPV

采取NPPV最初的2小时的密切监测十分关键EssentialFactsofNPPV

NPPV的基本特征Detectofapt,whoneedventilatorysupport.

鉴别患者是否需要机械通气

Choicearightcandidate

选择合适的对象Preparerightequipments&Rightsetting

准备合适的设备及适当的设置3StepsofNPPV

NPPV的三个步骤Cooperative

合作的

Fewersecretion

分泌物少的

Lesssick

病情较轻的Limitedmaskleak

面罩漏气量少的RightCandidate

合适的对象IntensiveCareMed2008;34:2248PhysiologicBenefittoUseNPPV

从生理学角度分析使用NPPV的益处AcuteExacerbationofCOPD（AECOPD）Mean(±SE)forthePaO2andPaCO2duringtheFirst12Hoursinthe32PatientsSuccessfullyTreatedwithNPPV.Pvaluescomparedwiththebase-linevalues.通过NPPV成功治疗后32例患者在最初12小时内氧分压、二氧化碳分压的变化。RCT,42withstandardTX,43withNPPV,IPAPupto20cmH2O,EPAP=0随机对照研究，42例标准治疗，43例NPPV治疗（IPAP最高至20cmH2O，EPAP为零）BrochardL,etal.NEnglJMed1995;333:817TheLengthoftheHospitalstayamongthesurvivors:幸存者的住院天数：3333dinstandardgroup标准治疗组2317dinNPPVgroup(p=0.005)NPPV治疗组MR死亡率：

29%vs.9%(p=0.02)NEnglJMed1995;333:817HospitalMortality

住院死亡率KeenanSP,etal.AnnInternMed2003;138:861RateofEndotrachealIntubation气管插管率KeenanSP,etal.AnnInternMed2003;138:861NocturnalNPPVinStableCOPD稳定COPD患者夜间应用NPPV治疗TypeofTrial/SourceStudyPopulation(Treatment/Control)MeanFEV1,L(Range)MeanPaCO2,mmHg(Range)Length,moIPAP/EPAPParallelgroup/GayetalRandomized(7/6)Completed(4/6)0.68(0.5–1.1)55(45–89)310/2Cross-over/StrumpfetalEnrolled(n=19)Completed(n=7)0.54(0.46–0.88)49(35–67)315/2Cross-over/MeechamJonesandPaulEnrolled(n=18)Completed(n=14)0.86(0.33–1.7)56(52–65)318/2Parallelgroup/CasanovaetalRandomized(26/26)Completed(17/19)0.85(0.44–1.28)51(37–66)1212-14/4NPPVsupportdidnotimprovePFT,gasexchange,orsleepefficiencyNPPV支持治疗不能提高肺功能，气体交换或睡眠质量。Chest2003;124:337NPPVUseinWeaningfromMVNPPV在机械通气脱机中的应用FacilitateExtubation(intendedextubation);UseofNPPVafterExtubationinpatientswhofailtomeetstandardextubationcriteria.

有助于成功拔管；对不能达到标准拔管指标患者拔管后应用NPPVRoleofNPPVfortheFacilitationofWeaning(1)NPPV有助于机械通气脱机成功78y-o-mwith20yrHxofCOPD

有20年COPD病史的78岁患者HomeO2with1.5LofNasalProngs

家庭氧疗鼻导管吸氧1.5L血气分析ER:7.322-101.6-23.9-19.2-51.4-34.2

Hospitalday#2

住院第二天PSVmode(PS16FiO228%PEEP4)压力支持模式ABGA7.511-46.9-79.6-11.9-36.7-96.6

T-piecewithFiO2

30%:

Respiratorydistresswith呼吸窘迫ABGA7.370-63.4-72.2-8.0-35.8-93.7

NPPV(facialmask)NPPV面罩PS10PEEP2FiO230%ABGA7.316-74.7-70.8-7.9-37.3-92.2PS12PEEP2FiO226%ABGA7.358-61.5-62.2-6.1-33.8-90.3Hospitalday#3

住院第三天NPPVPS14PEEP2FiO226%ABGA7.360-45.2-123.4–(-0.8)-25.0-98.3

Nasalprong鼻导管2L/min:ABGA7.433-61.0-66.2-12.7-39.9-93.1%12trials(530participants)withpredominantlyCOPD.12个中心（530个患者）主要都是COPD病人。OutcomeinCOPDpts:MRCOPD患者的预后：死亡率OutcomeoftheptsdependingonCOPDPts’ratio预后取决于COPD患者的比例BetterinOutcomeofthepts结果改善的:Intubationduration

气管插管时间

Nosocomialpneumoniaincidence

医院获得性肺炎的发生率ICULOS：ICU住院天数HospitalLOS：住院天数TVT

机械通气时间NPPVUseafterIntentionalExtubationinIntubatedCOPDNPPV应用于COPD插管患者的主动拔管后WangC,etal.ChinMedJ2005;118:1589

90intubatedCOPDwithinfectionin11hospitalsinChina

中国11家医院90例合并感染的COPD气管插管患者

Extubatedafterpulmonaryinfectioncontrol(PICwindow)vs.conventionaltreatment

肺部感染控制后拔管vs.常规治疗NPPVgroupshowedshorterTVT(6.4vs.11.3d)&ICUstay(12vs.16),lowerVAP(3/47vs.12/43)andhospitalmortality(1/47vs.7/43).NPPV组具有较短的机械通气时间和ICU住院天数，较低的呼吸机相关性肺炎的发生率及住院死亡率。RoleofNPPVfortheFacilitationofWeaning(II)NPPV有助于脱机成功Toavoidreintubation

避免再插管

Incidence

发生率Plannedextubation

计划拔管:5-20%

Unplannedextubation

意外拔管:40-50%Relatedmortality

相关的死亡率43%vs.12%ofsuccessfulextubation

（成功拔管）

ClinicalImpactofReintubation再插管的临床影响NPPVinPostextubationRF:Outcomein30COPDpatients

NPPV在拔管后的应用：30例COPD患者的研究结果NPPV+GroupN=30P-valueControlGroup*N=30Patientsrequiringintubation(%)患者的插管率6(20)<0.00120(67)Deaths(%)

死亡率2(7)NS6(20)Outcomeinsurvivors(days)存活者Durationofventilatoryassistance+

面罩辅助通气时间

6±4**<0.0111±8LengthofICUstay+

ICU住院天数8±4<0.0114±8Eur

RespirJ1998;11;1349+NPPVwithfacemask*Historiccomparison,**daysReasonsforreintubation,asdefinedintheprotocolguidelines,accordingtostudygroup.

正如指南中指出的，再插管的原因依研究对象而不同Reason

Non-invasiveVentilation(N=55)StandardMedicalTherapy(N=51)PValueLackofimprovementinsignsofmusclefatigue肌肉疲劳未得到纠正25(45)+23(45)0.97Hypoxemia

低氧血症9(16)15(29)0.11Copioussecretions

大量分泌物5(9)6(12)0.65LackofimprovementinpHorpartialpressureofcarbondioxide

血pH或二氧化碳分压未得到纠正8(15)3(6)0.13Changesinmentalstatus

神志改变4(7)2(4)0.45Hypotension

低血压4(7)2(4)0.45Noninvasivepositive-pressureventilation

forrespiratoryfailureafterextubation

拔管后呼吸衰竭患者的无创正压通气NEnglJMed2004;350:2452+%NoknownindextopredictthesuccessofNPPVtrialinpatientswithpostextubationrespiratorydistress.无法预测NPPV对于拔管后出现呼吸窘迫的患者是否有效AbletobreathespontaneouslyonT-pieceformorethan5minutes

能够通过T管自主呼吸超过5分钟PaO2/FiO2morethan150

氧合指数大于150Noupperairwayproblems

不存在上呼吸道的隐患MinimumRequirementofNPPVUseasaWeaningFacilitator逐渐减少使用NPPV有利于脱机成功CritCareMed2008;36:2766Resultsofthemultivariatelogisticregressionmodel:independentpredictorsofNIVfailure多中心逻辑回归模型结果提示：NIV失败的独立预测因子呼吸频率无创通气不及时需升压药需肾脏替代治疗符合ARDSJournalofCriticalCare(2009)24,473.e7–473.e14COPD患者无创通气的对照研究结果：无创通气组的插管率较低，动脉血pH和二氧化碳分压均改善，但无创通气组改善更显著，且住院天数缩短，住院死亡率在两组间无差别。ComplicationsofNPPVNPPV的并发症However,mostseriouscomplicationofNPPVisdelayedintubation!然而，最严重的NPPV并发症是插管不及时！Contraindication

禁忌症Cardiacorrespiratoryarrest

心跳呼吸停止Severeencephalopathy(GCS<10)

严重中枢神经系统疾病Hemodynamicinstabilityorunstable血流动力学不稳定cardiacarrhythmia

心律失常Upperairwayobstruction

上呼吸道梗阻Inabilitytocooperate/protecttheairway不能合作/保护气道Reanimation2001;10:112Contraindication

禁忌症Non-respiratoryorganfailure呼吸系统以外器官的衰竭SevereUGIbleeding

严重的上消化道出血Facialsurgery,traumaordeformity面部术后、外伤或畸形Highriskforaspiration有误吸的高危险因素Reanimation2001;10:112Patientspecificfactors患者的因素-Selection

患者的选择-Clearindication

明确适应症Unitspecificfactors

科室的因素-Experiencedcare-giver

有经验的医护人员-Technicalequipments

技术设备WhenstoptoNPPVtreatment

何时停止NPPV治疗

Forthe