无创呼吸机的临床运用

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,NIPPV,与急性呼吸衰竭,北京医院,呼吸与危重症医学科,柯会星,无创通气,气道内正压通气,胸外负压通气,美国妇女戴安,奥德尔 用铁肺,60,年,发展史,1989年Meduri等报道NPPV用于COPD急性加重期(AECOPD)导致的呼吸衰竭,临床研究可分为2个阶段：,第一阶段(19891995年)主要是开放式观察研究；,第二阶段(1995年后)是依据循证医学原则的前瞻性随机对照研究(RCT),NPPV,的临床应用被认为 是近十余年机械通气领域的 重要进步之一,优点,NPPV由于“无创”的特点使机械通气的“早期应用”成为可能；,NPPV减少了气管插管或气管切开的使用，从而减少人工气道的并发症；,NPPV在单纯氧疗与有创通气之间，提供了“过渡性”的辅助通气选择：在有创通气应用有困难时，可尝试NPPV治疗；在撤机过程中，NPPV可以作为一种“桥梁”或“降低强度”的辅助通气方法，有助于成功撤机；,NPPV作为一种短时或间歇的辅助通气方法扩展了机械通气的应用领域，,如：辅助进行纤维支气管镜检查、长期家庭应用、康复治疗、插管前准备等，,随着NPPV技术的进步和临床研究的进展，形成了有创与无创通气相互密切配合的机械通气新时代，提高了呼吸衰竭救治的成功率。,NIPPV:,临床效果,专家共识和指南,2001,年，美国胸科学会首先建立,NPPV,临床应用的专家共识,英国胸科学会等也建立了临床应用指南,众多的核心杂志也分别刊登专题综述和荟萃分析,中华医学会呼吸病学分会呼吸生理与重症监护学组也在,2002,年草拟了我国的“无创正压通气临床应用中的几点建议”,无创正压通气临床应用的专家共识,NPPV,的应用指征尚无统一标准,呼吸衰竭的严重程度；,基础疾病；,意识状态；,感染的严重程度；,是否存在多器官功能损害等多种因素；,应用者的经验和治疗单位人力设备条件,NPPV的应用指征,（,1,）总体应用指征；,（,2,）在不同疾病中的应用；,（,3,）在临床实践中动态决策。,NPPV,的总体应用指征和临床切入点,在急性呼吸衰竭中，其参考的应用指征：,疾病的诊断和病情的可逆性评价适合使用NPPV,NPPV,主要适合于轻中度呼吸衰竭，没有紧急插管指征、生命体征相对稳定和没有,NPPV,禁忌证的患者，用于呼吸衰竭早期干预和辅助撤机。,NIPPV,与,ARF,JAAPA, NOVEMBER 2011 24(11) ,背景,Acute respiratory failure (ARF) is one of the,most common diagnoses in adults admitted toan ICU.,In one study,Vincent and colleagues,found that 32% of patients had ARF on admission to the ICU and another 24% developed the condition during their stay.,Patients with ARF often require endotracheal intubation and mechanical ventilation,背景,The complications of these procedures in combination with risks associated with the underlying disease process lead to high morbidity and mortality rates in this patient population.,In critically ill patients with ARF, the mortality rate is between 40% and 65%.,Complications of endotracheal intubation and mechanical ventilation include dental damage,oropharyngeal damage, corneal abrasions, vocal cord damage, tracheal damage, pneumothorax, pulmonary aspiration, ventilator-associated pneumonia, alveolar damage,and bronchospasm, among others.,MECHANICS OF NIPPV,continuous positive airway pressure,(CPAP),pressure support mode,bilevel positive airway pressure,(BiPAP),CAUSES OF ARF AND THE ROLE OF NIPPV,COPD exacerbations,Cardiogenic pulmonary edema,Acute exacerbations of asthma,Other causes,Ram and colleagues report,：,14 randomized controlled trials (RCTs) conducted between 1993 and 2004,involving 758 patients,mortality was reduced by 48% with NIPPV compared to CMT,（,conventional medical therapies,）,NIPPV reduced the risk of endotracheal intubation by 59%.,Length of stay was reduced by an average of 3 days,Morbidity and mortality were significantly reduced with an overall risk reduction of 62%,Ram FS, Picot J, Lightowler J, Cochrane Database Syst Rev. 2004;(1):CD004104,一些研究,Mortality increases with age and the degree of respiratory acidosis,Patients with pH values less than 7.26 were found to have the highest mortality,NIPPV rapidly corrected acidosis in the first hour,Meduri and colleagues revealed a decrease in PaCO2 of greater than 16% and a pH value greater than 7.30 after 1 hour of treatment with NPPV,Brochard and colleagues found a significant improvement in respiratory rate, PaCO2, PaO2, and pH measurements during the first hour of treatment in the NIPPV group compared to the standard treatment group,NIPPV fails in only 10% to 20% of cases,无创通气的应用,经 常 是,“,用 不 好,”,而 不 是,“,不 好 用,”,Cardiogenic pulmonary edema,Health Technology Assessment,2009; Vol. 13: No. 33,Study,Objectives:,To determine whether non-invasive ventilation reduces mortality and whether there are important differences in outcome by treatment modality.,Design:,Multicentre open prospective randomised controlled trial.,Setting:,Patients presenting with severe acute cardiogenic pulmonary oedema in 26 emergency departments in the UK.,Participants:,Inclusion criteria were age 16 years, clinical diagnosis of acute cardiogenic pulmonary oedema, pulmonary oedema on chest radiograph, respiratory rate 20 breaths per minute, and arterial hydrogen ion concentration 45 nmol/l (pH 7.35).,Interventions:,Patients were randomised to standard oxygen therapy, continuous positive airway pressure (CPAP) (515 cmH2O) or non-invasive positive pressure ventilation (NIPPV) (inspiratory pressure 820 cmH2O, expiratory pressure 410 cmH2O) on a 1:1:1 basis for a minimum of 2 hours.,Main outcome measures:,The primary end point for the comparison between NIPPV or CPAP and standard therapy was 7-day mortality. The composite primary end point for the comparison of NIPPV and CPAP was 7-day mortality and tracheal intubation rate. Secondary end points were breathlessness, physiological variables, intubation rate, length of hospital stay and critical care admission rate. Economic evaluation took the form of a costutility analysis, taken from an NHS (and personal social services) perspective.,Results,In total, 1069 patients mean age 78 (SD 10) years; 43% male were recruited to standard therapy (,n,= 367), CPAP ,n,= 346; mean 10 (SD 4) cmH2O or NIPPV ,n,= 356; mean 14 (SD 5)/7 (SD 2) cmH2O.,There was no difference in 7-day mortality for standard oxygen therapy (9.8%) and non-invasive ventilation,(9.5%;,p,= 0.87).,The combined end point of 7-day death and intubation rate was similar, irrespective of non-invasive ventilation modality (CPAP 11.7% versus NIPPV 11.1%;,p,= 0.81). Compared with standard therapy,non-invasive ventilation was associated with greater reductions (treatment difference, 95% confidence intervals) in breathlessness (visual analogue scale score 0.7, 0.21.3;,p,= 0.008) and heart rate (4/min, 16;,p,= 0.004) and improvement in acidosis (pH 0.03, 0.020.04;,p, 0.001) and hypercapnia,(0.7 kPa, 0.40.9;,p,4 h/d)，则继续应用C级。,心源性肺水肿,NPPV可改善心源性肺水肿患者的气促症状，改善心功能，降低气管插管率和死亡率A级。,首选CPAP，而BiPAP应用于CPAP治疗失败和PaCO245 mm Hg的患者。,目前多数研究结果认为BiPAP不增加心肌梗塞的风险，,对于急性冠脉综合征合并心力衰竭患者仍应慎用BiPAP。,免疫功能受损合并呼吸衰竭,对于免疫功能受损合并呼吸衰竭患者，建议早期首先试用NPPV，可以减少气管插管的使用和病死率A级。,因为此类患者总死亡率较高，建议在ICU密切监护的条件下使用。,支气管哮喘急性严重发作,NPPV在哮喘严重急性发作中的应用存在争论,在没有应用禁忌证的前提下可以尝试应用C级。,治疗过程中应该同时给予雾化吸入支气管舒张剂等治疗。,如果NPPV治疗后无改善应及时气管插管有创通气。,NPPV,辅助撤机,建议在合适的病例中，可以应用NPPV辅助早期撤机拔管，尤其是在COPD并高碳酸性呼吸衰竭的患者A级。,此策略的应用需要掌握其应用指征，注意密切监护和做好再插管的准备。,在非COPD 患者中，NPPV辅助撤机拔管策略的有效性依据尚不足C级，指征也不明确，不宜常规应用，尤其是不适合用于气管插管操作难度大的患者,辅助支气管纤维镜检查,对于有呼吸困难和低氧血症和高碳酸血症患者，NPPV辅助支气管纤维镜检查操作过程可以改善低氧血症和降低气管插管风险B级，但应做好紧急气管插管的准备。,手术后呼吸衰竭,NPPV可应用于防治手术后呼吸衰竭，在COPD或充血性心衰患者行肺切除术后的作用尤为明显B级，,但不建议在上呼吸道、食道、胃和小肠术后的呼吸功能不全中应用,肺炎,NPPV治疗肺炎导致的低氧血症的失败率较高，应用需要综合考虑患者的临床状况和疾病的进展等问题，权衡NPPV治疗的利弊。对于合适的患者，可以常用在ICU中密切监护下实施NPPV治疗C级。,一旦NPPV治疗失败，应及时气管插管,急性肺损伤,/,急性呼吸窘迫综合征（,ALI/ARDS,）,不建议常规应用NPPV治疗ALI/ARDS，但对于特别适合者可在密切监护下试行治疗C级。,如NPPV治疗12 h后低氧血症不能改善或全身情况恶化，应及时气管插管有创通气,胸壁畸形或神经肌肉疾病,对于适合的患者，NPPV 可以改善胸壁畸形或神经肌肉疾病患者的动脉血气、生活治疗和减缓肺功能下降趋势C级。,但不适合于咳嗽无力和吞咽功能异常者。,胸部创伤,胸部创伤的患者予以足够的局部镇痛和高流量吸氧后，如仍存在低氧血症，且没有其他并发症和无创通气的禁忌证者，应选用NPPV治疗B级。,拒绝气管插管的呼吸衰竭,对于拒绝气管插管的呼吸衰竭患者，NPPV可以作为一种有效的替代治疗C。,其他疾病,尽管NPPV有应用于多种疾病导致的呼吸衰竭或短暂的辅助通气支持，但临床上需要综合考虑，权衡利弊来选择应用NPPVD级。,在临床实践中动态决策,NPPV,的使用,NPPV失败的指标,神志恶化或烦躁不安,不能清除分泌物,无法耐受连接方法,血流动力学不稳定,氧合功能恶化,CO2,潴留加重,治疗,14 h,后如无改善,PaCO2,无改善或加重、出现严重的呼吸性酸中毒（,pH7.20,）或严重的低氧血症（,FiO20.5,条件下，,PaO2 8 kPa,或,OI120 mm Hg),在临床实践中动态决策,NPPV,的使用,对于没有NPPV禁忌证的呼吸衰竭患者，可采用“试验治疗-观察反应”的策略D级。,治疗观察12 h后，根据治疗后的反应来决定是否继续应用NPPV或改为有创通气。,禁忌证,NPPV的主要禁忌证,心跳或呼吸停止、,意识障碍、,误吸危险性高、,呼吸道保护能力差、,气道分泌物清除障碍和多器官功能衰竭,D,级,NPPV,的基本操作程序,Neurological disorders与NIPPV,The specific timing of noninvasive ventilation very much depends on the underlying disease and the specific characteristics of thepatient. Some patients may not be candidates for noninvasive ventilation, especially if they are having difficulty with respiratory secretions or have a reduced conscious level.,Neurol Clin 30 (2012) 161185,谢 谢！,