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1、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
2、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
3、分别刊登专题综述和荟萃分析 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
4、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 th
5、e 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. I
6、n 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-associa
7、ted 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 asth
8、ma 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 w
9、as 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 le
10、ss 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
11、 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
12、. 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
13、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). Inter
14、ventions: 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
15、:,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, intubat
16、ion 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 fo
