无创正压机械通气的临床应用

无创正压机械通气(NPPV)是一种辅助通气的方法,可改善自身生理功能,减少一系列的并发症,提高生存质量,延长生命,已经广泛应用于治疗急、慢性疾病。     

无创正压通气降低心源性肺水肿患者的死亡率

无创通气与有创通气相比,具有使用方便、费用较低、减轻患者痛苦、并发症少等优点,逐渐被临床医生所认可,其临床用途也越来越广泛.已经有足够的证据表明无创正压通气（non-invasive positive pressure ventilation,NIPPV）的使用,包括持续气道正压（continuous positive airway pressure,CPAP）或者双水平正压通气模式（biLevel ventilation,BiLevel）可以减少心源性肺水肿患者继发的有创机械通气,但患者是否还有其他受益尚无循证医学的证据.     

无创正压机械通气治疗重症肺炎呼吸衰竭疗效分析

目的探讨分析无创正压机械通气治疗重症肺炎并发呼吸衰竭的临床疗效。方法将该院呼吸科收治的40例重症肺炎患者随机分为观察组和对照组,对照组按照常规给予持续的鼻导管氧气吸入,观察组给予无创正压机械通气治疗,观察两组患者治疗一天后动脉血气改善的情况,结果进行统计学分析。结果两组患者在治疗后动脉血气分析均有改善,与治疗前相比较差异有统计学意义（P〈0．05）;同时观察组动脉血气指标改善情况优于对照组,差异具有统计学意义（P〈O．05）。结论急性呼吸衰竭是重症肺炎一个严重的并发症,与传统的吸氧比较,无创正压机械通气治疗有着良好的疗效,在改善患者呼吸功能方面有优势,值得临床推广使用。     

无创正压机械通气技术临床应用研讨

SARS肆虐期间,北京、广州等重灾区大量应用无创正压机械通气技术救治 SARS患者.通过众多新闻媒体的报道,无创正压通气技术的概念和无创通气呼吸机为更多的人所认识.文章对无创正压机械通气技术临床应用进行研讨.     

如何应用无创正压机械通气?

编辑老师:您好!前几天我科收治了1例慢性阻塞性肺疾病急性加重(AE-COPD)患者,当时PaO2约50mm Hg(1mm Hg=0.133kPa),PaCO2约80mm Hg,患者意识恍惚,由于家属不同意气管插管,故给予双水平气道正压通气(BIPAP),第2d,患者的PaCO2升至100mm Hg,已不能唤醒。再次向家属交待:如不进行气管插管可能会危及生命,家属再次拒绝。故继续用BIPAP。2d后,患者居然恢复了意识,且状况越来越好。对此我很不理解:按指南上讲,如果无创正压机械通气(NIP-PV)使用后数小时血气仍未改善,应考虑气管插管(NIPPV临床应用中的几点建议)。但上述情况怎么解…     

无创正压机械通气治疗重症COPD患者护理分析

目的：探讨无创正压机械通气治疗重症COPD的临床疗效和护理方法。方法：选取重症COPD患者80例作为研究对象,随机分为2组,其中观察组42例,对照组38例,入院后所有患者均给予解痉平喘、按照药物敏感实验选择敏感抗生素抗感染、止咳化痰等对症治疗,观察组在此基础上给予无创正压机械通气治疗,对照组在常规治疗基础上给予持续低流量吸氧治疗。比较2组患者治疗前后动脉血气分析中氧分压（PaO2）和二氧化碳分压（PaCO2）的变化。结果：2组患者治疗后,PaO2、PaCO2均较治疗前明显改善,差异有统计学意义(P<0.05),而观察组的改善情况优于对照组,差异有统计学意义(P<0.05)。结论：无创正压机械通气治疗重症COPD患者临床疗效显著,在治疗的整个过程中进行各种有效的临床护理是保证治疗顺利进行的先决条件。     

无创正压通气治疗呼吸衰竭疗效探讨

目的 探讨应用无创正压机械通气治疗呼吸衰竭的疗效.方法 回顾分析我院2003年1月1日～2006年12月31日期间收治的呼吸衰竭患者553例;其中392例患者在治疗过程中接受了无创正压机械通气;有161例患者未行无创通气.比较治疗前后各项通气指标,住院时间及死亡率.结果 无创通气组治疗后各项血气指标显著改善(P＜0.05).并且总的住院时间、死亡率显著低于未行无创通气组(P＜0.05).结论 各种原因所致呼吸衰竭患者应尽早实施无创机械通气,能显著减少住院时间及死亡率,提高生活质量.     

社区医院如何掌握无创正压通气及临床应用

机械通气已成为治疗呼吸衰竭的最主要手段,无创和有创通气存在一定的差异,社区医院开展无创正压通气工作,首先要明确认识无创正压通气和有创正压通气的各自特点,其次正确掌握无创正压通气的作用机制,严格掌握NPPV的应用指征和时机,合理运用无创正压通气的疗效判断,应在严格掌握临床应用指征和密切监测的基础上选用,严格规范操作流程和应用技巧,提高依从性和临床疗效,减少不良反应和并发症。     

无创正压通气临床应用的进展：———第七届国际无创通气会议简介

作者介绍了第七届国际无创通气会议有关情况,重点介绍了经鼻或口鼻面罩正压通气临床应用的进展,评价了其优势和不足,可供临床应用时参考。     

无创机械正压通气治疗慢阻肺呼吸衰竭的护理

目的：探讨无创机械正压通气治疗慢阻肺（COPD）呼吸衰竭的疗效及护理。方法：选取我科2005-2009年住院的68例COPD并呼吸衰竭患者,应用无创机械正压通气治疗,观察治疗前后血气变化。结果：治疗前后血气结果有显著变化。结论：无创机械正压通气治疗COPD呼吸衰竭疗效明显,治疗中需加强护理,以保证戴机成功,配合治疗。     

呼吸机管道更换时间与呼吸机相关性肺炎发生相关性的Meta分析

目的系统评价呼吸机管道更换时间与呼吸机相关性肺炎(VAP)发生的相关性。方法应用计算机检索近10年的Pubmed电子数据库、中国生物医学文献数据库和中国期刊全文数据库,对符合标准的文献按Cochrane协作网推荐的方法进行Meta分析。结果共纳入10项研究,17419例病例。按呼吸机管道更换时间分为1 d组191例、2 d组9448例、3 d组174例和7 d组7606例。Meta分析结果显示,7 d组的VAP发生率与1 d组、2 d组和3 d组比较,差异均无统计学意义(RR分别为2.40、1.40和0.81;95%CI分别为0.61～9.47、0.97～2.03和0.51～1.30;P值分别为0.21、0.07和0.39)。结论呼吸机管道每7 d更换一次较为合理,有利于节省人力、物力,而并不增加VAP的发生率。     

Noninvasive positive-pressure ventilation in acute respiratory failure

Noninvasive positive-pressure ventilation is a type of mechanical ventilation that does not require an artificial airway. Studies published in the 1990s that evaluated the efficacy of this technique for the treatment of diseases as chronic obstructive pulmonary disease, congestive heart failure and acute respiratory failure have generalized its use in recent years. Important issues include the selection of the ventilation interface and the type of ventilator. Currently available interfaces include nasal, oronasal and facial masks, mouthpieces and helmets. Comparisons of the available interfaces have not shown one to be clearly superior. Both critical care ventilators and portable ventilators can be used for noninvasive positive-pressure ventilation; however, the choice of ventilator type depends on the patient's condition and therapeutic requirements and on the expertise of the attending staff and the location of care. The best results (decreased need for intubation and decreased mortality) have been reported among patients with exacerbations of chronic obstructive pulmonary disease and cardiogenic pulmonary edema.     

Noninvasive positive-pressure ventilation for postextubation respiratory distress: a randomized controlled trial

Context  Noninvasive positive-pressure ventilation (NPPV) has been demonstrated to be effective in preventing the need for endotracheal intubation in some patients who present with acute respiratory failure. It is also used for patients who develop acute respiratory distress after extubation, but there are no randomized controlled trials that address its effectiveness in this population. Objective  To determine the effectiveness of NPPV compared with standard medical therapy in preventing the need for endotracheal reintubation in high-risk patients who develop respiratory distress during the first 48 hours after extubation. Design  Randomized, controlled, unblinded study with concealed allocation conducted between August 1, 1996 and October 31, 1999. Setting  An intensive care unit (ICU) in an academic, tertiary care hospital in Ontario. Patients  Eighty-one patients with a history of cardiac or respiratory disease or who initially required ventilatory support for more than 2 days and who developed respiratory distress within 48 hours of extubation. Interventions  Patients were randomly assigned to receive standard medical therapy alone (supplemental oxygen to maintain oxygen saturation by pulse oximetry 95%; n = 42) or NPPV by face mask plus standard medical therapy (n = 39). Main Outcome Measures  Rates of reintubation, duration of mechanical ventilation, lengths of ICU and hospital stay, and hospital mortality. Results  Comparing the NPPV group with the standard-therapy group, there was no difference in the rate of reintubation (72% vs 69%; relative risk, 1.04; 95% confidence interval, 0.78-1.38) or hospital mortality (31% for both groups; relative risk, 0.99; 95% confidence interval, 0.52-1.91). Similarly, no difference was found in duration of mechanical ventilation or length of ICU or hospital stay. Conclusions  The addition of NPPV to standard medical therapy does not improve outcome in heterogeneous groups of patients who develop respiratory distress during the first 48 hours after extubation.      

双水平无创正压通气在慢性阻塞性肺疾病并发呼吸衰竭中的抢救作用

目的 观察双水平无创正压通气(BiPAP)在慢性阻塞性肺病(COPD)并发呼吸衰竭患者的抢救作用.方法 50例COPD伴Ⅱ型呼吸衰竭患者在常规治疗同时,用BiPAP呼吸机进行无创通气治疗,观察治疗前后的临床及动脉血气变化.结果 46例患者经机械通气治疗后意识恢复正常,动脉氧分压逐渐升高,动脉二氧化碳分压明显下降(P<0.01);1例放弃治疗,3例死亡.结论 BiPAP对COPD并呼吸衰竭疗效肯定,无严重不良反应. Abstract： Objective To estimate the efficacy of noninvasive positive pressure ventilation for chronic obstructive pulmonary disease (COPD) with severe respiratory failure. Methods Fifty cases of COPD with severe respiratory failure were treated by Bi-level noninvasive positive pressure ventilation and routine treatment. Observation was made on the clinical symptoms and changes of arterial blood gas before and after ventilation treatment. Results After ventilation, patients' symptoms of pulmonary encephalopathy and unconsciousness improved markedly and PaO2 improved significantly. Among forty-six cases, one patient dropped off and 3 cases died. Conclusions In COPD patients with severe respiratory failure, Bi-level positive airway pressure (BiPAP) noninvasive ventilation is effective with few serious complications.     

集束化干预在机械通气预防呼吸机相关性肺炎中的应用

目的：探讨机械通气患者实施集束化干预在预防呼吸机相关性肺炎（VAP）中的应用。方法选取2011年4月至2012年6月进行机械通气大于或等于48 h 的患者110例。随机分为口腔冲洗组36例（对照组）、口腔冲洗结合气囊上滞留物引流组37例（气囊上滞留物引流组）和口腔冲洗、气囊上滞留物引流联合半坐位组37例（集束化组）,观察3组患者 VAP 发生率、VAP 病死率、机械通气时间和住 ICU 时间。结果气囊上滞留物引流组和对照组在机械通气第3、7天 VAP 发生率比较差异有统计学意义（P ＜0．05）;集束化组与对照组在 VAP 发生率方面比较差异有统计学意义（P ＜0．05）,在大于9 d 与气囊上滞留物引流组比较差异有统计学意义（P ＜0．05）,机械通气时间和住 ICU 时间明显缩短。一旦发生 VAP,3组患者的病死率比较差异无统计学意义（P ＞0．05）。结论机械通气患者严格执行半坐卧位,加强口咽部各环节的干预管理,对预防呼吸机相关性肺炎有重要意义。     

有创机械通气发生早发性呼吸机相关性肺炎的临床分析

目的 探讨有创机械通气出现早发性呼吸机相关性肺炎(VAP)的临床特点。方法 监测和分析98例非肺部感染性疾病行气管插管或气管切开术进行机械通气的患者发生早发性VAP的相关因素、呼吸道感染菌群的特点及其耐药特性。结果 98例患者中，有31例在术后4d内发生VAP(VAP组)，占31．6％，其气道分泌物培养获得致病菌42株，均为多重耐药菌。VAP组患者的年龄、有慢性阻塞性肺疾病(COPD)史者、术前抗生素的使用率均高于无VAP组。结论 早发性VAP的出现与患者的年龄、COPD史有一定关系，术前抗生素的使用可能与致病菌的高度耐药有关。     

Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial

Marin H. Kollef, MD; Bekele Afessa, MD; Antonio Anzueto, MD; Christopher Veremakis, MD; Kim M. Kerr, MD; Benjamin D. Margolis, MD; Donald E. Craven, MD; Pamela R. Roberts, MD; Alejandro C. Arroliga, MD; Rolf D. Hubmayr, MD; Marcos I. Restrepo, MD; William R. Auger, MD; Regina Schinner, Dipl-Stat; for the NASCENT Investigation Group

JAMA. 2008;300(7):805-813.

Context  Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation.

Objective  To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.

Design, Setting, and Participants  Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized.

Intervention  Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube.

Main Outcome Measures  Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10⁴ colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events.

Results  Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events.

Conclusion  Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.

Trial Registration  clinicaltrials.gov Identifier: NCT00148642

     

成人呼吸机相关性肺炎的病因、发病率、病原学研究

目的:探讨成人呼吸机相关性肺炎(VAP)的病因、发病率、病原学特点及其治疗。方法:回顾性分析我院2009年7月至2011年7月258例VAP患者临床资料,比较VAP的发生率、病原体、耐药性与治疗情况。结果:我院VAP的发生率为58%,258例VAP患者共检出349个微生物。79%为单一微生物感染,21%为多重微生物感染。病原体包括最常见的金黄色葡萄球菌(36.1%),铜绿假单胞菌(26.9%),不动杆菌(22.6%),肠杆菌属(9.2%),肺炎克雷伯杆菌(1.7%),假单胞菌(1.1%)。其中不动杆菌、铜绿假单孢菌、金黄色葡萄球菌耐药性高。结论:早期合理抗生素治疗VAP,可以降低VAP的死亡率,减少微生物的耐药性。