2018～2019年度无创正压通气临床研究进展

无创正压通气(non-invasive positive pressure ventilation,NPPV)已成为医院内及家庭重要的呼吸支持技术,其在现代呼吸支持治疗中具有无可替代的重要地位。该文通过Medline检索2018-06~2019-10 NPPV相关的临床研究文献,对NPPV在急性呼吸衰竭、辅助有创通气撤机、预氧合、慢性呼吸衰竭、方法学应用优化以及与其他无创通气支持方式等方面有相关亮点的研究报道进行述评,为NPPV的优化应用提供更好的方法和更有力的依据。     

无创正压通气在COPD急性呼吸衰竭中的实践与操作

COPD急性加重时常合并呼吸衰竭 ,严重时需行机械通气治疗 ,在有创通气治疗过程中 ,存在着上机时间长 ,易发生呼吸机相关性肺炎 (VAP) ,呼吸机依赖等问题。随着无创正压通气 (NPPV)应用的日趋广泛 ,尤其在COPD急性发作期患者治疗中已得到肯定。如何能够及时恰当地应用该技术 ,从而达到较早地控制病情发展 ,降低COPD气管插管率的目的 ,普及和规范操作 ,提高医护人员对NPPV的认识 ,是成功使用NPPV的关键     

无创正压通气在有创-无创序贯通气中的应用

无创正压通气(NPPV)在急、慢性呼吸衰竭的治疗中有良好疗效。急性呼吸衰竭患者行有创通气后，应用无创通气辅助呼吸进行序贯治疗，可缩短有创通气时间，减少与有创通气相关的并发症。本文将结合我们的经验对此进行综述。     

无创机械通气治疗慢性呼吸衰竭患者的护理体会

无创正压通气（NPPV）是指无需建立人工气道的正压通气,通常经过鼻／面罩等方法连接患者。和有创机械通气一样,无创机械通气也能通过改善肺通气和肺换气功能降低呼吸功,对呼吸衰竭患者提供有效的呼吸支持。临床研究证明,部分患者应用NPPV可以减少急性呼吸衰竭的气管插管、气管切开及相应的并发症,改善预后。减少慢性呼吸衰竭患者呼吸机的依赖,减少患者的痛苦和医疗费用,提高生活质量。     

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尽管无创正压通气(NPPV)已广泛的应用于慢性阻塞性肺疾病急性加重(AECOPD)患者,但其在急性呼吸衰竭中的应用一直存在争议。最近的研究显示,NPPV不但难以预防急性呼吸衰竭的发生,而且也不能使早期急性呼吸衰竭患者避免气管插管,更不能替代有创机械通气,甚至有报道认为NPPV增加病     

无创正压通气治疗COPD并呼吸衰竭的研究概况

近年来元创正压通气（NPPV）的临床应用日益广泛,尤其在慢性阻塞性肺疾病（COPD）并呼吸衰竭治疗中的价值得到越来越多的肯定。NPPV能改善COPD并呼吸衰竭患者的肺功能,提高生活质量,减少有创一无创序贯机械通气患者呼吸机相关性肺炎（VAP）发生,降低再插管率和病死率。该文就NPPV在COPD并呼吸衰竭患者中的应用进展作一综述。     

无创正压通气在COPD急性呼吸衰竭中的实践与操作

COPD急性加重时常合并呼吸衰竭，严重时需行机械通气治疗，在有创通气治疗过程中，存在着上机时间长，易发生呼吸机相关性肺炎(VAP)，呼吸机依赖等问题。随着无创正压通气(NPPV)应用的日趋广泛，尤其在COPD急性发作期患者治疗中已得到肯定。如何能够及时恰当地应用该技术，从而达到较早地控制病情发展，降低COPD气管插管率的目的，普及和规范操作，提高医护人员对NPPV的认识，是成功使用NPPV的关键。     

无创正压通气救治重症哮喘的临床评价

目的　评价无创正压通气 (NPPV)在救治重症哮喘并呼吸衰竭中的价值。方法　 14例重症哮喘并呼吸衰竭患者在给予药物治疗同时实施 NPPV。结果　实施 NPPV后 1～ 6小时 ,该组患者的动脉血氧分压 (Pa O2 )、二氧化碳分压 (Pa CO2 )、p H以及呼吸频率 (RR)和心率 (HR)较 NPPV治疗前明显改善 (P<0 .0 5 ) ,随着 PSV的增高和潮气量 (VT)的增大 ,气道吸气峰压 (PIP)反而降低。 2例患者因病情加重而改为气管插管有创通气。最终 12例患者应用 NPPV救治成功。结论　 NPPV用于重症哮喘并呼吸衰竭的治疗是安全有效和可行的。但对 NPPV治疗后病情继续恶化的患者应及时改为气管插管有创通气     

无创正压通气的操作

经口/鼻面罩行无创正压机械通气(noninvasive positive pressure ventilation,NPPV)早期主要用来治疗睡眠呼吸暂停综合征,近10余年来已广泛用于治疗多种急慢性呼吸衰竭[1-3]。研究证明,NPPV可以减少急性呼吸衰竭患者的插管率,缩短有创通气时间,降低住院费用[4-7]。医务人员应正     

无创正压通气在治疗COPD呼吸衰竭中的应用

无创正压通气 (NPPV)治疗COPD呼吸衰竭仍存在不少问题 ,作者对治疗的机制、策略与方法及如何提高耐受性和依从性等方面进行文献复习 ,旨在合理、规范化应用NPPV ,降低气管插管率。     

无创正压通气对COPD急性发作伴高碳酸血症治疗效果

目的 观察无创正压通气(NPPV)对慢性阻塞性肺病急性发作(AECOPD)伴慢性高碳酸血症、pH值≥7.35住院患者效果.方法 48例患者随机分为标准治疗组(对照组),药物治疗加NPPV组(NPPV组).比较两组患者呼吸频率(R)、心率、呼吸困难症状评分(DSS)、血气、入住ICU和住院时间差异及并发症.结果 两组动脉血pH和PaCO2均改善,NPPV组变化更明显.NPPV组24 h后R下降较快(P<0.05)、PaCO2(P>0.05)和pH值(P<0.05)改善、DSS减轻更明显.出院时,NPPV组血气值、DSS无显著差异.所有患者均成功地出院,NPPV组住院时间比对照组明显缩短(P<0.05);腹胀和焦虑是最常见的并发症.结论 AECOPD伴慢性呼吸衰竭、pH值≥7.35患者施行NPPV可更快改善血气、减轻症状、缩短住院时间.     

严重急性呼吸综合征所致呼吸衰竭及无创通气治疗

目的　回顾性总结严重急性呼吸综合征 (SARS)并发呼吸衰竭患者的血气特点 ,探讨应用无创正压通气 (NPPV)治疗的策略。方法　 2 0 0 3年 4月 2 2日～ 5月 1日 ,12 0例临床符合SARS诊断标准的患者入住北京地坛医院 (SARS专科医院 )的 4个病区 ,30例患者 (占 2 5 % )在病程中出现呼吸衰竭 ,达到急性肺损伤 (ALI)和 (或 )急性呼吸窘迫综合征 (ARDS)的诊断标准。 2 8例应用双水平气道正压通气 (BiPAP)。主要观察指标 :(1)住院期间的血气分析、脉搏容积血氧饱和度 (SpO2 )及呼吸频率 ,特别是上机前、上机后 1h及撤机后的结果 ;(2 )放射学检查或临床提示住院后新出现的气胸、纵隔气肿、心包积气及皮下气肿 ;(3)应用无创通气的天数 ;(4 )需气管插管行有创通气的患者数 ;(5 )患者的病死率 ;(6 )一线医务人员因护理治疗无创通气SARS患者而感染SARS的情况。结果统计 30例患者在整个病程中的动脉血二氧化碳分压 (PaCO2 )变化情况 ,16例 (5 3% )患者出现CO2 潴留 ,PaCO2为 4 5～ 5 6mmHg ,平均 (4 8± 4 )mmHg。NPPV治疗后动脉血氧分压 (PaO2 )、SpO2 、氧合指数及呼吸频率均显著改善 (P均 <0 0 1) ,但pH及PaCO2 的变化并不明显。 18例患者成功撤机 ,应用NPPV的时间为5～ 30d ,平均 (10± 6 )d。除 1例不能耐受BiPAP     

异丙嗪对慢性阻塞性肺疾病急性加重期合并Ⅱ型呼吸衰竭患者使用无创正压通气耐受性及安全性的临床观察

目的 评估异丙嗪是否可以提高慢性阻塞性肺疾病急性加重期（AECOPD）合并Ⅱ型呼吸衰竭患者对无创正压通气（NPPV）的耐受性及其安全性.方法 将41例因AECOPD合并Ⅱ型呼吸衰竭进行NPPV治疗的住院患者随机分为对照组和治疗组,在使用NPPV治疗前半小时,对照组给予生理盐水1 ml,治疗组给予异丙嗪25 mg,分别肌肉注射.观察NPPV治疗过程中患者PaO2、PaCO2、呼吸频率、心率、辅助呼吸肌评分以及NPPV不耐受例数.结果 治疗组患者在NPPV后2小时,PaO2、PaCO2、呼吸频率、心率、辅助呼吸肌评分均明显改善（P＜0.05）,NPPV不耐受例数明显低于对照组.NIPPV后24小时,两组患者PaO2、PaC02、呼吸频率、心率、辅助呼吸肌评分及NPPV不耐受新增例数比较,差异均无统计学意义（P＞0.05）.结论 异丙嗪可以在早期提高AECOPD合并Ⅱ型呼吸衰竭患者对NPPV的耐受性,并且安全性良好.     

Noninvasive ventilation and obstructive lung diseases.

The key role of noninvasive positive pressure ventilation (NPPV) is well documented in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) since it may avoid endotrachal intubation in >50% of cases when used as the initial treatment. However, currently only minimal data is available to assess usefulness of NPPV in COPD patients on a long-term basis. Even if such studies are difficult to manage, there is clearly a need for prospective studies comparing long-term oxygen therapy (LTOT) and NPPV in the most severe COPD in a large amount of patients and on a real long-term basis of several years. Two randomized prospective studies are being completed in Europe and the first preliminary results show that NPPV is associated with a reduction of hospitalization for chronic respiratory failure decompensation. The main beneficial effect of long-term mechanical ventilation in COPD patients with chronic respiratory failure implies a correction of nocturnal hypoventilation that could persist beyond the ventilation period because of a temporary improvement in carbon dioxide sensitivity that is often blunted in these patients. A synthesis from the literature suggest to consider NPPV for severe COPD patients who present with chronic hypoxia and hypercapnia and develop an unstable respiratory condition. Instability may be appreciated on a clinical basis and confirmed by a progressive worsening of arterial blood gas tensions, leading to frequent cardiorespiratory decompensations with ominous ARF episodes. NPPV should also be considered after an ARF episode successfully treated by noninvasive ventilation but with the impossibility to wean the patient from the ventilator. Thus, noninvasive positive pressure ventilation could be proposed as a preventive treatment in severe chronic obstructive pulmonary disease patients with unstable respiratory condition associated with fluctuating hypercapnia before, during and after an acute respiratory failure episode, avoiding the need for a tracheotomy. Adjunction of noninvasive ventilation to exercise rehabilitation is under evaluation.     

Noninvasive ventilation for acute respiratory failure: a prospective randomised placebo-controlled trial.

The aim of the present study was to clarify whether the known effects of noninvasive positive-pressure ventilation (NPPV) in patients with respiratory failure are real or due to placebo effects and whether early application of NPPV in the emergency department leads to rapid improvement of the patients condition and outcome. A prospective randomised placebo-controlled study was conducted in 20 patients with severe acute respiratory failure (ARF) secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD) or acute pulmonary oedema, not improving under conventional medical therapy and on the edge of intubation. Patients received either conventional medical therapy plus two-level NPPV (hi-level NPPV) or conventional medical therapy plus "placebo" NPPV. The main outcome measures involved the need for endotracheal intubation in the bi-level NPPV arm and in the placebo arm after crossing over to active NPPV. Morbidity, length of stay, mortality and the effect of the ventilatory mode on clinical, arterial-blood gas parameters, and the sternocleidomastoid muscles electromyogram (EMG) activity were also measured. The 10 patients in the active NPPV group rapidly improved and none needed intubation. Placebo NPPV resulted in no change in the clinical condition of patients that continued to worsen and the 10 patients were crossed over to active NPPV. Three patients were intubated. No differences in terms of morbidity, length of stay or mortality between the two groups were observed. Active NPPV (but not placebo NPPV) led to a rapid and significant improvement in the clinical parameters, pH and the carbon dioxide tension in arterial blood and to a decrease in respiratory frequency and sternocleidomastoid EMG activity. Early application of bi-level noninvasive positive-pressure ventilation in patients with severe acute respiratory failure, due to chronic obstructive pulmonary disease and acute pulmonary oedema, leads to a rapid improvement in clinical status and blood gases. Noninvasive positive-pressure ventilation had no placebo effect.     

无创正压通气治疗慢性阻塞性肺疾病急性呼吸衰竭

无创正压通气已经广泛用于慢性阻塞性肺疾病急性加重期的治疗,主要适应证包括呼吸增快、动脉氧分压下降、二氧化碳分压升高和呼吸性酸中毒,颜面部畸形、严重意识障碍、呼吸心跳停止以及血流动力学不稳定是其主要禁忌证。无创正压通气能够减轻呼吸肌负荷、减轻呼吸肌疲劳,具有降低患者病死率和气管插管率的作用。无创正压通气治疗时给予足够的压力支持和治疗时间是取得治疗效果的重要保证。     

无创正压通气治疗慢性阻塞性肺病急性加重期呼吸衰竭临床研究

目的评价无刨正压通气（NPPV）治疗慢性阻塞性肺病（COPD）急性加重期呼吸衰竭的价值。方法收集2004年01月至2006年08月住我院重症监护室（ICU）54例COPD急性加重期呼吸衰竭的患者，观察所有患者在常规治疗基础上，进行NPPV治疗后的临床表现、动脉血气的变化。结果1例不能耐受、4例改用有创机械通气，49例患者经NPPV治疗2h后呼吸困难缓解，心率、呼吸频率下降（P〈0．05），动脉血气指标、氧合指数改善（P〈0．05）。结论NPPV能明显改善COPD急性加重期呼吸衰竭的症状、低氧血症、氧合指数及二氧化碳潴留，说明NPPV治疗有效，耐受件好，并发症少。     

Nasal positive pressure ventilation in patients with acute respiratory failure. Difficult and time-consuming procedure for nurses

Intubation and mechanical ventilation are well-established techniques in the management of patients with acute respiratory failure; however, there are situations in which these procedures cannot be used safely for various reasons. A recently described noninvasive technique, nasal positive-pressure ventilation (NPPV), has been developed for home ventilation of certain patients with chronic ventilatory insufficiency. We hypothesized that NPPV could be used in selected patients in whom intubation and mechanical ventilation were clearly indicated, but not immediately possible, or even contraindicated. Six patients were treated with NPPV during an episode of acute respiratory failure and enrolled in a prospective study. We found that NPPV was successful in avoiding intubation, but only in the three patients suffering from a restrictive pulmonary disorder, whereas the procedure was unsuccessful in patients with obstructive disorders. Moreover, in every patient, acute NPPV was very time-consuming for the nursing staff: in patients with restrictive disorders, a nurse had to monitor a patient submitted to NPPV during 41 +/- 9 percent of the duration of ventilation and during 91 +/- 9 percent of the NPPV time in patients with obstructive disorders. We conclude that acute NPPV may be attempted in selected patients with acute respiratory failure, predominantly patients with restrictive respiratory disorders, but that this procedure is very time-consuming for nurses.     

Noninvasive positive pressure ventilation in patients with acute exacerbations of pulmonary tuberculosis sequelae]

To clarify whether noninvasive positive pressure ventilation (NPPV) is effective in patients with acute exacerbations of pulmonary tuberculosis sequelae (PTS), 50 PTS patients (66 episodes) without long-term domiciliary noninvasive ventilation were studied, retrospectively. The average values (SD) of their pulmonary function tests and arterial blood gases were as follows; %predicted VC = 31.4 (8.4)%, pH = 7.29 (0.06), PaCO2 = 91.8 (19.7) mmHg, and PaO2 = 64.2 (20.3) mmHg. The probability of avoiding endotracheal intubation and recovering from an acute exacerbation with NPPV (NPPV success rate) was 92% as a whole. NPPV success rates according to the causes of deterioration were as follows; 96% in 26 episodes with only a simple right heart failure, 93% in 29 episodes with airway infectious diseases, 75% in eight episodes with pneumonia and/or acute respiratory distress syndrome. Moreover, the NPPV success rate of eight episodes in coma or semicoma was 88%. Most patients were treated in respiratory wards rather than intensive care units. Out of 46 patients who recovered from an acute exacerbation, 41 finally received domiciliary NPPV. In facilities where staff are well-trained for an acute NPPV, patients with exacerbations of PTS can be treated as successfully with NPPV as patients with COPD.