Hypophosphatemia induced by mechanical ventilation in patients with chronic obstructive pulmonary disease

The aim of this study was to assess prospectively the variations of serum phosphorus concentration (P) after onset of mechanical ventilation (MV) in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory acidosis. In 14 COPD patients, we measured P, PaCO2, and pH, immediately before MV (H0), then one hour (H1), 4 (H4), 7 (H7), 12 (H12), and 24 h (H24) after starting MV. P at H0 was in or above the normal range in ten patients and below normal range in four patients. P decreased significantly (p less than .001) after MV at H1, H4, H7, H12, and H24. Hypophosphatemia was present in all patients after MV, but was severe (p less than .3 mmol/L) in only two patients. There was a significant correlation (r = .56 p less than .01) between the decrease of P and the increase of pH after MV. Hypophosphatemia was a constant and early finding after institution of MV in COPD patients and was presumably related to an intracellular shift of P secondary to the correction of respiratory acidosis.     

慢性阻塞性肺疾病机械通气患者两种不同通气模式的比较

目的探讨适应性支持通气（ASV）在慢性阻塞性肺疾病（COPD）机械通气患者中的应用。方法24例存在自主呼吸行机械通气的COPD患者随机分成两组,一组先使用辅助／控制通气（A／C）模式后改为ASV模式,另一组先使用A／C模式后改为同步间歇指令通气联合压力支持通气（SIMV＋PSV）模式,采用对照性研究方法,比较前后两种通气模式对患者的呼吸力学、血流动力学和血气分析的影响,以及两组间的有创通气时间、机械通气总时间、撤机成功率及调机次数。结果从A／C模式改为ASV后患者的呼吸频率（RR）、气道峰压（Pp）、平均气道压（Pro）、气道闭合压（P0．1）和浅快呼吸指数（RSB）下降,潮气量（VT）和肺顺应性（C）上升（P〈0．01）;从A／C模式改为SIMV＋PSV后RR、Pp、Pm、P0.1和RSB下降（P〈0．01）。两组其余呼吸力学、血流动力学及血气分析指标变更模式前后差异均无统计学意义,两组之间的有创通气时间、机械通气总时间、撤机成功率差异无统计学意义,但是ASV组的调机次数明显少于SIMV＋PSV组（8．5±2．2vs13．1±3．1,P〈0．01）。结论ASV和SIMV＋PSV与A／C比较能在一定程度上降低呼吸负荷,保护肺组织。运用于撤机时两种模式效果无明显差别,但ASV操作相对简单,适合于临床医师使用。     

Intrapulmonary haematoma complicating mechanical ventilation in patients with chronic obstructive pulmonary disease

Intrapulmonary haematomas occurred during mechanical ventilation of two patients with advanced chronic obstructive pulmonary disease and bullous dystrophy. In both cases, the haematomas were revealed by blood-stained aspirates, a fall in haemoglobin level, and the appearance of radiological opacities. Haematoma occurrence in the area of a bulla which recently has rapidly increased in size, suggests that the haematoma is due to the rupture of stretched vessels embedded in the wall of the bulla.     

Noninvasive ventilation for chronic obstructive pulmonary disease

Noninvasive positive-pressure ventilation (NPPV) should be considered a standard of care to treat COPD exacerbations in selected patients, because NPPV markedly reduces the need for intubation and improves outcomes, including lowering complication and mortality rates and shortening hospital stay. Weaker evidence indicates that NPPV is beneficial for COPD patients suffering respiratory failure precipitated by superimposed pneumonia or postoperative complications, to allow earlier extubation, to avoid re-intubation in patients who fail extubation, or to assist do-not-intubate patients. NPPV patient-selection guidelines help to identify patients who need ventilatory assistance and exclude patients who are too ill to safely use NPPV. Predictors of success with NPPV for COPD exacerbations have been identified and include patient cooperativeness, ability to protect the airway, acuteness of illness not too severe, and a good initial response (within first 1-2 h of NPPV). In applying NPPV, the clinician must pay attention to patient comfort, mask fit and air leak, patient-ventilator synchrony, sternocleidomastoid muscle activity, vital signs, hours of NPPV use, problems with patient adaptation to NPPV (eg, nasal congestion, dryness, gastric insufflation, conjunctival irritation, inability to sleep), symptoms (eg, dyspnea, fatigue, morning headache, hypersomnolence), and gas exchange while awake and asleep. For severe stable COPD, preliminary evidence suggests that NPPV might improve daytime and nocturnal gas exchange, increase sleep duration, improve quality of life, and possibly reduce the need for hospitalization, but further study is needed. There is consensus, but without strong supportive evidence, that COPD patients who have substantial daytime hypercapnia and superimposed nocturnal hypoventilation are the most likely to benefit from NPPV. Adherence to NPPV is problematic among patients with severe stable COPD.     

无创通气治疗慢性阻塞性肺疾病急性加重期并肺性脑病临床研究

目的研究无创通气对慢性阻塞性肺疾病急性加重期(AECOPD)并肺性脑病患者的临床疗效。方法回顾性分析2008年6月至2012年6月在粤北人民医院呼吸内科行无创通气的AECOPD并肺性脑病的78例患者的临床资料,监测通气前及通气后2、12及24 h后的血气分析变化,观察患者的治疗转归及无创正压通气治疗的不良反应。结果与通气前比较,通气后患者临床症状逐渐改善,动脉血二氧化碳分压水平降低(P<0.01),动脉血氧分压水平升高(P<0.01),pH值升高(P<0.01)。结论无创通气对AECOPD并肺性脑病的患者有良好的治疗效果,值得临床推广。     

无创正压通气在慢性阻塞性肺疾病所致严重呼吸衰竭机械通气脱机过程中的应用

目的 探讨无创正压通气在慢性阻塞性肺疾病(COPD)并发呼吸衰竭患者有创机械通气撤机后的应用时机及治疗效果.方法 选择36例COPD患者,随机选取18例行气管插管机械通气并作为实验组,以同步间歇指令通气(SIMV) 压力支持通气(PSV) 呼气末正压(PEEP)方式行机械通气,待肺部感染控制窗出现,拔除气管插管,改为经面罩BIPAP无创通气,逐渐脱机.余18例做为对照组,行常规有创通气,最后以PSV方式至撤机.现察两组病例的呼吸机相关性肺炎(VAP)的发生例数、病死率、机械通气天数、总住院天数、动脉血气分析.结果 实验组住院时间少于对照组,(21.1±1.8)天vs(27.1±1.4)天(P<0.05);机械通气时间为(11.4±0.8)天vs(14.8±2.4)天(P<0.05);呼吸机相关性肺炎发生率为0 vs 5例(P<0.01);死亡例数为1例vs 4倒.实验组撤机前后血气分析比较差异无统计学意义(P>0.05);对照组撤机后pH降低、PaCO2升高(P<0.05).结论 对COPD并发呼吸衰竭患者采用早期有创机械通气,序贯应用无创正压通气可以显著降低VAP发生率,提高撤机成功率,缩短住院时间.     

High-frequency oscillatory ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease

Purpose

High-frequency oscillatory ventilation (HFOV) is usually considered not indicated for treatment of patients with chronic obstructive pulmonary disease (COPD) because of the theoretical risk of air trapping and hyperinflation. The aim of our study was to establish whether HFOV can be safely applied in patients with acute exacerbation of COPD and hypercapnic respiratory failure.

Methods

Ten patients (age, 63-83 years) requiring intensive care treatment who failed on noninvasive ventilation were studied. After initial conventional mechanical ventilation (CMV) of less than 72 hours, all patients were transferred to HFOV for 24 hours and then back to CMV. Arterial blood gases, spirometry, and hemodynamic parameters were repeatedly obtained in all phases of CMV and HFOV at different settings. Regional lung aeration and ventilation were assessed by electrical impedance tomography.

Results

High-frequency oscillatory ventilation was tolerated well; no adverse effects or severe hyperinflation and hemodynamic compromise were observed. Effective CO₂ elimination and oxygenation were achieved. Ventilation was more homogeneously distributed during HFOV than during initial CMV. Higher respiratory system compliance and tidal volume were found during CMV after 24 hours of HFOV.

Conclusions

Our study indicates that short-term HFOV, using lower mean airway pressures than recommended for acute respiratory distress syndrome, appears safe in patients with COPD while securing adequate pulmonary gas exchange.     

Effects of low-dose dopamine on ventilation in patients with chronic obstructive pulmonary disease

BACKGROUND: Dopamine plays an important role in the regulation of respiration and low-dose dopamine infusion is associated with a decreased respiratory drive response to hypoxia in animals and humans. The effects of dopamine on ventilation in patients with chronic obstructive pulmonary disease (COPD) is unknown. We tested the hypothesis that dopamine inhibits ventilation in patients with COPD. MATERIALS AND METHODS: In a double-blinded, cross-over, placebo-controlled, randomized study we studied nine patients with decompensated COPD, ventilated in the pressure support mode in the intensive care unit (ICU) and five ambulatory patients with stable COPD. All patients received 5 micro g kg(-1) min(-1) of dopamine or an equivalent volume of 5% glucose solution. RESULTS: In the mechanically ventilated COPD patients, there was no difference in the effects of dopamine compared with placebo on blood pressure, heart rate, minute ventilation (-0.5 +/- 1.1 vs. -0.2 +/- 0.9 L min(-1), P = 0.46, respectively), respiratory rate (-0.4 +/- 2.7 vs. -0.3 +/- 2.1 min(-1), P = 0.96), PaO(2) (-5 +/- 4 vs. -5 +/- 10 mmHg, P = 0.90, respectively), or PaCO(2) (-0.7 +/- 1.4 vs. -1.0 +/- 3.4 mmHg, P = 0.83, respectively). In spontaneously breathing stable patients, dopamine increased systolic blood pressure (P = 0.02) but did not influence other haemodynamic and respiratory variables. CONCLUSION: Although low-dose dopamine has been shown to depress ventilation in a variety of conditions, it does not compromise ventilation in COPD patients either breathing spontaneously or when weaned using pressure support ventilation.     

Efficacy of short-term intrapulmonary percussive ventilation in patients with chronic obstructive pulmonary disease

Abstract

Purpose: We evaluated the effectiveness of intrapulmonary percussive ventilation (IPV) compared to traditional standard chest physical therapy (CPT) in patients with chronic obstructive pulmonary disease (COPD) and productive cough.

Methods: We conducted a quasi-experimental clinical trial. Twenty patients, 40% female (mean?±?SD age: 70?±?8 years), with COPD and productive cough received a multimodal respiratory treatment including IPV and CPT or a control intervention CPT for 10 days. Outcomes: P_Imax, P_Emax, heart rate, respiratory rate, SBP, DBP, Likert scale, Borg dyspnea scale and arterial blood gas analysis: PO₂, PCO₂, pH, HCO₃ and SpO₂ measurements. All measures were collected at baseline and at the end of the intervention. We used repeated ANOVA to examine the effects of interventions within groups, between-subjects and the within-subjects.

Results: A significant effect of time interaction (F?=?7.27; p?=?0.015, F?=?6.16; p?=?0.02 and F?=?7.41; p?=?0.014) existed for PO₂, SpO₂ and dyspnea over the moderate COPD and productive cough immediately after the intervention (all, p?<?0.02). Both treatments are similarly effective in P_Imax and P_Emax. No significant group effect or group-by-time interaction was detected for any of them, which suggests that both groups improved in the same way.

Conclusions: This study provides evidence that a short-term combination of IPV and CPT improves PO₂, SpO₂ and perceived dyspnea than a traditional standard CPT in patients with COPD and productive cough.

• Implications for Rehabilitation

• We suggest that it could improve the oxygenation level on chronic obstructive pulmonary disease (COPD) patients. Beyond that, the intrapulmonary percussive ventilation (IPV) is a safety non-pharmacologic airway clearance therapy that can be used on patients with different sorts of respiratory diseases, and there are still questions to be answered, especially concerning the volume of secretion removed and its superiority when compared with other techniques.

     

慢性阻塞性肺疾病患者机械通气时间的影响因素

目的 探讨影响慢性阻塞性肺疾病(COPD)患者机械通气(MV)时间的危险因素.方法 回顾性研究128例COPD合并呼吸衰竭患者插管前及通气过程中的临床指标.单凶素分析采用t检验、秩和检验及X2检验.将统计意义的变量导人多元逐步togis～e回归分析.结果 NV>7 d、14 d和21 d的患者比例分别为61%、20%和9%.MV>7 d、14 d和21 d的患者,分别与MV≤7 d、14 d和21 d的患者进行比较,在COPD病史、吸烟指数、肺功能和合并症等方面差异无统计学意义(P<0.05).多因素回归分析显示,APACHEⅡ评分是影响MV>7 d的独立危险因子(OR:2.3;95%CI:1.2～5.7,P=0.02);影响MV>21 d的危险因素是休克(OR:0.7;95%CI:1.0～1.9,P=0.04)和低白蛋白水平(OR:0.4,95%CI:0.2～0.8,P=0.003);机械通气相关性肺炎(VAP)是影响机械通气时间最重要的危险因素(P<0.05).结论 APACHEⅡ评分、血清白蛋白水平、发生休克或VAP是影响COPD患者机械通气时间的主要因素.     

慢性阻塞性肺疾病合并呼吸衰竭的肺保护性通气研究

目的 研究慢性阻塞性肺疾病(chronic obstructive pulmonary disease COPD)合并呼吸衰竭患者进行小潮气量机械通气的肺保护效果。方法 35例COPD合并呼吸衰竭患者分为小潮气量组(17例)和常规潮气量通气组(18例),观察两组患者机械通气后支气管肺泡灌洗液(BALF)中肿瘤坏死因子α(TNF—α)、白细胞介素-6(IL-6)、白细胞介素-8(IL-8)的变化,机械通气期间发生呼吸机相关性肺损伤的情况,机械通气时间、平均住院时间及最终预后情况。结果 两组患者在存活率方面差异无显著性意义;小潮气量组机械通气后BALF中TNF—α、IL-6、IL-8的水平明显低于常规通气组;小潮气量组气压伤发生率、机械通气时间、住院时间也明显少于常规通气组。结论 对于COPD合并呼吸衰竭患者,选用小潮气量进行机械通气,可以减轻机械牵拉诱发的细胞因子释放,减轻机械通气相关性肺损伤,缩短机械通气时间和住院时间。     

音乐对慢性阻塞性肺病机械通气病人的影响

随着医学的进步以及人们对疾病认识程度的不断加深,特别是呼吸机的应用使慢性阻塞性肺疾病(COPD)病人呼吸衰竭时不再束手无策。可是机械通气、治疗操作、ICU特殊的环境、噪音的影响、没有亲人陪伴的孤独,加之疾病本身的痛苦,使病人产生焦虑、恐惧。而人机对抗时镇静药物的应用可能产生药物副反应,势必增加医药费用,甚至产生更多的问题。音乐主要影响人的高级神经活动,从而达到调节情绪、镇痛、降压、催眠等作用[1]。近3年来我院ICU对34例COPD病人实施了音乐疗法,现将应用体会报告如下。1临床资料将2002年6月—2006年3月入住我院ICU的…     

音乐对慢性阻塞性肺病机械通气病人的影响

随着医学的进步以及人们对疾病认识程度的不断加深，特别是呼吸机的应用使慢性阻塞性肺疾病（COPD）病人呼吸衰竭时不再束手无策。可是机械通气、治疗操作、ICU特殊的环境、噪音的影响、没有亲人陪伴的孤独。加之疾病本身的痛苦，使病人产生焦虚、恐惧。而人机对抗时镇静药物的应用可能产生药物副反应，势必增加医药费用，甚至产生更多的问题。     

Pulmonary gas exchange response to weaning with pressure-support ventilation in exacerbated chronic obstructive pulmonary disease patients

OBJECTIVE: To assess if pressure-support ventilation (PSV) can improve ventilation-perfusion (V(A)/Q) imbalance observed during the transition from positive-pressure ventilation to spontaneous breathing in intubated chronic obstructive pulmonary disease (COPD) patients during weaning. DESIGN: Prospective study. SETTING: Respiratory intensive care unit of a tertiary university hospital. PATIENTS: Seven mechanically ventilated COPD male patients (age 68+/-6 (SD) years; FEV(1) 26+/-6% predicted) during weaning. INTERVENTIONS: Patients were studied during three ventilatory modalities: (1) assist-control ventilation (ACV), tidal volume (V(T)), 8-10 ml. kg(-1); (2) PSV aimed to match V(T)in ACV, 15+/-1 cmH(2)O and (3) spontaneous breathing. MEASUREMENTS AND RESULTS: Arterial and mixed venous respiratory blood gases, V(A)/Q distributions, hemodynamics and breathing pattern were measured. Compared with both ACV and PSV, during spontaneous breathing patients exhibited decreases in V(T) (of 43%, p<0.001) and increases in respiratory rate (of 79%, p<0.001), PaCO(2) (of 8.5 mmHg, p=0.001), cardiac output (of 27%, p<0.001) and mixed venous oxygen tension (of 3.4 mmHg, p=0.003), while PaO(2) remained unchanged throughout the study. Except for a shift of the pulmonary blood flow distribution to areas with lower V(A)/Q ratios (p=0.044) and an increase of dead space (of 25%, p=0.004) during spontaneous breathing, no other changes in V(A)/Q distributions occurred. No differences were shown between ACV and PSV modalities. CONCLUSION: In COPD patients during weaning, PSV avoided V(A)/Q worsening during the transition from positive-pressure ventilation to spontaneous breathing. Hemodynamics, blood gases or V(A)/Q mismatch were no different between ACV and PSV when both modalities provided similar levels of ventilatory assistance.     

99m锝-二乙三胺五乙酸气溶胶肺通气指数在慢性阻塞性肺疾病肺功能评估中的价值

目的研究99m锝-二乙三胺五乙酸(Tc-DTPA)气溶胶肺通气显像的通气指数(ventilation index,VI)与慢性阻塞性肺病(COPD)肺功能之间的关系。方法 42例COPD患者均行气溶胶肺通气显像和COPD肺功能分级。肺通气显像结束后,利用感兴趣区(region of interest,ROI)技术分析左右肺中央带、周围带的放射性分布情况,并计算得到VI。分析肺功能分级和VI之间的关系。结果 VI≥50%组第1秒用力呼气容积(FEV1%)和FEV1/用力肺活量(FVC)分别为:(51.8±18.2)%和(60.0±11.9)%,VI<50%组FEV1%和FEV1/FVC分别为(40.5±13.0)%和(51.7±9.3)%,两组之间差异有统计学意义(P<0.05)。且FEV1%和VI之间有很好的相关性(r=0.391,P<0.05),FEV1/FVC与VI之间也有很好的相关性(r=0.517,P<0.01)。但FVC与VI之间无相关性(r=0.123,P>0.05)。结论 VI和COPD肺功能分级之间有很好的相关性。VI可直接和准确的预测和显示肺内的气体分布。联合应用VI和COPD分级能更准确的评估肺功能。     

慢性阻塞性肺疾病机械通气病人的营养支持与护理

慢性阻塞性肺疾病(COPD)是一种以气流受限为特征的疾病,COPD病人营养不良的发生率为25%～65%,随着病情的发展,营养不良逐步加重[1]。营养不良、免疫低下和严重感染是COPD病人重要的致病因素,三者互为因果,形成恶性循环。有研究表明,营养不良也是影响COPD病人预后的一个重要因     

Noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease in patients with and without home noninvasive ventilation

OBJECTIVE: The frequency of home ventilation has increased greatly. The objective of the study was, first, to compare the outcome of episodes of acute exacerbation of chronic obstructive pulmonary disease treated with mask intermittent positive-pressure ventilation (MIPPV) in patients with home MIPPV and in patients without home ventilatory support and, second, for each category of patients, to compare patients successfully ventilated with MIPPV with those who failed with MIPPV. DESIGN: Prospective, controlled, nonrandomized clinical study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: In the groups with and without home MIPPV, respectively, 31 and 78 episodes of acute exacerbations of chronic obstructive pulmonary disease were studied. INTERVENTIONS: MIPPV was performed in a sequential mode and delivered through a full-face mask with a bilevel positive airway pressure system. MEASUREMENTS AND MAIN RESULTS: The clinical and functional characteristics of the two groups, at admission, were similar. In groups with and without home ventilation, respectively, success rates were 68% and 72% (p =.68), length of intensive care unit stay was 8 +/- 6 and 10 +/- 4 days (p =.02), and intensive care unit deaths were 13% and 8% (p =.30). In survivors and in groups with and without home ventilation, respectively, the total time of ventilatory assistance in intensive care unit was 5 +/- 4 and 8 +/- 4 days (p =.004), and the length of intensive care unit stay was 7 +/- 5 and 10 +/- 4 days (p =.003). A greater correction of pH, after 45 mins of MIPPV with optimal settings, was recorded in the success patients than in the failure patients, respectively; in the group with home MIPPV, the pH after 45 mins was 7.34 +/- 0.04 vs. 7.31 +/- 0.04 (p =.06), and in the group without home MIPPV, pH was 7.34 +/- 0.04 vs. 7.30 +/- 0.04 (p =.001). CONCLUSION: MIPPV may also be favorable during episodes of acute exacerbations in patients with chronic obstructive pulmonary disease. Experience with MIPPV could benefit selected patients in the management of acute respiratory failure.     

Another step for noninvasive ventilation in chronic obstructive pulmonary disease patients!

The use of noninvasive positive pressure ventilation (NPPV) in chronic obstructive pulmonary disease (COPD) patients who are not eligible for the technique because of their incapability to spontaneously eliminate accumulated secretions associated with hypercapnic encephalopathy is not recommended and is often considered a contraindication. In a case-control study, an experienced team reported the feasibility and safety of the use of NPPV with early fibreoptic bronchoscopy in selected acutely decompensated COPD patients with hypercapnic encephalopathy, and reported the patients' inability to spontaneously clear copious secretions. The reported data suggest that this innovative therapeutic may be considered as a potential alternative to endotracheal intubation.