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.     

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.     

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。     

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.     

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.     

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。     

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…     

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     

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.     

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.     

无创正压通气对不同基础肺疾病合并Ⅱ型呼吸衰竭患者的疗效分析

目的:通过对无创正压通气(NIPPV)治疗非慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭与慢性阻塞性肺疾病急性加重(AECOPD)合并Ⅱ型呼吸衰竭患者的对比分析,了解NIPPV对非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭的治疗作用,评价NIPPV在治疗非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭中的治疗价值。方法:对比分析NIPPV对非慢性阻塞性肺疾病与AECOPD所致Ⅱ型呼吸衰竭的治疗效应。非慢性阻塞性肺疾病组18例,男12例,女6例,年龄(63.8±12.5)岁,其中职业性肺疾病10例(尘肺8例,石棉肺2例),脊柱后凸畸形或严重胸膜肥厚粘连5例,支气管扩张3例;AECOPD组33例,男26例,女7例,年龄(69.0±8.5)岁。结果:与NIPPV治疗前比较,非慢性阻塞性肺疾病组应用NIPPV治疗后第5天和出院前动脉血二氧化碳分压(PaCO2)显著下降(P<0.05);pH值在出院前显著改善(P<0.05);动脉血氧分压(PaO2)在应用NIPPV治疗后及出院时各时间点均显著升高(P<0.05)。在AECOPD组同NIPPV治疗前比,应用NIPPV治疗后各时间点和出院前PaCO2均显著下降(P<0.05),pH值显著改善(P<0.05);同NIPPV治疗前比,应用NIPPV治疗第2天、第3天、第5天和出院前PaO2显著升高(P<0.05)。结论:NIPPV对非慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭和AECOPD合并Ⅱ型呼吸衰竭均有较好的治疗效果。NIPPV治疗AECOPD所致Ⅱ型呼吸衰竭与非慢性阻塞性肺疾病相比,pH值和二氧化碳潴留改善得更快,而氧合在非慢性阻塞性肺疾病组改善得更快。NIPPV可用于非慢性阻塞性肺疾病所致Ⅱ型呼吸衰竭的抢救治疗。     

慢性阻塞性肺疾病的家庭无创通气治疗

家庭无创通气（HMV）通常采用无创正压通气（NPPV）,已经明确HMV治疗神经肌肉障碍性疾病,胸廓畸形和睡眠呼吸障碍性疾病导致的呼吸衰竭可以延长生命,缓解症状和改善生活质量。HMV治疗慢性阻塞性肺疾病（COPD）的结论不尽一致,HMV治疗重度COPD患者可缓解呼吸困难,多数研究表明HMV可改善生活质量,减少COPD急性加重。近期的研究表明,HMV时采用较高吸气压力支持水平治疗伴二氧化碳潴留的稳定期COPD患者,可以改善气体交换,肺功能和呼吸困难,减少COPD急性加重,而且具有较好的治疗依从性。     

Depression in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in adults in the United States and worldwide. Depression is a common comorbidity in this population, but often goes undiagnosed in persons with COPD. Because the presence of depression has the potential to negatively impact COPD-related outcomes, it is essential for health care practitioners involved in the care of patients with COPD to diagnose and treat COPD and the associated comorbidities, including depression. Although there is a lack of comprehensive guidelines for treating depression in those with COPD, an algorithm has been proposed to screen and manage depression in these patients. Several questionnaires are available that can be used to assess and assist in diagnosing depression in these patients. Following diagnosis, antidepressant therapy should be considered along with nonpharmacological strategies, such as pulmonary rehabilitation and cognitive behavioral therapy.