经鼻高流量氧疗在急危重症患者气管插管前预充氧的应用思考

<正>目前在重症加强治疗病房(intensive care unit,ICU)超过60%的患者需要气管插管^[1],同时作为一种高风险侵入性治疗方式,对于部分疾病引起的生理性气道困难,或因肥胖和怀孕等导致的解剖困难,可导致插管困难或不及时,插管过程中易发生低氧血症、血流动力学不稳定、凝血障碍、呼吸机相关性肺炎等,严重时可导致心搏骤停^[2-3]。自Frumin等^[4]在1959年首次通过鼻导管对手术患者插管前给予预充氧,再到2015年有关指南建议所有插管的患者都应预充氧^[5],预充氧技术取得了较大的发展。     

经鼻高流量氧疗在呼吸危重症中的应用

经鼻高流量氧疗是新型的呼吸支持技术,近年来在临床中迅速普及推广。其在许多呼吸功能不全的疾病中得到广泛应用,例如急性低氧性呼吸衰竭、伴高碳酸血症的呼吸衰竭以及辅助有创通气气管插管拔管等方面。然而,经鼻高流量氧疗仍缺乏高质量证据证实其有效性,因此临床中使用时更应谨慎把握适应证。     

经鼻高流量氧疗治疗急性呼吸衰竭的参数设置

经鼻高流量氧疗广泛应用于急性呼吸衰竭治疗,可以改善患者氧合状况、呼吸功和肺脏气体分布.通过调整氧浓度、湿化罐温度和气体流量三个参数,经鼻高流量氧疗提供高浓度氧气、湿化吸入气体和高流量气体.气体温度过低会影响呼吸道黏液纤毛功能,温度过高则影响患者舒适性.气体流量过低不但降低吸入氧气浓度,改善呼吸功作用也有限.为保证最佳治...     

经鼻高流量湿化氧疗对呼吸衰竭患者治疗的研究进展

氧疗是急性呼吸衰竭的一线治疗策略,其中非侵入性氧疗包括无创正压通气(NPPV)、标准氧(鼻导管吸氧)和经鼻高流量(HFNC)湿化氧疗.HFNC是新型辅助呼吸方式,近几年在临床上得到快速普及并推广.虽然HFNC是一种新型的呼吸支持技术,但其在临床的规范使用和适用范围尚需进一步临床研究.为了能更好地挽救患者生命,并积极促进...     

经鼻高流量氧疗

经鼻高流量氧疗(high-flow nasal oxygen,HFNO)是一种新型的氧疗技术,近年来开始逐步在临床普及应用。经过临床研究的不断探索,发现HFNO相较于传统氧疗具有诸多优势,并且在部分呼吸衰竭患者中的应用效果与无创通气相似,这为呼吸衰竭患者的呼吸支持提供了新的选择和思路。但其临床具体适应证仍不明确,因此现阶段应重视HFNO的临床使用规范,而其适用范围仍需临床研究的进一步探索。该文就其研究概况进行综述。     

经鼻或口气管插管和气管切开在呼吸衰竭患者中的应用探讨

目的研究经鼻或口气管插管和气管切开在呼吸衰竭患者中的治疗效果。方法128例呼吸衰竭患者随机分为A（48例）、B（40例）、C（40例）三组,A组患者经鼻气管插管,B组患者经口气管插管,C组患者行气管切开,观察三组患者治疗前后血气变化、置管时间、肺部感染等情况。结果三组呼吸衰竭患者血气改善时间和血气变化无显著差异,但是A组具有置管时间短、肺部感染少和降低了死亡率等优点。结论经鼻气管插管对呼吸衰竭患者有更好的临床应用价值,安全有效,值得临床推广应用。     

经鼻高流量氧疗在合并共病的老年急性呼吸衰竭病人中的应用价值

目的 探索经鼻高流量氧疗(high-flow nasal insufflation,HFNI)在合并共病的老年急性呼吸衰竭病人中的治疗效果,期望为病人提供安全且更加舒适、耐受的供氧方式.方法 通过对HFNI与无创通气(nonin-vasive ventilation,NIV)进行比较,分析其在合并共病的老年急性呼吸衰竭...     

经鼻持续气道正压通气对婴儿心脏术后机械通气撤机后呼吸功能不全的疗效

目的 探讨经鼻持续气道正压通气（NCPAP）对小婴儿心脏术后机械通气撤离后呼吸功能不全的作用.方法 对15例＜6个月的心脏体外循环术后气管插管呼吸机撤离后呼吸功能不全患儿行NCPAP治疗,并观察治疗效果.结果 经过治疗,13例患儿烦躁、呼吸困难症状和低氧血症改善;2例中途再次给予插管机械辅助2 d后,再次给予NCPAP,成功脱离呼吸机,患儿逐渐恢复.结论 NCPAP对小婴儿心脏术后机械通气撤离后呼吸功能不全具有较好的呼吸支持作用.     

Efficacy and safety of high-flow oxygen therapy application for chronic obstructive pulmonary disease with acute hypercapnic respiratory failure: A protocol for systematic review and meta-analysis

Background:Presently, there are no reviews or meta-analyses comparing the efficacy and safety of high-flow oxygen therapy (HFOT) and noninvasive ventilation (NIV) as first-line treatment in exacerbated chronic obstructive pulmonary disease (COPD) patients. The present protocol is conceived to evaluate whether HFOT is noninferior to NIV in treatment of patients with COPD and acute hypercapnic respiratory failure.Methods:We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and the recommendations of the Cochrane Collaboration to conduct this meta-analysis. Reviewers will search the PubMed, Cochrane Library, Web of Science, and EMBASE online databases using the key phrases “high-flow oxygen therapy,” “chronic obstructive pulmonary disease,” and “acute hypercapnic respiratory failure” for all English-language cohort studies published up to April, 2021. The cohort studies focusing on assess the efficacy and safety of HFOT and NIV in the treatment of patients with COPD and acute hypercapnic respiratory failure will be included in our meta-analysis. The primary outcome is treatment failure, whereas the secondary outcomes included arterial blood gas analysis, dyspnea score, comfort score, mortality, and total ICU and hospital lengths of stay.Results:The trial is conducted to test the hypothesis that HFOT, administered immediately after extubation, is not inferior to the NIV in reducing the rate of treatment failure in patients with COPD who were previously intubated due to hypercapniac respiratory failure.Registration number:10.17605/OSF.IO/Z2PEJ.     

体质量指数与ARDS发病率的荟萃分析

目的 采用荟萃分析的方法系统评价体质量指数(body mass index,BMI)对ARDS发病率的影响.方法 以“obese or overweight or body mass index or BMI"和“ARDS or acuterespiratory distress syndrome”为关键词,计算机检索Pubmed、EMBASE、Cochrane databases、Wiley、Ovid、Medline、CNKI、VIP、Wan fang数据库中关于BMI与ARDS发病率的相关文献,运用RevMan 5.0及stata 10.0软件进行荟萃分析.结果 共纳入14篇文献,共29 962例患者.荟萃分析结果显示:肥胖与ARDS发病率明显相关(OR =1.70,95％ CI 1.44～2.00,P＜0.01).亚组分析结果显示:与正常体质量患者比较,低体质量(BMI≤18.5 kg/m2)及超重(BMI 25～29.9 kg/m2)患者ARDS发病率差异无统计学意义(OR =1.21,95％ CI 0.72～2.02,P=0.47和OR =1.21,95％CI0.94～1.55,P=0.13);肥胖患者(BMI 30-39.9 kg/m2和BMI≥30 kg/m2)ARDS发病率较正常体质量患者明显升高(BMI 30～39.9 kg/m2:OR=1.35,95％ CI 1.12～1.63,P=0.002;BMI≥30kg/m2:OR =1.75,95％ CI 1.42～2.15,P＜0.01);重度肥胖(BMI≥40 kg/m2)患者ARDS发病率是正常体质量患者的1.85倍(OR =1.85,95％ CI 1.40～2.44,P＜0.01).结论 BMI是ARDS发病的独立危险因素之一.随着BMI增加,ARDS患病率明显升高.     

经鼻高流量湿化氧疗在COPD合并呼吸衰竭病人肺康复中的近期及远期疗效研究

目的探讨高流量湿化氧疗对COPD合并呼吸衰竭病人血气指标、肺部功能,近期、远期疗效的影响。方法以我院2017年1月至2020年5月老年病科收治的82例COPD合并呼吸衰竭病人作为观察对象,分为观察组42例和对照组40例。观察组病人给予高流量湿化氧疗,对照组给予无创正压通气治疗,比较2组病人干预后3 d的血气指标、肺功能、治疗效果、并发症发生情况及6个月后6分钟步行距离(6MWD)及改良英国医学研究委员会呼吸困难指数(mMRC)、COPD评估测试(CAT)评分、Borg评分与BODE指数结果。结果治疗3 d后,观察组病人PaO_(2)、FEV1、FEV1占预计值百分比、FVC占预计值百分比、FEV1/FVC均高于对照组(P<0.05),PaCO_(2)水平低于对照组(P<0.05);观察组的治疗有效率(92.85%)高于对照组(57.50%),2组并发症发生率差异无统计学意义(P>0.05)。随访6个月后,观察组6MWD、mMRC评分高于对照组(P<0.05),CAT评分、Borg评分及BODE指数低于对照组(P<0.05)。结论高流量湿化氧疗可改善COPD合并呼吸衰竭病人的血气指标和肺功能,改善疾病预后,值得临床应用。     

Implementation of bronchoalveolar lavage using a high-flow nasal cannula in five cases of acute respiratory failure

In recent clinical practice, high-flow nasal cannula (HFNC) therapy has been used to improve oxygenation in adults with acute respiratory failure (ARF). However, bronchoscopy using HFNC in ARF has not yet been reported. Herein, we describe 5 cases of ARF where bronchoalveolar lavage (BAL) was employed successfully using an HFNC. We were able to discontinue or reduce the HFNC fraction of inspired oxygen (FiO₂) 30 min after completion of the bronchoscopy. Only 1 patient needed non-invasive positive pressure ventilation for 16 h after bronchoscopy. The HFNC may be a useful tool for ARF patients who require bronchoscopy.     

Effectiveness of high-flow nasal cannula on pulmonary rehabilitation in subjects with chronic respiratory failure

BackgroundThe effects of exercise training using both high fraction of inspired oxygen (F_IO₂) and high flow oxygen delivered through a high-flow nasal cannula (HFNC) on exercise capacity in patients with chronic respiratory failure (CRF) receiving long-term oxygen therapy (LTOT) are unknown.MethodsIn this randomized study, 32 patients with CRF receiving LTOT were assigned to undergo 4 weeks of exercise training on a cycle ergometer using an HFNC (flow: 50 L/min) with a F_IO₂ of 1.0 (HFNC group; n = 16) or ordinary supplemental oxygen via a nasal cannula (flow: 6 L/min) (oxygen group; n = 16). A 6-min walking test and a constant-load test were performed before and after 4 weeks of exercise training.ResultsFollowing 4 weeks of exercise training, change in the 6-min walking distance was significantly greater in the HFNC than in the oxygen group (55.2 ± 69.6 m vs. −0.5 ± 87.3 m; p = 0.04). However, there was no significant difference between the two groups in the degree of improvement in the duration of the constant-load exercise test after exercise training.ConclusionsConsidering the effect on daily activities (e.g., walking), exercise training using both high F_IO₂ and high flow through an HFNC is a potentially superior exercise training modality for patients with CRF receiving LTOT.Clinical Trial Registration — http://www.clinicaltrials.gov. Unique identifier: NCT02804243