无创正压通气在COPD有创-无创序贯通气中的应用

目的探讨慢性阻塞性肺病(chronic obstructive pulmonary disease,COPD)并发重症呼吸衰竭行有创机械通气患者,以"肺部感染控制窗"的出现为切换点序贯无创正压通气(non-invasive positive pressure ventilation,NIPPV)进行撤机的效果。方法选择2009年1月-2010年9月新疆医科大学第一附属医院呼吸加强治疗病房(RICU)及急诊科加强治疗病房(EICU)收治的16例COPD急性加重行气管插管接有创机械通气的患者为序贯组,在临床上出现"肺部感染控制窗"后,立即拔除气管插管序贯经面罩无创正压通气渐至脱机。选取同期因COPD并发重症呼吸衰竭行有创机械通气并常规撤机拔管的15例患者为对照组,对照组患者在"肺部感染控制窗"出现后继续按常规行有创机械通气,以压力支持通气(PSV)方式撤机。观察两组病例治疗前后血气分析变化情况、有创和总机械通气时间、住RICU天数及复插率、院内死亡率的发生情况和总住院费用。结果与撤机前比较,对照组撤机后的pH值减低,PaCO2升高,差异有统计学意义(P<0.05)。撤机后1h序贯组PaCO2较对照组升高,差异有统计学意义(P<0.05)。撤机后24h序贯组的pH值高于对照组,而PaCO2低于与对照组,差异均有统计学意义(P<0.05)。与对照组比较,序贯组再插管率降低,有创机械通气时间减少,RICU入住时间缩短,住院死亡率降低及总住院费用减少,差异有统计学意义(P<0.05)。但两组总机械通气时间比较差异无统计学意义(P>0.05)。结论对因肺部感染导致COPD急性加重并发呼吸衰竭插管上机的病例,在肺部感染控制窗出现后早期拔管,序贯面罩无创正压通气进行撤机,是一种安全、经济、有效的治疗策略。

The application of non-invasive positive pressure ventilation in sequential non-invasive following invasive mechanical ventilation in the patient of COPD

Objective To investigate the efficacy of non-invasive positive pressure ventilation in sequential mechanical ventilation in chronic obstructive pulmonary disease(COPD) patients with severe respritory failure at the time ’pulmonary infection control’ window.Methods Sixteen patients with severe respiratory failure from January 2009 to September 2010 in Respiratory Intensive Care Unite(RICU) and Emergency Intensive Care Unite(EICU) of The First Affiliated Hospital of Xinjiang Medical University,treated by tracheal intubation connected with invasive mechanical ventilation as sequential group,extubation when the ’pulmonary infection control window’ appeared,sequential non-invasive positive pressure ventilation with face mask was used,until weaning.Fifteen patients in the same period with the same condition were chose as the control group,continue invasive mechanical ventilation was taken when the ’pulmonary infection control window’ appeared,used the way of pressure support ventilation(PSV) until weaning.Compared the blood gas analysis of two group,observed the time of invasive mechanical ventilation and total ventilation,days in RICU,re-intubation rate,death rate of two groups.Results In the control group,the pH value reduced,the PaCO2 increased after weaning,the difference was statistically significant(P<0.05).1 h after weaning,PaCO2 of sequential group advanced compared with the control group,the difference was statistically significant(P<0.05).24 h after weaning,the pH was higher and PaCO2 was lower in the sequential group than those in the control group,the difference was statistically significant(P<0.05).Compared with the control group,sequential group had the less reintubation rate,invasive mechanical ventilation,RICU occupancy time,lower hospital mortality and a decrease in total hospital costs,the difference was statistically significant(P<0.05).However,the total mechanical ventilation time difference between two groups was statistically significant(P>0.05).Conclusion As to the acute exacerbate COPD patiens treated by tracheal intubation connected with invasive mechanical ventilation caused by pulmonary infection,use the strategy of early extubation sequential non-invasive following short-term invasive mechanical ventilation at the piont of PIC window,it is a safe,economics and effective treating strategy.