有创机械通气-高流量氧疗序贯治疗慢性阻塞性肺疾病所致急性呼吸衰竭的临床研究

目的评价有创机械通气-经鼻高流量氧疗（HFNC）序贯性治疗慢性阻塞性肺疾病（COPD）所致急性呼吸衰竭患者的可行性与临床效果。 方法以2017年3月至2018年5月间盐城市第一人民医院重症医学科（ICU）收治的支气管-肺部感染所致COPD急性呼吸衰竭且需有创机械通气的患者为研究对象。出现肺部感染控制窗（PIC）后随机分为有创-无创序贯治疗组（NIV组）和有创-高流量氧疗序贯治疗组（HFNC组）。观察2组患者一般资料以及急性生理与慢性健康评分Ⅱ（APACHE Ⅱ）、全身性感染相关性功能衰竭评分（SOFA）、临床肺部感染评分（CPIS）；出窗时全身炎症性指标、呼吸力学指标；出窗时及序贯治疗2 h后呼吸、循环指标；48 h再插管率、面部压力性损伤发生率、住ICU时间、住院病死率。 结果（1）共纳入73例患者，其中NIV组38例，HFNC组35例。2组患者入组时一般资料以及APACHE Ⅱ、SOFA、CPIS等评分比较，差异无统计学意义（P>0.05）。（2）2组患者出窗时间及出窗时体温（T）、白细胞计数（WBC）、降钙素原（PCT）、超敏C反应蛋白（hs-CRP）、平均动脉血压（MAP）、心率（HR）、乳酸（Lac）、呼吸频率（RR）、氧分压（PaO₂）、二氧化碳分压（PaCO₂）、氧合指数（P/F）、呼吸舒适度评分、气道阻力（R）、静态肺顺应性（Cstat）、静态内源性呼气末正压（PEEPi-stat）等指标比较，差异均无统计学意义（P>0.05）。（3）与NIV组比较，HFNC组序贯治疗2 h后HR、RR、PaCO₂显著下降［（85.42±11.80）次/min vs （99.38±11.01）次/min，t=3.717，P=0.001；（21.26±5.23）次/min vs （26.88±9.26）次/min，t=2.254，P=0.033；（48.14±5.51）mmHg vs （51.48±4.32）mmHg，t=2.057，P=0.047］，舒适度评分显著升高［（3.92±0.79）分vs（1.83±0.57）分，t=-7.358，P=0.000］。序贯治疗期间HFNC组面部压力性损伤发生率明显于低NIV组（0 vs 21.05%，χ²=8.275，P=0.004）。2组患者脱机后48 h再插管率、患者住ICU时间以及住院病死率比较，差异均无统计学意义（P>0.05）。 结论有创机械通气-HFNC序贯性治疗在改善与维持氧合、48 h再插管率、ICU住院时间、住院病死率等方面与有创-无创序贯方式相当，而且在降低PaCO₂、避免面部压力性损伤发生、提高舒适度等方面有显著的优势。

A clinical study of invasive mechanical ventilation followed by high flow nasal cannula oxygen therapy in COPD patients with acute respiratory failure

ObjectiveTo evaluate the feasibility and effect of invasive mechanical ventilation followed by high flow nasal cannula oxygen therapy (HFNC) in AECOPD patients. MethodsAECOPD patients who underwent invasive mechanical ventilation were enrolled in the study. When pulmonary infection was significantly controlled (the period of pulmonary infection control was called PIC window), the patients were randomized into the invasive mechanical ventilation followed by non-invasive mechanical ventilation therapy group (NIV group) and the invasive mechanical ventilation followed by HFNC therapy group (HFNC group). The collected data included: general information, APACHEⅡ score, SOFA score, CPIS score, the levels of inflammatory markers (T, WBC, PCT, hs-CRP) in PIC window, respiratory (RR, PaO₂, PaCO₂, P/F, breathing comfort score) and circulatory indicators(MAP, HR, Lac) at the start of PIC window and two hours after extubation, the incidence of re-intubation rate in 48 hours, the incidence of facial stress injury, and hospital mortality. Results(1) 73 patients were enrolled in the study, 38 patients in the NIV group and 35 patients in the HFNC group. General conditions, the scores of APACHEⅡ, SOFA, and CPIS were similar between the two groups. (2) There was no significant difference between the two groups regarding T, WBC, PCT, hs-CRP, MAP, HR, Lac, RR, PaO₂, PaCO₂, P/F, breathing comfort score, R, Cstat, and PEEPi-stat at the beginning of PIC window. (3) Two hours after extubation the HR, RR and PaCO₂ in the HFNC group were significantly lower than those of the NIV group (85.42±11.80) times/min vs (99.38±11.01) times/min, t=3.717, P=0.001; (21.26±5.23) times/min vs (26.88±9.26) times/min, t=2.254, P=0.033; (48.14±5.51) mmHg vs (51.48±4.32) mmHg, t=2.057, P=0.047]. The comfort score after sequential treatment for two hours in the HFNC group was (3.92±0.79), which was significantly higher than that in the NIV group (1.83±0.57) (t=-7.358, P=0.000). Moreover, the incidence of facial stress injury in the HFNC group was considerably lower than that in the NIV group (0 vs 21.05%, χ²=8.275, P=0.004). There was no significantly difference between the two groups regarding the incidence of reintubation in 48 hours, the length of ICU stay and the hospital mortality (P>0.05). ConclusionThe therapeutic effect of invasive mechanical ventilation followed by HFNC are comparable with that of the invasive mechanical ventilation followed by non-invasive mechanical ventilation regarding oxygenation level, the incidence of reintubation in 48 hours, the length of ICU stay, and hospital mortality. Noticeably, the patients using HFNC has significantly lower level of PaCO₂, incidence of facial stress injury and respiratory comfort score than those using invasive mechanical ventilation following non-invasive mechanical ventilation.