无创正压通气减少儿童心内直视术后再次插管

目的 探讨鼻(面)罩双水平无创正压通气(bilevel positive airway pressure,BiPAP)应用于儿童心内直视术后呼吸功能不全的呼吸支持,减少再次插管的疗效.方法 将2007年1月至2007年12月在浙江大学医学院附属儿章医院行先天性心脏病(先心病)体外循环心内直视术后在拔除气管插管后表现呼吸费力、呼吸功能不全经常规治疗无效,已符合二次插管机械通气指征的25例患者进行前瞻性研究,记录无创BiPAP通气应用前后临床和动脉血气等指标的变化并进行单因素方差分析,同时分析患者的转1月.结果 (1)25例患者共30例次接受无创鼻(面)罩BiPAP.其中25例次患者(25/30,83.3%)在应用无创BiPAP通气后成功地避免了再次插管.4例患者共5例次接受无创鼻(面)罩BiPAP呼吸衰竭无法改善予气管捕管.(2)该组患者平均在撤离有创通气后9.4 h(0-72)h应用无创BiPAP治疗,BiPAP应用时间1.96 d(0.03-12)d,并发症少而轻微.(3)应用无创BiPAP治疗1 h后患者心率、呼吸频率及心率收缩压乘积显著降低(P<0.05);同时血气pH,SaO2 PaO2/FiO2显著升高(P<0.05),A-aDO2显著下降(P<0.05);4 h后PaCO2显著下降(P<0.05).结论 无创鼻(面)罩BiPAP正压通气可显著改善体外循环心内直视术后呼吸功能不全患儿的氧合,降低氧耗量,减少再次插管,是一种安全有效的无创的呼吸支持手段.

Non-invasive positive pressure ventilation reduces the rate of re-intubation in pediatric patients after cardiac surgery

Objective To evaluate the role of using non-invasive ventilation with bi-level positive airway pressure (BiPAP) in order to reduce the need of re-intubation in pediatric patients with respiratory failure after cardiac surgery. Method From January 2007 to December 2007, 25 patients aged from three months to 11 years with median 2.3 years operated on for cardiac surgery with respiratory insufficiency after extubation and re-intubation indicated were enrolled in this study. They were put on non-invasive nasal (mask) BiPAP ventilation before re-intubation. The arterial blood gas, A-aDO2 and PaO2/FiO2 were measured. In addition, clinical data including heart rate, respiratory rate, and the product of heart rate and systolic pressure were recorded before and after BiPAP. The software SPSSD 13.0 was used to process by ANOVA test for statistical analysis. Meanwhile, the outcome of these patients was analyzed. Results Twenty-five patients with 30 episodes of respiratory insufficiency were treated with BiPAP ventilation with median duration of 1.96 days ranged from 0.03 to 12 days. Of these respiratory failure episodes, 25 ones (83.3%) could be controlled by BiPAP and the needs of re-intubation were avoided. Five episodes of respiratory failure in 4 patients could not be quelled and the endo-tracheal tubes were inserted in these patients. All patients were saved with a median of mechanical ventilation duration of 3.4 days and ICU stay of 10.6 days. No major complications were observed. The heart rate, respiratory rate and the rate-pressure product were decreased significantly one hour after BiPAP (P < 0.05 all). Meanwhile, patients showed rapid improvement of oxygenation. The pH, SpO>2 and PaO2/FiO2 were increased significantly and A-aDO2 was decreased significantly (P < 0.05 all). The PaCO2, was decreased significantly four hours after BiPAP (P < 0.05). Conclusions Non-invasive nasal mask BiPAP can be used safely and effectively in children after cardiac surgery to improve oxygenation/ventilation, decreasing the work of breathing. It may be particularly useful in patients with high risk of re-intubation.