大剂量静脉注射硝酸异山梨酯治疗重度肺水肿比双水平气道正压通气联合传统治疗更安全且效果更好。

High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema.

作者信息

Sharon A, Shpirer I, Kaluski E, Moshkovitz Y, Milovanov O, Polak R, Blatt A, Simovitz A, Shaham O, Faigenberg Z, Metzger M, Stav D, Yogev R, Golik A, Krakover R, Vered Z, Cotter G

机构信息

Department of Medicine, Assaf-Harofeh Medical Center, Zerifin, Israel.

出版信息

J Am Coll Cardiol. 2000 Sep;36(3):832-7. doi: 10.1016/s0735-1097(00)00785-3.

DOI:10.1016/s0735-1097(00)00785-3

PMID:10987607

Abstract

OBJECTIVE

To determine the feasibility, safety and efficacy of bilevel positive airway ventilation (BiPAP) in the treatment of severe pulmonary edema compared to high dose nitrate therapy.

BACKGROUND

Although noninvasive ventilation is increasingly used in the treatment of pulmonary edema, its efficacy has not been compared prospectively with newer treatment modalities.

METHODS

We enrolled 40 consecutive patients with severe pulmonary edema (oxygen saturation <90% on room air prior to treatment). All patients received oxygen at a rate of 10 liter/min, intravenous (IV) furosemide 80 mg and IV morphine 3 mg. Thereafter patients were randomly allocated to receive 1) repeated boluses of IV isosorbide-dinitrate (ISDN) 4 mg every 4 min (n = 20), and 2) BiPAP ventilation and standard dose nitrate therapy (n = 20). Treatment was administered until oxygen saturation increased above 96% or systolic blood pressure decreased to below 110 mm Hg or by more than 30%. Patients whose conditions deteriorated despite therapy were intubated and mechanically ventilated. All treatment was delivered by mobile intensive care units prior to hospital arrival.

RESULTS

Patients treated by BiPAP had significantly more adverse events. Two BiPAP treated patients died versus zero in the high dose ISDN group. Sixteen BiPAP treated patients (80%) required intubation and mechanical ventilation compared to four (20%) in the high dose ISDN group (p = 0.0004). Myocardial infarction (MI) occurred in 11 (55%) and 2 (10%) patients, respectively (p = 0.006). The combined primary end point (death, mechanical ventilation or MI) was observed in 17 (85%) versus 5 (25%) patients, respectively (p = 0.0003). After 1 h of treatment, oxygen saturation increased to 96 +/- 4% in the high dose ISDN group as compared to 89 +/- 7% in the BiPAP group (p = 0.017). Due to the significant deterioration observed in patients enrolled in the BiPAP arm, the study was prematurely terminated by the safety committee.

CONCLUSIONS

High dose ISDN is safer and better than BiPAP ventilation combined with conventional therapy in patients with severe pulmonary edema.

摘要

目的

与大剂量硝酸盐疗法相比，确定双水平气道正压通气（BiPAP）治疗重度肺水肿的可行性、安全性和有效性。

背景

尽管无创通气在肺水肿治疗中的应用日益广泛，但其疗效尚未与更新的治疗方式进行前瞻性比较。

方法

我们连续纳入40例重度肺水肿患者（治疗前室内空气中氧饱和度<90%）。所有患者均以10升/分钟的速率吸氧，静脉注射（IV）速尿80毫克和静脉注射吗啡3毫克。此后，患者被随机分配接受1）每4分钟重复静脉推注4毫克异山梨醇二硝酸酯（ISDN）（n = 20），以及2）BiPAP通气和标准剂量硝酸盐疗法（n = 20）。治疗持续进行，直至氧饱和度升至96%以上，或收缩压降至110毫米汞柱以下或降低超过幅度超过30%。尽管接受治疗但病情仍恶化的患者进行气管插管并机械通气。所有治疗均在患者入院前由移动重症监护单元实施。

结果

接受BiPAP治疗的患者出现的不良事件显著更多。2例接受BiPAP治疗的患者死亡，而大剂量ISDN组为零。16例接受BiPAP治疗的患者（80%）需要气管插管和机械通气，而大剂量ISDN组为4例（20%）（p = 0.0004）。心肌梗死（MI）分别发生在11例（55%）和2例（10%）患者中（p = 0.006）。联合主要终点（死亡、机械通气或MI）分别在17例（85%）和5例（25%）患者中观察到（p = 0.0003）。治疗后1小时，大剂量ISDN组的氧饱和度升至96±4%，而BiPAP组为89±7%（p = 0.017）。由于BiPAP组患者出现显著恶化，该研究被安全委员会提前终止。