Carratù P, Bonfitto P, Dragonieri S, Schettini F, Clemente R, Di Gioia G, Loponte L, Foschino Barbaro M P, Resta O
Respiratory Diseases, Department of Clinical Methodology and Medical-surgical Technologies, University of Bari, Bari.
Eur J Clin Invest. 2005 Jun;35(6):404-9. doi: 10.1111/j.1365-2362.2005.01509.x.
Despite recent encouraging results, the use of noninvasive ventilation (NIV) in the management of acute exacerbations in chronic obstructive pulmonary disease (COPD), complicated by acute respiratory failure (ARF), is not always successful. Failure of NIV may require an immediate intubation after a few hours (usually 1-3) of ventilation ('early failure') or may result in clinical deterioration (one or more days later) after an initial improvement of blood gas tension and general conditions ('late failure').
We enrolled 122 patients affected by COPD complicated by ARF, and treated with NIV. The schedule of NIV provided sessions of 2-6 h twice daily.
Ninety-nine (81%) patients showed a progressive improvement of the clinical parameters and were discharged. Among the remaining 23 patients, 13 had an early failure and 10 had a late failure. In the 'success' group and 'late failure' groups we found after an increase of pH 2 h of NIV (from 7.31 +/- 0.05 to 7.38 +/- 0.04 P < 0.001 and from 7.29 +/- 0.03 to 7.36 +/- 0.02 P < 0.001, respectively) and a decrease of PaCO2 (from 80.93 +/- 9.79 to 66.48 +/- 5.95 P < 0.001 and from 85.96 +/- 10.77 to 76.41 +/- 11.02 P < 0.001, respectively). After 2 h of NIV in the 'late failure' group there were no significant changes in terms of pH (from 7.20 +/- 0.10 to 7.28 +/- 0.06) nor PaCO2 (from 92.86 +/- 35.49 to 93.68 +/- 23.68). The 'early failure' group had different characteristics and, owing to more severe conditions, the value of pH, of Glasgow Coma Score, and Apache II Score were the best predictors of the failure; while, among the complications on admission, metabolic alterations were the only independently significant predictor.
Our study confirms that NIV may be useful to avoid intubation in approximately 80% of patients with COPD complicated by moderate-severe hypercapnic respiratory failure.
尽管近期取得了令人鼓舞的成果，但在慢性阻塞性肺疾病（COPD）合并急性呼吸衰竭（ARF）的急性加重期管理中使用无创通气（NIV）并非总能成功。NIV失败可能需要在通气数小时（通常为1 - 3小时）后立即插管（“早期失败”），或者可能在血气张力和一般状况初步改善后（1天或数天后）导致临床恶化（“晚期失败”）。
我们纳入了122例COPD合并ARF并接受NIV治疗的患者。NIV方案为每天两次，每次2 - 6小时。
99例（81%）患者临床参数逐渐改善并出院。其余23例患者中，13例为早期失败，10例为晚期失败。在“成功”组和“晚期失败”组中，NIV 2小时后pH值升高（分别从7.31±0.05升至7.38±0.04，P < 0.001；从7.29±0.03升至7.36±0.02，P < 0.001），PaCO2降低（分别从80.93±9.79降至66.48±5.95，P < 0.001；从85.96±10.77降至76.41±11.02，P < 0.001）。“晚期失败”组NIV 2小时后pH值（从7.20±0.10升至7.28±0.06）和PaCO2（从92.86±35.49升至93.68±23.68）无显著变化。“早期失败”组具有不同特征，由于病情更严重，pH值、格拉斯哥昏迷评分和急性生理与慢性健康状况评分II是失败的最佳预测指标；而在入院时的并发症中，代谢改变是唯一独立的显著预测指标。
我们的研究证实，NIV可能有助于避免约80%的COPD合并中重度高碳酸血症呼吸衰竭患者进行插管。
