Critical Care Medicine, Hospital Virgen de la Salud, Toledo, Mezquite n degrees 12, 6 degrees A, 28045, Madrid, Spain.
Chest. 2010 Jan;137(1):74-80. doi: 10.1378/chest.09-1114. Epub 2009 Sep 11.
Guidelines for noninvasive mechanical ventilation (NIMV) recommend continuous positive airway pressure in patients with thoracic trauma who remain hypoxic despite regional anesthesia. This recommendation is rated only by level C evidence because randomized controlled trials in this specific population are lacking. Our aim was to determine whether NIMV reduces intubation in severe trauma-related hypoxemia.
This was a single-center randomized clinical trial in a nine-bed ICU of a level I trauma hospital. Inclusion criteria were patients with Pao(2)/Fio(2)<200 for >8 h while receiving oxygen by high-flow mask within the first 48 h after thoracic trauma. Patients were randomized to remain on high-flow oxygen mask or to receive NIMV. The interface was selected based on the associated injuries. Thoracic anesthesia was universally supplied unless contraindicated. The primary end point was intubation; secondary end points included length of hospital stay and survival. Statistical analysis was based on multivariate analysis.
After 25 patients were enrolled in each group, the trial was prematurely stopped for efficacy because the intubation rate was much higher in controls than in NIMV patients (10 [40%] vs 3 [12%], P = .02). Multivariate analysis adjusted for age, gender, chronic heart failure, and Acute Physiology and Chronic Health Evaluation II at admission revealed NIMV as the only variable independently related to intubation (odds ratio, 0.12; 95% CI, 0.02-0.61; P = .01). Length of hospital stay was shorter in NIMV patients (14 vs 21 days P = .001), but no differences were observed in survival or other secondary end points.
NIMV reduced intubation compared with oxygen therapy in severe thoracic trauma-related hypoxemia.
针对胸部创伤后持续存在低氧血症但接受区域麻醉的患者，无创机械通气（NIMV）指南推荐持续气道正压通气。这一推荐仅基于 C 级证据，因为缺乏针对该特定人群的随机对照试验。我们旨在确定 NIMV 是否能降低严重创伤相关低氧血症患者的插管率。
这是一项在一级创伤医院的九张床 ICU 中进行的单中心随机临床试验。纳入标准为胸部创伤后 48 小时内高流量面罩吸氧时，PaO2/FIO2<200 且持续>8 小时的患者。患者被随机分为继续高流量面罩吸氧或接受 NIMV。根据相关损伤选择接口。除非禁忌，否则普遍提供胸内麻醉。主要终点为插管；次要终点包括住院时间和生存。统计分析基于多变量分析。
在每组 25 例患者入组后，由于对照组的插管率明显高于 NIMV 组（10 [40%] 比 3 [12%]，P=0.02），试验因疗效而提前终止。多变量分析调整了年龄、性别、慢性心力衰竭和入院时的急性生理和慢性健康评估 II 后，发现 NIMV 是唯一与插管独立相关的变量（比值比，0.12；95%CI，0.02-0.61；P=0.01）。NIMV 组的住院时间更短（14 天比 21 天，P=0.001），但在生存或其他次要终点方面无差异。
与氧疗相比，NIMV 可降低严重胸部创伤相关低氧血症患者的插管率。
