U.O. Pneumologia e Unità di Terapia Semi-Intensiva Respiratoria, Campo di Marte Hospital, Lucca, Italy.
Respir Med. 2011 Aug;105(8):1109-17. doi: 10.1016/j.rmed.2011.02.004. Epub 2011 Feb 26.
According to the classical international guidelines, non-invasive ventilation is contraindicated in hypercapnic encephalopathy syndrome (HES) due to the poor compliance to ventilatory treatment of confused/agitated patients and the risk of aspirative pneumonia related to lack of airways protection. As a matter of fact, conventional mechanical ventilation has been recommended as "golden standard" in these patients. However, up to now there are not controlled data that have demonstrated in HES the advantage of conventional mechanical ventilation vs non-invasive ventilation. In fact, patients with altered mental status have been systematically excluded from the randomised and controlled trials performed with non-invasive ventilation in hypercapnic acute respiratory failure. Recent studies have clearly demonstrated that an initial cautious NPPV trial in selected HES patients may be attempt as long as there are no other contraindications and the technique is provided by experienced caregivers in a closely monitored setting where ETI is always readily available. The purpose of this review is to report the physiologic rationale, the clinical feasibility and the still open questions about the careful use of non-invasive ventilation in HES as first-line ventilatory strategy in place of conventional mechanical ventilation via endotracheal intubation.
根据经典的国际指南，由于神志不清/烦躁患者对通气治疗的顺应性差，以及缺乏气道保护相关的吸入性肺炎风险，无创通气在高碳酸血症性脑病综合征（HES）中被禁忌。实际上，传统的机械通气已被推荐为这些患者的“金标准”。然而，到目前为止，还没有对照数据表明在 HES 中常规机械通气与无创通气相比具有优势。事实上，神志改变的患者已被系统地排除在针对高碳酸血症性急性呼吸衰竭进行的无创通气的随机对照试验之外。最近的研究清楚地表明，只要没有其他禁忌证，并且有经验丰富的护理人员在密切监测的环境中提供该技术，其中始终可随时进行气管插管，那么对选定的 HES 患者进行初始谨慎的 NPPV 试验可能是可行的。本综述的目的是报告在 HES 中作为一线通气策略，谨慎使用无创通气替代经气管插管的常规机械通气的生理原理、临床可行性和仍存在的问题。
