Feltracco P, Serra E, Barbieri S, Milevoj M, Michieletto E, Carollo C, Rea F, Zanus G, Boetto R, Ori C
Department of Pharmacology and Anesthesiology, University Hospital of Padua, Padua, Italy.
Transplant Proc. 2012 Sep;44(7):2016-21. doi: 10.1016/j.transproceed.2012.05.062.
Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post-lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.
无创正压通气（NIV）是急性和慢性呼吸衰竭的一种成熟治疗方法，越来越多地用于维持有即将发生肺部并发症的肺移植患者的自主通气。增加无创吸气支持加呼气末正压（PEEP）已被证明有助于预防气管内机械通气、气道损伤和感染。依赖区域小气道闭合的肺移植受者也可能从俯卧位中获益，这有助于促进未通气肺泡的复张和实变肺不张区域更快愈合。对于有局部或弥漫性肺部浸润的患者，通过侵入性气道或面罩进行高频振荡通气（HFPV）已被用作一种替代通气模式，以增强气道开放、限制潜在的呼吸机相关性肺损伤并改善黏液清除。对于有传统机械通气导致气压伤风险的未插管肺移植受者，它能在较低的平均气道压力下使氧气扩散到远端气道，同时避免终末气道反复周期性开放和闭合。我们总结了3例肺移植后发生呼吸并发症并采用俯卧位HFPV进行无创通气患者的临床过程。这种治疗的主要优点包括支气管分泌物自主清除逐渐改善、移植肺浸润和实变显著减轻、所需支气管镜检查次数减少、自主呼吸频率和呼吸功降低以及气体交换显著改善。患者发现使用标准面罩或全脸面罩接口进行HFPV时感觉舒适或仅轻度不适，治疗后他们感觉恢复更好。俯卧位面罩HFPV可能是标准NIV的一种有趣且有吸引力的替代方法，在全面呼吸衰竭发生之前实施时更有用。
