Respiratory Care Services, Department of Anesthesia, University of California, San Francisco, at San Francisco General Hospital, San Francisco, California 94110, USA.
Respir Care. 2013 Jun;58(6):1053-73. doi: 10.4187/respcare.02217.
Mechanically ventilated patients in respiratory failure often require adjunct therapies to address special needs such as inhaled drug delivery to alleviate airway obstruction, treat pulmonary infection, or stabilize gas exchange, or therapies that enhance pulmonary hygiene. These therapies generally are supportive in nature rather than curative. Currently, most lack high-level evidence supporting their routine use. This overview describes the rationale and examines the evidence supporting adjunctive therapies during mechanical ventilation. Both mechanistic and clinical research suggests that intrapulmonary percussive ventilation may enhance pulmonary secretion mobilization and might reverse atelectasis. However, its impact on outcomes such ICU stay is uncertain. The most crucial issue is whether aerosolized antibiotics should be used to treat ventilator-associated pneumonia, particularly when caused by multi-drug resistant pathogens. There is encouraging evidence from several studies supporting its use, at least in individual cases of pneumonia non-responsive to systemic antibiotic therapy. Inhaled pulmonary vasodilators provide at least short-term improvement in oxygenation and may be useful in stabilizing pulmonary gas exchange in complex management situations. Small uncontrolled studies suggest aerosolized heparin with N-acetylcysteine might break down pulmonary casts and relieve airway obstruction in patients with severe inhalation injury. Similar low-level evidence suggests that heliox is effective in reducing airway pressure and improving ventilation in various forms of lower airway obstruction. These therapies generally are supportive and may facilitate patient management. However, because they have not been shown to improve patient outcomes, it behooves clinicians to use these therapies parsimoniously and to monitor their effectiveness carefully.
机械通气呼吸衰竭患者常需要辅助治疗来满足特殊需求，例如吸入药物输送以缓解气道阻塞、治疗肺部感染或稳定气体交换，或增强肺部卫生的治疗。这些治疗通常是支持性的，而不是治愈性的。目前，大多数治疗方法缺乏支持常规使用的高级别证据。这篇综述描述了辅助机械通气治疗的基本原理，并探讨了支持其应用的证据。机制和临床研究均表明，肺内叩击通气可能增强肺分泌物的清除，并可能逆转肺不张。然而，其对 ICU 入住时间等结局的影响尚不确定。最关键的问题是是否应使用雾化抗生素治疗呼吸机相关性肺炎，特别是当病原体为多药耐药菌时。有几项研究提供了令人鼓舞的证据支持其使用，至少在对全身抗生素治疗反应不佳的肺炎患者中是如此。吸入性肺血管扩张剂至少可在短期内改善氧合，在复杂的管理情况下，可能有助于稳定肺气体交换。小型非对照研究表明，肝素联合乙酰半胱氨酸雾化可能有助于分解严重吸入性损伤患者的肺内栓子并缓解气道阻塞。类似的低水平证据表明，氦氧混合气可有效降低气道压力并改善各种形式的下气道阻塞的通气。这些治疗通常是支持性的，可有助于患者管理。然而，由于它们并未显示可改善患者结局，因此临床医生应谨慎使用这些治疗方法，并仔细监测其疗效。
