Réanimation Médicale, Hôpitaux Universitaires Henri Mondor, Assistance Publique Hôpitaux de Paris, Créteil, France.
Respir Care. 2013 Dec;58(12):2045-52. doi: 10.4187/respcare.02456. Epub 2013 Jun 4.
Failure of noninvasive ventilation (NIV) is common in patients with COPD admitted to the ICU for acute hypercapnic respiratory failure (AHRF). We aimed to assess the rate of NIV failure and to identify early predictors of intubation under NIV in patients admitted for AHRF of all origins in an experienced unit.
This was an observational cohort study using data prospectively collected over a 3-year period after the implementation of a nurse-driven NIV protocol in a 24-bed medical ICU of a French university hospital.
Among 242 subjects receiving NIV for AHRF (P(aCO2) > 45 mm Hg), 67 had cardiogenic pulmonary edema (CPE), 146 had acute-on-chronic respiratory failure (AOCRF) (including 99 subjects with COPD and 47 with other chronic respiratory diseases), and 29 had non-AOCRF (mostly pneumonia). Overall, the rates of intubation and ICU mortality were respectively 15% and 5%. The intubation rates were 4% in CPE, 15% in AOCRF, and 38% in non-AOCRF (P < .001). After adjustment, non-AOCRF was independently associated with NIV failure, as well as acidosis (pH < 7.30) and severe hypoxemia (P(aO2)/F(IO2) ≤ 200 mm Hg) after 1 hour of NIV initiation, whereas altered consciousness on admission and ventilatory settings had no influence on outcome.
With a nurse-driven NIV protocol, the intubation rate was reduced to 15% in patients receiving NIV for AHRF, with a mortality rate of only 5%. Whereas the risk of NIV failure is associated with hypoxemia and acidosis after initiation of NIV, it is also markedly influenced by the presence or absence of an underlying chronic respiratory disease.
在因急性高碳酸血症性呼吸衰竭（AHRF）而入住 ICU 的 COPD 患者中，无创通气（NIV）失败很常见。我们旨在评估在经验丰富的单位中，所有病因导致的 AHRF 患者接受 NIV 治疗时，NIV 失败的发生率，并确定 NIV 下插管的早期预测因素。
这是一项观察性队列研究，使用了在法国大学附属医院的 24 床内科 ICU 实施护士主导的 NIV 方案后 3 年内前瞻性收集的数据。
在 242 例因 AHRF 接受 NIV 治疗的患者（P(aCO2) > 45mmHg）中，67 例患有心源性肺水肿（CPE），146 例患有急性加重的慢性呼吸衰竭（AOCRF）（包括 99 例 COPD 患者和 47 例其他慢性呼吸系统疾病患者），29 例患有非-AOCRF（主要为肺炎）。总的来说，插管率和 ICU 死亡率分别为 15%和 5%。CPE 的插管率为 4%，AOCRF 为 15%，非-AOCRF 为 38%（P<.001）。调整后，非-AOCRF 以及 NIV 开始后 1 小时内酸中毒（pH < 7.30）和严重低氧血症（P(aO2)/F(IO2) ≤ 200mmHg）与 NIV 失败独立相关，而入院时意识改变和通气设置对结果没有影响。
在使用护士主导的 NIV 方案的情况下，AHRF 患者接受 NIV 治疗的插管率降低至 15%，死亡率仅为 5%。尽管 NIV 失败的风险与 NIV 开始后低氧血症和酸中毒有关，但它也明显受到潜在慢性呼吸系统疾病存在与否的影响。
