Scala Raffaele
Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy -
Panminerva Med. 2016 Sep;58(3):211-21. Epub 2016 Mar 24.
Flexible bronchoscopy (FBO) and non-invasive positive pressure ventilation (NIPPV) are largely applied in respiratory and general intensive care units. FBO plays a crucial role for the diagnosis of lung infiltrates of unknown origin and for the treatment of airways obstruction due to bronchial mucous plugging and hemoptysis in critical patients. NIPPV is the first-choice ventilatory strategy for acute respiratory failure (ARF) of different causes as it could be used as prevention or as alternative to the conventional mechanical ventilation (CMV) via endotracheal intubation (ETI). Some clinical scenarios represent contraindications for these techniques such as severe ARF in spontaneous breathing patients for FBO and accumulated tracheo-bronchial secretions in patients with depressed cough for NIPPV. In these contexts, the decision of performing ETI should carefully consider the risk of CMV-correlated complications. An increasing amount of published data suggested the use of FBO during NIPPV in ARF in order to avoid/reduce the need of ETI. Despite a strong rationale for the combined use of the two techniques, there is not still enough evidence for a large-scale application of this strategy in all different clinical scenarios. The majority of the available data are in favor of the "help" given by NIPPV to diagnostic FBO in high-risk spontaneously breathing patients with severe hypoxemia. Preliminary findings report the successful "help" given by early FBO to NIPPV in patients with hypoxemic-hypercapnic ARF who are likely to fail because of hypersecretion. Synergy of FBO and NIPPV application is emerging also to perform ETI in challenging situations, such as predicted difficult laringoscopy and NPPV failure in severely hypoxemic patients. This combined approach should be performed only in centers showing a wide experience with both NIPPV and FBO, where close monitoring and ETI facilities are promptly available.
可弯曲支气管镜检查（FBO）和无创正压通气（NIPPV）在呼吸和综合重症监护病房中广泛应用。FBO在不明原因肺部浸润的诊断以及危重症患者因支气管黏液堵塞和咯血导致的气道梗阻治疗中发挥着关键作用。NIPPV是不同病因急性呼吸衰竭（ARF）的首选通气策略，因为它可作为预防措施或通过气管插管（ETI）进行传统机械通气（CMV）的替代方法。一些临床情况是这些技术的禁忌证，例如FBO对于自主呼吸患者的严重ARF，以及NIPPV对于咳嗽反射减弱患者气管支气管分泌物积聚。在这些情况下，进行ETI的决定应仔细考虑CMV相关并发症的风险。越来越多已发表的数据表明，在ARF患者的NIPPV期间使用FBO，以避免/减少ETI的需求。尽管两种技术联合使用有充分的理论依据，但在所有不同临床情况下大规模应用该策略仍没有足够的证据。大多数现有数据支持NIPPV对高危自主呼吸且严重低氧血症患者诊断性FBO的“辅助”作用。初步研究结果报告了早期FBO对因分泌物过多可能失败的低氧血症-高碳酸血症ARF患者NIPPV的成功“辅助”。FBO和NIPPV联合应用的协同作用也体现在具有挑战性的情况下进行ETI，例如预计喉镜检查困难和严重低氧血症患者NPPV失败。这种联合方法应仅在对NIPPV和FBO都有丰富经验、能进行密切监测且能迅速提供ETI设备的中心进行。
