Wang Jinrong, Cui Zhaobo, Liu Shuhong, Gao Xiuling, Gao Pan, Shi Yi, Guo Shufen, Li Peipei
Southern Medical University, Guangzhou, Guangdong Department of Critical Care Medicine Department of Respiratory and Critical Care Medicine, Harrison International Peace Hospital, Hengshui, Hebei Department of Respiratory and Critical Care Medicine, Nanjing General Hospital of Nanjing Military Command, Nanjing, Jiangsu, China.
Medicine (Baltimore). 2017 Mar;96(12):e6371. doi: 10.1097/MD.0000000000006371.
Noninvasive positive-pressure ventilation (NPPV) might be superior to conventional mechanical ventilation (CMV) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPDs). Inefficient clearance of respiratory secretions provokes NPPV failure in patients with hypercapnic encephalopathy (HE). This study compared CMV and NPPV combined with a noninvasive strategy for clearing secretions in HE and AECOPD patients.The present study is a prospective cohort study of AECOPD and HE patients enrolled between October 2013 and August 2015 in a critical care unit of a major university teaching hospital in China.A total of 74 patients received NPPV and 90 patients received CMV. Inclusion criteria included the following: physician-diagnosed AECOPD, spontaneous airway clearance of excessive secretions, arterial blood gas analysis requiring intensive care, moderate-to-severe dyspnea, and a Kelly-Matthay scale score of 3 to 5. Exclusion criteria included the following: preexisting psychiatric/neurological disorders unrelated to HE, upper gastrointestinal bleeding, upper airway obstruction, acute coronary syndromes, preadmission tracheostomy or endotracheal intubation, and urgent endotracheal intubation for cardiovascular, psychomotor agitation, or severe hemodynamic conditions.Intensive care unit participants were managed by NPPV. Participants received standard treatment consisting of controlled oxygen therapy during NPPV-free periods; antibiotics, intravenous doxofylline, corticosteroids (e.g., salbutamol and ambroxol), and subcutaneous low-molecular-weight heparin; and therapy for comorbidities if necessary. Nasogastric tubes were inserted only in participants who developed gastric distension. No pharmacological sedation was administered.The primary and secondary outcome measures included comparative complication rates, durations of ventilation and hospitalization, number of invasive devices/patient, and in-hospital and 1-year mortality rates.Arterial blood gases and sensorium levels improved significantly within 2 hours in the NPPV group with lower hospital mortality, fewer complications and invasive devices/patient, and superior weaning off mechanical ventilation. Mechanical ventilation duration, hospital stay, or 1-year mortality was similar between groups.NPPV combined with a noninvasive strategy to clear secretions during the first 2 hours may offer advantages over CMV in treating AECOPD patients complicated by HE.
无创正压通气（NPPV）在慢性阻塞性肺疾病急性加重期（AECOPD）患者中可能优于传统机械通气（CMV）。呼吸分泌物清除效率低下会导致高碳酸血症性脑病（HE）患者NPPV失败。本研究比较了CMV与NPPV联合无创分泌物清除策略在HE和AECOPD患者中的效果。本研究是一项前瞻性队列研究，研究对象为2013年10月至2015年8月在中国一所大型大学教学医院重症监护病房收治的AECOPD和HE患者。共有74例患者接受NPPV，90例患者接受CMV。纳入标准包括：医生诊断为AECOPD、能自主清除过多分泌物、动脉血气分析提示需要重症监护、中重度呼吸困难以及凯利-马泰量表评分为3至5分。排除标准包括：既往存在与HE无关的精神/神经疾病、上消化道出血、上气道梗阻、急性冠状动脉综合征、入院前气管切开或气管插管，以及因心血管、精神运动性激越或严重血流动力学状况而紧急气管插管。重症监护病房的参与者采用NPPV进行管理。参与者接受标准治疗，包括在无NPPV期间进行控制性氧疗；使用抗生素、静脉注射多索茶碱、皮质类固醇（如沙丁胺醇和氨溴索）以及皮下注射低分子肝素；必要时治疗合并症。仅在出现胃扩张的参与者中插入鼻胃管。未给予药物镇静。主要和次要结局指标包括比较并发症发生率、通气和住院时间、每位患者使用侵入性设备的数量以及院内和1年死亡率。NPPV组在2小时内动脉血气和意识水平显著改善，院内死亡率较低，并发症和每位患者使用侵入性设备的数量较少，且机械通气撤机情况较好。两组之间的机械通气持续时间、住院时间或1年死亡率相似。在治疗合并HE的AECOPD患者时，NPPV联合在前2小时采用无创策略清除分泌物可能比CMV更具优势。
