Stéphan François, Bérard Laurence, Rézaiguia-Delclaux Saida, Amaru Priscilla
Service de Réanimation adulte, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
APHP, GH HUEP, Hôpital St Antoine, Plateforme de recherche Clinique de l'Est Parisien (URC-Est-CRC-Est), Paris, France.
Respir Care. 2017 Sep;62(9):1193-1202. doi: 10.4187/respcare.05473. Epub 2017 Aug 14.
Obese patients are considered at risk of respiratory failure after cardiothoracic surgery. High-flow nasal cannula has demonstrated its non-inferiority after cardiothoracic surgery compared to noninvasive ventilation (NIV), which is the recommended treatment in obese patients. We hypothesized that NIV was superior to high-flow nasal cannula for preventing or resolving acute respiratory failure after cardiothoracic surgery in this population.
We performed a post hoc analysis of a randomized, controlled trial. Obese subjects were randomly assigned to receive NIV for at least 4 h/d (inspiratory pressure, 8 cm HO; expiratory pressure, 4 cm HO; F , 0.5) or high-flow nasal cannula delivered continuously (flow, 50 L/min, F 0.5).
Treatment failure (defined as re-intubation, switch to the other treatment, or premature discontinuation) occurred in 21 of 136 (15.4%, 95% CI 9.8-22.6%) subjects with NIV compared to 18 of 135 (13.3%, 95% CI 8.1-20.3%) subjects with high-flow nasal cannula ( = .62). No significant differences were found for dyspnea and comfort scores. Skin breakdown was significantly more common with NIV after 24 h (9.2%, 95% CI 5.0-16.0 vs 1.6%, 95% CI 1.0-6.0; = .01). No significant differences were found for ICU mortality (5.9% for subjects with NIV vs 2.2% for subjects with high-flow nasal cannula, = .22) or for any of the other secondary outcomes.
Among obese cardiothoracic surgery subjects with or without respiratory failure, the use of continuous high-flow nasal cannula compared to intermittent NIV (8/4 cm HO) did not result in a worse rate of treatment failure. Because high-flow nasal cannula presents some advantages, it may be used instead of NIV in obese patients after cardiothoracic surgery.
肥胖患者被认为在心胸外科手术后有呼吸衰竭的风险。与无创通气（NIV）相比，高流量鼻导管已证明其在心胸外科手术后的非劣效性，NIV是肥胖患者的推荐治疗方法。我们假设在该人群中，NIV在预防或解决心胸外科手术后的急性呼吸衰竭方面优于高流量鼻导管。
我们对一项随机对照试验进行了事后分析。肥胖受试者被随机分配接受至少每天4小时的NIV（吸气压力，8 cm HO；呼气压力，4 cm HO；F，0.5）或持续给予高流量鼻导管（流量，50 L/分钟，F 0.5）。
136名接受NIV治疗的受试者中有21名（15.4%，95%CI 9.8 - 22.6%）出现治疗失败（定义为再次插管、改用另一种治疗或提前停药），而135名接受高流量鼻导管治疗的受试者中有18名（13.3%，95%CI 8.1 - 20.3%）出现治疗失败（P =.62）。在呼吸困难和舒适度评分方面未发现显著差异。24小时后，NIV导致皮肤破损明显更常见（9.2%，95%CI 5.0 - 16.0对比1.6%，95%CI 1.0 - 6.0；P =.01）。在ICU死亡率（接受NIV治疗的受试者为5.9%，接受高流量鼻导管治疗的受试者为2.2%，P =.22）或任何其他次要结局方面均未发现显著差异。
在有或没有呼吸衰竭的肥胖心胸外科手术受试者中，与间歇性NIV（8/4 cm HO）相比，使用持续高流量鼻导管并未导致更差的治疗失败率。由于高流量鼻导管具有一些优势，在肥胖患者心胸外科手术后可使用其替代NIV。
