Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia.
Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia.
Respirology. 2018 May;23(5):492-497. doi: 10.1111/resp.13228. Epub 2017 Dec 10.
Non-invasive ventilation (NIV) improves clinical outcomes in hypercapnic acute exacerbations of COPD (AECOPD), but the optimal model of care remains unknown.
We conducted a prospective observational non-inferiority study comparing three models of NIV care: general ward (Ward) (1:4 nurse to patient ratio, thrice weekly consultant ward round), a high dependency unit (HDU) (1:2 ratio, twice daily ward round) and an intensive care unit (ICU) (1:1 ratio, twice daily ward round) model in three similar teaching tertiary hospitals. Changes in arterial blood gases (ABG) and clinical outcomes were compared and corrected for differences in AECOPD severity (Blood urea > 9 mmol/L, Altered mental status (Glasgow coma scale (GCS) < 14), Pulse > 109 bpm, age > 65 (BAP-65)) and co-morbidities. An economic analysis was also undertaken.
There was no significant difference in age (70 ± 10 years), forced expiratory volume in 1 s (FEV ) (0.84 ± 0.35 L), initial pH (7.29 ± 0.08), partial pressure of CO in arterial blood (PaCO ) (72 ± 22 mm Hg) or BAP-65 scores (2.9 ± 1.01) across the three models. The Ward achieved an increase in pH (0.12 ± 0.07) and a decrease in PaCO (12 ± 18 mm Hg) that was equivalent to HDU and ICU. However, the Ward treated more patients (38 vs 28 vs 15, P < 0.001), for a longer duration in the first 24 h (12.3 ± 4.8 vs 7.9 ± 4.1 vs 8.4 ± 5.3 h, P < 0.05) and was more cost-effective per treatment day ($AUD 1231 ± 382 vs 1745 ± 2673 vs 2386 ± 1120, P < 0.05) than HDU and ICU. ICU had a longer hospital stay (9 ± 11 vs 7 ± 7 vs 13 ± 28 days, P < 0.002) compared with the Ward and HDU. There was no significant difference in intubation rate or survival.
In acute hypercapnic Chronic obstructive pulmonary disease (COPD) patients, the Ward model of NIV care achieved equivalent clinical outcomes, whilst being more cost-effective than HDU or ICU models.
无创通气（NIV）可改善慢性阻塞性肺疾病（COPD）急性加重期（AECOPD）合并高碳酸血症患者的临床结局，但最佳的护理模式仍不清楚。
我们进行了一项前瞻性观察性非劣效性研究，比较了三种 NIV 护理模式：普通病房（Ward）（护士与患者比例为 1:4，每周三次顾问查房）、高依赖病房（HDU）（1:2 比例，每日两次查房）和重症监护病房（ICU）（1:1 比例，每日两次查房），在三所类似的教学型三级医院中进行。比较了动脉血气（ABG）的变化和临床结局，并对 AECOPD 严重程度（血尿素>9mmol/L、意识改变（格拉斯哥昏迷评分（GCS）<14）、脉搏>109bpm、年龄>65 岁（BAP-65））和合并症的差异进行了校正。还进行了经济分析。
三组患者的年龄（70±10 岁）、用力呼气量（FEV1）（0.84±0.35L）、初始 pH 值（7.29±0.08）、动脉血二氧化碳分压（PaCO）（72±22mmHg）或 BAP-65 评分（2.9±1.01）均无显著差异。Ward 组 pH 值升高（0.12±0.07），PaCO 下降（12±18mmHg），与 HDU 和 ICU 相当。然而，Ward 治疗的患者更多（38 例 vs 28 例 vs 15 例，P<0.001），第 1 个 24 小时的治疗时间更长（12.3±4.8 小时 vs 7.9±4.1 小时 vs 8.4±5.3 小时，P<0.05），治疗日的成本效益更高（AUD1231±382 美元 vs 1745±2673 美元 vs 2386±1120 美元，P<0.05）。与 Ward 和 HDU 相比，ICU 的住院时间更长（9±11 天 vs 7±7 天 vs 13±28 天，P<0.002）。两组患者的插管率和生存率无显著差异。
在急性高碳酸血症性慢性阻塞性肺疾病（COPD）患者中，Ward 模式的 NIV 护理在临床结局上与 HDU 或 ICU 模式相当，且更具成本效益。
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