Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France.
Intensive Care Unit, Arras Hospital, Arras, France.
Respir Care. 2019 Sep;64(9):1023-1030. doi: 10.4187/respcare.06346. Epub 2019 Mar 19.
The use of noninvasive ventilation (NIV) in the emergency setting to reverse hypercapnic coma in frail patients with end-stage chronic respiratory failure and do-not-intubate orders remains a questionable issue given the poor outcome of this vulnerable population. We aimed to answer this issue by assessing not only subjects' outcome with NIV but also subjects' point of view regarding NIV for this indication.
A prospective observational case-control study was conducted in 3 French tertiary care hospitals during a 2-y period. Forty-three individuals who were comatose (with pH < 7.25 and P > 100 mm Hg at admission) were compared with 43 subjects who were not comatose and who were treated with NIV for acute hypercapnic respiratory failure. NIV was applied by using the same protocol in both groups. They all had a do-not-intubate order and were considered vulnerable individuals with end-stage chronic respiratory failure according to well-validated scores.
NIV yielded similar outcomes in the 2 groups regarding in-hospital mortality ( = 12 [28%] vs = 12 [28%] in the noncomatose controls, > .99) and 6-month survival ( = 28 [65%] vs = 22 [51%] in the noncomatose controls, = .31). Despite poor quality of life scores (21.5 ± 10 vs 31 ± 6 in the awakened controls, = .056) as assessed by using the VQ11 questionnaire 6 months to 1 y after hospital discharge, a large majority of the survivors ( = 23 [85%]) would be willing to receive NIV again if a new episode of acute hypercapnic respiratory failure occurs.
In the frailest subjects with supposed end-stage chronic respiratory failure that justifies treatment limitation decisions, it is worth trying NIV when acute hypercapnic respiratory failure occurs, even in the case of extreme respiratory acidosis with hypercapnic coma at admission.
对于有终末期慢性呼吸衰竭且有“不插管”医嘱的虚弱患者，在急诊环境中使用无创通气（NIV）来逆转高碳酸血症性昏迷仍然存在争议，因为这一脆弱人群的预后较差。我们旨在通过评估不仅是患者接受 NIV 的结果，还评估患者对该适应证使用 NIV 的观点，来回答这个问题。
在 2 年期间，我们在法国 3 家三级护理医院进行了一项前瞻性观察性病例对照研究。43 名昏迷患者（入院时 pH 值 <7.25 和 PCO2 >100mmHg）与 43 名未昏迷且因急性高碳酸血症性呼吸衰竭接受 NIV 治疗的患者进行比较。两组均采用相同的方案应用 NIV。他们都有“不插管”医嘱，并且根据经过验证的评分，被认为是终末期慢性呼吸衰竭的脆弱个体。
在住院死亡率方面，两组 NIV 的结果相似（昏迷组为 12 例[28%]，非昏迷对照组为 12 例[28%]，>.99），6 个月生存率相似（昏迷组为 28 例[65%]，非昏迷对照组为 22 例[51%]，>.31）。尽管出院后 6 个月至 1 年使用 VQ11 问卷评估的生活质量评分较差（昏迷组为 21.5 ± 10，非昏迷对照组为 31 ± 6， =.056），但绝大多数幸存者（=23 [85%]）如果再次发生急性高碳酸血症性呼吸衰竭，愿意再次接受 NIV。
对于有终末期慢性呼吸衰竭且有治疗限制决策的最虚弱的患者，即使在入院时出现严重呼吸性酸中毒和高碳酸血症性昏迷的情况下，发生急性高碳酸血症性呼吸衰竭时也值得尝试使用 NIV。
