慢性阻塞性肺疾病（COPD）患者拔管后无创通气与高流量鼻导管吸氧交替使用对比单纯高流量鼻导管吸氧：一项随机对照试验的事后分析
Non-invasive ventilation alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation in COPD patients: a post hoc analysis of a randomized controlled trial.
作者信息
Thille Arnaud W, Coudroy Rémi, Nay Mai-Anh, Gacouin Arnaud, Decavèle Maxens, Sonneville Romain, Beloncle François, Girault Christophe, Dangers Laurence, Lautrette Alexandre, Levrat Quentin, Rouzé Anahita, Vivier Emmanuel, Lascarrou Jean-Baptiste, Ricard Jean-Damien, Razazi Keyvan, Barberet Guillaume, Lebert Christine, Ehrmann Stephan, Massri Alexandre, Bourenne Jeremy, Pradel Gael, Bailly Pierre, Terzi Nicolas, Dellamonica Jean, Lacave Guillaume, Robert René, Ragot Stéphanie, Frat Jean-Pierre
机构信息
Centre Hospitalier Universitaire de Poitiers, Médecine Intensive Réanimation, Poitiers, France.
Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France.
出版信息
Ann Intensive Care. 2021 Feb 9;11(1):30. doi: 10.1186/s13613-021-00823-7.
BACKGROUND
Several randomized clinical trials have shown that non-invasive ventilation (NIV) applied immediately after extubation may prevent reintubation in patients at high-risk of extubation failure. However, most of studies included patients with chronic respiratory disorders as well as patients without underlying respiratory disease. To date, no study has shown decreased risk of reintubation with prophylactic NIV after extubation among patients with chronic obstructive pulmonary disease (COPD). We hypothesized that prophylactic NIV after extubation may decrease the risk of reintubation in COPD patients as compared with high-flow nasal oxygen. We performed a post hoc subgroup analysis of COPD patients included in a multicenter, randomized, controlled trial comparing prophylactic use of NIV alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone immediately after extubation.
RESULTS
Among the 651 patients included in the original study, 150 (23%) had underlying COPD including 86 patients treated with NIV alternating with high-flow nasal oxygen and 64 patients treated with high-flow nasal oxygen alone. The reintubation rate was 13% (11 out of 86 patients) with NIV and 27% (17 out of 64 patients) with high-flow nasal oxygen alone [difference, - 14% (95% CI - 27% to - 1%); p = 0.03]. Whereas reintubation rates were significantly lower with NIV than with high-flow nasal oxygen alone at 72 h and until ICU discharge, mortality in ICU did not differ between groups: 6% (5/86) with NIV vs. 9% (6/64) with high-flow nasal oxygen alone [difference - 4% (95% CI - 14% to 5%); p = 0.40].
CONCLUSIONS
In COPD patients, prophylactic NIV alternating with high-flow nasal oxygen significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone. Trial registration The study was registered at http://www.clinicaltrials.gov with the trial registration number NCT03121482 (20 April 2017).
背景
多项随机临床试验表明，拔管后立即应用无创通气（NIV）可预防拔管失败高危患者再次插管。然而，大多数研究纳入了慢性呼吸系统疾病患者以及无基础呼吸系统疾病的患者。迄今为止，尚无研究表明慢性阻塞性肺疾病（COPD）患者拔管后预防性应用NIV可降低再次插管风险。我们推测，与高流量鼻导管吸氧相比，拔管后预防性应用NIV可降低COPD患者再次插管风险。我们对一项多中心、随机、对照试验纳入的COPD患者进行了事后亚组分析，该试验比较了拔管后预防性使用NIV与高流量鼻导管吸氧交替使用与单纯高流量鼻导管吸氧的效果。
结果
在原研究纳入的651例患者中，150例（23%）患有COPD，其中86例接受NIV与高流量鼻导管吸氧交替治疗，64例仅接受高流量鼻导管吸氧治疗。接受NIV治疗的患者再次插管率为13%（86例患者中有11例），单纯接受高流量鼻导管吸氧治疗的患者再次插管率为27%（64例患者中有17例）[差异为-14%（95%CI -27%至-1%）；p = 0.03]。虽然在72小时及直至ICU出院时，NIV组的再次插管率显著低于单纯高流量鼻导管吸氧组，但两组的ICU死亡率无差异：NIV组为6%（5/86），单纯高流量鼻导管吸氧组为9%（6/64）[差异为-4%（95%CI -14%至5%）；p = 0.40]。
结论
在COPD患者中，与单纯高流量鼻导管吸氧相比，NIV与高流量鼻导管吸氧交替预防性应用可显著降低再次插管风险。试验注册 该研究已在http://www.clinicaltrials.gov注册，试验注册号为NCT03121482（2017年4月20日）。
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