Wang Shi-Ya, Liang Han-Wen, Lu Guang-Sheng, Jiang Zhen-Jie, Zhang Bao-Zhu, Deng Qiu-Xue, Sun Qing-Wen, Lin Zhi-Min, Chen Qiang, Yang Chun, Xu Yuan-Da, Sang Ling
National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
Ann Transl Med. 2021 Aug;9(15):1251. doi: 10.21037/atm-21-3408.
Patients with difficult weaning who undergo mechanical ventilation are more likely to be at risk of reintubation and the sequential use of oxygen therapy after extubation is a concern for clinicians. Therefore, the aim of the present study was to compare the effects of transnasal high-flow nasal cannula (HFNC) oxygen therapy and non-invasive positive-pressure ventilation (NIV) on respiratory mechanics in patients with difficult weaning.
The present study was a single-center, retrospective, observational study. Twenty-nine patients with difficult weaning off invasive mechanical ventilation from the Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, from December 2018 to April 2021, were included. Within 48 h after extubation, alternate respiratory support with HFNC and NIV was provided. Relevant indicators were recorded after each support mode had been maintained for at least 60 min. These included esophageal pressure (Pes), gastric pressure (Pga), transdiaphragmatic pressure (Pdi), pressure-time product of Pes (PTPes), pressure-time product of Pga (PTPga), pressure-time product of Pdi (PTPdi), ratio of the PTPdi to the PTPes (PTPdi/PTPes), and ratio of the Pes to the Pdi (Pes/Pdi), diaphragmatic electromyogram (EMGdi), percentage of esophageal pressure coefficient of variation (CVes%),diaphragmatic electromyogram coefficient of variation (CVEMG),inspiratory time (Ti), expiratory time (Te) and respiratory cycle time (Ttot).
Of the 29 patients included, 22 were males and 7 were females [age: 63.97±15.34 years, Acute Physiological and Chronic Health Estimation II (APACHE II) score: 18.00±5.63]. The CVes% and the Pes/Pdi were significantly higher in patients with NIV than HFNC using 40 L/min, CVes%: 9 (-6, 20) -7 (-23, 6) and Pes/Pdi: 0.17 (-0.1, 0.53), -0.12 (-0.43, 0.08) (P<0.05). The remaining indicators were not statistically different.
The sequential NIV and HFNC can be tolerated in patients with such difficult weaning off mechanical ventilation after extubation, and more patients tend to choose HFNC subjectively. Compared with HFNC, NIV reduces the work of adjunctive respiratory muscle, but the patient's Pes dispersion is high when NIV is used, and it is necessary to pay attention to patient-ventilator coordination in clinical practice. We recommend alternating HFNC and NIV during the sequential respiratory therapy after extubation.
接受机械通气的撤机困难患者再次插管的风险更高，拔管后序贯使用氧疗是临床医生关注的问题。因此，本研究的目的是比较经鼻高流量鼻导管（HFNC）氧疗和无创正压通气（NIV）对撤机困难患者呼吸力学的影响。
本研究为单中心、回顾性观察研究。纳入了2018年12月至2021年4月在广州医科大学附属第一医院重症医学科有创机械通气撤机困难的29例患者。在拔管后48小时内，交替给予HFNC和NIV呼吸支持。每种支持模式维持至少60分钟后记录相关指标。这些指标包括食管压力（Pes）、胃内压力（Pga）、跨膈压（Pdi）、Pes的压力-时间乘积（PTPes）、Pga的压力-时间乘积（PTPga）、Pdi的压力-时间乘积（PTPdi）、PTPdi与PTPes的比值（PTPdi/PTPes）、Pes与Pdi的比值（Pes/Pdi）、膈肌肌电图（EMGdi）、食管压力变异系数百分比（CVes%）、膈肌肌电图变异系数（CVEMG）、吸气时间（Ti）、呼气时间（Te）和呼吸周期时间（Ttot）。
纳入的29例患者中，男性22例，女性7例[年龄：63.97±15.34岁，急性生理与慢性健康状况评分系统II（APACHE II）评分：18.00±5.63]。使用40 L/min时，NIV组患者的CVes%和Pes/Pdi显著高于HFNC组，CVes%：9（-6，20）对-7（-23，6），Pes/Pdi：0.17（-0.1，0.53）对-0.12（-0.43，0.08）（P<0.05）。其余指标无统计学差异。
序贯NIV和HFNC可被机械通气撤机困难的患者耐受，更多患者主观上倾向选择HFNC。与HFNC相比，NIV可减少辅助呼吸肌的做功，但使用NIV时患者的Pes离散度较高，临床实践中需注意患者与呼吸机的协调性。我们建议在拔管后的序贯呼吸治疗中交替使用HFNC和NIV。
