IRCCS Azienda Ospedaliero Universitaria di Bologna, University Hospital Sant´Orsola-Malpighi- Respiratory and Critical Care Unit- Bologna, Italy; Alma Mater Studiorum, University of Bologna, Department of Clinical Integrated and Experimental Medicine (DIMES), Bologna, Italy.
IRCCS MultiMedica, Division of Radiology Sesto, San Giovanni, Lombardia, Italy.
Eur J Intern Med. 2022 Jun;100:110-118. doi: 10.1016/j.ejim.2022.04.012. Epub 2022 Apr 22.
Various forms of Non-invasive respiratory support (NRS) have been used during COVID-19, to treat Hypoxemic Acute Respiratory Failure (HARF), but it has been suggested that the occurrence of strenuous inspiratory efforts may cause Self Induced Lung Injury(P-SILI). The aim of this investigation was to record esophageal pressure, when starting NRS application, so as to better understand the potential risk of the patients in terms of P-SILI and ventilator induced lung injury (VILI).
21 patients with early de-novo respiratory failure due to COVID-19, underwent three 30 min trials applied in random order: high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and non-invasive ventilation (NIV). After each trial, standard oxygen therapy was reinstituted using a Venturi mask (VM). 15 patients accepted a nasogastric tube placement. Esophageal Pressure (ΔPes) and dynamic transpulmonary driving pressure (ΔPLDyn), together with the breathing pattern using a bioelectrical impedance monitor were recorded. Arterial blood gases were collected in all patients.
No statistically significant differences in breathing pattern and PaCO were found. PaO/FiO ratio improved significantly during NIV and CPAP vs VM. NIV was the only NRS to reduce significantly ΔPes vs. VM (-10,2 ±5 cmH20 vs -3,9 ±3,4). No differences were found in ΔPLDyn between NRS (10,2±5; 9,9±3,8; 7,6±4,3; 8,8±3,6 during VM, HFNC, CPAP and NIV respectively). Minute ventilation (Ve) was directly dependent on the patient's inspiratory effort, irrespective of the NRS applied. 14% of patients were intubated, none of them showing a reduction in ΔPes during NRS.
In the early phase of HARF due to COVID-19, the inspiratory effort may not be markedly elevated and the application of NIV and CPAP ameliorates oxygenation vs VM. NIV was superior in reducing ΔPes, maintaining ΔPLDyn within a range of potential safety.
在 COVID-19 期间，各种形式的无创呼吸支持（NRS）已被用于治疗低氧性急性呼吸衰竭（HARF），但有人认为剧烈的吸气努力可能会导致自发性肺损伤（P-SILI）。本研究的目的是记录开始应用 NRS 时的食管压力，以便更好地了解患者在 P-SILI 和呼吸机相关性肺损伤（VILI）方面的潜在风险。
21 例因 COVID-19 早期出现新发呼吸衰竭的患者，以随机顺序进行了三次 30 分钟的试验：高流量鼻导管（HFNC）、持续气道正压通气（CPAP）和无创通气（NIV）。每次试验后，均使用文丘里面罩（VM）重新进行标准氧疗。15 例患者接受了鼻胃管放置。记录食管压力（ΔPes）和动态跨肺驱动压（ΔPLDyn），并使用生物电阻抗监测仪记录呼吸模式。所有患者均采集动脉血气。
呼吸模式和 PaCO 无统计学差异。与 VM 相比，NIV 和 CPAP 可显著改善 PaO/FiO 比值。只有 NIV 可显著降低与 VM 相比的 ΔPes（-10.2 ±5cmH20 对-3.9 ±3.4cmH20）。在 NRS 之间，ΔPLDyn 无差异（VM、HFNC、CPAP 和 NIV 时分别为 10.2±5cmH20、9.9±3.8cmH20、7.6±4.3cmH20 和 8.8±3.6cmH20）。分钟通气量（Ve）直接取决于患者的吸气努力，与应用的 NRS 无关。14%的患者需要插管，他们在应用 NRS 时的 ΔPes 均无降低。
在 COVID-19 所致 HARF 的早期阶段，吸气努力可能不会明显升高，NIV 和 CPAP 的应用可改善与 VM 相比的氧合作用。NIV 可更好地降低 ΔPes，将 ΔPLDyn 维持在潜在安全范围内。
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