Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark
Respiratory Medicine Unit, Department of Internal Medicine, Herlev-Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark.
BMJ Open Respir Res. 2022 Jun;9(1). doi: 10.1136/bmjresp-2022-001260.
Updated treatment guidelines for acute hypercapnic respiratory failure (AHRF) in chronic obstructive pulmonary disease (COPD) with non-invasive ventilation (NIV) in 2016 recommended a rapid increase in inspiratory positive airway pressure (IPAP) to 20 cm HO with possible further increase for patients not responding. Previous guidelines from 2006 suggested a more conservative algorithm and maximum IPAP of 20 cm HO.
To determine whether updated guidelines recommending higher IPAP during NIV were related with improved outcome in patients with COPD admitted with AHRF, compared with NIV with lower IPAP.
A retrospective cohort study comparing patients with COPD admitted with AHRF requiring NIV in 2012-2013 and 2017-2018.
101 patients were included in the 2012-2013 cohort with low IPAP regime and 80 patients in the 2017-2018 cohort with high IPAP regime. Baseline characteristics, including age, forced expiratory volume in 1 s (FEV), pH and PaCO at initiation of NIV, were comparable. Median IPAP in the 2012-2013 cohort was 12 cm HO (IQR 10-14) and 20 cm HO (IQR 18-24) in the 2017-2018 cohort (p<0.001). In-hospital mortality was 40.5% in the 2012-2013 cohort and 13.8% in the 2017-2018 cohort (p<0.001). The 30-days and 1-year mortality were significantly lower in the 2017-2018 cohort. With a Cox model 1 year survival analysis, adjusted for age, sex, FEV and pH at NIV initiation, the HR was 0.45 (95% CI 0.27 to 0.74, p=0.002).
Short-term and long-term survival rates were substantially higher in the cohort treated with higher IPAP. Our data support the current strategy of rapid increase and higher pressure.
2016 年，慢性阻塞性肺疾病（COPD）急性高碳酸血症性呼吸衰竭（AHRF）的治疗指南更新，建议对接受无创通气（NIV）治疗的患者快速将吸气正压气道（IPAP）增加到 20cmH2O，对于无反应的患者可能进一步增加。2006 年的先前指南建议采用更保守的算法和最大 IPAP 为 20cmH2O。
确定与较低 IPAP 的 NIV 相比，在接受 AHRF 治疗的 COPD 患者中，使用更新指南推荐的更高 IPAP 是否与改善预后相关。
一项回顾性队列研究比较了 2012-2013 年和 2017-2018 年接受 NIV 治疗的 AHRF 合并 COPD 患者。
2012-2013 年队列中纳入 101 例低 IPAP 治疗组患者，2017-2018 年队列中纳入 80 例高 IPAP 治疗组患者。两组患者的基线特征，包括年龄、1 秒用力呼气量（FEV1）、开始 NIV 时的 pH 值和 PaCO2，均无差异。2012-2013 年队列的中位 IPAP 为 12cmH2O（IQR 10-14），2017-2018 年队列的中位 IPAP 为 20cmH2O（IQR 18-24）（p<0.001）。2012-2013 年队列的院内死亡率为 40.5%，2017-2018 年队列的院内死亡率为 13.8%（p<0.001）。2017-2018 年队列的 30 天和 1 年死亡率显著降低。在调整了 NIV 开始时的年龄、性别、FEV1 和 pH 值的 Cox 模型 1 年生存分析中，HR 为 0.45（95%CI 0.27 至 0.74，p=0.002）。
接受更高 IPAP 治疗的患者短期和长期生存率显著提高。我们的数据支持快速增加和更高压力的当前策略。
