急性低氧性呼吸衰竭时无创性呼吸支持策略的转换：来自回顾性观察研究的监测需求。
Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study.
机构信息
Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain.
Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM); Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA.
出版信息
Med Intensiva (Engl Ed). 2024 Apr;48(4):200-210. doi: 10.1016/j.medine.2023.11.006. Epub 2023 Nov 18.
OBJECTIVE
To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients.
DESIGN
Retrospective, single-center observational study.
SETTING
Intensive Care Medicine.
PATIENTS
AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC).
INTERVENTIONS
Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated.
MAIN VARIABLES OF INTEREST
Reasons for switching, NIRS failure and mortality rates.
RESULTS
A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001).
CONCLUSIONS
NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.
目的
探讨急性低氧性呼吸衰竭（AHRF）患者联合无创呼吸支持（NIRS）模式、NIRS 切换原因及其对临床结局的潜在影响。
设计
回顾性、单中心观察性研究。
设置
重症监护医学科。
患者
接受 NIRS 联合治疗（如无创通气（NIV）和高流量鼻导管（HFNC））的 AHRF 患者（排除心源性和呼吸性酸中毒）。
干预措施
根据首次进行的 NIRS 切换（HFNC 切换至 NIV 或 NIV 切换至 HFNC）对患者进行分类，并进一步评估特定的 NIRS 切换策略（NIV 试验样与非 NIV 试验样和单次切换与多次切换）。
主要观察变量
切换原因、NIRS 失败和死亡率。
结果
共纳入 63 例 AHRF 患者，接受联合 NIRS 治疗，58.7%归入 HFNC 切换至 NIV 组，41.3%归入 NIV 切换至 HFNC 组。HFNC 切换至 NIV 的原因是 AHRF 恶化（100%），而 NIV 切换至 HFNC 的原因是呼吸改善（76.9%）。HFNC 切换至 NIV 组的 NIRS 失败率高于 NIV 切换至 HFNC 组（81%比 35%，p<0.001）。HFNC 切换至 NIV 的患者中，NIV 试验样与非 NIV 试验样组的失败率无差异（86%比 78%，p=0.575），但 NIV 试验样组的死亡率显著较低（14%比 52%，p=0.02）。NIV 切换至 HFNC 的患者中，单次切换组的 NIV 失败率低于多次切换组（15%比 53%，p=0.039），且住院时间更短（5[2-8]比 12[8-30]天，p=0.001）。
结论
NIRS 联合治疗在现实生活中得到应用，HFNC 切换至 NIV 和 NIV 切换至 HFNC 这两种切换策略在 AHRF 管理中都很常见。从 HFNC 切换至 NIV 被认为是一种治疗升级策略，在此背景下进行 NIV 试验可能有益。相反，从 NIV 切换至 HFNC 被认为是一种降级策略，如果没有 NIRS 失败则是安全的。
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