Frat Jean-Pierre, Grieco Domenico L, De Jong Audrey, Gibbs Kevin, Carteaux Guillaume, Roca Oriol, Lemiale Virginie, Piquilloud Lise, Rittayamai Nuttapol, Pisani Lara, Hernandez Gonzalo, Thille Arnaud W
CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.
INSERM, ALIVE, CIC-1402, Poitiers, France.
Intensive Care Med. 2025 Aug;51(8):1476-1489. doi: 10.1007/s00134-025-08036-3. Epub 2025 Jul 24.
Noninvasive respiratory supports are routinely applied in critically ill patients with acute respiratory failure to avoid intubation and invasive mechanical ventilation, thereby reducing the risk of related complications, and to facilitate successful weaning from mechanical ventilation after extubation. They are also applied during the intubation procedure for preoxygenation with the aim of enhancing oxygenation and ensuring the safety of the procedure.
High-flow nasal oxygen decreases airway dead space, provides a stable concentration of inspired oxygen, generates low level of flow-dependent positive airway pressure, and optimizes comfort. Positive-pressure noninvasive supports include continuous positive-airway pressure and noninvasive ventilation and enable providing higher end-expiratory pressure, thereby further improving oxygenation. Noninvasive ventilation, but not continuous positive-airway pressure, better decreases inspiratory effort, and increases tidal volume and transpulmonary driving pressure.
High-flow nasal oxygen has become the first-line therapy in acute hypoxemic respiratory failure, while noninvasive ventilation remains the reference treatment during exacerbations of chronic obstructive pulmonary disease, in patients with respiratory acidosis. In patients requiring intubation, noninvasive ventilation is the optimal technique for preoxygenation to decrease the risk of hypoxemia, while high-flow nasal oxygen is an alternative option for non-hypoxemic patients or those with contraindications to noninvasive ventilation. After extubation in patients at high risk of reintubation, prophylactic noninvasive ventilation, eventually alternating with high-flow nasal oxygen, improves weaning outcome compared to other strategies; high-flow nasal oxygen alone outperforms conventional oxygen in low-risk patients.
无创呼吸支持常规应用于急性呼吸衰竭的危重症患者，以避免气管插管和有创机械通气，从而降低相关并发症的风险，并有助于拔管后成功撤离机械通气。在插管过程中也会应用无创呼吸支持进行预充氧，目的是增强氧合并确保操作安全。
高流量鼻导管吸氧可减少气道死腔，提供稳定的吸入氧浓度，产生低水平的流量依赖性气道正压，并优化舒适度。正压无创支持包括持续气道正压通气和无创通气，能够提供更高的呼气末压力，从而进一步改善氧合。无创通气而非持续气道正压通气能更好地降低吸气用力，并增加潮气量和跨肺驱动压。
高流量鼻导管吸氧已成为急性低氧性呼吸衰竭的一线治疗方法，而无创通气仍然是慢性阻塞性肺疾病急性加重期合并呼吸性酸中毒患者的参考治疗方法。对于需要插管的患者，无创通气是预充氧以降低低氧血症风险的最佳技术，而高流量鼻导管吸氧是无低氧血症患者或有创通气禁忌证患者的替代选择。在再插管高风险患者拔管后，预防性无创通气（最终可与高流量鼻导管吸氧交替使用）与其他策略相比可改善撤机结局；在低风险患者中，单独使用高流量鼻导管吸氧优于传统吸氧。
