Chesi G, Pinelli G, Galimberti D, Navazio A, Montanari P
Servizio di Cardiologia, USL n. 8-Ospedale di Montecchio E. Reggio Emilia.
Minerva Cardioangiol. 1994 Apr;42(4):149-55.
Ehen refractory to optimal medical treatment cardiogenic pulmonary edema requires mechanical ventilation as a last therapeutic resource. In recent years an increasing number of authors reported their experience in the management of acute or subacute respiratory failure with non-invasive mechanical ventilation by nasal mask.
Encouraged by the first promising results reported in literature we experimented this new therapeutic tool in a first group of seven elderly patients (mean age: 76.57--range: 65-89); they all had been admitted for severe cardiogenic pulmonary edema unresponsive to maximal doses of the conventional drugs available for treating acute decompensated heart failure. The enrolled patients were treated with intermittent ventilation administered by nasal mask at selected values of inspiratory positive airway pressure (IPAP) that were comprised between 10 and 20 cm H2O. At the same time an expiratory positive airway pressure (EPAP) at values comprised between 3 and 8 cm H2O was applied. Ventilation was continued for variable periods of 3-24 hours until acceptable values of PaO2 and PaCO2 were obtained. The ventilation modality was spontaneous, spontaneous-time or timed depending on the patients' level of consciousness at starting time.
A good short-term outcome was achieved in all the patients regardless of the ventilation modality applied. The main blood gas alteration was severe hypercapnia with acidosis in three patients, while the other four presented critical hypoxemia unresponsive to simple oxygen supply even if delivered by high-flow Venturi mask. Four of our seven patients were discharged from hospital in satisfactory haemodynamic conditions; the remaining three died during hospitalization from refractory heart failure.
In this our preliminary experience the therapeutic approach with nasal positive pressure ventilation (NPPV) and EPAP proved to be very effective to improve the signs and symptoms of acute refractory cardiogenic pulmonary edema as it avoided the need of invasive mechanical ventilation. It was well tolerated by all our patients; besides it was not difficult to use or time-consuming for physician and nurses. On the other hand it didn't modify our patients' medium or long-time prognosis which was strictly related to their preexisting left ventricular pump derangement.
当最佳药物治疗难以控制时，心源性肺水肿需要机械通气作为最后的治疗手段。近年来，越来越多的作者报告了他们使用鼻罩进行无创机械通气治疗急性或亚急性呼吸衰竭的经验。
受文献中首次报道的令人鼓舞的结果的鼓舞，我们在第一组7名老年患者（平均年龄：76.57岁，范围：65 - 89岁）中试用了这种新的治疗工具；他们均因严重的心源性肺水肿入院，对治疗急性失代偿性心力衰竭的最大剂量常规药物无反应。入选患者采用鼻罩进行间歇通气，吸气气道正压（IPAP）设定在10至20 cm H₂O之间。同时，呼气气道正压（EPAP）设定在3至8 cm H₂O之间。通气持续3至24小时不等，直到获得可接受的PaO₂和PaCO₂值。通气模式根据患者开始时的意识水平为自主通气、自主 - 时间通气或定时通气。
无论采用何种通气模式，所有患者均取得了良好的短期疗效。主要的血气改变是3例患者出现严重高碳酸血症伴酸中毒，另外4例即使通过高流量文丘里面罩供氧仍表现为严重低氧血症且对单纯供氧无反应。我们的7例患者中有4例在血流动力学状况良好的情况下出院；其余3例在住院期间死于难治性心力衰竭。
在我们的初步经验中，鼻正压通气（NPPV）和EPAP的治疗方法被证明对于改善急性难治性心源性肺水肿的体征和症状非常有效，因为它避免了有创机械通气的需要。所有患者对其耐受性良好；此外，对医生和护士来说，它使用并不困难也不耗时。另一方面，它并未改变我们患者的中长期预后，这与他们先前存在的左心室泵功能紊乱密切相关。
