Antonelli M, Conti G, Riccioni L, Meduri G U
La Sapienza, Policlinico Umberto I, Rome, Italy.
Chest. 1996 Sep;110(3):724-8. doi: 10.1378/chest.110.3.724.
The aim of this study was to assess the feasibility and safety of noninvasive positive-pressure ventilation (NPPV) via a face mask to aid in performing fiberoptic bronchoscopy (FOB) with BAL in immunosuppressed patients with gas exchange abnormalities that contraindicate using conventional unassisted FOB.
Eight consecutive immunosuppressed patients (40 +/- 14 years old) with suspected pneumonia entered the study. Entrance criteria included the following: (1) PaO2/fraction of inspired oxygen (FIo2) of 100 or less; pH of 7.35 or more; and (3) improvement in O2 saturation during NPPV before initiating FOB.
Patients had routine application of topical anesthesia to the nasopharynx. A full face mask was connected to a ventilator (Servo 900C; Solna, Sweden) set to deliver continuous positive airway pressure (CPAP) of 4 cm H2O, pressure support ventilation of 17 cm H2O, and 1.0 FIo2. The mask was secured to the patient with head straps. NPPV began 10 min before starting FOB and continued for 90 min or more after the procedure was completed. The bronchoscope was passed through a T-adapter and advanced through the nose. BAL was obtained by sequential instillation and aspiration of 5 to 25 mL aliquots of sterile saline solution through a bronchoscope wedged in a radiographically involved subsegment. Oxygen saturation, heart rate, respiratory rate, and arterial blood gases were monitored during the study.
NPPV significantly improved PaO2/FIo2 and O2 saturation. FOB with NPPV was well tolerated, and no patient required endotracheal intubation. A causative pathogen was identified by BAL in all patients. Six patients responded to treatment and survived hospital admission. Two patients died 5 to 7 days after FOB from unrelated complications of the underlying illness.
NPPV should be considered during bronchoscopy of immunosuppressed patients with severe hypoxemia.
本研究旨在评估通过面罩进行无创正压通气（NPPV）辅助免疫抑制且存在气体交换异常而禁忌使用传统非辅助纤维支气管镜检查（FOB）的患者进行带支气管肺泡灌洗（BAL）的纤维支气管镜检查的可行性和安全性。
8例连续的疑似肺炎的免疫抑制患者（40±14岁）进入本研究。入选标准包括：（1）动脉血氧分压（PaO2）/吸入氧分数（FIo2）≤100；（2）pH≥7.35；（3）在开始FOB前进行NPPV期间氧饱和度有所改善。
患者接受鼻咽部局部麻醉常规操作。将全面罩连接至设置为提供4 cm H2O持续气道正压（CPAP）、17 cm H2O压力支持通气和1.0 FIo2的呼吸机（Servo 900C；瑞典索尔纳）。用头带将面罩固定于患者面部。NPPV在开始FOB前10分钟启动，并在操作完成后持续90分钟或更长时间。支气管镜通过T形适配器经鼻插入。通过将支气管镜楔入影像学显示受累亚段，依次注入和吸出5至25 mL无菌生理盐水进行BAL。研究期间监测氧饱和度、心率、呼吸频率和动脉血气。
NPPV显著改善了PaO2/FIo2和氧饱和度。NPPV辅助下的FOB耐受性良好，无患者需要气管插管。所有患者通过BAL均鉴定出致病病原体。6例患者治疗有效并存活至出院。2例患者在FOB后5至7天因基础疾病的无关并发症死亡。
对于免疫抑制且存在严重低氧血症的患者，在支气管镜检查期间应考虑使用NPPV。
