L'Her E, Duquesne F, Paris A, Mouline J, Renault A, Garo B, Boles J M
Réanimation et Urgences médicales, CHU de la Cavale Blanche, Brest.
Presse Med. 1998 Jun 20;27(22):1089-94.
Intubation and ventilatory assistance are often required in patients presenting severe hypoxemic respiratory distress, but may be contraindicated in elderly subjects due to an underlying condition. The aim of this study was to assess the feasibility, acceptability and contribution of early assistance with spontaneous positive end-expiratory pressure ventilation for elderly subjects admitted to an emergency unit for acute respiratory distress due to cardiogenic pulmonary edema.
In our emergency admission unit, all patients with life-threatening hypoxemic respiratory distress are initially assisted with noninvasive spontaneous positive end-expiratory pressure ventilation using a standardized commercial device. We retrospectively analyzed the the files of all patients aged over 70 years who were treated with this standard protocol for cardiogenic pulmonary edema from April 1996 through September 1997.
During the study period, 36 patients aged over 70 years required ventilatory assistance according to the standard protocol. Intubation was not reasonable in most of the patients (n = 30). After 1 hour of ventilation, none of the patients developed clinical signs of life-threatening distress. Blood gases demonstrated improved oxygenation (AEPO2 = +184.9 +/- 105.4 mmHg; p < 0.000001). Thirty-two patients were considered to be cured (88.9%) and were discharged; the cardiovascular condition was fatal in 4 patients (11.1%).
The rapid improvement in clinical signs and blood gases as well as the final outcome suggests that early assistance with spontaneous positive end-expiratory pressure ventilation is warranted at admission for elderly patients with respiratory distress due to cardiogenic pulmonary edema. Compared with a control group of hospitalized patients cared for during the preceding year and who were not treated with the standard protocol, we also demonstrated a clear improvement in mortality (11% versus 20%).
严重低氧性呼吸窘迫患者常需要插管和通气辅助，但由于存在基础疾病，老年患者可能禁忌使用。本研究的目的是评估对因心源性肺水肿入住急诊科的老年患者早期给予自主呼气末正压通气辅助的可行性、可接受性及作用。
在我们的急诊入院病房，所有有危及生命的低氧性呼吸窘迫的患者最初均使用标准化商用设备给予无创自主呼气末正压通气辅助。我们回顾性分析了1996年4月至1997年9月期间按照该标准方案治疗心源性肺水肿的所有70岁以上患者的病历。
在研究期间，36例70岁以上患者根据标准方案需要通气辅助。大多数患者（n = 30）插管不合理。通气1小时后，没有患者出现危及生命的窘迫临床体征。血气显示氧合改善（平均动脉血氧分压升高 = +184.9 +/- 105.4 mmHg；p < 0.000001）。32例患者被认为治愈（88.9%）并出院；4例患者（11.1%）心血管状况导致死亡。
临床体征和血气的快速改善以及最终结果表明，对于因心源性肺水肿出现呼吸窘迫的老年患者，入院时早期给予自主呼气末正压通气辅助是必要的。与前一年住院且未接受标准方案治疗的对照组患者相比，我们还证明死亡率有明显改善（11%对20%）。
