無(wú)創(chuàng)與有創(chuàng)機(jī)械通氣間的轉(zhuǎn)換首都醫(yī)科大學(xué)附屬北京朝陽(yáng)醫(yī)院北京呼吸疾病研究所曹志新1無(wú)創(chuàng)-有創(chuàng)通氣間的轉(zhuǎn)換成為臨床實(shí)踐中的重要問(wèn)題和研究熱點(diǎn)無(wú)創(chuàng)通氣→有創(chuàng)通氣專家共識(shí)應(yīng)用無(wú)創(chuàng)通氣時(shí)，患者病情無(wú)改善或惡化，需及時(shí)轉(zhuǎn)為有創(chuàng)通氣行無(wú)創(chuàng)通氣后2-4小時(shí)內(nèi)呼吸困難癥狀無(wú)緩解，指標(biāo)無(wú)改善出現(xiàn)嘔吐、嚴(yán)重上消化道出血?dú)獾婪置谖镌龆?，排痰困難出現(xiàn)低血壓、嚴(yán)重心律失常等循環(huán)系統(tǒng)異常表現(xiàn)有創(chuàng)通氣→無(wú)創(chuàng)通氣有創(chuàng)通氣→無(wú)創(chuàng)通氣的臨床意義縮短有創(chuàng)通氣時(shí)間避免再次氣管插管減少有創(chuàng)通氣相關(guān)并發(fā)癥有創(chuàng)通氣→無(wú)創(chuàng)通氣的時(shí)機(jī)早期拔管，轉(zhuǎn)為無(wú)創(chuàng)（序貫通氣）常規(guī)撤離有創(chuàng)通氣，轉(zhuǎn)為無(wú)創(chuàng)有創(chuàng)通氣撤機(jī)后呼吸惡化，轉(zhuǎn)為無(wú)創(chuàng)有創(chuàng)通氣插管上機(jī)拔管撤機(jī)①②③早期拔管，轉(zhuǎn)為無(wú)創(chuàng)（序貫通氣）序貫通氣的概念以兩種方式實(shí)施正壓通氣縮短有創(chuàng)通氣時(shí)間無(wú)創(chuàng)向有創(chuàng)的切換點(diǎn)是關(guān)鍵InvasiveMVPositivepressureventilationNoninvasiveMV序貫通氣在COPD中的實(shí)施序貫通氣在COPD更具必要性及可能性COPD急性加重行有創(chuàng)通氣的患者需要逐步撤機(jī)(weaning)的比例達(dá)35－67％逐步撤機(jī)使“帶管”時(shí)間延長(zhǎng)無(wú)創(chuàng)通氣在COPD急性加重期取得良好療效“肺部感染控制窗”作為序貫通氣切換點(diǎn)肺部感染控制窗pulmonaryinfectioncontrolwindow(PICwindow)出現(xiàn)“PIC窗”時(shí)痰液引流問(wèn)題已得到較好解決嚴(yán)重呼吸衰竭得以糾正仍存在呼吸肌疲勞和呼吸力學(xué)異常出窗后繼續(xù)有創(chuàng)通氣可能招致VAPPICVAPPulmonaryInfection肺部感染控制窗的判斷標(biāo)準(zhǔn)支氣管-肺部感染影較前明顯吸收，無(wú)明顯融合斑片影痰量較前明顯減少，痰色轉(zhuǎn)白或變淺，黏度降低并在II度*以下同時(shí)至少伴有下述指征中的1項(xiàng)外周血白細(xì)胞計(jì)數(shù)低于10000個(gè)/mm3或較前下降2000個(gè)/mm3以上體溫較前下降并低于38C*姜超美,白淑玲,孫繼紅,等.建立人工氣道后痰液粘稠度的判別方法及臨床意義.中華護(hù)理雜志,1994,29:434.以“肺部感染控制窗”為切換點(diǎn)行有創(chuàng)與無(wú)創(chuàng)序貫機(jī)械通氣治療慢性阻塞性肺疾病所致嚴(yán)重呼吸衰竭的多中心前瞻性隨機(jī)對(duì)照研究

－全國(guó)無(wú)創(chuàng)機(jī)械通氣協(xié)作組

中華結(jié)核和呼吸雜志，2006，29：13-17.

組別例數(shù)年齡（歲）性別（男/女）COPD病程（年）體溫（。C）心率（次/分）呼吸頻率（次/分）序貫通氣組4767.6±10.428/1920.5±10.037.0±0.9108±1626±8常規(guī)通氣組4369.7±7.532/1121.0±12.237.0±0.8108±1826±5P值0.2770.9720.8420.8720.9320.984組別平均動(dòng)脈壓（mmHg）pHPaCO2（mmHg）PaO2（mmHg）外周血白細(xì)胞計(jì)數(shù)（個(gè)/mm3）APACHEⅡ序貫通氣組94±187.20±0.1103±2278±6710923±453721±7常規(guī)通氣組94±147.20±0.1100±2870±7411828±660818±7P值0.9530.9030.5880.9720.4500.057序貫通氣組與對(duì)照組患者基礎(chǔ)情況序貫通氣組和常規(guī)通氣組的有關(guān)醫(yī)療指標(biāo)對(duì)比組別例數(shù)有創(chuàng)通氣天數(shù)總機(jī)械通氣天數(shù)VAP發(fā)生例數(shù)院內(nèi)死亡例數(shù)住ICU天數(shù)序貫通氣組476.4±4.413.3±7.63112±8常規(guī)通氣組4311.3±6.211.3±6.212716±11P值0.0000.1010.0060.0190.047國(guó)外對(duì)COPD行序貫通氣的研究結(jié)論與國(guó)內(nèi)研究相似序貫通氣可明顯縮短有創(chuàng)通氣時(shí)間，減少VAP，縮短住ICU時(shí)間Nava等的研究發(fā)現(xiàn)序貫通氣降低患者死亡率Navaetal.NoninvasiveMechanicalVentilationintheWeaningofPatientswithRespiratoryFailureDuetoChronicObstructivePulmonaryDisease.AnnlInternMed,1998,128:721-728.Giraultetal.NoninvasiveVentilationasaSystematicExtubationandWeaningTechniqueinAcute-on-ChronicRespiratoryFailure.AmJRespirCritCareMed,1999,160:86-92.StudyNO.ofpatientsWeaningeligibilityNava,199850Simpleweaningcriteria,1hrSBTfailureGirault,199933Simpleweaningcriteria,2hrSBTfailureHill,20002130minuteSBTfailureChen,200134Day3+weaningcriteriaFerrer,2003432hrSBTfailureon3consecutivedaysRabie,2004372hrSBTfailureWang,200429PICwindowZheng,200533PICwindowZou,200676PICwindowWang,200590PICwindowTrevisan,20086530minSBTfailureShivaPrasad302hrSBTfailure序貫通氣顯著降低：住院病死率VAP發(fā)生率住ICU時(shí)間總住院時(shí)間有創(chuàng)通氣時(shí)間總機(jī)械通氣時(shí)間PICwindowprioritisesresolutionofthecauseofrespiratoryfailureovermeetingconventionalweaningcriteriaandrepresents

a

novel

approach

to

identifying

candidates

for

wean-ing

in

selected

populations.BMJ.2009May21;338.序貫機(jī)械通氣成為AECOPD臨床治療的規(guī)范常規(guī)撤離有創(chuàng)通氣，轉(zhuǎn)為無(wú)創(chuàng)2項(xiàng)研究2項(xiàng)隨機(jī)對(duì)照研究（Nava97例、Ferrer162例）有創(chuàng)通氣患者常規(guī)撤機(jī)，但具有較大的再插管風(fēng)險(xiǎn)者高齡、拔管時(shí)PaCO2↑、合并心衰、拔管時(shí)APACHEⅡ＞12等AECOPD約占30%撤機(jī)后隨機(jī)分為無(wú)創(chuàng)通氣組和常規(guī)治療組Nava,S.CritCareMed.2005,33:2465-70.MiquelFerrer.AmJRespirCritCareMed.2006,173:164–170.

支持的結(jié)果無(wú)創(chuàng)通氣組與常規(guī)治療組相比再插管率↓（Nava8%vs24%p=0.027)再發(fā)呼吸衰竭↓（Ferrer16%vs33%p=0.029）ICU病死率↓（Ferrer3%vs14%p=0.015）MiquelFerrer.AmJRespirCritCareMed.2006,173:164–170.有創(chuàng)通氣撤機(jī)后呼吸惡化，轉(zhuǎn)為無(wú)創(chuàng)

支持的結(jié)果既往病例對(duì)照研究30例AECOPD有創(chuàng)通氣患者常規(guī)撤機(jī)后72小時(shí)內(nèi)出現(xiàn)呼吸功能不全予以無(wú)創(chuàng)通氣無(wú)創(chuàng)通氣組與常規(guī)治療組相比再插管率、機(jī)械通氣時(shí)間、住ICU時(shí)間↓病死率無(wú)差別G.Hilbert.NoninvasivepressuresupportventilationinCOPDpatientswithpostextubationhypercapnicrespiratoryinsufficiency.EurRespirJ1998;11:1349–1353.G.Hilbert.NoninvasivepressuresupportventilationinCOPDpatientswithpostextubationhypercapnicrespiratoryinsufficiency.EurRespirJ1998;11:1349–1353.否定的結(jié)果2項(xiàng)隨機(jī)對(duì)照研究1項(xiàng)單中心研究（Keenan81例）,1項(xiàng)多中心研究（Esteban221例）呼吸衰竭有創(chuàng)通氣患者COPD患者約占10%常規(guī)撤機(jī)后48小時(shí)內(nèi)出現(xiàn)呼吸功能不全隨機(jī)分為無(wú)創(chuàng)通氣組和常規(guī)治療組無(wú)創(chuàng)通氣組與常規(guī)治療組比較再插管率、HAP發(fā)生率、機(jī)械通氣時(shí)間、住院時(shí)間無(wú)差別病死率↑*COPD亞組，無(wú)創(chuàng)組再插管率有下降趨勢(shì)*（7of14[50%]vs6of9[67%],P=0.67)SeanP.Keenan.JAMA.2002;287(24):3238-3244.AndrésEsteban.NEnglJMed2004;350:2452-60.*無(wú)創(chuàng)通氣組與常規(guī)治療組比較ICU病死率↑（25%vs14%p=0.048）AndrésEsteban.NEnglJMed2004;350:2452-60.研究中的兩個(gè)重要標(biāo)準(zhǔn)拔管撤機(jī)1：再發(fā)呼吸衰竭的標(biāo)準(zhǔn)2：再次插管上機(jī)的標(biāo)準(zhǔn)達(dá)到標(biāo)準(zhǔn)1增加常規(guī)治療強(qiáng)度或應(yīng)用NIPPV達(dá)到標(biāo)準(zhǔn)2再次插管上機(jī)標(biāo)準(zhǔn)1：RespiratoryfailurecriteriaAfterextubation,patientswereobservedfor48hoursfortheonsetof,asdefinedbythepresenceoftwoormoreofthefollowing:RespiratoryacidosisdefinedasanarterialpHbelow7.35withapartialpressureofarterialcarbondioxidegreaterthan45mmHgclinicalsignssuggestiveofrespiratory-musclefatigueorincreasedrespiratoryeffortarespiratoryrategreaterthan25breathsperminutefortwoconsecutivehourshypoxemia(arterialoxygensaturationoflessthan90percentorapartialpressureofarterialoxygenoflessthan80mmHgwithafractionofinspiredoxygengreaterthan0.50)AndrésEsteban.NEnglJMed2004;350:2452-60.AndrésEsteban.NEnglJMed2004;350:2452-60.標(biāo)準(zhǔn)2：Patientswerereintubatediftheymetatleastoneof

thefollowingcriteriaJudgedaftertheyhadundergonetheassignedtreatmentforatleast1hourlackofimprovementinthepHorinthepartialpressureofcarbondioxide;changesinmentalstatus,renderingthepatientunabletotoleratenoninvasiveventilation;adecreaseintheoxygensaturationtolessthan85percent,despitetheuseofahighfractionofinspiredoxygen;lackofimprovementinsignsofrespiratory-musclefatigue;hypotension,withasystolicbloodpressurebelow90mmHgformorethan30minutesdespiteadequatevolumechallenge,theuseofvasopressors,orboth;copioussecretionsthatcouldnotbeadequatelyclearedAndrésEsteban.NEnglJMed2004;350:2452-60.AndrésEsteban.NEnglJMed2004;350:2452-60.拔管撤機(jī)1：再發(fā)呼吸衰竭的標(biāo)準(zhǔn)2：再次插管上機(jī)的標(biāo)準(zhǔn)無(wú)創(chuàng)通氣組與常規(guī)治療組比較再發(fā)呼