无创正压通气(蔡洪流).ppt
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1、浙江大学医学院附属第一医院 ICU蔡洪流,无创正压通气,Noninvasive Positive Pressure VentilationNPPV,无创正压通气,NPPV概述NPPV的优势与不足NPPV适应证、禁忌证及并发症NPPV的实施,机械通气,正压通气负压通气,机械通气,机械通气,有创机械通气无创机械通气正压通气负压通气高频通气,无创正压通气,定义 采用非气管插管或气管切开方法而提供正压通气支持的技术。,International Consensus Conferences in Intensive Care Medicine:Noninvasive Positive Pressure
2、Ventilation in Acute Respiratory Failure Organized Jointly by the American Thoracic Society,the European Respiratory Society,the European Society of Intensive Care Medicine,and the Socit de Ranimation de Langue Franaise,and approved by the ATS Board of Directors,December 2000,Am.J.Respir.Crit.Care M
3、ed.2001;163:283-291,NPPV,NPPV,NPPV was defined as any form of ventilatory support applied without the use of an endotracheal tube,and was considered to include continuous positive airway pressure(CPAP),with or without inspiratory pressure support;volume-and pressure-cycled systems,propotional assist
4、 ventilation(PAV),and adjuncts such as the use of helium-oxygen(heliox)gas mixture.,Am.J.Respir.Crit.Care Med.2001;163:283-291,NPPV,正压通气的主要目的,改善氧合和肺泡通气降低呼吸作功,缓解呼吸困难,适当选择适应证,上述目标通过NPPV同样可以达到,而且NPPV可以有效避免与气管插管/气管切开相关的并发症。,NPPV是非常有效的机械通气手段,它与传统的有创机械通气不是相互替代,而是,NPPV是非常有效的机械通气手段,它与传统的有创机械通气不是相互替代,而是相互补充,
5、NPPV的优点(1),病人痛苦小,易接受,NPPV的优点(2),减少气管插管/气管切开相关并发症上呼吸道正常屏障功能的破坏上呼吸道损伤院内感染(VAP),NPPV的优点(3),镇静剂用量减少保持病人清醒、增加活动和交流、减少心理问题。增加自主吸气努力,促进静脉回流保持咳嗽能力,促进排痰,减少肺不张,改善通气/血流比。减少对其他脏器功能的影响,避免镇静剂掩盖其他并发症。,NPPV的优点(4),保持气道防御反应,允许咳嗽、咳痰,NPPV的优点(5),允许讲话及吞咽,NPPV的优点(6),使用方便、灵活,NPPV的不足,需要病人清醒配合不利于气道分泌物的引流不能完全替代气管插管/气管切 开,通气效果
6、不十分确切NPPV相关并发症,NPPV与有创正压通气的比较,NPPV的适应证,急性呼吸功能衰竭慢性呼吸功能衰竭,Acute applications of noninvasive positive pressure ventilation,Chest.2003 Aug;124(2):699-713,Acute applications of NPPV,Chest.2003 Aug;124(2):699-713,Acute applications of NPPV,Type of Evidence Strong(multiple controlled trials)Less strong(sin
7、gle controlled trial or multiple case series)Weak(few case series or case reports),Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型强(多个对照研究)次强(单个对照研究或多个病例系列)弱(病例系列或病例报告),Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型:强COPD急性加重,Chest.2003 Aug;124(2):699-713,COPD急性加重时NPPV应用指征中重度气促伴有使用辅助呼吸肌或反常呼吸轻中度酸中
8、毒(PH7.307.35)和高碳酸血症(PaCO24560mmHg)RR25次/分,COPD国际防治指南,BTS GUIDELINENon-invasive ventilation in acute respiratory failureBritish Thoracic Society Standards of Care Committee,Thorax.2002 Mar;57(3):192-211,NIV has been shown to be an effective treatment for acute hypercapnic respiratory failure(AHRF),pa
9、rticularly in chronic obstructive pulmonary disease(COPD).Facilities for NIV should be available 24 hours per day in all hospitals likely to admit such patients.A,Thorax.2002 Mar;57(3):192-211,NIV should be considered in patients with an acute exacerbation of COPD in whom a respiratory acidosis(pH 4
10、5 nmol/l)persists despite maximum medical treatment on controlled oxygen therapy.A,Thorax.2002 Mar;57(3):192-211,Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation?A systematic review of the literature,Ann Intern Med
11、.2003 Jun 3;138(11):861-70,DATA SOURCES:MEDLINE(1966 to 2002)EMBASE(1990 to 2002).,Ann Intern Med.2003 Jun 3;138(11):861-70,Additional data sources included Cochrane Librarypersonal filesabstract proceedingsreference lists of selected articlesexpert contact,Ann Intern Med.2003 Jun 3;138(11):861-70,A
12、nn Intern Med.2003 Jun 3;138(11):861-70,结果显示COPD急性发作患者在标准治疗基础上加用NPPV:气管插管风险下降28%,95%可信区间1540%住院时间下降4.57天,95%可信区间2.306.83天住院死亡率下降10%,95%可信区间515%,Ann Intern Med.2003 Jun 3;138(11):861-70,severe COPD exacerbationsBaseline PH7.30 orAn in-hospital mortality rate of greater than 10%in the control group,分组
13、结果显示COPD严重急性发作患者在标准治疗基础上加用NPPV:气管插管风险下降34%,95%可信区间2246%住院时间下降5.59天,95%可信区间3.667.52天住院死亡率下降12%,95%可信区间618%,Ann Intern Med.2003 Jun 3;138(11):861-70,分组结果显示COPD非严重急性发作患者在标准治疗基础上加用NPPV:气管插管风险下降0%,95%可信区间1111%住院时间下降0.82天,95%可信区间0.121.77天住院死亡率下降2%,95%可信区间812%,Ann Intern Med.2003 Jun 3;138(11):861-70,CONCL
14、USIONS:Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy.However,NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations.,Ann Intern Med.2003 Jun 3;138(11):861-70,NPPV在急性呼衰中的应用,证据类型:强急性心原性肺水肿,Chest.2003 Aug;124(2):699-713
15、,NPPV在急性呼衰中的应用,Pending further studies,the most sensible recommendation is to use CPAP(10 cm H2O)initially and to consider switching to NPPV if the patient is found to have substantial hypercapnia or unrelenting dyspnea.,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,This recommendation is in line with
16、 the conclusion of a meta-analysis that found insufficient evidence to support the use of NPPV in preference to CPAP to treat patients with acute pulmonary edema.,Chest.2003 Aug;124(2):699-713,Continuous positive airway pressure(CPAP)has been shown to be effective in patients with cardiogenic pulmon
17、ary oedema who remain hypoxic despite maximal medical treatment.NIV should be reserved for patients in whom CPAP is unsuccessful.B,Thorax.2002 Mar;57(3):192-211,NPPV在急性呼衰中的应用,证据类型:强免疫抑制病人,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,Thus,the avoidance of intubation in this patient population is a des
18、irable outcome,and the use of NPPV is,therefore,justifiable in selected patients with immunocompromised states.,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,It is important to note,however,that the authors of these studies stress the importance of early initiation of therapy before progression to sev
19、ere compromise.,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型:强帮助COPD病人撤机,Chest.2003 Aug;124(2):699-713,Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure,Cochrane Database Syst Rev.2003;(4):CD004127,随机对照研究:Cochrane Central Register of Co
20、ntrolled Trials(The Cochrane Library,issue 2,2003)MEDLINE(January 1966 to July 2003)EMBASE(January 1980 to July 2003),Cochrane Database Syst Rev.2003;(4):CD004127,入选5个研究,包括171名患者。以COPD患者为主 NPPV strategy IPPV strategy,Cochrane Database Syst Rev.2003;(4):CD004127,NPPV组较IPPV组降低死亡率RR 0.41,95%CI 0.22 to
21、0.76降低VAP发生率 RR 0.28,95%CI 0.09 to 0.85,Cochrane Database Syst Rev.2003;(4):CD004127,NPPV组较IPPV组缩短住ICU时间-6.88 days,95%CI-12.60 to-1.15缩短住院时间-7.33 days,95%CI-14.05 to-0.61,Cochrane Database Syst Rev.2003;(4):CD004127,NPPV组较IPPV组缩短总机械通气时间-7.33 days,95%CI-11.45 to-3.22缩短气管插管时间-6.79 days,95%CI-11.70 to-
22、1.87,Cochrane Database Syst Rev.2003;(4):CD004127,NPPV在急性呼衰中的应用,证据类型:次强哮喘,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型:次强囊性纤维化,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型:次强术后呼吸衰竭,Chest.2003 Aug;124(2):699-713,NPPV在急性呼衰中的应用,证据类型:次强避免拔管失败,Chest.2003 Aug;124(2):699-713,Noninvasive positive-pr
23、essure ventilation for respiratory failure after extubation,N Engl J Med.2004 Jun 10;350(24):2452-60,8个国家:阿根廷、巴西、哥伦比亚、沙特阿拉伯、西班牙、美国、委内瑞拉等37个医疗中心,N Engl J Med.2004 Jun 10;350(24):2452-60,上机48小时以上,选择性拔管后48小时内发生呼吸衰竭的221名患者随机分为经面罩NPPV组(n=114)常规内科治疗组(n=107),N Engl J Med.2004 Jun 10;350(24):2452-60,N Engl
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