急性呼吸窘迫综合征患者拔管后经鼻高流量通气的疗效分析
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摘要
目的:比较急性呼吸窘迫综合征(ARDS)患者拔管后经鼻高流量通气与无创正压通气的临床疗效。方法:选取本院2016年8月到2018年8月急危重症医学科(ICU)行气管插管,符合标准的ARDS患者57例,根据随机数字表法分为经鼻高流量通气(HFNC)组(n=26)和无创正压通气(NIPPV)组(n=31)。所有患者拔管前1 h及拔管后1,12,24,48 h行血气分析,记录患者氧分压(PaO2)、二氧化碳分压(PaCO2)、氧合指数(OI)、平均动脉压(MAP)、心率(HR)。比较两组患者舒适度、误吸发生率、再插管、拔管-再插管时间、ICU入住天数、总住院天数、ICU死亡率。结果:两组拔管前1 h、拔管后1,12,24,48 h PaCO2、MAP、HR差异无统计学意义;拔管后1,12,2,48h HFNC组患者PaO2及OI优于NIPPV组患者[PaO2(mmHg):1 h:79. 35±18. 05 vs 89. 76±18. 30,P=0. 036;12h:74. 58±17. 15 vs 88. 00±25. 97,P=0. 018;24 h:80. 10±18. 69 vs 91. 85±19. 11,P=0. 023;48 h:83. 29±22. 05vs 94. 19±16. 27, P=0. 041;OI:1 h:298. 29±37. 04 vs 336. 92±45. 03, P=0. 001;12 h:281. 10±70. 92 vs342. 04±81. 61,P=0. 004;24 h:305. 19±53. 81 vs 359. 12±47. 05,P=0. 000;48 h:294. 13±44. 83 vs 340. 35±46. 32,P=0. 000]。NIPPV的舒适度低于HFNC(平均秩次22. 69 vs 36. 52,Z=-3. 162,P=0. 002)。两组患者误吸发生率、再插管、总住院天数、ICU死亡率、住院死亡率差异无统计学意义(P>0. 05);HFNC组患者ICU入住天数少于NIPPV组患者,差异有统计学意义(P=0. 016);拔管-再插管时间差异有统计学意义(P=0. 011),HFNC组患者时间长于NIPPV组患者。结论:ARDS患者拔管后HFNC的疗效并不亚于NIPPV,在氧合及舒适度方面甚至优于NIPPV,但在应用HFNC时,我们要注意避免延误插管。
Objective: To compare the clinical efficacy of high-flow nasal cannula(HFNC) and non-invasive positive pressure ventilation(NIPPV) after extubation in patients with acute respiratory distress syndrome(ARDS).Methods: From August 2016 to August 2018, 57 patients with ARDS and receiving endotracheal intubation were enrolled. The patients were divided into HFNC group(n=26) and NIPPV(n=31) group according to random number table. Arterial blood gas analysis was performed in several time points(1 hour before extubation, 1, 12, 24, and 48 hours after extubation), and the PaO2, PaCO2, oxygenation index(OI), mean arterial pressure(MAP), and heart rate(HR) were recorded. Comfort of patients, incidence rate of aspiration, rate of re-intubation, extubation-reintubation time, ICU check-in days, total hospitalization days and ICU mortality were compared between the two groups.Results: There were no significant difference between the two groups in PaCO2,MAP, and HR at all time-pionts. PaO2 and oxygenation index in HFNC group were better than those in NIPPV group 1, 12, 24 and 48 hours after extubation. There were significant differences between the two groups in following indices(PaO2(mmHg): 1 hour after extubation, 79. 35±18. 05 vs 89. 76±18. 30, P=0. 036; 12 hours after extubation,74. 58± 17. 15 vs 88. 00± 25. 97, P=0. 018; 24 hours after extubation, 80. 10 ± 18. 69 vs 91. 85 ± 19. 11, P=0. 023;48 hours after extubation, 83. 29 ±22. 05 vs 94. 19±16. 27, P=0. 041; OI: 1 hour after extubation, 298. 29±37. 04 vs 336. 92±45. 03,P=0. 001; 12 hours after extubation, 281. 10± 70. 92 vs 342. 04± 81. 61, P=0. 004; 24 hours after extubation, 305. 19 ± 53. 81 vs 359. 12 ± 47. 05, P=0. 000; 48 hours after extubation, 294. 13 ±44. 83 vs 340. 35± 46. 32, P=0. 000). HFNC was more comfortable and better tolerated than NIPPV(average rank: 22. 69 vs 36. 52, Z=-3. 162, P=0. 002). There were no significant difference in incidence rate of aspiration, rate of re-intubationtotal hospitalization days, and ICU mortality(all P>0. 05) between this two groups. ICU check-in days in HFNC group were less than in NIPPV group(P=0. 016). There were significant difference in extubation-reintubation time between HFNC group and NIPPV group(P=0. 011).Conclusion: The efficacy of HFNC in ARDS patients after extubation is similar with that of NIPPV, and it is even better than NIPPV in oxygenation and comfort of patients. However, when applying HFNC, we should pay attention to avoiding delayed intubation.
Objective: To compare the clinical efficacy of high-flow nasal cannula(HFNC) and non-invasive positive pressure ventilation(NIPPV) after extubation in patients with acute respiratory distress syndrome(ARDS).Methods: From August 2016 to August 2018, 57 patients with ARDS and receiving endotracheal intubation were enrolled. The patients were divided into HFNC group(n=26) and NIPPV(n=31) group according to random number table. Arterial blood gas analysis was performed in several time points(1 hour before extubation, 1, 12, 24, and 48 hours after extubation), and the PaO2, PaCO2, oxygenation index(OI), mean arterial pressure(MAP), and heart rate(HR) were recorded. Comfort of patients, incidence rate of aspiration, rate of re-intubation, extubation-reintubation time, ICU check-in days, total hospitalization days and ICU mortality were compared between the two groups.Results: There were no significant difference between the two groups in PaCO2,MAP, and HR at all time-pionts. PaO2 and oxygenation index in HFNC group were better than those in NIPPV group 1, 12, 24 and 48 hours after extubation. There were significant differences between the two groups in following indices(PaO2(mmHg): 1 hour after extubation, 79. 35±18. 05 vs 89. 76±18. 30, P=0. 036; 12 hours after extubation,74. 58± 17. 15 vs 88. 00± 25. 97, P=0. 018; 24 hours after extubation, 80. 10 ± 18. 69 vs 91. 85 ± 19. 11, P=0. 023;48 hours after extubation, 83. 29 ±22. 05 vs 94. 19±16. 27, P=0. 041; OI: 1 hour after extubation, 298. 29±37. 04 vs 336. 92±45. 03,P=0. 001; 12 hours after extubation, 281. 10± 70. 92 vs 342. 04± 81. 61, P=0. 004; 24 hours after extubation, 305. 19 ± 53. 81 vs 359. 12 ± 47. 05, P=0. 000; 48 hours after extubation, 294. 13 ±44. 83 vs 340. 35± 46. 32, P=0. 000). HFNC was more comfortable and better tolerated than NIPPV(average rank: 22. 69 vs 36. 52, Z=-3. 162, P=0. 002). There were no significant difference in incidence rate of aspiration, rate of re-intubationtotal hospitalization days, and ICU mortality(all P>0. 05) between this two groups. ICU check-in days in HFNC group were less than in NIPPV group(P=0. 016). There were significant difference in extubation-reintubation time between HFNC group and NIPPV group(P=0. 011).Conclusion: The efficacy of HFNC in ARDS patients after extubation is similar with that of NIPPV, and it is even better than NIPPV in oxygenation and comfort of patients. However, when applying HFNC, we should pay attention to avoiding delayed intubation.
引文
[1] Bellani G, Laffey J G, Pham T, et al. Epidemiology,patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50countries[J]. JAMA, 2016,315(8):788-800.
[2] Bos LD, Martin-Loeches I, Schultz MJ. ARDS:challenges in patient care and frontiers in research[J]. Eur Respir Rev, 2018,27:170107.
[3] Chawla R, Mansuriya J, Modi N, et al. Acute respiratory distress syndrome:predictors of noninvasive ventilation failure and intensive care unit mortality in clinical practice[J]. J Crit Care, 2016,31(1):26-30.
[4] Thille AW, Contou D, Fragnoli C, et al. Non-invasive ventilation for acute hypoxemic respiratory failure:intubation rate and risk factors[J]. Crit Care, 2013,17(6):R269.
[5] Messika J, Ben AK, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS:a1-year observational study[J]. Respir Care, 2015,60(2):162-169.
[6] Mauri T, Turrini C, Eronia N, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure[J]. Am J Respir Crit Care Med, 2017,195(9):1 207-1 215.
[7] Mauri T, Alban L, Turrini C, et al. Optimum support by high-flow nasal cannula in acute hypoxemic respiratory failure:effects of increasing flow rates[J]. Intensive Care Med, 2017,43(10):1 453-1 463.
[8] Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure[J]. N Engl J Med, 2015, 372(23):2 185-2 196.
[9] Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients:a randomized clinical trial[J]. JAMA, 2016,316(15):1 565-1 574.
[10] Koyauchi T, Hasegawa H, Kanata K, et al. Efficacy and tolerability of high-flow nasal cannula oxygen therapy for hypoxemic respiratory failure in patients with interstitial lung disease with do-not-intubate orders:A retrospective single-center study[J]. Respiration, 2018,96(4):323-329.
[2] Bos LD, Martin-Loeches I, Schultz MJ. ARDS:challenges in patient care and frontiers in research[J]. Eur Respir Rev, 2018,27:170107.
[3] Chawla R, Mansuriya J, Modi N, et al. Acute respiratory distress syndrome:predictors of noninvasive ventilation failure and intensive care unit mortality in clinical practice[J]. J Crit Care, 2016,31(1):26-30.
[4] Thille AW, Contou D, Fragnoli C, et al. Non-invasive ventilation for acute hypoxemic respiratory failure:intubation rate and risk factors[J]. Crit Care, 2013,17(6):R269.
[5] Messika J, Ben AK, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS:a1-year observational study[J]. Respir Care, 2015,60(2):162-169.
[6] Mauri T, Turrini C, Eronia N, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure[J]. Am J Respir Crit Care Med, 2017,195(9):1 207-1 215.
[7] Mauri T, Alban L, Turrini C, et al. Optimum support by high-flow nasal cannula in acute hypoxemic respiratory failure:effects of increasing flow rates[J]. Intensive Care Med, 2017,43(10):1 453-1 463.
[8] Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure[J]. N Engl J Med, 2015, 372(23):2 185-2 196.
[9] Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients:a randomized clinical trial[J]. JAMA, 2016,316(15):1 565-1 574.
[10] Koyauchi T, Hasegawa H, Kanata K, et al. Efficacy and tolerability of high-flow nasal cannula oxygen therapy for hypoxemic respiratory failure in patients with interstitial lung disease with do-not-intubate orders:A retrospective single-center study[J]. Respiration, 2018,96(4):323-329.