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1、Noninvasive Positive Pressure Ventilation in Acute Exacerbation of COPD无创正压通气在AECOPD的应用,Younsuck Koh,M.D.Department of Pulmonary and Critical Care Medicine,Asan Medical Center,University of Ulsan College of Medicine,Seoul,Korea,Tongji Mechanical Ventilation Forum,Noninvasive Pressure Ventilation无创正压
2、通气,Any form of ventilatory support applied without the use of an endotracheal tube 任何形式的无气管插管的机械通气支持Negative/Positive pressure ventilation 负压/正压通气Mode:CPAP with or without pressure support,volume-and pressure-cycled systems.proportional assist ventilation(PAV).模式：有或无压力支持的CPAP 容量控制/压力控制 支持通气,Hill NS.
3、Lancet 2009;374:250-259,Interfaces for NPPV,Early 1960s:IPPV with mouth piece/facial maskLate 1960s:MV with ETI1989:NPPV with PSV in COPD patients(Meduri GU,et al.Chest 1991:100;445),Brand New?,Eur Respir J 2008;31:874,Time course of published references on noninvasive(NIV)mechanical ventilation(),a
4、nd NIV mechanical ventilation and acute respiratory failure().Source:PubMed.Update:December,2007.关于无创机械通气及其与急性呼吸衰竭的文章逐年增多,Hill NS.Resp Care 2009;54:62-70,院前,家庭治疗,病房,长期急救,后续治疗科室,急诊室,No Intubation Tube 不插管-Communication 交流-VAP incidence呼吸机相关性肺炎:14-28%,Advantage of NPPV NPPV的优点,Easy to perform 易操作Easy
5、monitoring 易监护 sedation 镇静 Comfortness 舒适 Easy to wean 易脱机Less nosocomial infections 减少院内感染,Advantage of NPPV(2)NPPV的优点,Frequency of Nosocomial Infections in the 2 Groups两组患者院内感染的发生率,Girou,E.et al.JAMA 2000;284:2361-2367,Subjects:The patients with acute exacerbation of COPD or severe CPE对象：AECOPD 或严
6、重肺气肿,NPPV is not replacing intubation.NPPV无需更换气管插管First 2 h monitoring is critical after initiation of NPPV 采取NPPV最初的2小时的密切监测十分关键,Essential Facts of NPPV NPPV的基本特征,Detect of a pt,who need ventilatory support.鉴别患者是否需要机械通气 Choice a right candidate 选择合适的对象Prepare right equipments&Right setting 准备合适的设备及
7、适当的设置,3 Steps of NPPV NPPV的三个步骤,Cooperative 合作的 Fewer secretion 分泌物少的 Less sick 病情较轻的Limited mask leak 面罩漏气量少的,Right Candidate 合适的对象,Intensive Care Med 2008;34:2248,Physiologic Benefit to Use NPPV 从生理学角度分析使用NPPV的益处,Acute Exacerbation of COPD（AECOPD）,Mean(SE)for the PaO2 and PaCO2 during the First 12
8、 Hours in the 32 Patients Successfully Treated with NPPV.P values compared with the base-line values.通过NPPV成功治疗后32例患者在最初12小时内氧分压、二氧化碳分压的变化。,RCT,42 with standard TX,43 with NPPV,IPAP up to 20 cm H2O,EPAP=0 随机对照研究，42例标准治疗，43例NPPV治疗（IPAP 最高至20cmH2O，EPAP为零）,Brochard L,et al.N Engl J Med 1995;333:817,The
9、 Length of the Hospital stay among the survivors:幸存者的住院天数：33 33 d in standard group 标准治疗组 23 17 d in NPPV group(p=0.005)NPPV治疗组 MR死亡率：29%vs.9%(p=0.02),N Engl J Med 1995;333:817,Hospital Mortality 住院死亡率,Keenan SP,etal.Ann Intern Med 2003;138:861,Rate of Endotracheal Intubation气管插管率,Keenan SP,etal.Ann
10、 Intern Med 2003;138:861,Nocturnal NPPV in Stable COPD稳定COPD患者夜间应用NPPV治疗,NPPV support did not improve PFT,gas exchange,or sleep efficiencyNPPV支持治疗不能提高肺功能，气体交换或睡眠质量。,Chest 2003;124:337,NPPV Use in Weaning from MVNPPV在机械通气脱机中的应用,Facilitate Extubation(intended extubation);Use of NPPV after Extubation i
11、n patients who fail to meet standard extubation criteria.有助于成功拔管；对不能达到标准拔管指标患者拔管后应用NPPV,Role of NPPV for the Facilitation of Weaning(1)NPPV有助于机械通气脱机成功,78 y-o-m with 20 yr Hx of COPD 有20年COPD病史的78岁患者Home O2 with 1.5 L of Nasal Prongs 家庭氧疗 鼻导管吸氧1.5L血气分析ER:7.322-101.6-23.9-19.2-51.4-34.2,Hospital day#2
12、 住院第二天 PSV mode(PS 16 FiO2 28%PEEP 4)压力支持模式 ABGA 7.511-46.9-79.6-11.9-36.7-96.6 T-piece with FiO2 30%:Respiratory distress with呼吸窘迫 ABGA 7.370-63.4-72.2-8.0-35.8-93.7 NPPV(facial mask)NPPV 面罩 PS 10 PEEP 2 FiO2 30%ABGA 7.316-74.7-70.8-7.9-37.3-92.2 PS 12 PEEP 2 FiO2 26%ABGA 7.358-61.5-62.2-6.1-33.8-9
13、0.3,Hospital day#3 住院第三天NPPV PS 14 PEEP 2 FiO2 26%ABGA 7.360-45.2-123.4(-0.8)-25.0-98.3 Nasal prong 鼻导管 2 L/min:ABGA 7.433-61.0-66.2-12.7-39.9-93.1%,12 trials(530 participants)with predominantly COPD.12个中心（530个患者）主要都是COPD病人。,Outcome in COPD pts:MRCOPD患者的预后：死亡率,Outcome of the pts depending on COPD Pt
14、s ratio预后取决于COPD患者的比例,Better inOutcome of the pts结果改善的:Intubation duration 气管插管时间 Nosocomial pneumonia incidence 医院获得性肺炎的发生率 ICU LOS：ICU住院天数 Hospital LOS：住院天数 TVT 机械通气时间,NPPV Use after Intentional Extubation in Intubated COPDNPPV应用于COPD插管患者的主动拔管后,Wang C,et al.Chin Med J 2005;118:1589,90 intubated CO
15、PD with infection in 11 hospitals in China 中国11家医院90例合并感染的COPD气管插管患者 Extubated after pulmonary infection control(PIC window)vs.conventional treatment 肺部感染控制后拔管 vs.常规治疗 NPPV group showed shorter TVT(6.4 vs.11.3 d)&ICU stay(12 vs.16),lower VAP(3/47 vs.12/43)and hospital mortality(1/47 vs.7/43).NPPV组具有
16、较短的机械通气时间和ICU住院天数，较低的呼 吸机相关性肺炎的发生率及住院死亡率。,Role of NPPV for the Facilitation of Weaning(II)NPPV有助于脱机成功,To avoid reintubation 避免再插管,Incidence 发生率 Planned extubation 计划拔管:5-20%Unplanned extubation 意外拔管:40-50%Related mortality 相关的死亡率 43%vs.12%of successful extubation（成功拔管）,Clinical Impact of Reintubatio
17、n再插管的临床影响,NPPV in Postextubation RF:Outcome in 30 COPD patients NPPV在拔管后的应用：30例COPD患者的研究结果,Eur Respir J 1998;11;1349,+NPPV with face mask*Historic comparison,*days,Noninvasive positive-pressure ventilation for respiratory failure after extubation拔管后呼吸衰竭患者的无创正压通气N Engl J Med 2004;350:2452,+%,No known
18、 index to predict the success of NPPV trial in patients with postextubation respiratory distress.无法预测NPPV对于拔管后出现呼吸窘迫的患者是否有效,Able to breathe spontaneously on T-piece for more than 5 minutes 能够通过T管自主呼吸超过5分钟PaO2/FiO2 more than 150 氧合指数大于150No upper airway problems 不存在上呼吸道的隐患,Minimum Requirement of NPPV
19、 Use as a Weaning Facilitator 逐渐减少使用NPPV有利于脱机成功,Crit Care Med 2008;36:2766,Results of the multivariate logistic regression model:independent predictors of NIV failure多中心逻辑回归模型结果提示：NIV失败的独立预测因子,呼吸频率,无创通气不及时,需升压药,需肾脏替代治疗,符合ARDS,Journal of Critical Care(2009)24,473.e7473.e14,COPD患者无创通气的对照研究,结果：无创通气组的插管
20、率较低，动脉血pH和二氧化碳分压均改善，但无创通气组改善更显著，且住院天数缩短，住院死亡率在两组间无差别。,Complications of NPPVNPPV的并发症,However,most serious complication of NPPV is delayed intubation!然而，最严重的NPPV并发症是插管不及时！,Contraindication 禁忌症,Cardiac or respiratory arrest 心跳呼吸停止Severe encephalopathy(GCS10)严重中枢神经系统疾病Hemodynamic instability or unstable
21、 血流动力学不稳定cardiac arrhythmia 心律失常Upper airway obstruction 上呼吸道梗阻Inability to cooperate/protect the airway不能合作/保护气道,Reanimation 2001;10:112,Contraindication 禁忌症,Non-respiratory organ failure呼吸系统以外器官的衰竭Severe UGI bleeding 严重的上消化道出血Facial surgery,trauma or deformity面部术后、外伤或畸形High risk for aspiration有误吸的
22、高危险因素,Reanimation 2001;10:112,Patient specific factors 患者的因素-Selection 患者的选择-Clear indication 明确适应症Unit specific factors 科室的因素-Experienced care-giver 有经验的医护人员-Technical equipments 技术设备When stop to NPPV treatment 何时停止NPPV治疗,For the Successful NPPV Use 成功应用NPPV,Summary:Incidence of NPPV Use总结：NPPV使用率,
23、Carlucci A,et al.Am J Respir Crit Care Med 2001;163:874,42 centers in France over a period of 3 weeks 法国42个研究中心超过三周的观察,Underutilization.通气不足,1st airway method(n=515)首选的气道方法,Tracheostomy 气管切开,nasal mask 鼻罩,facial mask 面罩,nasotracheal intubation经鼻插管,orotracheal intubation经口气管插管,396(76.9%),2003 KOSREF
24、Study result,NPPV used in 49%of Belgium ED比利时49%急诊室应用NPPVNo available equipment 缺乏设备Lack of experience 缺乏经验More time consuming for care-givers 需要更密切的监护Only 3.8%of the physicians doubted the benefit of NPPV Tx.只有3.8%的临床医师怀疑NPPV治疗的好处Eur J Emerg Med 2002;9:217,The best indication for NPPV use is acute respiratory failure combined with COPD.NPPV的最佳适应症是急性呼吸衰竭合并COPD,Conclusion 结论,You should try NPPV in a cooperative COPD patient with ARF and consider the facility to apply NPPV.对合作的，且合并急性肾衰的COPD患者尝试NPPV，并选择合适的设备实施NPPV。,Take home message 建议：,
