有创无创序贯机械通气治疗慢性阻塞性肺病所致急性呼吸衰竭的研究

Prospective randomized controlled clinical study of sequential non-invasive following invasive mechanical ventilation in patients with acute respiratory failure induced by COPD

目的 评价有创无创序贯性机械通气治疗慢性阻塞性肺病 (COPD)所致急性呼吸衰竭患者的可行性及其临床效果。方法 以 2 0 0 1年 12月至 2 0 0 3年 12月间本院危重病医学科 (ICU)收治的严重肺部感染所致慢性阻塞性肺病 (COPD)急性呼吸衰竭并需要机械通气的患者为研究对象。临床出现“肺部感染控制窗 (出窗 )”后 ,前瞻性随机分为有创无创序贯性治疗组 (NIV组 )和常规治疗组 (对照组 )。NIV组立即拔除气管插管 ,应用口鼻面罩双水平正压 (BiPAP)模式无创机械通气支持直至脱机。对照组则继续有创机械通气 ,以压力支持方式脱机。观察两组患者一般情况、急性生理学与慢性健康状况评分 (APACHE)Ⅱ、动脉血气分析指标、心率、血压、肺部感染控制窗出现时间、机械通气时间、ICU住院时间、总住院时间、呼吸机相关肺炎 (VAP)患病率和患者转归。结果 共有 33例患者入选研究 ,其中NIV组 17例 ,对照组 16例。两组患者在治疗前年龄、性别、APACHEⅡ评分、心率、血压、动脉血氧分压 (PaO2 )和动脉血二氧化碳分压 (PaCO2 )等指标相似 (P >0 0 5 )。NIV组和对照组出窗的时间分别为 (2 9± 0 6 )d和(5 0± 0 5 )d ,出窗时间和出窗时两组患者的心率、血压、呼吸频率、PaO2 和PaCO2 等指标无显著性差异(P >0 0 5 )。

Objective To evaluate the feasibility and the clinical efficacy of sequential non-invasive following invasive mechanical ventilation (MV) in patients with acute respiratory failure induced by chronic obstructive pulmonary disease(COPD).Methods From December 2001 to December 2003, COPD patients with severe respiratory failure caused by pulmonary infection were intubated and involved in the study. When pulmonary infection had been significantly controlled (we call the time as ‘pulmonary infection control window, PIC window’) after the antibiotic and comprehensive therapy, patients were prospectively randomized into either NIV group or control group.The early extubation was conducted and followed by non-invasive mechanical ventilation via facial mask with bi-level positive airway pressure(BiPAP)mode immediately(NIVgroup), conventional invasive pressure support ventilation was used as the control weaning technique (control group).The data of age, sex, acute physiology and chronic health evaluation II (APACHE II) score, arterial blood gas analysis, heart rate(HR), mean artery blood pressure(MAP), the time of PIC window, the duration of invasive mechanical ventilation and total mechanical ventilation, the duration of ICU stay and hospital stay, the incidence of ventilation associated pneumonia ( VAP ) and the mortality in hospital were recorded.Results Seventeen patients among thirty-three patients involved in the study were in NIV group,and another 16 were in control group. NIV group and control group had similar age, sex, APACHE II score, HR, MAP, partial pressure of oxygen in artery (PaO 2) and partial pressure of carbon dioxide in artery (PaCO 2) at the time of commencement and PIC window (P>0.05).The occurrence of PIC window was(2.9±0.6) days in NIV group and(3.0± 0.5)days in control group (P>0.05).In NIV group, the durations of invasive MV and total MV were(4.4±2.5)days and(12.8±3.9)days, respectively,and in control group the durationss were(8.4±2.6)days and(12.8±3.9)days respectively,P<0.05.The duration of ICU stay was(10.3±2.9)days in NIV group and(16.3±4.3)days in control group (P< 0.01), and the duration of hospital stay in NIV group was shorter than that in control group (18 ±3) days vs (26 ± 5) days, P< 0.01.The incidence of VAP was 5.9% in NIV group compared with 25% in control group (P<0.05).Hospital mortality showed no difference between NIV group and control group (17.6% vs 18.7%, P>0.05).Conclusion In COPD patients requiring intubation and MV for acute respiratory failure induced by severe pulmonary infection, sequential non-invasive following invasive mechanical ventilation at the time of PIC window could decrease the morbidity of VAP, reduce the duration of MV, the length of ICU and hospital stay.