早期无创正压通气治疗慢性阻塞性肺疾病急性加重期的前瞻性随机对照研究

Prospective randomized controlled clinical study of early use of noninvasive positive pressure ventilation in the treatment for acute exacerbation of chronic obstructive pulmonary disease

目的观察早期无创正压通气(NIPPV)对慢性阻塞性肺疾病(COPD)急性加重期患者气体交换、呼吸肌疲劳、气管插管率以及住院病死率的影响。方法36例收住重症监护治疗病房(ICU)的COPD急性加重期患者〔7.25≤动脉血pH(pHa)<7.35,动脉血二氧化碳分压(PaCO2)>45mmHg(1mmHg=0.133kPa)〕纳入观察。入选病例随机分配到标准治疗组(A组,n=18)和NIPPV治疗组(B组,n=18)。A组接受常规药物治疗;B组在常规药物治疗的同时,立即应用面罩以双水平正压(BiPAP)模式行NIPPV,首次NIPPV持续时间需在2h以上,NIPPV至少持续3d,并保证每日累计时间达8h以上。观察两组患者入选后0、2、24和72h的心率(HR)、呼吸频率(RR)、气体交换指标及辅助呼吸肌动用评分;观察B组患者停用NIPPV24h后的上述指标;比较两组患者气管插管率和住院病死率。结果两组患者0h的一般情况、HR、RR、气体交换指标及辅助呼吸肌动用评分差异均无显著性(P均>0.05),有可比性。与0h比较,A组患者72hHR、RR、PaCO2及辅助呼吸肌动用评分明显下降,pHa明显上升(P均<0.05),但在2h及24h上述指标无明显改善。B组患者2hHR、RR、PaCO2较0h均明显下降,动脉血氧分压(PaO2)明显上升,24h及72h上述指标持续改善,停用NIPPV后24h上述指标无恶化。B组气管插管率11.1%明显低于A组的44.4%(P<0.05)。B组的住院病死率(5.6%)略低于A组(16.7%),但差异无显著性(P>0.05)。结论早期应用NIPPV能迅速改善COPD急性加重期患者的气体交换,缓解呼吸肌疲劳,减少气管插管率。

Objective To evaluate the effect of the early use of noninvasive positive pressure ventilation （NIPPV） on gas exchange, rate of endotracheal intubation and in- hospital mortality in patients with acute exacerbation of chronic obstructive pulmonary disease （COPD）. Methods Thirty - six patients with acute exacerbation of COPD [7.25≤arterial blood pH （pHa）〈7.35, partial pressure of carbon dioxide in artery （PaCO2）〉45 mm Hg, 1 mm Hg=0. 133 kPa] were enrolled in the study. The patients were divided randomly into standard therapy group （group A, n=18） and standard therapy＋NIPPV group （group B, n=18）. The patients in group A were treated with standard therapy only and those in group B were treated with both standard therapy and NIPPV with Bi- level positive airway pressure （BiPAP） mode. NIPPV should be maintained over 2 hours in the first time. In the first 3 days, the duration of NIPPV should not be less than 8 hours per day. In each group, heart rate （HR）, respiratory rate （RR）, parameters of gas exchange, and scale for accessory muscle use were measured at the time of enrollment （0 hour）, 2 hours, 24 hours and 72 hours after randomization. In group B, the foregoing parameters were also observed at 24 hours after the end of NIPPV. Rate of endotracheal intubation and in - hospital mortality were recorded in each group. Results The general conditions were similar in both groups at 0 hour. Compared with that of 0 hour, marked improvement in HR, RR, pHa, PaCO2 and scale for accessory muscle use was found only at 72 hours after treatment in group A. In group B, significant improvement in HR, RR, PaCO2, partial pressure of oxygen in artery （PaO2） and scale for accessory muscle use was found 2 hours after the treatment. In this group, the foregoing parameters were improved continuously in the course of the treatment, and they showed no deterioration 24 hours after termination of NIPPV. The rate of endotracheal intubation in group B （11.1%） was significantly lower than that in group A （44.4%, P〈0.05）. In group B, the in -hospital mortality was slightly lower than that in group A （5.6% vs. 16. 7%, P〉 0. 05）. Conclusion Early use of NIPPV can improve gas exchange, lessen respiratory muscle fatigue and decrease the need for intubation in patients with acute exacerbation of COPD.