以肺部感染控制窗为切换点行有创与无创序贯机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的随机对照研究

Application of pulmonary infection control window as switching point for sequential invasive to noninvasive ventilation in treatment of severe respiratory failure of chronic obstructive pulmonary disease:a randomized controlled study

目的明确以肺部感染控制(PIC)窗为切换点实施序贯通气策略在慢性阻塞性肺疾病急性加重(AECOPD)并呼吸衰竭治疗中的作用。方法12家医院的内科或呼吸重症监护病房参加本项研究。因支气管-肺部感染致AECOPD并严重呼吸衰竭行有创通气,治疗后出现PIC窗的患者入选,随机分为有创-无创序贯通气组和常规通气组,监测患者有创通气时间、呼吸机相关肺炎(VAP)发生率、住ICU时间和病死率等。结果90例患者入选,序贯通气组47例,常规通气组43例。序贯通气组与常规通气组比较,有创通气时间明显缩短[(6.4±4.4)、(11.3±6.2)d,P=0.000],VAP发生率明显下降(3/47、12/43,P=0.014),住ICU时间减少[(12±8)、(16±11)d,P=0.047],患者病死率降低(1/47、7/43,P=0.025)。结论以PIC窗为切换点实施序贯通气策略可缩短有创通气时间,显著改善AECOPD并呼吸衰竭患者的预后。

Objective To evaluate the feasibility and the efficacy of early extubation and sequential noninvasive mechanical ventilation （MV） switched by pulmonary infection control window （PIC window） in chronic obstructive pulmonary disease （ COPD ） with exacerbated hypercapnic respiratory failure. Methods Respiratory or Medical Intensive Care Units （RICU/MICU） of 12 teaching hospitals in China participated in this study. COPD patients with severe hypercapnic respiratory failure exacerbated by pulmonary infection, and for whom intubation and MV were indicated,were enrolled in the study. PIC window was defined as the time point when pulmonary infection was considered under control based on clinical parameters. At PIC window,all the cases were randomly assigned to sequential MV group or conventional MV group. The invasive MV duration ,ventilator-associated pneumonia（VAP） ,days in ICU and mortality rate in both groups were measured. Results Ninety cases were enrolled. Compared with conventional MV group （ n = 43 ） sequential MV group（ n = 47 ） had shorter duration of invasive MV [ （ 6. 4 ± 4.4 ）, （ 11.3 ± 6. 2 ） d, P = 0. 000] ,lower rate of VAP（ 3/47,12/43, P = 0. 014 ）, fewer days in ICU [ （ 12 -± 8 ）, （ 16 ± 11 ） d, P = 0. 047 ] and lower mortality rate（ 1/47,7/43 ,P = 0. 025 ）. Conclusion Early extubation followed by noninvasive MV initiated at the point of PIC window may decrease the duration of invasive MV and improve the prognosis.