慢性阻塞性肺疾病并呼吸衰竭救治时无创和有创通气相互转换的时机探讨

Time of mutual switch between invasive ventilation and noninvasive positive pressure ventilation in patients with chronic obstructive pulmonary disease with respiratory failure

目的 探讨慢性阻塞性肺疾病 (COPD)急性加重并呼吸衰竭进行机械通气救治时无创和有创通气相互转换的适当时机。方法 观察入院后首先应用无创正压通气 (NIPPV)患者经NIPPV治疗失败后 :(1)及时转换为有创通气 ;(2 )延缓转换为有创通气 ;(3)维持NIPPV治疗患者的预后。比较入院后首先应用气管插管有创通气患者中提前拔管转用NIPPV患者 (提前拔管组 )和按正常程序拔管患者 (正常拔管组 )的机械通气时间、住院时间、呼吸机相关性肺炎 (VAP)发生率和病死率。结果 首用NIPPV治疗失败立即转换为有创通气患者病死率为 11 1% (1/ 9) ,延缓转换为有创通气和维持NIPPV治疗患者的病死率为 88 9% (8/ 9) (P <0 0 5 )。首用有创通气患者中提前拔管组与正常拔管组比较 ,机械通气时间和住院时间明显缩短 (P <0 0 5 ) ,VAP发生率和病死率明显降低 (P <0 0 5 )。结论 COPD急性加重并呼吸衰竭患者机械通气治疗期间 ,准确把握从无创到有创或有创到无创的转换时机 ,合理、灵活选用NIPPV和有创通气 ,可提高治疗效果 ,降低VAP发生率和病死率。

Objective To estimate the optimal time of mutual switch between invasive ventilation and noninvasive positive pressure ventilation (NIPPV) in treatment of patients with chronic obstructive pulmonary disease (COPD) induced respiratory failure (RF).Methods The prognosis of COPD patients with RF was compared as (1) immediate switch;(2)delayed switch;(3)no switch from NIPPV to invasive ventilation after NIPPV was fail.In patients underwent intubation and invasive ventilation at admission,the duration of mechanical ventilation and hospital stay,the incidence of ventilator associated pneumonia (VAP) and the mortality were compared between patients recieved early extubation followed NIPPV and patients with routin extubation.Results After failure of NIPPV,the mortality (11.1%) in patients by immediate switch was significantly lower than that (88.9%) in patients by delayed switch and no switch (P<0.05).In patients received invasive ventilation at admission,those with early extubation followed NIPPV had the duration of mechanical ventilation of 6.8±3.5 days and hospitalization days of 18.8±7.2 days which were shorter than those with routine extubation (10.5±4.7 days and 26.8±11.4 days,P<0.05,respectively).The incidence of VAP and the mortality in patients with early extubation followed NIPPV were markedly lower than those in patients with routine extubation.Conclusions During mechanical ventilation of COPD patients with RF,it is very important to determine the optimal time to switch mechanical ventilation from NIPPV to invasive ventilation or from invasive ventilation to NIPPV.A prompt change of mechanical ventilation mode can improve outcome of patients and decrease the incidence of VAP and mortality.