应用无创通气治疗慢性阻塞性肺疾病急性加重期合并呼吸衰竭的时机探讨

Optimal time of the use of non-invasive positive pressure ventilation on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure

目的探讨无创通气在慢性阻塞性肺疾病急性加重期(AECOPD)合并呼吸衰竭的临床应用时机。方法将2005年1月至2007年12月北京大学第三医院呼吸科住院的AECOPD合并呼吸衰竭的131例患者分为常规治疗组和常规治疗+无创正压通气(NIPPV)治疗组,再根据治疗前血气值将NIPPV组分为PaCO2≥9.31kPa、7.98～9.31kPa、6.65～<7.98kPa3组,观察其治疗前、治疗后2h、24h、72h的动脉血气分析变化,观察住院天数、气管插管率、病死率。结果两组比较NIPPV组治疗后2hPaO2较对照组明显升高,后期插管率(7.4%)、住院病死率(8.8%)均显著低于对照组(19.0%,22.2%),差异有统计学意义。NIPPV组各亚组比较,PaCO27.98～9.31kPa组与PaCO2≥9.31kPa组比较,前者治疗后2hpH、PaO2、PaCO2有明显改善(P<0.05),与PaCO26.65～7.98kPa组比较,前者治疗后2hPaO2有明显改善(P<0.05),住院天数较其他两组缩短,与PaCO26.65～7.98kPa组比较差异有统计学意义,但病死率及插管率未见下降。结论NIPPV治疗AECOPD合并呼吸衰竭疗效确切,在PaCO27.98～9.31kPa范围内应用无创通气效果好,不会延误治疗效果。

Objective To evaluate the optimal time of the use of non-invasive positive pressure ventilation on the patients with acute exacerbation of COPD（AECOPD）. Methods 131 patients were divided at random conventional therapy group （control group ） and conventional therapy plus NIPPV group, the patients of NIPPV group were again divided into PaCO2 t〉9. 31 kPa,7.98 - 〈9. 31 kPa,6. 65 - 〈7.98 kPa group. We observed the blood gas analysis before mechanical ventilation,2 h,24 h, 72 h after mechanical ventilation and discharge, intubation rate, in-hospital mortality, dutation of hospitalization. Results There was significant difference in PaO2 at 2 h after therapy between the NIPPV group and control group （P 〈 0.05 ）. Intubation rate （7.4%）and mortality（ 8. 8% ）were significantly lower in NIPPV group than those in the control group（ 19.0% ,22. 2% ） （ P 〈 0. 05 ）. There was significant different in pH, PaO2 and PaCO2 at 2 h after therapy between PaCO2 7.98 - 〈9. 31 kPa group and PaCO2 ≥9. 31 kPa group. There was significant different in PaO2 at 2 h after therapy between PaCO2 7. 98 - 〈9. 31 kPa group and PaCO2 6. 65 - 〈7.98 kPa group. The duration of hospitalization in PaCO2 7.98 - 〈 9. 31 kPa group was significantly lower than PaCO2 6. 65 - 〈 7.98 kPa group and PaCO2≥ 9.31 kPa group,but there was no difference in intubation and mortality. Conclusion NIPPV should be used earlier in the respiratory failure and AECOPD. The optimal time was PaCO2 7. 98 - 〈 9. 31 kPa.