无创正压通气治疗急性低氧性呼吸衰竭前瞻性队列研究

Non-invasive positive pressure ventilation in patients with acute hypoxemic respiratory failure： a prospective cohort study

目的探讨无刨正压通气（NPPV）对急性低氧性呼吸衰竭（AHRF）的治疗作用和治疗失败的危险因素。方法采用前瞻性队列研究方法，收集2004年1月-2007年12月北京朝阳医院呼吸重症监护病房应用NPPV治疗AHRF患者的临床资料，根据NPPV成功与否将患者分为成功组和失败组，比较两组患者的基本临床资料、NPPV模式和时间以及NPPV前和2h、24h的生命体征、血气分析和氧合指数（PaO2／FiO2）的变化。结果①59例患者NPPV成功率为62．7%（37／59）。②与NPPV失败组比较，成功组平均年龄及因肺部感染导致AHRF比例较低（P均〈0．01）。NPPV前成功组PaO2／FiO2与失败组无显著差异，但成功组NPPV后2h和24hPaO2／FiO2均较失败组显著改善（P〈0．05和P〈0．01），且NPPV后24h成功组心率和呼吸频率均较失败组显著降低（P均〈O．0i）。（3）logistic回归分析显示：NPPV失败的危险因素为年龄≥60岁[比值比（0R）=8．30，95％可信区间（CI）2．49～27．60，P=0．002]、呼衰诱因为肺部感染（OR=6．19，95％CI1．90～20．20，P=0．027）、NPPV后2hPa02／Fi02〈150mmHg（1mmHg=0．133kPa，OR=3．65，95％CI1．20～11．04，P=0．044）、NPPV后24h心率〉100次／rain（OR=7．45，95％CI2．15～25．58，P=0．010）和呼吸频率〉30次／rain（OR=7．26，95％C11．88～24．49，P=0．018）。结论NPPV可作为无绝对禁忌证AHRF的一线呼吸支持方式，但对老龄和肺部感染诱发的AHRF患者失败率较高；短期应用NPPV治疗后呼吸、循环和氧合状况无显著改善的AHRF患者，应及早改为有创通气。

Objective To investigate the clinical effect of non-invasive positive pressure ventilation （NPPV） on acute hypoxemic respiratory failure （AHRF）, and to look for predictors of failure of NPPV in patients with AHRF. Methods In the cohor study, the clinical data of patients with AHRF in respiratory intensive care unit （RICU） of Belling Chaoyang Hospital from January 2004 to December 2007 were collected prospectively. Patients were divided into successful group and failure group according to outcome of NPPV. Basic clinical information, NPPV mode and duration, vital signs, arterial blood gas analysis, and oxygenation index （PaO2/FiO2） before and 2 hours, 24 hours after NPPV were analyzed and compared between two groups. Results （1）The NPPV successful rate in 59 cases was 62.7% （37/59）.（2）Compared with failure group, mean age, the ratio of patients in whom respiratory failure were induced by pulmonary infection were lower in successful group （both P〈0. 01）. There was no difference in PaO2/FiO2 between two groups before NPPV, but PaO2/FiO2 in successful group was markedly higher than those of failure group after 2 hours and 24 hours of NPPV （P〈0. 05 and P〈0. 01）, while heart rate （HR）, respiratory rate （RR） were significantly lower （all P〈0. 01）. （3）Logistic regression analysis identified age≥60 years [oddo ratio （OR） 8.30, 95% confidence interval （CI） 2.49 - 27.60, P= 0. 0023, pulmonary infection as underlying disease of respiratory failure （OR 6.19, 95%CI 1.90 - 20. 20, P=O. 027）, PaO2/FiO2〈150 ram Hg （1 mm Hg：0. 133 kPa） after 2 hours of NPPV （OR 3.65, 95~CI 1.20 - 11.04, P：0. 044）, HR〉100 times/min after 24 hours of NPPV （OR 7. 45, 95%CI 2.15 - 25.58, P=0. 010）, and RR〉30 times/min after 24 hours of NPPV （OR 7.26, 95%CI 1- 88 - 24.49, P=0. 018） as risk factors independently associated with failure of NPPV. Conclusion NPPV can be the first line treatment for severe AHRF patients without absolute contraindication, while patients of older age with pulmonary infection, the risk of failure of NPPV is higher. Lack of improvement in cardiorespiratory and oxygenation condition after a short period of NPPV is the predictor of NPPV failure.