有创与无创序贯性机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的研究

Sequential non-invasive following short-term invasive mechanical ventilation in COPD induced hypercapnic respiratory failure

目的探索早期拔管改换无创机械通气策略的技术可行性并评价其治疗效果。方法选择接受气管插管和机械通气的慢性阻塞性肺疾病（COPD）病例11例，设为序贯治疗组，以同步间歇强制通气＋压力支持通气（SIMV＋PSV）方式行机械通气，待肺部感染明显控制时判为“肺部感染控制窗”出现，此时拔除气管导管，改用经鼻面罩压力支持通气＋呼气末正压（PSV＋PEEP）通气，以后渐减PSV水平直至脱离呼吸机；选择同样病情病例11例作为对照组，在肺部感染控制窗出现后继续按常现行有创机械通气，以SIMV＋PSV方式撤机。动态观察两组病例的感染、通气及氧合指标，记录出现肺部感染控制窗的时间、有创和总机械通气时间、住急重症监护病房（ICU）天数及呼吸机相关肺炎的发生情况。结果序贯治疗组与对照组的治疗前各指标相仿（P＞0．05）；出现感染控制窗的时间及当时情况相仿（P＞0．05）；有创机械通气时间分别为（7．1±2．9）和（23．0±14．0）d，P＜0．01；总机械通气时间分别为（13±7）和（23±14）d，P＜0．05；呼吸机相关肺炎发生例数分别为0和6例，P＜0．01；住ICU时间分别为（13±7）和（26±14）d，P＜0．05。结论对合并明显支气管-肺部感染的COPD插管上机病例，以肺部感染控制窗为时机早期拔管，改用经鼻面罩无?

Objective To estimate the feasibility and the efficacy of early extubation and sequential noninvasive mechanical ventilation (MV) in COPD with exacerbated hypercapnic respiratory failure. Methods 22 intubated COPD cases with severe hypercapnic respiratory failure due to pulmonary infection (pneumonia or purulent bronchitis) were involved in the study. At the time pulmonary infection had been significantly controlled (resolution of fever and decrease in purulent sputum, radiographic infiltrations,and leukocytosis. We call the fime as Pulmonary Infection Control Window", PIC window) after the antibiotic and the comprehensive therapy, the early extubation was conducted and followed hy non-invasive MV via facial mask immediately in 11 cases (study group). Other 11 COPD cases with similar clinical characteristics who continuously received invasive MV after PIC window were used as control group. Results The groups had similar clinical characteristics and gas exchange,initially and at the time of PIC window. For study group and control group, the duration of invasive MV was (7.1 ± 2.9) vs (23 .0 ±14.0) days, P < 0.01; the total duration of ventilatory support was (13 ±7) vs (23 ±14) days,P< 0.05; the incidence of VAP were 0/11 vs 6/11, P < 0.01; the duration of ICU stay was (13 ±7) vs (26 ±14) days, P < 0.05, respectively. Conclusions In COPD patients requiring intubation and are for pulmonary infection and hypercapnic respiratory failure, early extubation followed by non-invasive MV initiated at the point of PIC window may significantly decrease the invasive and total durations of ventilatory support, the risk of VAP, and the duration of ICU stay.