两种无创通气模式治疗急性心源性肺水肿疗效比较

Therapeutic effects of two modes of non-invasive mechanical ventilation on patients with acute cardiogenic pulmonary edema

目的通过观察两种无创通气模式成比例辅助通气（PAV）和双水平气道正压通气（BiPAP）对急性心源性肺水肿（ACPE）患者的通气反应、血流动力学等方面的变化规律，比较两者的治疗效果。方法选取广州医学院附属第二医院急诊科2008年5月至2009年4月收治的32例急性心源性肺水肿患者经常规治疗（强心、利尿、扩管、吸氧）0．5h无显效后，随机分成对照组、BiPAP组、PAV组。对照组继续按常规处理，BiPAP组、PAV组分别行常规治疗＋BiPAP通气和常规治疗＋PAV通气，检测三组患者治疗前和治疗后1h的血气分析、血压、心率、呼吸频率（RR）、氧合指数、呼吸困难缓解时间、视觉模拟评分（VAS评分）、辅助呼吸肌动用评分、气道峰压等指标，对比三种治疗方法在治疗前后各项指标的变化。结果经治疗1h后，三组间的RR、动脉血氧分压（PaO2）和氧合指数均较治疗前明显改善（P〈0．05），其中BiPAP组与PAV组较对照组的氧合指数、PaO2均升高（P〈0．05）、RR减低（P〈0．05）；BiPAP组与PAV组治疗后呼吸困难缓解的时问较对照组明显缩短（P〈0．05），治疗1h后PAV组患者的气道峰压较BiPAP组为低，差异具有统计学意义（P〈0．05），PAV组患者的舒适度相关指标（VAS评分、辅助呼吸肌动用评分）均较BiPAP组为低，差异具有统计学意义（P〈0．05）。结论无创PAV、BiPAP对改善急性心源性肺水肿患者氧合和缓解呼吸困难具有显著的临床疗效；PAV与BiPAP对ACPE患者的疗效相仿；PAV的同步性、舒适性较BiPAP好，气道峰压较低，更易被患者接受。

Objective To compare the therapeutic effects in respect of ventilatory response and the change of hemodynamics of two modes of mechanical ventilation [ proportional assist ventilation （PAV） vs. Bi-level positive airway pressure ventilation （BiPAP） ] on patients with acute cardiogenic pulmonary edema （ACPE）. Methods Thirty-two patients diagnosed as ACPE were recruited from May 2008 to April 2009. After conventional therapy （cardiotonic, diuretic, vasodilators, oxygen） were ineffective for half an hour, 32 patients were randomly divided into three groups： control group （12 cases kept conventional treatment without mechanical ventilation）, BiPAP group （12 cases were treated with BiPAP mode of non-invasive mechanical ventilation plus conventional treatment） and PAV group （8 cases were treated with PAV mode of non-invasive mechanical ventilation along with conventional treatment ）. Results PaO2, RR and oxygenation index were improved significantly in three groups after 1 hour treatment （ P 〈 0. 05）. While PaO2 and oxygenation index in noninvasive ventilation groups were higher than those in control group （ P 〈0. 05 ）. The time required for amelioration of dyspnea in noninvasive ventilation groups was shorter than that in control group （ P 〈 0. 05 ）. The peak airway pressure and the index of degree of comfort （ VAS score, auxiliary respiratory muscles score ） in 19AV group were lower than those in BiPAP group （ P 〈 0. 05 ）. Conclusions Both modes of noninvasive mechanical ventilations could improve the oxygenation and relief of dyspnea in patients with ACPE. PAV and BiPAP had the similar effect in patients with ACPE. The synchronization and comfort in PAV group were better than those in BiPAP group. The PAV mode of non- invasive mechanical ventilation was well accepted by patients with ACPE.