COPD急性加重并呼吸衰竭患者无创正压通气治疗失败原因分析

Analysis of the Cause of Treatment Failure by Noninvasive Positive Pressure Ventilation in Patients with Exacerbation of Chronic Obstructive Pulmonary Disease(COPD) and Respiratory Failure

目的分析经面罩无创正压通气(noninvasive positive pressure ventilation,NPPV)常见的失败原因,探讨其禁忌证和改行有创机械通气的指征。方法选择2008年1月—2011年12月我科收治的COPD急性加重并呼吸衰竭210例,按无创机械通气结果分为有效组和无效组,分别记录两组的基线资料、脏器功能障碍情况、NPPV影响因素、并发症、NPPV治疗前和治疗后2～4 h血气分析结果,比较两组间的差异,分析导致NPPV治疗失败的原因。结果 NPPV治疗前无效组APACHⅡ评分明显高于有效组,白蛋白水平明显低于有效组,差异均有统计学意义(P<0.01)。无效组2个脏器功能障碍者23.1%,明显低于有效组51.7%,但出现≥3个脏器功能障碍者76.9%明显高于有效组48.3%,差异有统计学意义(P<0.01)。无效组中出现肾功能不全、休克、排痰障碍、呕吐物误吸的比例明显高于有效组(P<0.01)。无效组NPPV治疗后2～4 h血pH值和二氧化碳分压改善程度均不及有效组(P<0.01)。结论 COPD急性加重并呼吸衰竭患者入院时APACHⅡ评分高、白蛋白水平低、出现较多脏器功能障碍和并发症等是NPPV治疗失败的重要相关因素。

Objective To analyze the cause of treatment failure by noninvasive positive pressure ventilation （NPPV） in patients with exacerbation of chronic obstructive pulmonary disease （COPD） and respiratory failure and explore indication of contraindication and invasive mechanical ventilation. Methods 210 patients with exacerbation of COPD combined with respiratory failure during January 2008 and December 2011 were divided into 2 groups （ effective group, non-effective group） according to the results of noninvasive mechanical ventilation. The basic condition, functional disturbance of organ, HPPV influencing factors, complications, the results of blood gas analysis pretherapy and 2-4 hours after NPPN of the two groups were recorded, and the differences of the two groups were compared. The causes of treatment failure of NPPV were analyzed. Results The APACH II score in NPPV non-effec- tive group was significantly higher than that of NPPV effective group （ P 〈 0. 01 ） ; albumin levels was lower than that of effective group （P 〈 0. 01 ）. The incidence rates of two organ dysfunctions in NPPV non-effective group （23.0%） was significantly lower than that of the effective group （51.7%, P 〈0. 01 ） ; but the percentage of more than three organ dysfunctions （76.9%） was significantly higher than that of the effective group （48.3% , P 〈0. 01）. The incidence rates of renal insufficiency, shock, sputum disorder and vomit aspiration in non-effective group were significantly higher than those of the effective group （P 〈 0. 01 ）. After 2-4 hours of NPPV, the pH and PaCO2 of the effective group were improve significantly than that of the useless group （ P 〈0. 01 ）. Conclusion The high APACH Ⅱ score, the low albumin levels, multiple organ dysfunctions and complications may be the direct cause of treatment failure of NPPV.