无创正压通气在急性肺损伤/急性呼吸窘迫综合征中的随机对照研究

Noninvasive Positive Pressure Ventilation in Acute Lung Injury and Acute Respiratory Distress Syndrome:A Randomized Controlled Study

目的探讨无创正压通气(NPPV)治疗急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)的疗效及影响成败的相关因素。方法 28例ALI/ARDS患者随机分为对照组和NPPV治疗组,所有患者在基础疾病治疗的基础上,对照组采用文丘里面罩吸氧,NPPV治疗组应用NPPV进行呼吸支持。动态观察治疗后的变化,评估达到预设气管插管标准的病例数和相关的指标。结果 NPPV成功率为66.7%(10/15),与对照组比较显著降低气管插管率(33.3%比86.4%,P=0.009),但病死率无显著差异(7.7%比27.3%,P=0.300)。NPPV治疗成功组合并肺部细菌感染和多器官功能损害例数明显少于失败组(2/10比4/5,P=0.01;1/10比3/5,P=0.03)。相关分析显示NPPV治疗失败与合并肺部细菌感染和多器官功能损害显著相关(r=0.58,P<0.05;r=0.53,P<0.05),Logistic逐步回归分析显示合并肺部细菌感染是NPPV失败的独立因素(r2=0.33,P=0.024)。与NPPV治疗前相比,成功组治疗24 h后呼吸频率显著降低[(29±4)次/min比(33±5)次/min,P<0.05],氧合指数(PaO2/FiO2)显著升高[(191±63)mm Hg比(147±55)mm Hg,P<0.05],心率、APACHEⅡ评分、pH值和PaCO2无显著变化(P>0.05);失败组24 h后呼吸频率显著增快[(40±3)次/分min比(33±3)次/min,P<0.05],PaO2/FiO2呈下降趋势[(98±16)mm Hg比(123±34)mmHg,P>0.05]。治疗过程中未观察到NPPV相关的严重不良事件。结论在有选择的病例中,NPPV治疗ALI/ARDS有效和安全,可以改善ALI/ARDS氧合,降低插管率。此研究结果支持NPPV作为ALI/ARDS早期机械通气治疗的一线选择。

Objective To evaluate the efficiency and associated factors of noninvasive positive pressure ventilation （NPPV） in the treatment of acute lung injury （ALI） and acute respiratory distress syndrome（ARDS）. Methods Twenty-eight patients who fulfilled the criteria for ALI/ARDS were enrolled in the study. The patients were randomized to receive either noninvasive positive pressure ventilation（ NPPV group） or oxygen therapy through a Venturi mask （control group）. All patients were closely observed and evaluated during observation period in order to determine if the patients meet the preset intubation criteria and the associated risk factors. Results The success rate in avoiding intubation in the NPPV group was 66. 7% （ 10/15 ）, which was significantly lower than that in the control group （ 33.3% vs. 86.4% , P = 0. 009 ）. However, there was no significant difference in the mortality between two groups （7.7 % vs. 27.3 %, P = 0. 300）. The incidence rates of pulmonary bacteria infection and multiple organ damage were significantly lower in the NPPV success subgroup as compared with the NPPV failure group （2/10 vs. 4/5, P = 0. 01 ;1/10 vs. 3/5, P = 0. 03 ）. Correlation analysis showed that failure of NPPV was significantly associated with pulmonary bacterial infection and multiple organ damage （ r = 0. 58, P 〈 0. 05 ; r = 0. 53, P 〈 0. 05 ）. Logistic stepwise regression analysis showed that pulmonary bacterial infection was an independent risk factor associated with failure of NPPV （ r2 = 0. 33, P = 0. 024）. In the success subgroup, respiratory rate significantly decreased（ 29 ± 4 breaths/min vs. 33 ± 5 breaths/min, P 〈 0. 05 ） and PaO2/FiO2 significantly increased （ 191 ±63 mmHg vs. 147 ±55 mmHg,P 〈0. 05） at the time of 24 hours after NPPV treatment as compared with baseline. There were no significant change after NPPV treatment in heart rate, APACHE Ⅱ score, pH and PaCO2 （ all P 〉 0.05 ）. On the other hand in the failure subgroup, after 24 hours NPPV treatment, respiratory rate significantly increased （40 ± 3 breaths/min vs. 33 ± 3 breaths/min, P 〈 0. 05 ） and PaOE/FiO2 showed a tendency to decline （ 98 ± 16 mmHg vs. 123 ± 34 mmHg, P 〉 0. 05 ）. Conclusions In selected patients, NPPV is an effective and safe intervention for ALI/ARDS with improvement of pulmonary oxygenation and decrease of intubation rate. The results of current study support the use of NPPV in ALI/ARDS as the firstline choice of early intervention with mechanical ventilation.