无创正压通气治疗心脏术后急性呼吸衰竭的疗效和安全性研究

Noninvasive positive-pressure ventilation for extubation failure after cardiac surgery

目的:探讨无创正压通气(NPPV)治疗心脏术后急性呼吸衰竭的疗效和安全性。方法:选择2011年9月至2012年10月,心脏外科术后发生急性呼吸衰竭适合进行NPPV的患者,随机分为无创通气组及常规治疗组。记录生命体征、血气分析测值,比较两组患者的再插管率、气管切开率、呼吸机相关性肺炎(VAP)发生率、病死率、入组后机械通气时间、住重症监护室(ICU)时间和术后住院时间。结果:研究期间,共有急性呼吸衰竭患者113例,符合纳入标准77例,男性48例,女性29例,平均年龄(61.7±11.0)岁,其中冠状动脉搭桥术38例,瓣膜手术20例,瓣膜手术+冠状动脉搭桥术9例,大血管手术7例,其他手术3例。无创通气组(n=39),常规治疗组(n=38)。无创通气组再插管率为12.8%,气管切开率10.2%,VAP发生率0,住院病死率12.8%,均明显低于常规治疗组(分别为84.2%、31.6%、18.4%和26.3%)(P<0.05或P<0.01)。无创通气组入组后机械通气时间和住ICU时间中位数分别为28.0(10.5,43.0)h和4.0(2.0,5.0)d,显著低于常规治疗组的69.5(3.8,248.0)h和5.0(4.0,9.0)d,(P<0.05或P<0.01),两组术后住院时间相近[分别为13.0(10.5,20.0)d和17.0(11.0,28.3)d,P>0.05]。NPPV治疗后2～4h,pH、PaCO2和PaO2均显著改善,心率和呼吸频率减慢(P<0.05或P<0.01),与同时间点常规治疗组水平相近。结论:NPPV选择性用于心脏术后急性呼吸衰竭,可显著降低再插管率,改善患者预后,疗效明显优于常规治疗组。需多中心大样本随机对照研究,以明确NPPV在心脏术后患者中应用的适应证和影响疗效因素。

Objective：To evaluate the efficacy and safety of noninvasive positive pressure ventilation（NPPV） on acute respiratory failure after cardiac surgery.Methods： Selected post cardiac surgery patients with acute respiratory failure after extubation from September 2011 to October 2012 were prospectively randomized to either NPPV or standard therapy（Control） group.Data were gathered on vital sign,arterial blood gas analysis.Reintubation and tracheotomy rates,incidence of ventilator associated pneumonia（VAP）,mechanical ventilation duration,ICU stay and postoperative hospital stay were compared.Results： During the year of study,77 patients（48 were male and 29 were female with a mean age of（61.7±11.0） years were enrolled,including 38 coronary artery bypass grafts（CABG）,20 valvular procedures,9 CABG＋valvular procedures,7aortic surgeries other cardiac surgeries.NPPV group had 39 patients and control group 38 patients.NPPV group had significantly（P0.05 or P0.01） lower reintubation rate（12.8%）,tracheotomy rate（10.2%）,VAP incidence（0）,and hospital mortality（12.8%） as compared with those of control group（84.2%,31.6%,18.4%,and 26.3% respectively）.The mechanical ventilation time and the ICU stay [median（P25,P75）] were significant shorter（nonparametric Mann-Whitney test,P0.05 or P0.01）in the NPPV group [28.0（10.5,43.0）h and 4.0（2.0,5.0）d respectively] than in the control group [ 69.5（3.8,248.0）h and 5.0（4.0,9.0）d],while there was no difference in the postoperative hospital stay [13.0（10.5,20.0） d vs.17.0（11.0,28.3） d,P0.05].The heart rate,respiratory rate and arterial blood gas analysis values（pH,PaCO2and PaO2） were significantly improved as compared with baseline values after 2-4 h of NPPV therapy,and there were no significant between-groups differences either at baseline or 2-4 h of treatment.Conclusion： Our study indicates that in selected post cardiac surgery patients with acute respiratory failure after extubation,NPPV can significantly reduce the reintubation rate,improve the clinical outcomes as compare with standard therapy.