无创正压通气在17例肾移植术后呼吸衰竭患者中的应用

Noninvasive positive pressure ventilation for respiratory failure of patients undergoing renal transplantation: a report of 17 cases

目的探讨无创正压通气(NPPV)在肾移植术后呼吸衰竭患者中的临床价值。方法回顾性分析2010年7月至2013年5月复旦大学附属中山医院麻醉与外科监护室(SICU)收治的17例肾移植术后使用NPPV治疗呼吸衰竭患者的临床资料,观察患者NPPV治疗前、治疗1 h后及治疗结束时动脉血压分压/氧体积分数(PaO2/FiO2)的变化,同时记录NPPV时间和预后情况。根据NPPV治疗后患者病情的改善情况,将患者分为NPPV成功组和NPPV失败组。正态分布计量资料使用成组t检验进行比较,非正态分布计量资料使用Mann-Whitney U检验进行比较。使用Fisher精确概率法比较NPPV成功组和失败组患者死亡比例。使用单因素方差分析比较NPPV治疗前、治疗1 h后及治疗结束时成功组和失败组患者PaO2/FiO2的变化情况,并用LSD方法进行两两比较。结果 17例患者中男性13例,女性4例,平均年龄(49±13)岁(19~68岁)。分别于肾移植术后11 d^8 y发生急性呼吸衰竭,行NPPV治疗,共8例成功,9例失败。两组患者在进入SICU时疾病严重程度具有可比性,PaO2/FiO2基线情况差异无统计学意义(t=-1.036,P>0.05)。成功组患者NPPV治疗1 h后、治疗结束时PaO2/FiO2分别为193±62和238±31,均高于治疗前146±31,差异均有统计学意义(P均<0.05);而NPPV治疗结束与治疗1 h后相比,差异无统计学意义(P>0.05),提示PaO2/FiO2未再持续改善。失败组患者NPPV治疗前、治疗1 h后及治疗结束相比较,PaO2/FiO2差异均无统计学意义(F=1.585,P>0.05)。8例NPPV成功组患者死亡1例,9例失败组患者死亡7例,两组患者死亡比例差异有统计学意义(P=0.015)。成功组中生存和死亡患者NPPV中位时间分别为240 h和93 h,差异无统计学意义(z=-1.098,P>0.05)。失败组中存活和死亡患者NPPV时间分别为24 h和65 h,差异有统计学意义(z=-2.049,P<0.05)。结论 NPPV可用于治疗肾移植术后呼吸衰竭患者。NPPV治疗1 h后PaO2/FiO2改善明显可预测NPPV成功,但若改善不明显应及时终止NPPV,转为有创机械通气治疗。

Objective To assess the clinical value of noninvasive positive pressure ventilation （NPPV） in patients with respiratory failure after renal transplantation.Methods We retrospectively analyzed 17 consecutive patients with respiratory failure after renal transplantation treated with NPPV from July 2010 to May 2013 in Department of Anesthesiology and Surgical Intensive Care Unit of Zhongshan Hospital.We studied the differences of PaO2/FiO2 at three time points （before,1 hour after,and at the end of NPPV treatment）,and analyzed the duration of NPPV and the prognosis of the patients.Patients were divided into the NPPV success group and NPPV failure group according to their medical improvement.Student＇s t test was used for normally distributed data while Mann-Whitney U test was used for non-normal distributions.The proportion of death in the two groups was compared using the Fisher＇s exact test.One-way analysis of variance procedure was used to analyze the change of PaO2/FiO2 in the two groups at the three time points and the least significant difference was used for post-hoc analysis.Results There were 17 patients,containing 13 males and 4 females.Their average age was （49 ± 13） years old （19-68 years） and the time between the renal transplantation and the acute expiratory failure was 11 days to 8 years.All of the 17 patients received NPPV treatment,but the NPPV only worked in 8 patients.No differences were found regarding baseline characters containing the PaO2/FiO2 between the two groups （P 〉 0.05）.The PaO2/FiO2 got after 1 hour of NPPV and at the end of the NPPV （193 ± 62 and 238 ± 61,respectively） were both higher than that of the baseline with a significantly difference （P 〈 0.05）.However,there was no significantly improvement of PaO2/FiO2 at the end of the NPPV when compared with the PaO2/FiO2 at 1 hour after NPPV （P 〉 0.05）,which indicated that the PaO2/FiO2 did not improve any more after 1 hour of NPPV.There was no significant improvement in the NPPV failure group as compared the PaO2/FiO2 at the same three time points （F =1.585,P 〉 0.05）.There was only one patient died in the eight patients of the NPPV success group while there were seven patients died in the nine patients of the NPPV failure group,indicating that there was a significant difference of proportion of death between the two groups （P =0.015）.The median NPPV duration was 240 hours for survival patients and 93 hours for the deaths in the NPPV success group,and the difference was not statistically significant （Z =-1.098,P 〉 0.05）.However,the median NPPV duration was 24 hours for survival patients and 65 hours for the deaths in the NPPV failure group,and the difference was statistically significant （Z =-2.049,P 〈 0.05）.Conclusions NPPV is feasible to treat respiratory failure in patients undergoing renal transplantation.Higher PaO2/FiO2 after 1 hour of NPPV predicts NPPV success.However,NPPV should be discontinued and transferred to invasive mechanical ventilation if PaO2/FiO2 failed to improve after 1 hour of NPPV.