优化无创机械通气：哪个科室应护理这些患者？一项队列研究

Optimising non-invasive mechanical ventilation: which unit should care for these patients? A cohort study

背景:无创通气(NIV)已经不局限于在重症监护室(ICUs)使用,在急诊科(EDs)和普通病房,NIV也逐渐成为常规手段。目的:分析不同临床科室中,护理和NIV结局的关系。方法:根据患者特点、所提供的护理和所使用的医疗程序、评估治疗的成功和失败、接口不耐受以及并发症。并发症分析包括支气管吸引术、气胸、皮肤损伤、气道分泌物过多、眼刺激、意识水平恶化、胃扩张和面罩周围过量的空气消耗。结果:387例患者中,194例(50.1%)来自ICU,121例(31.3%)来自ED,38例(9.8%)来自术后病房,34例(8.8%)来自普通病房。校正APACHE评分和NIV适应证后,进行回归分析。结果显示,与社区医院ICU比较,在一所每年NIV病例数低于50例的大学医院的ICU,NIV失败的风险升高3.3倍[95%CI(1.2~9.2)];在ICUs和普通病房,12%的患者由于接口不耐受而中止使用NIV;急慢性肺病(ACLD)患者的NIV失败风险更低[OR 0.2,95%CI(0.06~0.69)];缺乏湿化与治疗失败没有相关性[OR 0.2,95%CI(0.1~0.4)];气道分泌物过多的相关因素是肺炎[OR 2.5,95%CI(1.1~5.9)]和早期中止和(或)拔管[OR 3.3,95%CI(1.2~8.9)];接口不耐受的相关因素是使用传统ICU呼吸机[OR 4.4,95%CI(2.1~9.2)]和过度空气消耗造成的鼻部皮肤损伤[OR 2.4,95%CI(1.1~5.3)],尤其是口鼻面罩的使用[OR 3.5,95%CI(1.1~11.3)]。结论:普通病房收治的急性呼吸衰竭的肺炎患者,其接口不耐受和NIV失败的风险增加。在任何给予NIV治疗的科室,旋转型面罩均能促进NIV的成功。

Background： Use of noninvasive ventilation （NIV） has extended beyond intensive care units （ICUs）, becoming usual practice in emergency departments （EDs） and general wards. Objective： To analyse the relationship between nursing care and NIV outcome in different hospital units. Methods： Treatment success/failure, interface intolerance and complications were evaluated according to patient characteristics, nursing care provided, and procedures used. Complications analysed included bronchoaspiration, pneumothorax, skin lesions, inability to manage secretions, eye irritations, deteriorating level of consciousness, gastric distension, and excessive air losses around the mask. Results： Of 387 patients, 194 （50.1%） were treated in ICU, 121 （31.3%） in ED, 38 （9.8%） postsurgery, and 34 （8.8%） in general wards. Regression analysis, adjusted for APACHE score and NIV indication, showed 3.3 times greater risk of NIV failure [95% CI（1.2-9.2）] in a university-hospital ICU with 〈50 NIV cases/year, compared to a community hospital ICU. In ICUs and general wards, NIV was suspended in 12% of patients due to interface intolerance. Acute-on-chronic lung diseases （ACLD） had lower risk of NIV failure [OR 0.2, 95% CI （0.06-0.69）] and lack of humidification was not associated with treatment failure [OR 0.2, 95% C1 （0.1-0.4）]. Poor secretion management was linked to pneumonia [OR 2.5, 95% CI （1.1-5.9）] and early weaning/extubation [OR 3.3, 95% C1 （1.2-8.9）]. Interface intolerance was associated with conventional ICU ventilators [OR 4.4, 95% CI （2.1-9.2）] and nasal skin lesions with excessive air losses [OR 2.4, 95% CI（1.1-5.3）], especially with oronasal masks [OR 3.5, 95% CI （1.1-11.3）]. Conclusion： Acute respiratory failure patients with pneumonia admitted to general wards had increased interface intolerance and NIV failure. Rotating mask types could improve NIV success in any unit administering this therapy.