早期集束化气道清理技术联合无创通气治疗肺性脑病临床研究

Early use of noninvasive bundle techniques for clearing respiratory secretions during noninvasive ventilation inhypercapnic encephalopathy

目的观察早期集束化无创气道清理技术联合无创通气（NIV）治疗肺性脑病的安全性和有效性。方法将2014年10月至2016年10月在重症监护病房住院的慢性阻塞性肺疾病急性加重期（AEc0PD）合并肺性脑病的患者纳入研究，随机分为NIV组和有创通气（IMV）组。NIV组初始治疗2h内，给予以下气道清理措施：①保持半卧位或高坐位；②通过口咽通气道（OPA）负压吸引气道分泌物，每隔20-30min吸引一次；③经呼吸机管路雾化吸入平喘药物。人选IMV组患者未经NIV尝试治疗，直接行经口气管插管呼吸机辅助呼吸。主要观察指标：NIV初始治疗2h的安全性（是否需要紧急气管插管）和有效性（血气分析和意识改善情况）；住院期间主要并发症，尤其是脓毒症和院内感染（包括吸人性肺炎）事件。结果共有186例患者接受筛查，22例患者被排除，164例纳入研究，其中NIV组74例，IMV组90例。与基线相比，两组患者机械通气2h后，血气指标均明显改善，但两组之间pH、氧合指数和动脉血二氧化碳分压变化趋势相似，组间比较差异无统计学意义（F=24．35、113．81、238．14，P值均〉o．05）。NIV组治疗2h意识水平较治疗前明显好转（t=5．32，Pd0．001），IMV组由于给予镇静治疗，未对意识进行评估。与NIV组相比，IMV组并发症发生率更高，主要是由于接受更多的侵入性操作，导致院内感染。NIV组住院病死率更低，但随访1年病死率两组之间差异无统计学意义。两组住院时间和机械通气时间并无差别，但NIV组脱机时间更早（10grank检验，P=0．002）。结论在重症监护病房密切监测下，早期集束化气道清理技术联合NIV治疗AECOPD并发的肺性脑病是简单易行、安全有效的。

Objective To examine the safety and effectiveness of early use of noninvasive techniques for clearing respiratory secretions during noninvasive ventilation （NIV） in patients with acute exacerbation of chronic obstructive pulmonary disease （AECOPD） and hypercapnic encephalopathy. Methods This prospective cohort study was performed between October 2014 and October 2016 in intensive care unit （ICU）.：All included participants with hypercapnic encephalopathy in the ICU were randomly divided into two groups, NIV and invasive mechanism ventilation （IMV）. Participants were managed using NIV, with airway management and clearance of secretions performed in the initial 2 hours of NIV, including repeated suctioning of secretions from an oropharyngeal airway （OPA）, appropriate patient posture, nebulized inhalation of salbutamol and ambroxol and close monitoring, could be used to maintain a clear airway during the first two hours of NIV. Participants who received IMV were carried out after admission to the ICU without NIV being first attempted. The primary endpoints were： the safety（need for urgent ETI） and effectiveness （changes in ABGs and KMS） of the secretion clearing strategy within the first 2 hours of NIV, and the rate of major complications, especially septic complications and nosocomial pneumonia （including pulmonary aspiration） that were diagnosed using strict criteria. Results of 186 patients with AECOPD screened for inclusion in the study, 164 were included in the analysis （90 in the IMV group and 74 in the NIV group）. There were no significant differences between the two groups in any of the baseline characteristics. Compared to baseline, the ABGs improved significantly in both groups after 2 hours of mechanical ventilation, but no significant differences were observed in pH, partial pressure of oxygen/fraction of inspired oxygen and partial pressure of carbon dioxide between the NIV and IMV groups within the initial 2-hour period （ F = 24 . 35 ,113. 81, 238.14 , all P 〉0.05）. The sensorium level significantly improved within 2 hours in the NIV group （t = 5.32, P〈0.001）, but was not evaluated in the IMV group due to the use of sedation. Subjects receiving IMV had a higher complication rate than those receiving NIV due to a greater occurrence of nosocomial infections and use of more invasive devices. There were no differences between the two groups in the overall duration of mechanical ventilation and the length of hospital stay. However, Kaplan-Meier analysis showed that the percentage of subjects not weaned from mechanical ventilation within 30 days was significantly lower in the NIV group than in the IMV group （log rank test, P = 0.002）. Conclusions The use of an OPA and suction aspiration, in combination with appropriate positioning of the patient and nebulized inhalation of salbutamol/ambroxol, was a feasible, simple, safe and effective method for clearing respiratory secretions in patients with AECOPD and hypercapnic encephalopathy.