Non-Invasive Positive Pressure Ventilation (NIPPV) in the Pregnant Patient: A Case Series

Rationale: Acute respiratory failure is an uncommon complication of pregnancy. However, it is the most frequent organ dysfunction associated with obstetric admissions to an intensive care unit. The obstetric population is a different group due to its physiology and the presence of the fetus that lacks evidence in the literature within the subject of ventilatory support. Noninvasive positive pressure ventilation (NIPPV) is often avoided due to the lack of knowledge on the safety and efficacy of this modality. Currently, there are no guidelines for the management of respiratory failure in pregnancy. Objectives: To provide evidence in support of the use of NIPPV as a safe and reasonable modality for pregnant patients with respiratory failure. Methods: We retrospectively reviewed medical records of 29 pregnant patients of the Obstetric Critical Care Unit of a tertiary hospital in Panamá City who received NIPPV from 2013 to 2015. Failure to response was defined as the lack of increase in the paO2/FiO2 ratio or clinical deterioration 6 hours after initiating NIPPV. Demographics, indication for NIPPV, duration of treatment, as well as maternal and fetal outcomes were collected. Measurements and Main Results: Mean age was 28.4 ± 6 years, mean body mass index 27.4 ± 3.3, and mean gestational age at admission was 305/7 ± 5 weeks. Twenty-four patients (82.8%) met the criteria for acute lung injury (ALI) and an additional two (6.9%) for acute respiratory distress syndrome (ARDS). The mean duration of ventilation was 50.6 ± 17.27 hours. Statistically significant differences were noted between the paO2/FiO2 ratios in failure and successful patients within 2 hours of NIPPV therapy (P = 0.007) and paO2/FiO2 ratio within 6 hours of NIPPV therapy (P = 0.03). Success was defined when the patient was administered NIPPV, resulting in an improvement (increase in pa/FiO2 ratio) of her ventilatory parameters. Three patients (10.3%) failed to respond to NIPPV and needed to be converted to invasive mechanical ventilation. Patients who required intubation had a longer duration of ICU stay (P = 0.006) and overall hospital stay (P = 0.03). None of patients presented aspiration during NIPPV therapy. Conclusion: The current series is the largest report of pregnant patients requiring ventilatory support who received NIPPV as first line of therapy. This report shows the usefulness of this ventilation modality, avoiding intubation with its risks, of a significant number of patients, especially ventilator-associated pneumonia.

病友互助模式对肺癌患者术后希望、幸福感、呼吸功能、生活质量的影响

目的探讨病友互助模式对肺癌患者术后希望、幸福感、呼吸功能、生活质量的影响。方法选取2021年9月至2022年9月河南省胸科医院收治的84例肺癌患者,按随机数字表法分为常规组和联合组,各42例。常规组接受常规护理和呼吸锻炼指导,联合组在常规组基础上接受基于病友互助模式的护理干预。对比两组干预前后希望水平评分、主观幸福感评分、呼吸功能、生活质量评分等。结果两组患者干预前希望水平、主观幸福感、生活质量评分差异无统计学意义(P>0.05);经6个月干预后,两组患者希望水平、主观幸福感及生活质量评分均升高,联合组高于常规组(P<0.05)。两组患者干预前柏格度量表(Borg)评分、第1秒用力呼气容积(FEV_(1))、用力肺活量(FVC)差异无统计学意义(P>0.05);经6个月干预后,两组患者Borg评分、FEV_(1)、FVC均升高,但联合组Borg评分低于常规组,FEV_(1)、FVC高于常规组(P<0.05)。结论基于病友互助模式的护理干预有助于提高肺癌患者术后希望水平和主观幸福感,促进呼吸功能恢复,提高生活质量,为改善预后提供帮助。

无创高频振荡通气和双水平正压通气在早产儿呼吸窘迫综合征中的临床应用效果比较研究

目的比较经鼻无创高频振荡通气(NHFOV)和双水平正压通气(DuoPAP)在早产儿呼吸窘迫综合征(RDS)中的临床应用效果。方法选取2016年6月—2017年5月新乡市中心医院新生儿重症监护病房收治的65例早产儿为研究对象,采用随机数字表法分为NHFOV组33例,DuoPAP组32例。比较两组患儿一般情况,无创呼吸支持前、无创呼吸支持后1、12、24、48、72h动脉血氧分压(PaO_2)、二氧化碳分压(PaCO_2)及氧合指数(OI),72h内呼吸暂停发生率、有创呼吸支持率、无创呼吸支持时间、总用氧时间、猪肺磷脂注射液重复使用率、肺气漏、支气管肺发育不良(BPD)、新生儿坏死性小肠结肠炎(NEC)、脑室周围白质软化(PVL)发生率及死亡率。结果两组患儿性别、出生体质量、发病时间、胎龄、产前使用激素情况、猪肺磷脂注射液使用时间、剖宫产率及RDS分级比较,差异无统计学意义(P>0.05)。两组患儿PaCO_2比较,差异有统计学意义(P<0.05),PaO_2、OI比较,差异无统计学意义(P>0.05)。不同时间点PaO_2、PaCO_2及OI比较,差异有统计学意义(P<0.05)。组别和时间在PaCO_2上存在交互作用(P<0.05),组别和时间在PaO_2及OI上不存在交互作用(P>0.05)。NHFOV组呼吸暂停发生率低于DuoPAP组,差异有统计学意义(P<0.05);NHFOV组与DuoPAP组有创呼吸支持率、无创呼吸支持时间、总用氧时间、猪肺磷脂注射液重复使用率、肺气漏、BPD、NEC、PVL发生率及死亡率比较,差异无统计学意义(P>0.05)。结论在RDS的初始治疗中,NHFOV与DuoPAP相比可以更好减少CO2潴留和呼吸暂停发生率,且不增加不良反应发生率,是安全有效的通气方式。

应用COPD模型比较不同呼气触发灵敏度设置对5款双水平正压呼吸机呼气同步的影响

目的观察存在系统气体泄漏状态下不同呼气触发灵敏度（ETS）设置对5款不同型号双水平正压呼吸机的呼气切换同步性的影响。方法对5款双水平正压呼吸机[V60／Synchrony（Mutrysville，PA）、VENTImotion（Hamburg，Gerrnanv）、VPAPⅢST—A（NoahRyde，Australia）和Flexo ST30（Santa Clara，CA）]，使用机械肺模拟器模拟慢性阻塞性肺疾病（COPD）患者，设置顺应性（Crs）为60mL/0．098kPa（60mL/cmH2O）、气道阻力（Raw）为1．47kPa（15cmH2O）／（L·s）。吸气时间为1．0s．呼吸频率为15次／分。双水平正压呼吸机以压力支持通气（PSV）模式运行。参数为1．47kPa（15cmH2O）的压力支持及0．49kPa（5cmH2O）的呼气末正压，后备通气频率为10次／分。收集在泄漏量为20～22L／min时的通气参数。结果在ETS设置为最敏感时，VPAPUIST—A的潮气量（VT）和呼气峰流量（PEF）最低[（616．33±2．58）mL和（41．45±0．51）L／min]（P〈0．05），同时出现过早切换。VENTImotion的吸气末气道压（P1end）最高[（2．11±0．01）kPa（21．58cmH2O±0．15cmH2O）]，PEF也高达（64．97±0．27）L／min。虽然均采用自动触发／切换技术，Respironics V60与Synchronv的表现各不相同．Synchrony的VT和PIF均显著低于V60。随着ETS设置的改变，FlexoST30、VENTImotion和VPAPⅢST—A的吸气时间（T1）和VT均出现增加，PEF也逐渐增高，VPAPⅢST—A仍有过早切换现象。Flexo ST30在ETS设置为最不敏感时孔可高达4s，导致呼吸频率降低。结论5款双水平正压呼吸机均能提供同步通气．但呼气切换同步性各不相同。除VPAPⅢST—A外，其余4款机型均能较好地完成同步呼气切换：改变ETS水平会对呼气同步产生较明显影响．此时应及时调整通气参数，避免过早切换或严重的延迟切换的发生．

无创呼吸支持模式对早产儿支气管肺发育不良及相关生物学指标的影响

目的分析无创呼吸支持模式对早产儿支气管肺发育不良(BPD)及相关生物学指标的影响。方法 56例需呼吸支持的早产儿,根据患儿无创呼吸支持模式的不同分为NIPPV组及NCPAP组,每组28例。NIPPV组开展经鼻间歇正压通气(NIPPV), NCPAP组开展经鼻持续正压通气(NCPAP)。比较两组患儿BPD发病情况及相关生物学指标变化情况。结果 NIPPV组患儿BPD发病率为3.57%,低于NCPAP组的10.71%,但差异无统计学意义(P>0.05);生后第1天,两组患儿血白细胞介素-6(IL-6)、白细胞介素-10(IL-10)、肿瘤坏死因子-α(TNF-α)水平比较,差异无统计学意义(P>0.05)。生后第3天, NIPPV组患儿血IL-6(211.37±206.38)pg/ml、IL-10(1890.48±1840.10)pg/ml高于NCPAP组患儿的(7.34±7.19)、(59.73±34.80)pg/ml,差异具有统计学意义(P<0.05);两组患儿TNF-α水平比较差异无统计学意义(P>0.05)。结论 NIPPV较NCPAP可能更利于减少BPD的发生不能被证实,但NIPPV较NCPAP更能上调血炎症介质水平。

体外膜肺氧合支持下的急性呼吸窘迫综合征动物模型研究进展

急性呼吸窘迫综合征(Acute Respiratory Distress Syndrome,ARDS)是指由于肺内或肺外因素导致的急性、进行性低氧血症和呼吸窘迫。临床上ARDS患者死亡率很高,发病机制尚未阐明,体外膜肺氧合(Extracorporeal Membrane Oxygenation,ECMO)支持为重症ARDS患者的救治带来转机,但是由于相关研究较少,仍然存在撤机困难和术后并发症等问题,严重影响ARDS患者的生存和生活质量。目前,国内外已经建立相关的动物模型进行转化研究。本文就目前国内外ECMO支持下的ARDS动物模型的研究进展进行综述。

Efficacy and safety of awake prone positioning in the treatment of non-intubated spontaneously breathing patients with COVID-19-related acute respiratory failure:A systematic review and meta-analysis

Background Since the beginning of the coronavirus disease 2019(COVID-19)pandemic,prone positioning has been widely applied for non-intubated,spontaneously breathing patients.However,the efficacy and safety of prone positioning in non-intubated patients with COVID-19-related acute hypoxemic respiratory failure remain unclear.We aimed to systematically analyze the outcomes associated with awake prone positioning(APP).Methods We conducted a systematic literature search of PubMed/MEDLINE,Cochrane Library,Embase,and Web of Science from January 1,2020,to June 3,2022.This study included adult patients with acute respiratory failure caused by COVID-19.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines were followed,and the study quality was assessed using the Cochrane risk-of-bias tool.The primary outcome was the reported cumulative intubation risk across randomized controlled trials(RCTs),and the effect estimates were calculated as risk ratios(RRs;95%confidence interval[CI]).Results A total of 495 studies were identified,of which 10 fulfilled the selection criteria,and 2294 patients were included.In comparison to supine positioning,APP significantly reduced the need for intubation in the overall population(RR=0.84,95%CI:0.74–0.95).The two groups showed no significant differences in the incidence of adverse events(RR=1.16,95%CI:0.48–2.76).The meta-analysis revealed no difference in mortality between the groups(RR=0.93,95%CI:0.77–1.11).Conclusions APP was safe and reduced the need for intubation in patients with respiratory failure associated with COVID-19.However,it did not significantly reduce mortality in comparison to usual care without prone positioning.