1、无创正压通气的临床应用Noninvasive ventilation in acute respiratory failure武汉协和医院急诊科张劲农Pickwickian syndrome and Sleep apnea1980s以前，以气管切开治疗高血压1980s经鼻CPAP用于治疗OSAHSColin Sulliven，2002.11.1980s,Australia按人-机连接方式分类 侵入性(有创)机械通气(IMV)经口或鼻气管插管 气管切开气管插管 非侵入性(无创)通气(NIV)正压(Noninvasive Positive Pressure Ventilation,NIPPV)负压
2、(Negative Pressure ventilation,NPV)侵入性(有创)通气经气管插管NIPPV的连接方式Normal,OSA and OSA treated with CPAPCPAP treatmentPrevalence of SDB in the general population:the HypnoLaus studyThe CoLaus/PsyCoLaus database included a sample of 6733 people aged 3575 yrs selected at random between 2003 to 2006 in Switzerl
3、and2121 people were included between Sept 1,2009 to June 30,2013,48%M,52%F,median age 57 years and mean BMI 256 kg/m2The median AHI was 69/h in women and 149/h in men The AHI 15/h was 234%in women and 497%in menAHI 206/h was associated independently with presence Hypertension,odds ratio 160,p=00292
4、Diabetes,200,p=00467),metabolic syndrome 280,p00001)Depression,192,p=00292).Heinzer R,et al.The Lancet Respiratory medicine 2015:3(4):310-318.OSAHS:CPAP or Tracheotomy?1999年 武汉OSAHS 与睡眠剥夺2001年武汉肢端肥大症男，50岁，EDS，睡眠不均匀打鼾多年甲状腺功能减退合并OSApHPaO2mmHgPaCO2mmHgHCO3mmol/LBEmmol/LK+mmol/LNa+mmol/LClmmol/L7.455450
5、.735.211.23.413486女,29岁.呼吸困难、乏力、嗜睡半年。体检:呼吸困难，极度困乏，口唇和指(趾)明显紫绀，心率108次/分，律齐，无杂音，双肺无明显干湿啰音，下肢凹陷性浮肿。动脉血气分析和电解质测定结果如下:10年追踪观察SDB相关病死率264 healthy men,377 simple snorers,403 with untreated mild-moderate obstructive sleep apnoea-hypopnoea,235 with untreated severe disease,and 372 with the disease and treate
6、d with CPAP Marin JM,et al.Lancet 2005;365:1046-53 澳大利亚Busselton Health Study 14年队列研究:中重度OSA是全因死亡的独立危险因素Survival Distribution FunctionSurvive timeRDI15 RDI 514(红)RDI 5(黑)P 45 mm Hg Obese,BMI 30 kg/m2 Exclude other causes that could account for awake hypoventilation,such as lung or neuromuscular dise
7、ase Sleep hypoventilation alone does not define OHSPiper AJ and Grunstein R.Am J Respir Crit Care Med,2011,183:292298Some of the interactions between factors believed to be contributing to hypercapnia in pts with severe obesityPiper AJ,Grunstein RR.J Appl Physiol 2010;108:199205HCVR=hypercapnic vent
8、ilatory responseMechanisms of heart failure in obesityEbong IM,et al.Obesity Research&Clinical Practice,2014:8,e540e548Kaplan-Meier outcome curves for OHS and OSAHSPLOS ONE|DOI:10.1371/journal.pone.0117808 February 11,2015Survival of Obesity hypoventilationPriou P,et al.Chest,2010 138:8490With/Witho
9、ut O2With/Without NIVA prospective RCT:NIV vs.standard treatment in immunosuppressed pts with pulmonary infiltrates,fever,and ARFHilbert G,et al.N Engl J Med 2001;344:481-7NIV vs.standard treatment in immunosuppressed pts with pulmonary infiltrates,fever,and ARFHilbert G,et al.N Engl J Med 2001;344:
10、481-7.)Serious complications and death in ICUHilbert G,et al.N Engl J Med 2001;344:481-7.)NIV用于免疫低下ARF：当前的证据Study reference(No.O2/NIV)NIV is betterO2 is betterLemiale V,et al.2015NIV用于免疫低下ARF：当前的认识 NIV may be useful as a prophylactic treatment to obviate the need for IMV In contrast,the use of NIV a
11、s an alternative to IMV in patients with severe ARF seems to adversely impact survivalDiscontinuation of ventilatory support:newsolutions to old dilemmasAm J Respir Crit Care Med Vol 184.pp 672679,2011AT A GLANCE COMMENTARYThe use of noninvasive ventilation(NIV)as an early weaning/extubation techniq
12、ue from invasive mechanicalventilation remains controversial.What This Study Adds to the FieldNIV used as an early weaning/extubation technique in difficult-to-wean patients with chronic respiratory failure did not reduce the reintubation rate within 7 days as compared with conventional weaning and
13、early extubation with standard oxygen therapy.Nevertheless,NIV may improve the weaning results in these patients by shortening the intubation duration and reducing the risk of postextubation acute respiratory failure.The potential benefit of rescue postextubation NIV in these patients needs further
14、study.应用NIPPV前应该思考的问题人机接口能否牢靠？鼻罩还是口鼻面罩？如何进行给氧？治疗压需要多大？口腔闭合压有多大？食道能承受多大压？鼓膜能承受多大压？有无脑脊液漏？痰从哪里排除？有无吞咽障碍？患者为什么会张口？CO2重吸收如何控制？如何防治窒息？有无插管必要？呼吸机的模式应用什么样的无创呼吸模式？带有目标潮气量功能有效的漏气补偿能力 高达170L/min，坚固耐用且静音极佳 26dbTrigger lockout,解决了提高触发灵敏度和误触发之间的矛盾独有ATC技术，有效治疗肺泡塌陷，纠正血气紊乱流速-时间曲线，容量-时间曲线，吸气同步率/呼气同步率监测通气管路外设连接接口数据下载
15、接口一体化湿化器接口 显示屏数字显示/图形显示操作快捷键IPAPEPAP呼吸频率吸呼比导航旋钮Pts with COPD and hypercapnic encephalopathyBiPAP S/T with AVAPS vs.BiPAP S/T aloneGlasgow Coma ScaleBrain injury is classified as:Severe,with GCS 89Moderate,GCS 8 or 912(controversial)Minor,GCS 13123456EyeDoes not open eyesOpens eyes in response to pai
16、nful stimuliOpens eyes in response to voiceOpens eyes spontaneouslyN/AN/AVerbalMakes no soundsIncomprehensible soundsUtters inappropriate wordsConfused,disorientedOriented,converses normallyN/AMotorMakes no movementsExtension to painful stimuli(decerebrate response)Abnormal flexion to painful stimul
17、i(decorticate response)Flexion/Withdrawal to painful stimuliLocalizes painful stimuliObeys commands Pts with COPD and hypercapnic encephalopathyBriones Claudett et al.BMC Pulmonary Medicine 2013,13:12BiPAP S/T with AVAPS vs.BiPAP S/T aloneContraindications of NIVAbsoluteRelativeRespiratory arrestMed
18、ically unstable(hypotensive shock,uncontrolled cardiac ischemia,or arrhythmia)Unable to fit maskAgitated,uncooperativeUncontrolled vomiting or copious upper gastrointestinal bleedingUnable to protect airwayTotal upper airway obstructionSwallowing impairmentFacial traumaExcessive secretions not manag
19、ed by secretion clearance techniquesPatient declineMultiple(two or more)organ failureRecent upper airway or upper gastrointestinal surgeryProgressive severe respiratory failurePregnancyMas A and Masip J.International J COPD,2014:9:837-852结论 NIV应用越来越多 认识提高和技术掌握是应用增加主要原因 下列情况获益NIV具有高级别证据 AECOPD 急性心源性肺水肿 OHS 免疫低下ARF 辅助脱机
