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浙江大学医学院附属第一医院 ICU 蔡洪流

无创正压通气. 浙江大学医学院附属第一医院 ICU 蔡洪流. Noninvasive Positive Pressure Ventilation NPPV. 无创正压通气. NPPV 概述 NPPV 的优势与不足 NPPV 适应证、禁忌证及并发症 NPPV 的实施. 机械通气. 正压通气 负压通气. 负压通气. 正压通气. 胸廓容量改变. 压差. 气流. 压差. 容量变化. 气流. 机械通气. 机械通气. 有创机械通气 无创机械通气 正压通气 负压通气 高频通气. 无创正压通气. 定义

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浙江大学医学院附属第一医院 ICU 蔡洪流

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  1. 无创正压通气 浙江大学医学院附属第一医院 ICU 蔡洪流

  2. Noninvasive Positive Pressure VentilationNPPV

  3. 无创正压通气 • NPPV概述 • NPPV的优势与不足 • NPPV适应证、禁忌证及并发症 • NPPV的实施

  4. 机械通气 • 正压通气 • 负压通气

  5. 负压通气 正压通气 胸廓容量改变 压差 气流 压差 容量变化 气流 机械通气

  6. 机械通气 • 有创机械通气 • 无创机械通气 • 正压通气 • 负压通气 • 高频通气

  7. 无创正压通气 • 定义 采用非气管插管或气管切开方法而提供正压通气支持的技术。

  8. NPPV International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure Organized Jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Société de Réanimation de Langue Française, and approved by the ATS Board of Directors, December 2000 Am. J. Respir. Crit. Care Med. 2001; 163: 283-291

  9. NPPV NPPV was defined as any form of ventilatory support applied without the use of an endotracheal tube, and was considered to include continuous positive airway pressure (CPAP), with or without inspiratory pressure support; volume- and pressure-cycled systems, propotional assist ventilation (PAV), and adjuncts such as the use of helium-oxygen (heliox) gas mixture. Am. J. Respir. Crit. Care Med. 2001; 163: 283-291

  10. NPPV

  11. 正压通气的主要目的 • 改善氧合和肺泡通气 • 降低呼吸作功，缓解呼吸困难 适当选择适应证，上述目标通过NPPV同样可以达到，而且NPPV可以有效避免与气管插管/气管切开相关的并发症。

  12. NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是

  13. NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是相互补充NPPV是非常有效的机械通气手段，它与传统的有创机械通气不是相互替代，而是相互补充

  14. NPPV的优点（1） • 病人痛苦小，易接受

  15. NPPV的优点（2） • 减少气管插管/气管切开相关并发症 • 上呼吸道正常屏障功能的破坏 • 上呼吸道损伤 • 院内感染（VAP）

  16. NPPV的优点（3） • 镇静剂用量减少 • 保持病人清醒、增加活动和交流、减少心理问题。 • 增加自主吸气努力，促进静脉回流 • 保持咳嗽能力，促进排痰，减少肺不张，改善通气/血流比。 • 减少对其他脏器功能的影响，避免镇静剂掩盖其他并发症。

  17. NPPV的优点（4） • 保持气道防御反应，允许咳嗽、咳痰

  18. NPPV的优点（5） • 允许讲话及吞咽

  19. NPPV的优点（6） • 使用方便、灵活

  20. NPPV的不足 • 需要病人清醒配合 • 不利于气道分泌物的引流 • 不能完全替代气管插管/气管切 开，通气效果不十分确切 • NPPV相关并发症

  21. NPPV与有创正压通气的比较

  22. NPPV的适应证 • 急性呼吸功能衰竭 • 慢性呼吸功能衰竭

  23. Acute applications of noninvasive positive pressure ventilation Chest. 2003 Aug;124(2):699-713

  24. Acute applications of NPPV Chest. 2003 Aug;124(2):699-713

  25. Acute applications of NPPV • Type of Evidence • Strong ( multiple controlled trials ) • Less strong (single controlled trial or multiple case series) • Weak (few case series or case reports) Chest. 2003 Aug;124(2):699-713

  26. NPPV在急性呼衰中的应用 • 证据类型 • 强（多个对照研究） • 次强（单个对照研究或多个病例系列） • 弱（病例系列或病例报告） Chest. 2003 Aug;124(2):699-713

  27. NPPV在急性呼衰中的应用 • 证据类型：强 • COPD急性加重 Chest. 2003 Aug;124(2):699-713

  28. COPD急性加重时NPPV应用指征 • 中重度气促伴有使用辅助呼吸肌或反常呼吸 • 轻中度酸中毒（PH7.30~7.35）和高碳酸血症（PaCO245~60mmHg) • RR≥25次/分 COPD国际防治指南

  29. BTS GUIDELINE Non-invasive ventilation in acute respiratory failure British Thoracic Society Standards of Care Committee Thorax. 2002 Mar;57(3):192-211

  30. NIV has been shown to be an effective treatment for acute hypercapnic respiratory failure (AHRF), particularly in chronic obstructive pulmonary disease (COPD). Facilities for NIV should be available 24 hours per day in all hospitals likely to admit such patients. [A] Thorax. 2002 Mar;57(3):192-211

  31. NIV should be considered in patients with an acute exacerbation of COPD in whom a respiratory acidosis (pH <7.35, H+ >45 nmol/l) persists despite maximum medical treatment on controlled oxygen therapy. [A] Thorax. 2002 Mar;57(3):192-211

  32. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature Ann Intern Med. 2003 Jun 3;138(11):861-70

  33. DATA SOURCES: • MEDLINE (1966 to 2002) • EMBASE (1990 to 2002). Ann Intern Med. 2003 Jun 3;138(11):861-70

  34. Additional data sources included • Cochrane Library • personal files • abstract proceedings • reference lists of selected articles • expert contact Ann Intern Med. 2003 Jun 3;138(11):861-70

  35. Ann Intern Med. 2003 Jun 3;138(11):861-70

  36. 结果显示COPD急性发作患者在标准治疗基础上加用NPPV：结果显示COPD急性发作患者在标准治疗基础上加用NPPV： • 气管插管风险下降28% ，95%可信区间15~40% • 住院时间下降4.57天，95%可信区间2.30~6.83天 • 住院死亡率下降10%，95%可信区间5~15% Ann Intern Med. 2003 Jun 3;138(11):861-70

  37. severe COPD exacerbations • Baseline PH＜7.30 or • An in-hospital mortality rate of greater than 10% in the control group

  38. 分组结果显示COPD严重急性发作患者在标准治疗基础上加用NPPV：分组结果显示COPD严重急性发作患者在标准治疗基础上加用NPPV： • 气管插管风险下降34% ，95%可信区间22~46% • 住院时间下降5.59天，95%可信区间3.66~7.52天 • 住院死亡率下降12%，95%可信区间6~18% Ann Intern Med. 2003 Jun 3;138(11):861-70

  39. 分组结果显示COPD非严重急性发作患者在标准治疗基础上加用NPPV：分组结果显示COPD非严重急性发作患者在标准治疗基础上加用NPPV： • 气管插管风险下降0% ，95%可信区间﹣11~11% • 住院时间下降0.82天，95%可信区间﹣0.12~1.77天 • 住院死亡率下降2%，95%可信区间﹣8~12% Ann Intern Med. 2003 Jun 3;138(11):861-70

  40. CONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been shown to benefit hospitalized patients with milder COPD exacerbations. Ann Intern Med. 2003 Jun 3;138(11):861-70

  41. NPPV在急性呼衰中的应用 • 证据类型：强 • 急性心原性肺水肿 Chest. 2003 Aug;124(2):699-713

  42. NPPV在急性呼衰中的应用 • Pending further studies, the most sensible recommendation is to use CPAP(10 cm H2O) initially and to consider switching to NPPV if the patient is found to have substantial hypercapnia or unrelenting dyspnea. Chest. 2003 Aug;124(2):699-713

  43. NPPV在急性呼衰中的应用 • This recommendation is in line with the conclusion of a meta-analysis that found insufficient evidence to support the use of NPPV in preference to CPAP to treat patients with acute pulmonary edema. Chest. 2003 Aug;124(2):699-713

  44. Continuous positive airway pressure (CPAP) has been shown to be effective in patients with cardiogenic pulmonary oedema who remain hypoxic despite maximal medical treatment. NIV should be reserved for patients in whom CPAP is unsuccessful. [B] Thorax. 2002 Mar;57(3):192-211

  45. NPPV在急性呼衰中的应用 • 证据类型：强 • 免疫抑制病人 Chest. 2003 Aug;124(2):699-713

  46. NPPV在急性呼衰中的应用 • Thus, the avoidance of intubation in this patient population is a desirable outcome, and the use of NPPV is, therefore, justifiable in selected patients with immunocompromised states. Chest. 2003 Aug;124(2):699-713

  47. NPPV在急性呼衰中的应用 • It is important to note, however, that the authors of these studies stress the importance of early initiation of therapy before progression to severe compromise. Chest. 2003 Aug;124(2):699-713

  48. NPPV在急性呼衰中的应用 • 证据类型：强 • 帮助COPD病人撤机 Chest. 2003 Aug;124(2):699-713

  49. Noninvasive positive pressure ventilation as a weaning strategy for intubated adults with respiratory failure Cochrane Database Syst Rev. 2003;(4):CD004127

  50. 随机对照研究： • Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 2, 2003) • MEDLINE (January 1966 to July 2003) • EMBASE (January 1980 to July 2003) Cochrane Database Syst Rev. 2003;(4):CD004127

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