ERS／ATS急性呼吸衰竭無(wú)創(chuàng)通氣治療

1、 ERS/ATS急性呼吸衰竭無(wú)創(chuàng)通氣指南解讀第1頁(yè)歐洲呼吸學(xué)會(huì)（ERS）與美國(guó)胸科學(xué)會(huì)（ATS）在歐洲呼吸雜志上聯(lián)合發(fā)表了ARF患者無(wú)創(chuàng)通氣指南。該指南采取PICO(populationinterventioncomparisonoutcome)范式對(duì)11個(gè)臨床相關(guān)問(wèn)題進(jìn)行了解答。推薦意見(jiàn)整理以下：第2頁(yè)Question 1: Should NIV be used in COPD exacerbation?問(wèn)題1：NIV是否應(yīng)用于AECOPD？第3頁(yè)Question 1a: Should NIV be used in ARF due to a COPD exacerbation to prev

2、ent the development of respiratory acidosis?RecommendationWe suggest NIV not be used in patients with hypercapnia who are not acidotic in the setting of a COPD exacerbation. (Conditional recommendation, low certainty of evidence.)第4頁(yè)問(wèn)題1a：NIV是否應(yīng)用于COPD急性加重造成急性呼吸衰竭（ARF）以預(yù)防發(fā)展為呼吸性酸中毒？推薦意見(jiàn)：提議NIV不適合用于COPD急

3、性加重患者中無(wú)酸中毒高碳酸血癥患者（條件性推薦，低質(zhì)量證據(jù)）。第5頁(yè)See forest plots and the evidence profile in the supplementary material for further details regarding included evidence. Pooled analysis was very imprecise but demonstrated that bilevel NIV does not reduce mortality (RR 1.46, 95% CI 0.643.35) and decrease the need f

4、or intubation (RR 0.41, 95% CI 0.180.72).Given the lack of consistent evidence demonstrating be-nefit in those without acidosis and the potential for harm, the committee decided on a conditional recommendation against bilevel NIV in this setting.最近幾項(xiàng)研究表明雙相氣道正壓NIV不降低死亡率（RR 1.46,95CI 0.64-3.35），不降低對(duì)插管

5、需要（RR 0.41,95CI 0.18-0.72）。鑒于缺乏證據(jù)證實(shí)對(duì)沒(méi)有酸中毒患者益處和潛在危害，委員會(huì)決定在這一環(huán)境中對(duì) bilevel NIV提出反對(duì)意見(jiàn)。第6頁(yè)Question 1b: Should NIV be used in es-tablished acute hypercapnic respiratory failure due to a COPD exacerbation?Recommendations We recommend bilevel NIV for patients with ARF leading to acute or acute-on-chronic re

6、spiratory acidosis (pH 7.35) due to COPD exacerbation. (Strong recommendation, high certainty of evidence.) We recommend a trial of bilevel NIV in patients con-sidered to require endotracheal intubation and mechanical ventilation, unless the patient is immediately deteriorating. (Strong recommendati

7、on, moderatecertainty of evidence.)第7頁(yè)問(wèn)題1b：NIV是否應(yīng)用于因?yàn)镃OPD急性加重而造成急性高碳酸血癥呼吸衰竭？推薦意見(jiàn)：我們推薦雙相氣道正壓NIV用于因?yàn)镃OPD急性加重造成急性呼吸衰竭引發(fā)急性或慢性急性加重呼吸性酸中毒（pH7.35）（強(qiáng)烈推薦，高質(zhì)量證據(jù)）。第8頁(yè)我們提議在認(rèn)為需要?dú)夤軆?nèi)插管患者中進(jìn)行試驗(yàn)性雙相氣道正壓NIV機(jī)械通氣，除非患者馬上惡化（強(qiáng)烈推薦，中等質(zhì)量證據(jù)）。實(shí)施考慮：當(dāng)pH值7.35，PaCO245mmHg，呼吸頻率 20-24次/min時(shí)，應(yīng)考慮雙相氣道正壓NIV， 盡管采取標(biāo)準(zhǔn)藥品治療。雙相氣道正壓NIV依然是住院期間COP

8、D患者發(fā)生呼吸性酸中毒首選。第9頁(yè)There is no lower limit of pH below which a trial of NIV isinappropriate; however, the lower the pH, the greater risk of failure, and patients must be very closelymonitored with rapid access to endotracheal intubation and invasive ventilation if not improving.對(duì)于試驗(yàn)性NIV沒(méi)有pH下限是不適當(dāng); 然而，

9、pH越低失敗風(fēng)險(xiǎn)越大，患者必須非常親密監(jiān)測(cè)，假如沒(méi)有改進(jìn)，能夠快速取得氣管內(nèi)插管和有創(chuàng)通氣。第10頁(yè)問(wèn)題2a：應(yīng)該在因?yàn)樾脑葱苑嗡[引發(fā)急性呼吸衰竭中使用NIV嗎？推薦意見(jiàn)：我們提議對(duì)心源性肺水腫引發(fā)呼吸衰竭患者提供雙氣道正壓NIV或CPAP。（強(qiáng)烈推薦，中等質(zhì)量證據(jù)）。第11頁(yè)In , GRAYet al.43 published the largest multicentre trial from 26 emergency departments, in which1069 patients were randomised to CPAP, bilevel NIV or standard

10、oxygen therapy. This trial found physiological improvement in the CPAP and bilevel NIP groups compared with the standard group, but no difference in intubation rate or mortality at 7 and 30 days.這項(xiàng)試驗(yàn)發(fā)覺(jué)CPAP及Bilevel NIP組與標(biāo)準(zhǔn)組相比，有生理上改進(jìn)， 但插管率和死亡率在7天和30天內(nèi)沒(méi)有差異。 第12頁(yè)five systematic reviews 4448 that have in

11、corporated the data from GRAYet al.43, as well as other new trials, have been published. They consistently conclude that: 1) NIV decreases the need for intubation, 2) NIV is associated with a reduction in hospital mortality, 3) NIV isnot associated with increased myocardial infarction (a concern rai

12、sed by the first study comparing NIVand CPAP 49),4) CPAP and NIV have similar effects on these outcomes. Recommendation We recommend either bilevel NIV or CPAP for patients with ARF due to cardiogenic pulmonary oedema.(Strong recommendation, moderate certainty of evidence.)1）降低氣管插管需要， 2）與降低住院死亡率相關(guān)，

13、3）和合不增加心肌梗死相關(guān)4）CPAP和Bilevel NIV治療對(duì)這些結(jié)果有相同影響。第13頁(yè)Question 2b: Should a trial of CPAP prior to hospitalisation be used to prevent deterioration in patients with ARF due to cardiogenic pulmonary oedema? Pooled analysis demonstrated that NIV decreased mortality (RR 0.88, 95% CI 0.451.70; moderate certai

14、nty) decreased the need for intubation (RR 0.31, 95% CI 0.170.55; low certainty)We suggest that CPAP or bilevel NIV be used for patients with ARF due to cardiogenic pulmonaryoedema in the pre-hospital setting. (Conditional recommendation, low certainty of evidence.) 第14頁(yè)問(wèn)題2b：在院前是否應(yīng)使用CPAP進(jìn)行以預(yù)防心源性肺水腫引

15、發(fā)ARF患者惡化？推薦意見(jiàn)：提議在院前對(duì)心源性肺水腫引發(fā)ARF患者使用CPAP或雙相氣道正壓NIV（條件性推薦，低質(zhì)量證據(jù)）。匯總分析表明 NIV 降低死亡率（RR 0.88，95% CI 0.45 - 1.70；適度確定性） 降低了插管需要（RR 0.31，95% CI 0.17 - 0.55；低確定性）。 第15頁(yè)Question 3: Should NIV be used in ARF due to acute asthma? Recommendation Given the uncertainty of evidence we are unable to offer a recomme

16、ndation on the use of NIV for ARF due to asthma. NIV has an unclear effect on mortality, intubation(RR 4.48, 95% CI 0.2389.23; very low certainty) or ICU length of stay (mean difference 0.3 higher, 95%CI 0.63 lower to 1.23 higher) in this population. 第16頁(yè)問(wèn)題3：NIV是否用于因?yàn)榧毙韵l(fā)ARF？推薦意見(jiàn)：鑒于證據(jù)不確定性，我們無(wú)法就因?yàn)橄?/p>

17、喘引發(fā)ARF使用NIV提出提議。似乎有利于改進(jìn)1 s用力呼氣量。 （平均差值高14.02，95% CI 7.73 - 20.32；低確定性） 和呼氣峰流量（平均差值高19.97，95% CI 15.01 - 24.93；低確定性）。 第17頁(yè)Question 4: Should NIV be used for ARF in immunocompromised patients? Recommendation We suggest early NIV for immunocompromised patients with ARF. (Conditional recommendation,mode

18、rate certainty of evidence.)第18頁(yè)問(wèn)題4：NIV是否用于免疫缺點(diǎn)患者ARF？推薦意見(jiàn)：我們提議免疫功效低下ARF患者早期使用NIV（條件性推薦，中等質(zhì)量證據(jù)）。第19頁(yè) one recent RCT 67 showed benefits of high-flow nasal cannula oxygen therapy over bilevel NIV with regard to intubation and mortality. 高流量鼻套管氧療在插管率和死亡率改進(jìn)上高于 Bilevel NIV。 and more study is required to d

19、etermine whether this modality has advantages over NIV in immunocompromised patients with ARF.第20頁(yè)Question 5: Should NIV be used in de novo ARF? RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for de novo ARF. 第21頁(yè)問(wèn)題5：NIV是否用于新發(fā)急性呼吸衰竭？推薦意見(jiàn)：鑒于證

20、據(jù)不確定性，無(wú)法就因?yàn)樾掳l(fā)ARF使用NIV提出提議。第22頁(yè)Question 6: Should NIV be used in ARF in the post-operative setting? RecommendationWe suggest NIV for patients with post-operative ARF. (Conditional recommendation, moderate certainty of evidence.) 第23頁(yè)問(wèn)題6：NIV是否用于手術(shù)后ARF患者中？ 推薦意見(jiàn)： 提議在手術(shù)后ARF患者使用NIV（條件性推薦，中等質(zhì)量證據(jù)）。第24頁(yè)Quest

21、ion 7: Should NIV be used in patients with ARF receiving palliative care? RecommendationWe suggest offering NIV to dyspnoeic patients for palliation in the setting of terminal cancer or other terminal conditions. (Conditional recommendation, moderate certainty of evidence.) 第25頁(yè)問(wèn)題7：NIV是否用于接收姑息治療ARF患

22、者？推薦意見(jiàn)：提議將NIV提供給癌癥終末期或其它疾病終末期呼吸困難患者（條件性推薦，中等質(zhì)量證據(jù)）。第26頁(yè)Question 8: Should NIV be used in ARF due to chest trauma? RecommendationWe suggest NIV for chest trauma patients with ARF. (Conditional recommendation, moderate certainty of evidence.) 第27頁(yè)問(wèn)題8：NIV是否用于因?yàn)樾夭縿?chuàng)傷造成ARF？推薦意見(jiàn)：提議胸部創(chuàng)傷引發(fā)ARF患者中使用NIV。 （條件性推薦，

23、中等質(zhì)量證據(jù)）。第28頁(yè)Question 9: Should NIV be used in ARF due to pandemic viral illness? RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation for this question 第29頁(yè)問(wèn)題9：NIV是否用于因?yàn)榱餍行圆《拘约膊∫l(fā)ARF？推薦意見(jiàn)：鑒于證據(jù)不確定性，無(wú)法就此提出提議。第30頁(yè)Question 10: Should NIV be used in ARF following extuba

24、tion from invasive mechanical ventilation?問(wèn)題10：NIV是否用于有創(chuàng)機(jī)械通氣拔管后ARF？第31頁(yè)Question 10a: Should NIV be used to prevent respiratory failure post-extubation? RecommendationsWe suggest that NIV be used to prevent post-extubation respiratory failure in high-risk patientspost-extubation. (Conditional recomme

25、ndation, low certainty of evidence.)We suggest that NIV should not be used to prevent post-extubation respiratory failure in non-high-riskpatients. (Conditional recommendation, very low certainty of evidence.) 第32頁(yè)問(wèn)題10a：NIV是否用于預(yù)防拔管后呼吸衰竭？推薦意見(jiàn)：提議NIV用于預(yù)防拔管后有呼吸衰竭高風(fēng)險(xiǎn)患者呼吸衰竭 （條件性推薦，低質(zhì)量證據(jù)）。提議NIV不應(yīng)用于預(yù)防非呼吸衰竭高風(fēng)險(xiǎn)拔管后患者 （條件性推薦，低質(zhì)量證據(jù)）。第33頁(yè)Question 10