無創(chuàng)正壓通氣蔡洪流課件

1、無創(chuàng)正壓通氣蔡洪流無創(chuàng)正壓通氣蔡洪流Noninvasive Positive Pressure VentilationNPPVNoninvasive Positive Pressure 無創(chuàng)正壓通氣NPPV概述NPPV的優(yōu)勢與不足NPPV適應(yīng)證、禁忌證及并發(fā)癥NPPV的實(shí)施無創(chuàng)正壓通氣NPPV概述機(jī)械通氣正壓通氣負(fù)壓通氣機(jī)械通氣正壓通氣正壓通氣壓差氣流容量變化氣流胸廓容量改變壓差負(fù)壓通氣機(jī)械通氣正壓通氣壓差氣流容量變化氣流胸廓容量改變壓差負(fù)壓通氣機(jī)械通氣機(jī)械通氣有創(chuàng)機(jī)械通氣無創(chuàng)機(jī)械通氣正壓通氣負(fù)壓通氣高頻通氣機(jī)械通氣有創(chuàng)機(jī)械通氣無創(chuàng)正壓通氣定義 采用非氣管插管或氣管切開方法而提供正壓通氣支持的

2、技術(shù)。無創(chuàng)正壓通氣定義 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 Socit de R

3、animation de Langue Franaise, and approved by the ATS Board of Directors, December 2000 Am. J. Respir. Crit. Care Med. 2019; 163: 283-291NPPV International ConsensusNPPV NPPV was defined as any form of ventilatory support applied without the use of an endotracheal tube, and was considered to include

4、 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. 2019; 163: 283-291NPPV NPPV was defi

5、ned NPPVNPPV正壓通氣的主要目的改善氧合和肺泡通氣降低呼吸作功，緩解呼吸困難 適當(dāng)選擇適應(yīng)證，上述目標(biāo)通過NPPV同樣可以達(dá)到，而且NPPV可以有效避免與氣管插管/氣管切開相關(guān)的并發(fā)癥。正壓通氣的主要目的改善氧合和肺泡通氣 適當(dāng)選擇適應(yīng) NPPV是非常有效的機(jī)械通氣手段，它與傳統(tǒng)的有創(chuàng)機(jī)械通氣不是相互替代，而是 NPPV是非常有效的機(jī)械通氣手段，它與傳統(tǒng)的有創(chuàng)機(jī)械 NPPV是非常有效的機(jī)械通氣手段，它與傳統(tǒng)的有創(chuàng)機(jī)械通氣不是相互替代，而是相互補(bǔ)充 NPPV是非常有效的機(jī)械通氣手段，它與傳統(tǒng)的有創(chuàng)機(jī)械NPPV的優(yōu)點(diǎn)（1）病人痛苦小，易接受NPPV的優(yōu)點(diǎn)（1）病人痛苦小，易接受NPPV的

6、優(yōu)點(diǎn)（2）減少氣管插管/氣管切開相關(guān)并發(fā)癥上呼吸道正常屏障功能的破壞上呼吸道損傷院內(nèi)感染（VAP）NPPV的優(yōu)點(diǎn)（2）減少氣管插管/氣管切開相關(guān)并發(fā)癥NPPV的優(yōu)點(diǎn)（3）鎮(zhèn)靜劑用量減少保持病人清醒、增加活動(dòng)和交流、減少心理問題。增加自主吸氣努力，促進(jìn)靜脈回流保持咳嗽能力，促進(jìn)排痰，減少肺不張，改善通氣/血流比。減少對其他臟器功能的影響，避免鎮(zhèn)靜劑掩蓋其他并發(fā)癥。NPPV的優(yōu)點(diǎn)（3）鎮(zhèn)靜劑用量減少NPPV的優(yōu)點(diǎn)（4）保持氣道防御反應(yīng)，允許咳嗽、咳痰NPPV的優(yōu)點(diǎn)（4）保持氣道防御反應(yīng)，允許咳嗽、咳痰NPPV的優(yōu)點(diǎn)（5）允許講話及吞咽NPPV的優(yōu)點(diǎn)（5）允許講話及吞咽NPPV的優(yōu)點(diǎn)（6）使用方便、

7、靈活NPPV的優(yōu)點(diǎn)（6）使用方便、靈活NPPV的不足需要病人清醒配合不利于氣道分泌物的引流不能完全替代氣管插管/氣管切 開，通氣效果不十分確切NPPV相關(guān)并發(fā)癥NPPV的不足需要病人清醒配合 NPPV有創(chuàng)正壓通氣連接方法面/鼻罩插管或切開死腔增大減少密封緊固性較差好同步觸發(fā)要求較高要求稍低吸氣相壓力需較低可較高輔助通氣的保證較低較高鎮(zhèn)靜藥物使用謹(jǐn)慎使用可以病人舒適性和配合要求高要求低清除分泌物困難容易入睡后上氣道阻塞有無NPPV與有創(chuàng)正壓通氣的比較 NPPV有創(chuàng)正壓通氣連接方法面/鼻罩插管或切開死腔增大減NPPV的適應(yīng)證急性呼吸功能衰竭慢性呼吸功能衰竭NPPV的適應(yīng)證急性呼吸功能衰竭Acute

8、 applications of noninvasive positive pressure ventilationChest. 2019 Aug;124(2):699-713 Acute applications of noninvasAcute applications of NPPVChest. 2019 Aug;124(2):699-713 Acute applications of NPPVChesAcute applications of NPPVType of Evidence Strong ( multiple controlled trials )Less strong (s

9、ingle controlled trial or multiple case series) Weak (few case series or case reports) Chest. 2019 Aug;124(2):699-713 Acute applications of NPPVTypeNPPV在急性呼衰中的應(yīng)用證據(jù)類型強(qiáng)（多個(gè)對照研究）次強(qiáng)（單個(gè)對照研究或多個(gè)病例系列）弱（病例系列或病例報(bào)告）Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型Chest. 2019 ANPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)COPD急性加重Chest. 20

10、19 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)Chest. 2019COPD急性加重時(shí)NPPV應(yīng)用指征中重度氣促伴有使用輔助呼吸肌或反常呼吸輕中度酸中毒（PH7.307.35）和高碳酸血癥（PaCO24560mmHg)RR25次/分COPD國際防治指南COPD急性加重時(shí)NPPV應(yīng)用指征COPD國際防治指南BTS GUIDELINENon-invasive ventilation in acute respiratory failureBritish Thoracic Society Standards of Care Committee Thorax. 20

11、19 Mar;57(3):192-211 BTS GUIDELINEThorax. 2019 Mar;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

12、such patients. AThorax. 2019 Mar;57(3):192-211 NIV has been shown to be an efNIV should be considered in patients with an acute exacerbation of COPD in whom a respiratory acidosis (pH 45 nmol/l) persists despite maximum medical treatment on controlled oxygen therapy. AThorax. 2019 Mar;57(3):192-211

13、NIV should be considered in paWhich patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature Ann Intern Med. 2019 Jun 3;138(11):861-70 Which patients with acute exacDATA SOURCES: MEDLINE (1

14、966 to 2019) EMBASE (1990 to 2019). Ann Intern Med. 2019 Jun 3;138(11):861-70 DATA SOURCES: Ann Intern Med. Additional data sources included Cochrane Librarypersonal filesabstract proceedingsreference lists of selected articlesexpert contact Ann Intern Med. 2019 Jun 3;138(11):861-70 Additional data

15、sources includAnn Intern Med. 2019 Jun 3;138(11):861-70 Ann Intern Med. 2019 Jun 3;138結(jié)果顯示COPD急性發(fā)作患者在標(biāo)準(zhǔn)治療基礎(chǔ)上加用NPPV：氣管插管風(fēng)險(xiǎn)下降28% ，95%可信區(qū)間1540%住院時(shí)間下降4.57天，95%可信區(qū)間2.306.83天住院死亡率下降10%，95%可信區(qū)間515%Ann Intern Med. 2019 Jun 3;138(11):861-70 結(jié)果顯示COPD急性發(fā)作患者在標(biāo)準(zhǔn)治療基礎(chǔ)上加用NPPV：Asevere COPD exacerbationsBaseline PH7.

16、30 orAn in-hospital mortality rate of greater than 10% in the control groupsevere COPD exacerbations分組結(jié)果顯示COPD嚴(yán)重急性發(fā)作患者在標(biāo)準(zhǔn)治療基礎(chǔ)上加用NPPV：氣管插管風(fēng)險(xiǎn)下降34% ，95%可信區(qū)間2246%住院時(shí)間下降5.59天，95%可信區(qū)間3.667.52天住院死亡率下降12%，95%可信區(qū)間618%Ann Intern Med. 2019 Jun 3;138(11):861-70 分組結(jié)果顯示COPD嚴(yán)重急性發(fā)作患者在標(biāo)準(zhǔn)治療基礎(chǔ)上加用NP分組結(jié)果顯示COPD非嚴(yán)重急性發(fā)作患者在

17、標(biāo)準(zhǔn)治療基礎(chǔ)上加用NPPV：氣管插管風(fēng)險(xiǎn)下降0% ，95%可信區(qū)間1111%住院時(shí)間下降0.82天，95%可信區(qū)間0.121.77天住院死亡率下降2%，95%可信區(qū)間812%Ann Intern Med. 2019 Jun 3;138(11):861-70 分組結(jié)果顯示COPD非嚴(yán)重急性發(fā)作患者在標(biāo)準(zhǔn)治療基礎(chǔ)上加用NCONCLUSIONS: Patients with severe exacerbations of COPD benefit from the addition of NPPV to standard therapy. However, NPPV has not been sho

18、wn to benefit hospitalized patients with milder COPD exacerbations.Ann Intern Med. 2019 Jun 3;138(11):861-70 CONCLUSIONS: Patients with sevNPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)急性心原性肺水腫Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)Chest. 2019NPPV在急性呼衰中的應(yīng)用Pending further studies, the most sensible recommendation is

19、 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. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用Pending further sNPPV在急性呼衰中的應(yīng)用This recommendation is in line with the conclusion of a meta-analysis that fou

20、nd insufficient evidence to support the use of NPPV in preference to CPAP to treat patients with acute pulmonary edema.Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用This recommendatiContinuous positive airway pressure (CPAP) has been shown to be effective in patients with cardiogenic pulmonary oedema

21、who remain hypoxic despite maximal medical treatment. NIV should be reserved for patients in whom CPAP is unsuccessful. BThorax. 2019 Mar;57(3):192-211 Continuous positive airway preNPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)免疫抑制病人Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)Chest. 2019NPPV在急性呼衰中的應(yīng)用Thus, the avoidance

22、 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. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用Thus, the avoidanNPPV在急性呼衰中的應(yīng)用It is important to note, however, that the authors of these s

23、tudies stress the importance of early initiation of therapy before progression to severe compromise. Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用It is important tNPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)幫助COPD病人撤機(jī)Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)Chest. 2019Noninvasive positive pressure ventilation as a w

24、eaning strategy for intubated adults with respiratory failureCochrane Database Syst Rev. 2019;(4):CD004127 Noninvasive positive pressure 隨機(jī)對照研究：Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 2, 2019) MEDLINE (January 1966 to July 2019) EMBASE (January 1980 to July 2019)

25、Cochrane Database Syst Rev. 2019;(4):CD004127 隨機(jī)對照研究：Cochrane Database Syst 入選5個(gè)研究，包括171名患者。以COPD患者為主 NPPV strategy IPPV strategyCochrane Database Syst Rev. 2019;(4):CD004127 入選5個(gè)研究，包括171名患者。以COPD患者為主CochrNPPV組較IPPV組降低死亡率RR 0.41, 95% CI 0.22 to 0.76降低VAP發(fā)生率 RR 0.28, 95% CI 0.09 to 0.85Cochrane Datab

26、ase Syst Rev. 2019;(4):CD004127 NPPV組較IPPV組Cochrane Database SNPPV組較IPPV組縮短住ICU時(shí)間- 6.88 days, 95% CI -12.60 to -1.15縮短住院時(shí)間- 7.33 days, 95%CI -14.05 to -0.61 Cochrane Database Syst Rev. 2019;(4):CD004127 NPPV組較IPPV組Cochrane Database SNPPV組較IPPV組縮短總機(jī)械通氣時(shí)間-7.33 days, 95% CI -11.45 to -3.22縮短氣管插管時(shí)間-6.79

27、 days, 95% CI -11.70 to -1.87Cochrane Database Syst Rev. 2019;(4):CD004127 NPPV組較IPPV組Cochrane Database SNPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)哮喘Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)囊性纖維化Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)術(shù)后呼吸衰竭

28、Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)避免拔管失敗Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201Noninvasive positive-pressure ventilation for respiratory failure after extubation N Engl J Med. 2019 Jun 10;350(24):2452-60 Noninvasive positive-pressu

29、re 8個(gè)國家 :阿根廷、巴西、哥倫比亞、沙特阿拉伯、西班牙、美國、委內(nèi)瑞拉等37個(gè)醫(yī)療中心N Engl J Med. 2019 Jun 10;350(24):2452-60 8個(gè)國家 :阿根廷、巴西、哥倫比亞、沙特阿拉伯、西班牙、美國上機(jī)48小時(shí)以上，選擇性拔管后48小時(shí)內(nèi)發(fā)生呼吸衰竭的221名患者隨機(jī)分為經(jīng)面罩NPPV組 （n=114 ）常規(guī)內(nèi)科治療組（n=107 ）N Engl J Med. 2019 Jun 10;350(24):2452-60 上機(jī)48小時(shí)以上，選擇性拔管后48小時(shí)內(nèi)發(fā)生呼吸衰竭的221N Engl J Med. 2019 Jun 10;350(24):2452-60

30、 N Engl J Med. 2019 Jun 10;350(N Engl J Med. 2019 Jun 10;350(24):2452-60 N Engl J Med. 2019 Jun 10;350(再插管比例經(jīng)面罩NPPV組 55/114（48%）常規(guī)內(nèi)科治療組 51/107（48%）relative risk 0.9995%可信區(qū)間 0.751.30N Engl J Med. 2019 Jun 10;350(24):2452-60 再插管比例N Engl J Med. 2019 Jun 10ICU死亡率經(jīng)面罩NPPV組 28/114（25%）常規(guī)內(nèi)科治療組 15/107（14%）re

31、lative risk 1.7895%可信區(qū)間1.033.20；P = 0.048N Engl J Med. 2019 Jun 10;350(24):2452-60 ICU死亡率N Engl J Med. 2019 Jun 1CONCLUSIONS: Noninvasive positive-pressure ventilation does not prevent the need for reintubation or reduce mortality in unselected patients who have respiratory failure after extubation

32、N Engl J Med. 2019 Jun 10;350(24):2452-60 CONCLUSIONS: Noninvasive positNPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)DNI（Do-Not-Intubate）患者Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱上呼吸道堵塞Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱Chest. 2019NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱ARDSChest. 2019 Aug;

33、124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱Chest. 2019Mechanical ventilation in sepsis-induced acute lung injury/acute respiratory distress syndrome: an evidence-based reviewCrit Care Med. 2019 Nov;32(11 Suppl):S548-53 Mechanical ventilation in sepsRole of noninvasive positive-pressure ventilation in acute l

34、ung injury/ARDS is undefined Crit Care Med. 2019 Nov;32(11 Suppl):S548-53 Role of noninvasive positive-pNPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱外傷Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱Chest. 2019NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱阻塞性睡眠呼吸暫停，肥胖性低通氣Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱Chest. 2019NPPV在急性呼衰中的應(yīng)用SARS（

35、Severe Acute Respiratory Syndrome ）NPPV在急性呼衰中的應(yīng)用SARS（Severe AcuteNPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)COPD急性加重急性心原性肺水腫免疫抑制病人幫助COPD病人撤機(jī)Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：強(qiáng)Chest. 2019NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)哮喘囊性纖維化術(shù)后呼吸衰竭避免拔管失敗DNI（Do-Not-Intubate）患者Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：次強(qiáng)Chest. 201N

36、PPV在急性呼衰中的應(yīng)用證據(jù)類型：弱上呼吸道堵塞ARDS外傷阻塞性睡眠呼吸暫停，肥胖性低通氣Chest. 2019 Aug;124(2):699-713 NPPV在急性呼衰中的應(yīng)用證據(jù)類型：弱Chest. 2019NPPV在急性呼吸衰竭中應(yīng)用的病理生理指征（1）急性呼吸窘迫的癥狀和體征中重度呼吸困難或呼吸困難程度較平時(shí)嚴(yán)重 和RR24次/分，使用輔助呼吸肌，出現(xiàn)矛盾呼吸Mehta S. Am J Respir Crit Care Med 2019;163(2):540-77NPPV在急性呼吸衰竭中應(yīng)用的病理生理指征（1）急性呼吸窘迫氣體交換異常PaCO245mmHg，PH7.35 或PaO2/

37、FiO2 200無NPPV禁忌證NPPV在急性呼吸衰竭中應(yīng)用的病理生理指征（2）Mehta S. Am J Respir Crit Care Med 2019;163(2):540-77氣體交換異常NPPV在急性呼吸衰竭中應(yīng)用的病理生理指征（2）NPPV治療成功的急性呼吸衰竭患者的臨床特點(diǎn)（1）年齡較小病情較輕（APACHE評分低）能配合治療，神志較好自主呼吸能與呼吸機(jī)配合面罩漏氣少，牙齒完整Mehta S. Am J Respir Crit Care Med 2019;163(2):540-77NPPV治療成功的急性呼吸衰竭患者的臨床特點(diǎn)（1）年齡較小M不十分嚴(yán)重的CO2潴留（PaCO2 4

38、592mmHg）不十分嚴(yán)重的酸中毒（PH 7.107.35） 通氣后最初2小時(shí)內(nèi)氣體交換、心率、呼吸頻率改善NPPV治療成功的急性呼吸衰竭患者的臨床特點(diǎn)（2）Mehta S. Am J Respir Crit Care Med 2019;163(2):540-77不十分嚴(yán)重的CO2潴留（PaCO2 4592mmHg）NPNPPV在慢性呼吸功能衰竭的適應(yīng)證胸廓限制性疾病神經(jīng)肌肉疾病慢性阻塞性肺部疾病夜間低通氣綜合征Chest. 2019;116:521-534 NPPV在慢性呼吸功能衰竭的適應(yīng)證胸廓限制性疾病Chest.A meta-analysis of nocturnal noninvasi

39、ve positive pressure ventilation in patients with stable COPDChest. 2019 Jul;124(1):337-43 A meta-analysis of nocturnal nConclusions: This meta-analysis of 3 months of NIPPV in patients with stable COPD showed that ventilatory support did not improve lung function, gas exchange, or sleep efficiency.

40、 Chest. 2019 Jul;124(1):337-43 Conclusions: This meta-analysiThe high upper limit of the confidence interval for the 6MWD suggested that some people do improve their walking distance. The small overall sample size precluded a clear clinical direction regarding the effects of NIPPV in patients with C

41、OPD. Chest. 2019 Jul;124(1):337-43 The high upper limit of the co緩慢進(jìn)展的呼吸衰竭上呼吸道功能完整氣道分泌物少清醒合作病人慢性呼衰使用NPPV的入選標(biāo)準(zhǔn)緩慢進(jìn)展的呼吸衰竭慢性呼衰使用NPPV的入選標(biāo)準(zhǔn)NPPV的禁忌癥絕對禁忌癥相對禁忌癥中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV的禁忌癥絕對禁忌癥中華結(jié)核和呼吸雜志.2019,25心跳呼吸停止自主呼吸微弱、昏迷誤吸可能性高中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV的絕對禁忌癥 （1）心跳呼吸停止中華結(jié)核和呼吸雜志.2019,25(3):1

42、30合并其它臟器功能衰竭（血流動(dòng)力學(xué)不穩(wěn)定、消化道大出血/穿孔、嚴(yán)重腦部疾病等）面部創(chuàng)傷/術(shù)后/畸形不合作中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV的絕對禁忌癥 （2）合并其它臟器功能衰竭（血流動(dòng)力學(xué)不穩(wěn)定、消化道大出血/穿孔、NPPV的相對禁忌證（1）氣道分泌物多/排痰障礙嚴(yán)重感染極度緊張嚴(yán)重低氧血癥(PaO245mmHg)/嚴(yán)重酸中毒(pH7.20)中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV的相對禁忌證（1）氣道分泌物多/排痰障礙中華結(jié)核和呼NPPV的相對禁忌證（2）近期上腹部手術(shù)后（尤其是需要嚴(yán)格胃腸減壓者）嚴(yán)重肥胖上氣道機(jī)械性阻塞中華結(jié)核和呼

43、吸雜志.2019,25(3):130-134NPPV的相對禁忌證（2）近期上腹部手術(shù)后（尤其是需要嚴(yán)格胃Noninvasive positive-pressure ventilation to treat hypercapnic coma secondary to respiratory failureChest. 2019 Mar;127(3):952-60 Noninvasive positive-pressure RESULTS: A total of 76 coma patients (80%) responded to NPPV therapy, and 605 patients w

44、ith GCS scores 8 responded to therapy (70%; p = 0.04). A total of 25 coma patients died in the hospital (26.3%), and 287 noncoma patients died in the hospital (33.2%; p = 0.17). Chest. 2019 Mar;127(3):952-60 RESULTS: A total of 76 coma paThe variables related to the success of NPPV therapy were GCS

45、score 1 h posttherapy (odds ratio OR, 2.32; 95% confidence interval CI, 1.53 to 3.53) and higher levels of multiorgan dysfunction, as measured by the maximum sequential organ failure assessment index score reached during NPPV therapy (OR, 0.72; 95% CI, 0.55 to 0.92).Chest. 2019 Mar;127(3):952-60 The

46、 variables related to the sCONCLUSIONS: We concluded that selected patients with hypercapnic coma secondary to ARF can be treated as successfully with NPPV as awake patients with ARFChest. 2019 Mar;127(3):952-60 CONCLUSIONS: We concluded thatNPPV的并發(fā)癥面/鼻罩相關(guān)并發(fā)癥正壓通氣相關(guān)并發(fā)癥NPPV的并發(fā)癥面/鼻罩相關(guān)并發(fā)癥面/鼻罩相關(guān)并發(fā)癥（1）面/鼻

47、罩周圍漏氣面/鼻罩相關(guān)并發(fā)癥（1）面/鼻罩周圍漏氣局部壓迫皮膚損傷面/鼻罩相關(guān)并發(fā)癥（2）局部壓迫皮膚損傷面/鼻罩相關(guān)并發(fā)癥（2）吞氣癥，引起胃腸脹氣并可引起嘔吐、誤吸排痰障礙鼻腔、口咽部 、眼部干燥刺激 面/鼻罩相關(guān)并發(fā)癥（3）吞氣癥，引起胃腸脹氣并可引起嘔吐、誤吸面/鼻罩相關(guān)并發(fā)癥（3面/鼻罩相關(guān)并發(fā)癥（4）恐懼（幽閉恐怖癥）睡眠性上呼吸道阻塞面/鼻罩相關(guān)并發(fā)癥（4）恐懼（幽閉恐怖癥）正壓通氣相關(guān)并發(fā)癥通氣機(jī)所致肺損傷（VILI）肺泡外氣體系統(tǒng)性氣體栓塞彌漫性肺水腫氧中毒靜脈回流障礙、影響心輸出量正壓通氣相關(guān)并發(fā)癥通氣機(jī)所致肺損傷（VILI）病人選擇選擇需要通氣支持的病人（排除可以單獨(dú)采用

48、常規(guī)治療的病人）排除不適合 NPPV治療和需立即氣管插管的病人病人具有上呼吸道防御功能是重要條件之一病人選擇選擇需要通氣支持的病人（排除可以單獨(dú)采用常規(guī)治療的病NPPV臨床應(yīng)用策略有效積極的常規(guī)治療NPPV有創(chuàng)正壓通氣常規(guī)撤機(jī)NPPV輔助撤機(jī)繼續(xù)使用無效12h后如無改善（PaCO2下降16%，pH 7.30，PaO240mmHg）NPPV臨床應(yīng)用策略有效積極的常規(guī)治療NPPV有創(chuàng)正壓通氣常NPPV療效評價(jià)（1）氣促改善輔助呼吸肌肉動(dòng)用減輕和反常呼吸消失呼吸頻率減慢SaO2增加心率減慢Mehta S. Am J Respir Crit Care Med 2019;163(2):540-77NPP

49、V療效評價(jià)（1）氣促改善Mehta S. Am J RNPPV療效評價(jià)（2）初始治療有效12h后臨床情況改善血?dú)夥治鯬aCO2下降16%pH 7.30PaO240mmHgAm. J. Respir. Crit. Care Med. 2019; 163: 283-291NPPV療效評價(jià)（2）初始治療有效Am. J. RespirNPPV不易成功的因素（1）嚴(yán)重的呼吸衰竭嚴(yán)重的肺炎氣道分泌物多排痰能力差中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV不易成功的因素（1）嚴(yán)重的呼吸衰竭中華結(jié)核和呼吸雜志NPPV不易成功的因素（2）患者不合作嚴(yán)重酸血癥（pH7.20）急性生理學(xué)慢性健康

50、（APACHE）評分15治療12 h后效果不明顯中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV不易成功的因素（2）患者不合作中華結(jié)核和呼吸雜志.2NPPV臨床應(yīng)用策略無創(chuàng)-有創(chuàng)-無創(chuàng)序貫治療NPPV臨床應(yīng)用策略無創(chuàng)-有創(chuàng)-無創(chuàng)序貫治療NPPV通氣機(jī)的選擇ICU通氣機(jī)NPPV專用通氣機(jī)NPPV通氣機(jī)的選擇ICU通氣機(jī)氧濃度精確可調(diào)吸氣管和呼氣管分開，減少管路死腔，減少 CO2重吸收吸氣流速加速快監(jiān)測報(bào)警功能完善ICU通氣機(jī)用于NPPV的優(yōu)點(diǎn)氧濃度精確可調(diào)ICU通氣機(jī)用于NPPV的優(yōu)點(diǎn)體積小，重量輕，操作簡單，價(jià)格便宜不需高壓空氣，可用低壓供氧NPPV專用通氣機(jī)的優(yōu)點(diǎn)(1)體積小

51、，重量輕，操作簡單，價(jià)格便宜NPPV專用通氣機(jī)的優(yōu)點(diǎn)(NPPV專用通氣機(jī)的優(yōu)點(diǎn)(2)識(shí)別并精確補(bǔ)償可能存在的漏氣維持觸發(fā)靈敏度，保持理想的同步狀態(tài) 在有大量漏氣的情況下保持預(yù)設(shè)壓力NPPV專用通氣機(jī)的優(yōu)點(diǎn)(2)識(shí)別并精確補(bǔ)償可能存在的漏氣NPPV專用通氣機(jī)的優(yōu)點(diǎn)(3)特殊設(shè)計(jì)的智能靈敏度控制系統(tǒng)NPPV專用通氣機(jī)的優(yōu)點(diǎn)(3)特殊設(shè)計(jì)的智能靈敏度控制系統(tǒng)BiPAP通氣機(jī)主要模式S同步S/T同步/時(shí)間T時(shí)間控制BiPAP通氣機(jī)主要模式S同步BiPAP（Bi-level Positive Airway Pressure）IPAP（Inspiratory Positive Airway Pressur

52、e）與PS類似EPAP（Expiratory Positive Airway Pressure）與CPAP類似BiPAP（Bi-level Positive AirwaIPAP的作用降低吸氣作功增大潮氣量IPAP的作用降低吸氣作功EPAP的作用（1）減少肺內(nèi)分流，改善通氣/血流比增加功能殘氣量改善頑固性低氧EPAP的作用（1）減少肺內(nèi)分流，改善通氣/血流比EPAP的作用（2）對抗 AutoPEEPEPAP的作用（2）對抗 AutoPEEPEPAP的作用（）改善肺順應(yīng)性降低氣道阻力保護(hù)肺組織EPAP的作用（）改善肺順應(yīng)性BiPAP的設(shè)置改善氧合降低PaCO2BiPAP的設(shè)置改善氧合降低 PaCO

53、2的措施 PaCO2 Vco2k（VtVd）RRBiPAP的設(shè)置降低 PaCO2的措施 PaCO2 Vco2k（VtV降低 PaCO2的措施降低 PaCO2產(chǎn)量增加 Vt ，減少Vd增加 RRBiPAP的設(shè)置降低 PaCO2的措施BiPAP的設(shè)置BiPAP的設(shè)置增加潮氣量的措施IPAPEPAP順應(yīng)性氣道阻力患者吸氣努力BiPAP的設(shè)置增加潮氣量的措施BiPAP的設(shè)置IPAP初始設(shè)置為48cmH2OEPAP初始設(shè)置為23cmH2O潮氣量主要取決于 IPAPEPAP增大EPAP和/或IPAP值均可改善氧合BiPAP的設(shè)置IPAP初始設(shè)置為48cmH2ONPPV常用的通氣參數(shù)的參考值參數(shù)參考值潮氣量

54、715 ml/kg呼吸頻率1630次/min吸氣流量遞減型，足夠可變，峰值：4060L/min吸氣時(shí)間0.81.2 s吸氣壓力1025 cmH2O呼氣壓力(PEEP)依患者情況而定（常用：35 cmH2O，型呼吸衰竭時(shí)需要增加）中華結(jié)核和呼吸雜志.2019,25(3):130-134NPPV常用的通氣參數(shù)的參考值參數(shù)參考值潮氣量715 mlBiPAP與PSV+CPAP的區(qū)別BiPAP IPAP 10cmH2OEPAP 5cmH2OPSV+CPAP PS 10cmH2OCPAP 5cmH2OBiPAP與PSV+CPAP的區(qū)別BiPAPPSV+CPAP面罩鼻罩死腔大小影響進(jìn)食發(fā)音大小影響咳痰大小誤吸風(fēng)險(xiǎn)大小經(jīng)口漏氣