2017+ERS／ATS急性呼吸衰竭无创通气治疗ppt

2017 ERS/ATS急性呼吸衰竭无 创通气指南解读
• 欧洲呼吸学会（ERS）与美国胸科学会（ATS） 在《欧洲呼吸杂志》上联合发表了ARF患者 无创通气指南。该指南采用
PICO(population–intervention–comparison– outcome)范式对11个临床相关问题进行了解 答。推荐意见整理如下：
• 对于试验性NIV没有pH的下限是不适当的; 然而， pH越低失败的风险越大，患者必须非常密切监 测，如果没有改善，可以快速获得气管内插管 和有创通气。
• 问题2a：应该在由于心源性肺水肿引起的 急性呼吸衰竭中使用NIV吗？
• 推荐意见：
• 我们建议对心源性肺水肿引起的呼吸衰竭 患者提供双气道正压NIV或CPAP。（强烈推 荐，中等质量证据）。
• 实施考虑：当pH值≤7.35，PaCO2>45mmHg， 呼吸频率> 20-24次/min时，应考虑双相气 道正压NIV， 尽管采用标准药物治疗。
• 双相气道正压NIV仍然是住院期间COPD患者 发生呼吸性酸中毒的首选。
• 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.
NIV has an unclear effect on mortality, intubation(RR 4.48, 95% CI 0.23–89.23; 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.
问题3：NIV是否用于由于急性哮喘 引起的ARF？
• 推荐意见： • 鉴于证据的不确定性，我们无法就由于哮
喘引起的ARF使用NIV提出建议。
• 似乎有助于改善1 s用力呼气量。 （平均差 值高14.02，95% CI 7.73 - 20.32；低确定性） 和呼气峰流量（平均差值高19.97，95% CI 15.01 - 24.93；低确定性）。
• 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.
问题2b：在院前是否应使用CPAP进 行以防止心源性肺水肿引起的ARF患
者恶化？
• 推荐意见： • 建议在院前对心源性肺水肿引起的ARF患者使用CPAP或
双相气道正压NIV（条件性推荐，低质量证据）。 • 汇总分析表明 • NIV 降低死亡率（RR 0.88，95% CI 0.45 - 1.70；适度确定
• 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）减少气管插管的需要， 2）与减少住院死亡率有关， 3）和合不增加心肌梗死相关的 4）CPAP和Bilevel NIV治疗对这些结果有相似的影响。
Question 1: Should NIV be used in COPD exacerbation?
• 问题1：NIV是否应用于AECOPD？
Question 1a: Should NIV be used in ARF due to a COPD exacerbation to prevent the development of respiratory acidosis?
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 0.45–
1.70; moderate certainty) • decreased the need for intubation (RR 0.31, 95%
We recommend a trial of bilevel NIV in patients considered to require endotracheal intubation and mechanical ventilation, unless the patient is immediately deteriorating. (Strong recommendation, moderatecertainty of evidence.)
CI 0.17–0.55; low certainty) • We suggest that CPAP or bilevel NIV be used for
patients with ARF due to cardiogenic pulmonary oedema in the pre-hospital setting. (Conditional recommendation, low certainty of evidence.)
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 respiratory acidosis (pH ⩽7.35) due to COPD exacerbation. (Strong recommendation, high certainty of evidence.)
问题1a：NIV是否应用于COPD急性加 重导致的急性呼吸衰竭（ARF）以防 止发展为呼吸性酸中毒？
• 推荐意见： • 建议NIV不适用于COPD急性加重患者中无酸
中毒的高碳酸血症患者（条件性推荐，低 质量证据）。
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 0.64–3.35) and decrease the need for intubation (RR 0.41, 95% CI 0.18–0.72). 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.
• 这项试验发现CPAP及Bilevel NIP组与标准组相 比，有生理上的改善， 但插管率和死亡率在7 天和30天内没有差别。
five systematic reviews [44–48] that have incorporated the data from GRAYet al.[43], as well as other new trials, have been published.
• Recommendation
We 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.)
最近的几项研究表明双相气道正压NIV不减少死亡率（RR 1.46,95％CI 0.64-3.35）， 不减少对插管的需要（RR 0.41,95％CI 0.18-0.72）。鉴于缺乏证据证明对没有酸中 毒患者的益处和潜在的危害，委员会决定在这一环境中对 bilevel NIV提出反对意见。
Question 1b: Should NIV be used in es-
问题1b：NIV是否应用于由于COPD急 性加重而导致的急性高碳酸血症呼
吸衰竭？
• 推荐意见： • 我们推荐双相气道正压NIV用于由于COPD急