单位:西京医院呼吸与危重症医学科
一、流行病学
流行病学数据显示,2014年12月至2015年12月中国大陆20岁以上人群中慢性阻塞性肺疾病(COPD,慢阻肺)患者约占8.6%,推测中国COPD患病人数约为9990万。2012年6月至2015年5月,40岁以上人群中COPD患者约占13.6%。国外数据显示,在过去的12个月中有24%的COPD患者到急诊就诊,15%的患者需要住院;大多数COPD轻度加重患者(70%~90%需住院)可以仅通过氧疗和药物来治疗,余下的10%~30%需要呼吸机辅助通气。
二、COPD全程呼吸支持
(一)
慢阻肺急性加重期(AECOPD)
(二)
慢阻肺稳定期
基于现阶段的研究证据,不同指南也有不同的推荐,比较统一的是,对于有慢性高碳酸血症的稳定期COPD患者,推荐使用NIV。对于高强度无创通气,没有做出明确的推荐。推荐2~4周后评重新评估,再决定是否需要使用家庭NIV。GOLD指南也推荐,如果患者有疲劳、日间嗜睡、呼吸困难等症状,或者有气体交换障碍,或者对最佳药物治疗无效,或者对中度至重度阻塞性睡眠呼吸暂停CPAP治疗无效,这些情况下可以考虑使用NIV。2个月后重新评估,如果患者依从性良好(每天使用>4 h)且治疗反应良好,则继续治疗。
三、总结
COPD的病程分为急性加重期和稳定期两个阶段,在急性加重期的氧疗应该明确目标(SpO2 88%~92%)。对于HFNC,无论是在避免插管阶段介入,还是在插管后提前拔管阶段介入,目前的研究证据仍不足,需要大样本RCT研究加以证实。NIV仍然是AECOPD患者的首选,IMV目前在COPD患者中使用越来越少。对于稳定期COPD患者,不能过度使用LTOT,应遵循指南推荐的指征进行,并且每天使用时长应≥15 h。在通气支持方面,多部指南也推荐稳定期COPD患者使用家庭NIV,尤其对于合并呼吸性酸中毒患者,而且尽可能降低PaCO2的参数设置方法得到越来越多研究的证实。家庭HFNC的研究目前样本量仍然太少,缺乏大型RCT研究证据。
参考文献
[1] Wang C, Xu J, Yang L, et al. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China Pulmonary Health [CPH] study): a national cross-sectional study[J]. Lancet, 2018, 391(10131):1706-1717.
[2] Landis SH, Muellerova H, Mannino DM, et al. Continuing to Confront COPD International Patient Survey: methods, COPD prevalence, and disease burden in 2012–2013[J]. Int J Chron Obstruct Pulmon Dis, 2014, 9:597-611.
[3] Scala R. High-Flow Nasal Oxygen Therapy: One More Chance for Extubation?[J]. Respir Care, 2014, 59(4):609-612.
[4] Quintana JM, Esteban C, Unzurrunzaga A, et al. Predictive score for mortality in patients with COPD exacerbations attending hospital emergency departments[J]. BMC Med, 2014, 12:66.
[5] Cameron L, Pilcher J, Weatherall M, et al. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD[J]. Postgrad Med J, 2012, 88(1046):684-689.
[6] Ward MM, Javitz HS, Smith WM, et al. Direct medical cost of chronic obstructive pulmonary disease in the U.S.A[J]. Respir Med, 2000, 94(11):1123-1129.
[7] Carlos E, John S, James W, et al. Oxygen therapy and inpatient mortality in COPD exacerbation[J]. Emerg Med J, 2021, 38:170-177.
[8] Piraino T, Madden M, Roberts KJ, et al. Management of adult patients with oxygen in the acute care setting[J]. Respir Care, 2022, 67(1):115-128.
[9] Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'swimming between the flags'[J]. Respirology, 2015, 20: 1182-1191.
[10] Bruni A. High Flow Through Nasal Cannula in Stable and Exacerbated Chronic Obstructive Pulmonary Disease Patients[J].. Rev Recent Clin Trials, 2019, 14(4):247-260.
[11] Judith E. Clinical Evidence of Nasal High-Flow Therapy in Chronic Obstructive Pulmonary Disease Patients[J]. Respiration, 2020, 99:140-153.
[12] Xia J. High-flow nasal cannula versus conventional oxygen therapy in acute COPD exacerbation with mild hypercapnia: a multicenter randomized controlled trial[J]. Crit Care, 2022, 26(1):109.
[13] Yang H, Huang D, Luo J, et al. The use of high-flow nasal cannula in patients with chronic obstructive pulmonary disease under exacerbation and stable phases: A systematic review and meta-analysis[J]. Heart Lung, 2023, 60:116-126.
[14] Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure[J]. Eur Respir J, 2017, 50:1602426.
[15] 中华医学会呼吸病学分会呼吸生理与重症监护学组, 《中华结核和呼吸杂志》编辑委员会. 无创正压通气临床应用专家共识[J]. 中华结核和呼吸杂志, 2009, 32(2):86-98.
[16] Stefan MS, Shieh MS, Pekow PS, et al. Trends in mechanical ventilation among patients hospitalized with acute exacerbations of COPD in the United States, 2001 to 2011[J]. Chest, 2015, 147(4):959-968.
[17] Fahey AC, O'Connell M, Cornally N, et al. High flow nasal cannula versus noninvasive ventilation in the treatment of acute hypercapnic respiratory failure: A systematic review and meta-analysis[J]. Clin Respir J, 2023, 17(11):1091-1102.
[18] Oczkowski S. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure[J]. Eur Respir J, 2022, 59(4):2101574.
[19] Bruni A. Current Practice of High Flow through Nasal Cannula in Exacerbated COPD Patients[J]. Healthcare (Basel), 2022, 10(3):536.
[20] 王辰. 呼吸治疗教程[M]. 北京:人民卫生出版社,2010.
[21] Mughal MM, Culver DA, Minai OA, et al. Auto-positive end-expiratory pressure: mechanisms and treatment[J]. Cleve Clin J Med, 2005, 72(9):801-809.
[22] 中华医学会重症医学分会. 慢性阻塞性肺疾病急性加重患者的机械通气指南(2007)[J]. 中国危重病急救医学, 2007, 19(9):513-518.
[23] Branson RD. Oxygen Therapy in COPD[J]. Respir Care, 2018, 63(6):734-748.
[24] Koh Y. Ventilatory management in patients with chronic airflow obstruction[J]. Crit Care Clin, 2007, 23(2):169-181.
[25] Yeung J, Couper K, Ryan EG, et al. Non-invasive ventilation as a strategy for weaning from invasive mechanical ventilation: a systematic review and Bayesian meta-analysis[J]. Intensive Care Med, 2018, 44(12):2192-2204.
[26] Zhouzhou F, Lu Z, Haichuan Y, et al. High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation for AECOPD Patients After Extubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials[J]. Int J Chron Obstruct Pulmon Dis, 2022, 17:1987-1999.
[27] Jacobs SS. Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline[J].. Am J Respir Crit Care Med, 2020, 202(10):e121-e141.
[28] Tristan B, Mark E, Clément P, et al. Nasal High Flow for Stable Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis[J]. COPD, 2019, 16:368-377.
[29] Crimi C, Noto A, Princi P, et al Domiciliary Non-invasive Ventilation in COPD: An International Survey of Indications and Practices[J]. COPD, 2016, 13(4):483-490.
[30] Struik FM, Lacasse Y, Goldstein RS, et al. Nocturnal noninvasive positive pressure ventilation in stable COPD: a systematic review and individual patient data meta-analysis[J]. Respir Med, 2014, 108(2):329-337.
[31] Jen R, Ellis C, Kaminska M, et al. Noninvasive Home Mechanical Ventilation for Stable Hypercapnic COPD: A Clinical Respiratory Review from Canadian Perspectives[J]. Can Respir J, 2023, 2023:8691539.
[32] Wilson ME. Association of Home Noninvasive Positive Pressure Ventilation With Clinical Outcomes in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis[J]. JAMA, 2020, 323(5):455-465.
[33] Wu Z. Baseline Level and Reduction in PaCO2 are Associated with the Treatment Effect of Long-Term Home Noninvasive Positive Pressure Ventilation in Stable Hypercapnic Patients with COPD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials[J]. Int J Chron Obstruct Pulmon Dis, 2022, 17:719-733.
[34] Hatipoğlu U, Aboussouan LS. Chronic hypercapnic respiratory failure and non-invasive ventilation in people with chronic obstructive pulmonary disease[J]. BMJ Med, 2022, 1(1):e000146.
[35] Mehta S, Hill NS. Noninvasive ventilation[J]. Am J Respir Crit Care Med, 2001, 163(2):540-577.
作者简介
友情链接
联系我们