ERS／ATS急性呼吸衰竭無創(chuàng)通氣治療PPT參考幻燈片

2017ERS/ATS急性呼吸衰竭無創(chuàng)通氣指南解讀,1,歐洲呼吸學會（ERS）與美國胸科學會（ATS）在歐洲呼吸雜志上聯(lián)合發(fā)表了ARF患者無創(chuàng)通氣指南。該指南采用PICO(populationinterventioncomparisonoutcome)范式對11個臨床相關(guān)問題進行了解答。推薦意見整理如下：,2,Question1:ShouldNIVbeusedinCOPDexacerbation?,問題1：NIV是否應用于AECOPD？,3,Question1a:ShouldNIVbeusedinARFduetoaCOPDexacerbationtopreventthedevelopmentofrespiratoryacidosis?,RecommendationWesuggestNIVnotbeusedinpatientswithhypercapniawhoarenotacidoticinthesettingofaCOPDexacerbation.(Conditionalrecommendation,lowcertaintyofevidence.),4,問題1a：NIV是否應用于COPD急性加重導致的急性呼吸衰竭（ARF）以防止發(fā)展為呼吸性酸中毒？,推薦意見：建議NIV不適用于COPD急性加重患者中無酸中毒的高碳酸血癥患者（條件性推薦，低質(zhì)量證據(jù)）。,5,Seeforestplotsandtheevidenceprofileinthesupplementarymaterialforfurtherdetailsregardingincludedevidence.PooledanalysiswasveryimprecisebutdemonstratedthatbilevelNIVdoesnotreducemortality(RR1.46,95%CI0.643.35)anddecreasetheneedforintubation(RR0.41,95%CI0.180.72).Giventhelackofconsistentevidencedemonstratingbe-nefitinthosewithoutacidosisandthepotentialforharm,thecommitteedecidedonaconditionalrecommendationagainstbilevelNIVinthissetting.,最近的幾項研究表明雙相氣道正壓NIV不減少死亡率（RR1.46,95CI0.64-3.35），不減少對插管的需要（RR0.41,95CI0.18-0.72）。鑒于缺乏證據(jù)證明對沒有酸中毒患者的益處和潛在的危害，委員會決定在這一環(huán)境中對bilevelNIV提出反對意見。,6,Question1b:ShouldNIVbeusedines-tablishedacutehypercapnicrespiratoryfailureduetoaCOPDexacerbation?,RecommendationsWerecommendbilevelNIVforpatientswithARFleadingtoacuteoracute-on-chronicrespiratoryacidosis(pH7.35)duetoCOPDexacerbation.(Strongrecommendation,highcertaintyofevidence.)WerecommendatrialofbilevelNIVinpatientscon-sideredtorequireendotrachealintubationandmechanicalventilation,unlessthepatientisimmediatelydeteriorating.(Strongrecommendation,moderatecertaintyofevidence.),7,問題1b：NIV是否應用于由于COPD急性加重而導致的急性高碳酸血癥呼吸衰竭？,推薦意見：我們推薦雙相氣道正壓NIV用于由于COPD急性加重導致急性呼吸衰竭引起的急性或慢性急性加重呼吸性酸中毒（pH7.35）（強烈推薦，高質(zhì)量證據(jù)）。,8,我們建議在認為需要氣管內(nèi)插管的患者中進行試驗性雙相氣道正壓NIV機械通氣，除非患者立即惡化（強烈推薦，中等質(zhì)量證據(jù)）。實施考慮：當pH值7.35，PaCO245mmHg，呼吸頻率20-24次/min時，應考慮雙相氣道正壓NIV，盡管采用標準藥物治療。雙相氣道正壓NIV仍然是住院期間COPD患者發(fā)生呼吸性酸中毒的首選。,9,ThereisnolowerlimitofpHbelowwhichatrialofNIVisinappropriate;however,thelowerthepH,thegreaterriskoffailure,andpatientsmustbeverycloselymonitoredwithrapidaccesstoendotrachealintubationandinvasiveventilationifnotimproving.對于試驗性NIV沒有pH的下限是不適當?shù)?然而，pH越低失敗的風險越大，患者必須非常密切監(jiān)測，如果沒有改善，可以快速獲得氣管內(nèi)插管和有創(chuàng)通氣。,10,問題2a：應該在由于心源性肺水腫引起的急性呼吸衰竭中使用NIV嗎？推薦意見：我們建議對心源性肺水腫引起的呼吸衰竭患者提供雙氣道正壓NIV或CPAP。（強烈推薦，中等質(zhì)量證據(jù)）。,11,In2008,GRAYetal.43publishedthelargestmulticentretrialfrom26emergencydepartments,inwhich1069patientswererandomisedtoCPAP,bilevelNIVorstandardoxygentherapy.ThistrialfoundphysiologicalimprovementintheCPAPandbilevelNIPgroupscomparedwiththestandardgroup,butnodifferenceinintubationrateormortalityat7and30days.這項試驗發(fā)現(xiàn)CPAP及BilevelNIP組與標準組相比，有生理上的改善，但插管率和死亡率在7天和30天內(nèi)沒有差別。,12,fivesystematicreviews4448thathaveincorporatedthedatafromGRAYetal.43,aswellasothernewtrials,havebeenpublished.Theyconsistentlyconcludethat:1)NIVdecreasestheneedforintubation,2)NIVisassociatedwithareductioninhospitalmortality,3)NIVisnotassociatedwithincreasedmyocardialinfarction(aconcernraisedbythefirststudycomparingNIVandCPAP49),4)CPAPandNIVhavesimilareffectsontheseoutcomes.RecommendationWerecommendeitherbilevelNIVorCPAPforpatientswithARFduetocardiogenicpulmonaryoedema.(Strongrecommendation,moderatecertaintyofevidence.)1）減少氣管插管的需要，2）與減少住院死亡率有關(guān)，3）和合不增加心肌梗死相關(guān)的4）CPAP和BilevelNIV治療對這些結(jié)果有相似的影響。,13,Question2b:ShouldatrialofCPAPpriortohospitalisationbeusedtopreventdeteriorationinpatientswithARFduetocardiogenicpulmonaryoedema?,PooledanalysisdemonstratedthatNIVdecreasedmortality(RR0.88,95%CI0.451.70;moderatecertainty)decreasedtheneedforintubation(RR0.31,95%CI0.170.55;lowcertainty)WesuggestthatCPAPorbilevelNIVbeusedforpatientswithARFduetocardiogenicpulmonaryoedemainthepre-hospitalsetting.(Conditionalrecommendation,lowcertaintyofevidence.),14,問題2b：在院前是否應使用CPAP進行以防止心源性肺水腫引起的ARF患者惡化？,推薦意見：建議在院前對心源性肺水腫引起的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（RR0.88，95%CI0.45-1.70；適度確定性）減少了插管的需要（RR0.31，95%CI0.17-0.55；低確定性）。,15,Question3:ShouldNIVbeusedinARFduetoacuteasthma?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationontheuseofNIVforARFduetoasthma.NIVhasanuncleareffectonmortality,intubation(RR4.48,95%CI0.2389.23;verylowcertainty)orICUlengthofstay(meandifference0.3higher,95%CI0.63lowerto1.23higher)inthispopulation.,16,問題3：NIV是否用于由于急性哮喘引起的ARF？,推薦意見：鑒于證據(jù)的不確定性，我們無法就由于哮喘引起的ARF使用NIV提出建議。似乎有助于改善1s用力呼氣量。（平均差值高14.02，95%CI7.73-20.32；低確定性）和呼氣峰流量（平均差值高19.97，95%CI15.01-24.93；低確定性）。,17,Question4:ShouldNIVbeusedforARFinimmunocompromisedpatients?,RecommendationWesuggestearlyNIVforimmunocompromisedpatientswithARF.(Conditionalrecommendation,moderatecertaintyofevidence.),18,問題4：NIV是否用于免疫缺陷患者的ARF？,推薦意見：我們建議免疫功能低下的ARF患者早期使用NIV（條件性推薦，中等質(zhì)量證據(jù)）。,19,onerecentRCT67showedbenefitsofhigh-flownasalcannulaoxygentherapyoverbilevelNIVwithregardtointubationandmortality.高流量鼻套管氧療在插管率和死亡率的改善上高于BilevelNIV。andmorestudyisrequiredtodeterminewhetherthismodalityhasadvantagesoverNIVinimmunocompromisedpatientswithARF.,20,Question5:ShouldNIVbeusedindenovoARF?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationontheuseofNIVfordenovoARF.,21,問題5：NIV是否用于新發(fā)的急性呼吸衰竭？,推薦意見：鑒于證據(jù)的不確定性，無法就由于新發(fā)的ARF使用NIV提出建議。,22,Question6:ShouldNIVbeusedinARFinthepost-operativesetting?,RecommendationWesuggestNIVforpatientswithpost-operativeARF.(Conditionalrecommendation,moderatecertaintyofevidence.),23,問題6：NIV是否用于手術(shù)后ARF的患者中？,推薦意見：建議在手術(shù)后ARF患者使用NIV（條件性推薦，中等質(zhì)量證據(jù)）。,24,Question7:ShouldNIVbeusedinpatientswithARFreceivingpalliativecare?,RecommendationWesuggestofferingNIVtodyspnoeicpatientsforpalliationinthesettingofterminalcancerorotherterminalconditions.(Conditionalrecommendation,moderatecertaintyofevidence.),25,問題7：NIV是否用于接受姑息治療的ARF患者？,推薦意見：建議將NIV提供給癌癥終末期或其他疾病終末期的呼吸困難患者（條件性推薦，中等質(zhì)量證據(jù)）。,26,Question8:ShouldNIVbeusedinARFduetochesttrauma?,RecommendationWesuggestNIVforchesttraumapatientswithARF.(Conditionalrecommendation,moderatecertaintyofevidence.),27,問題8：NIV是否用于由于胸部創(chuàng)傷導致的ARF？,推薦意見：建議胸部創(chuàng)傷引起的ARF患者中使用NIV。（條件性推薦，中等質(zhì)量證據(jù)）。,28,Question9:ShouldNIVbeusedinARFduetopandemicviralillness?,RecommendationGiventheuncertaintyofevidenceweareunabletoofferarecommendationforthisquestion,29,問題9：NIV是否用于由于流行性病毒性疾病引起的ARF？,推薦意見：鑒于證據(jù)的不確定性，無法就此提出建議。,30,Question10:ShouldNIVbeusedinARFfollowingextubationfrominvasivemechanicalventilation?問題10：NIV是否用于有創(chuàng)機械通氣拔管后的ARF？,31,Question10a:ShouldNIVbeusedtopreventrespiratoryfailurepost-extubation?,RecommendationsWesuggestthatNIVbeusedtopreventpost-extubationrespiratoryfailureinhigh-riskpatientspost-extubation.(Conditionalrecommendation,lowcertaintyofevidence.)WesuggestthatNIVshouldnotbeusedtopreventpost-extubationrespiratoryfailureinnon-high-riskpatients.(Conditionalrecommendation,verylowcertaintyofevidence.),32,問題10a：NIV是否用于預防拔管后的呼吸衰竭？,推薦意見：建議NIV用于預防拔管后有呼吸衰竭高風險的患者呼吸衰竭（條件性推薦，低質(zhì)量證據(jù)）。建議NIV不應用于防止非呼吸衰竭高風險的拔管后患者（條件性推薦，低質(zhì)量證據(jù)）。,33,Question10b:ShouldNIV