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(xué)會（ERS）與美國胸科學(xué)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(gè)臨床相關(guān)問題進(jìn)行了解答。推薦意見整理如下：,2,Question1:ShouldNIVbeusedinCOPDexacerbation?,問題1：NIV是否應(yīng)用于AECOPD？,3,Question1a:ShouldNIVbeusedinARFduetoaCOPDexacerbationtopreventthedevelopmentofrespiratoryacidosis?,RecommendationWesuggestNIVnotbeusedinpatientswithhypercapniawhoarenotacidoticinthesettingofaCOPDexacerbation.(Conditionalrecommendation,lowcertaintyofevidence.),4,問題1a：NIV是否應(yīng)用于COPD急性加重導(dǎo)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(xiàng)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(yīng)用于由于COPD急性加重而導(dǎo)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(dǎo)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(qiáng)烈推薦，高質(zhì)量證據(jù)）。,8,我們建議在認(rèn)為需要?dú)夤軆?nèi)插管的患者中進(jìn)行試驗(yàn)性雙相氣道正壓NIV機(jī)械通氣，除非患者立即惡化（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，盡管采用標(biāo)準(zhǔn)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(yàn)性NIV沒有pH的下限是不適當(dāng)?shù)?然而，pH越低失敗的風(fēng)險(xiǎn)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(yīng)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(qiáng)烈推薦，中等質(zhì)量證據(jù)）。,11,In2008,GRAYetal.43publishedthelargestmulticentretrialfrom26emergencydepartments,inwhich1069patientswererandomisedtoCPAP,bilevelNIVorstandardoxygentherapy.ThistrialfoundphysiologicalimprovementintheCPAPandbilevelNIPgroupscomparedwiththestandardgroup,butnodifferenceinintubationrateormortalityat7and30days.這項(xiàng)試驗(yàn)發(fā)現(xiàn)CPAP及BilevelNIP組與標(biāo)準(zhǔn)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(yīng)使用CPAP進(jìn)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(dǎo)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(jī)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(yù)防拔管后的呼吸衰竭？,推薦意見：建議NIV用于預(yù)防拔管后有呼吸衰竭高風(fēng)險(xiǎn)的患者呼吸衰竭（條件性推薦，低質(zhì)量證據(jù)）。建議NIV不應(yīng)用于防止非呼吸衰竭高風(fēng)險(xiǎn)的拔管后患者（條件性推薦，低質(zhì)量證據(jù)）。,33,Question10b:ShouldNIV