经鼻高流量湿化氧疗在慢性阻塞性肺疾病急性加重期合并Ⅱ型呼吸衰竭患者中的临床疗效.pdf

内科急危重症杂志2 0 2 3年第2 9卷第5期经鼻高流量湿化氧疗在慢性阻塞性肺疾病急性加重期合并型呼吸衰竭患者中的临床疗效381黄斌覃超群林惠曼”李丽英廖艺黄汉灿莫艳菊诀桂林市人民医院1呼吸与危重症医学科；重症医学科，广西桂林摘要目的：探讨经鼻高流量湿化氧疗(HFNC)在慢性阻塞性肺疾病急性加重期(AECOPD)合并I型呼吸衰竭患者中的临床疗效。方法：将90 例AECOPD合并I型呼吸衰竭患者随机分为对照组和观察组,每组45例。在抗感染、解痤平喘、祛痰、营养支持等常规治疗基础上，对照组给予无创正压通气（NPPV）、观察组予以HFNC治疗，疗程均为7 d。比较2 组患者治疗前、治疗1 d及7 d后动脉血气分析指标(PaO2、Pa C O,)、氢离子浓度指数(pH)、平均动脉压（MAP）、心率、呼吸频率、C反应蛋白（CRP）、白细胞介素6（IL-6）、肿瘤坏死因子-（T NF-）、生存质量圣乔治医院呼吸疾病调查问卷(SGRQ)评分、舒适状况量表(GCQ)评分、住院时间及不良反应。结果：治疗 1 d、7 d 后,2 组PaO2 pH值及GCQ 评分较治疗前升高,且治疗 7 d 后高于治疗1 d 后,观察组 GCQ评分高于对照组(P均0.05);PaCO2、M A P、心率、呼吸频率及SGRQ评分较治疗前降低,且治疗7 d后低于治疗1 d后,观察组SGRQ评分低于对照组(P均 0.0 5)。治疗7 d 后,观察组心率及呼吸频率低于对照组,2 组 CRP、I L-6、T NF-水平较治疗前降低,且观察组低于对照组(P均 0.0 5)。观察组平均住院时间短于对照组，不耐受、面部压伤、鼻腔出血及胃肠胀气发生率低于对照组(P均 0.0 5）。结论:HFNC与NPPV均是AECOPD合并I型呼吸衰竭呼吸支持治疗的有效方式,但HFNC在改善临床症状、缓解炎性反应及舒适耐受性方面更具优势,可显著提高生存质量,降低不良反应发生率。关键词慢性阻塞性肺疾病；急性加重期；呼吸衰竭；经鼻高流量湿化氧疗；无创正压通气中图分类号R563.8Clinical efficacy of high-flow nasal canula oxygen therapy in patients with acute exacerbation of chronic obstructivepulmonary disease complicated with type I respiratory failure HUANG Bin*,QIN Chao-qun,LIN Hui-min?,LI Li-ying,LIAO Y,HUANG Han-can,MO Yan-ju,TAN Yong-xian,LIU Ruo-nan.Department of Respiratory and CriticalCare,Department of Critical Medicine,Guilin Peoples Hospital,Guangxi Guilin 541002,ChinaCorresponding author:HUANG Bin,E-mail:Huangbin7611 Abstract Objective:To investigate the clinical efficacy of high-flow nasal canula oxygen therapy(HFNC)in patientswith acute exacerbation of chronic obstructive pulmonary disease(AECOPD)complicated with type II respiratory failure.Methods:A total of 90 AECOPD patients with type II respiratory failure were randomly divided into control group andobservation group,with 45 cases in each group.On the basis of conventional treatments such as anti-infection,antispasmodicand asthma relief,expectoration and nutritional support,the control group was given non-invasive positive-pressure ventila-tion(NPPV),and the observation group was given HFNC,and the course of treatment was 7 days.Arterial blood gas analy-sis indexes(PaO2,PaCO,),hydrogen ion concentration index(pH),mean arterial pressure(MAP),heart rate,respirato-ry rate,C-reactive protein(CRP),interleukin-6(IL-6)and tumor necrosis factor-(TNF-)were compared between thetwo groups before treatment,1 day afer treatment and 7 days after treatment.Quality of life St.Georges Hospital Respira-tory Disease Questionnaire(SGRQ)score,general comfort questionnaire(CCQ)score,length of hospital stay and adverseevents were analyzed.Results:After ld and 7d of treatment,PaO2,pH and GCQ scores in the 2 groups were higher thanthose before treatment,those were higher after 7 d than after 1d of treatment,and GCQ scores in the observation group werehigher than those in the control group(all P0.05).PaCO2,MAP,heart rate,respiratory rate and SGRQ scores aftertreatment were lower than those before treatment,and those were lower after 7 d than after 1d of treatment,and SGRQ scoresin the observation group were lower than those in the control group(all P0.05).After 7 d of treatment,the heart rate andrespiratory rate in the observation group were lower than those in the control group,and the levels of CRP,IL-6,and TNF-in the 2 groups were lower than those before treatment,and those in the observation group were lower than those in the control*基金项目：国家自然科学基金（No:82160002;82160014）；桂林市科学研究与技术开发计划项目（No:20190218-7-8）*通信作者：黄斌,E-mail:H，广西省桂林市象山区文明路12 号谭永仙1刘若岚541002文献标识码AD0110.11768/nkjwzz20230506382慢性阻塞性肺疾病(chronic obstructive pulmona-ry disease,COPD)是以气流受限为特征的慢性气道炎性疾病,主要累及肺脏,是目前最常见且高发的非传染性慢性疾病,其中 COPD急性加重期（acute ex-acerbation of COPD,AECOPD)是 COPD病情中最为凶险的一个分期，若不及时有效的治疗，极易诱发高碳酸血症及低氧血症导致呼吸衰竭,危及生命1.2 。氧疗是治疗AECOPD以及缓解呼吸困难的重要手段，其中无创正压通气（non-invasive positive pressureventilation，NPPV）是通过面（鼻）罩等无创方式实施正压辅助通气,可有效缓解呼吸困难症状,降低死亡率 3。然而,NPPV操作复杂，易发生误吸、面部压伤等并发症,治疗舒适性及耐受性较差,且专业性更强，基层医院无法顺利开展 4。经鼻高流量湿化氧疗(high-flow nasal canula oxygen therapy,HFNC)是一种无创呼吸支持新疗法，是通过加粗鼻导管对吸气体进行充分加湿加温的高流量吸氧，易耐受且舒适度较高，可快速地改善氧合，保障吸氧浓度，促进痰液引流,改善通气功能,预防二氧化碳潴留,适用于心功能不全、术后呼吸支持、急性低氧性呼吸衰竭以及呼吸衰竭未行气管插管等患者 5.6 。本文探讨HFNC治疗AECOPD合并型呼吸衰竭患者的临床疗效。资料与方法一般资料选取2 0 2 0 年2 月至2 0 2 2 年2 月桂林市人民医院呼吸与危重症医学科收治的9 0 例AECOPD合并型呼吸衰竭患者,采用随机数字表法分为对照组和观察组，每组45例。对照组男25例，女2 0 例；年龄55 8 0 岁，平均（6 8.2 47.34)岁;COPD病程4 10 年,平均(7.2 41.52)年,其他基础疾病:高血压2 9 例,糖尿病15例,心脏病12 例。观察组男2 3 例,女 2 2 例；年龄 56 82岁,平均(6 8.7 6 7.44)岁;COPD病程5 10 年，平均（7.7 31.56)年；其他基础疾病：高血压2 7 例，糖尿病16 例,心脏病14 例。2 组患者一般资料比较,内科急危重症杂志2 0 2 3年第2 9 卷第5期group(all P0.05).The average hospitalization time in the observation group was shorter than that in the control group,and the incidence of intolerance,facial compression,nasal hemorrhage and gastrointestinal flatulence in the observationgroup was lower than those in the control group(all P 18 岁；符合无创通气指征。排除标准:心率 0.0 5）。内科急危重症杂志2 0 2 3年第2 9卷第5期assay,ELISA）检测白细胞介素 IL（i n t e r l e u k i n）-6、肿瘤坏死因子（t u m o r n e c r o s i s f a c t o r-,TNF-）水平；生存质量于人院时及治疗1d、7 d 后采用圣乔治医院呼吸疾病调查问卷（St.Georges RespiratoryQuestionnaire,SGRQ）量表 8 评估，包括具体症状（气喘、咳嗽、咳痰）、疾病影响（失眠、紧张、焦虑）和活动情况（慢走、家务、上楼），总分为10 0 分，分值越低则生活质量越好；于入院时及治疗1d、7 d 后采用Kolcaba 的舒适状况量表（general comfort ques-tionnaire,GCQ评估 9舒适度：包括心理、生理、环境和社会，总分为112 分，评分越高则越舒适；记录患者住院时间及不耐受、面部压伤、鼻腔出血和胃肠胀气发生情况。组别例对照组45治疗前治疗1d后治疗7 d后观察组治疗前治疗1d后治疗7 d后注：与本组治疗前比较，*P0.05;与本组治疗1d后比较，P0.05;与对照组同时间比较，P 0.0 5);治疗7 d后,2 组 CRP、IL-6、T NF-水平较治疗前降低,且观察组低于对照组(P均 0.0 5),见表2。表2 2 组患者炎症因子水平比较（xs）组别例治疗前对照组4515.88 4.32观察组4516.72 4.47组别例治疗前对照组4521.83 4.23观察组4522.57 4.12组别例治疗前对照组4545.36 9.42观察组4546.28 9.39注：与本组治疗前比较，*P0.05;与本组治疗1 d后比较,#P0.05;与对照组同时间比较,P0.05生存质量及舒适度治疗 1 d、7 d 后,2 组383统计学分析采用SPSS24.0统计学软件，计量资料以（s)表示,组内比较采用配对t检验，计数资料以例（%）表示,采用检验,组间比较应用独立样本t检验分析,以PpH 值均较治疗前升高,且治疗 7 d 后高于治疗1d后,PaCO2、M A P、心率及呼吸频率较治疗前降低,且治疗7 d后低于治疗1 d后(P均0.05;治疗7 d后,观察组心率及呼吸频率低于对照组,差异有统计学意义（P0.05）,见表1。表12 组患者动脉血气指标及心率、呼吸频率比较（xs)PaO2PaCO,(mmHg)(mmHg)53.42 5.6869.34 6.5662.36 5.86*59.42 4.43*74.54 7.92*#53.23 4.85*#4552.28 5.2263.64 6.23*72.16 8.66*#CRP(mg/L)治疗1d后14.95 3.969.74 2.45*#15.16 3.867.32 1.83*#IL-6(pg/mL)治疗1d后20.76 3.4516.64 2.94*#21.38 3.0914.85 2.21*#TNF-(pg/mL)治疗1d 后43.25 8.3428.25 5.03*#43.16 7.2924.23 4.87*#MAPpH值(mmHg)7.28 0.06102.34 10.34 7.31 0.07*88.18 7.85*7.37 0.08*#84.35 8.33*#68.52 7.497.27 0.0558.28 5.36*7.33 0.06*52.67 4.52*#7.38 0.09*#SCRQ评分较治疗前降低,且观察组低于对照组（P均 0.0 5);GCQ评分较治疗前升高,且观察组高于对照组(P均 0.0 5),见表3。住院时间与不良反应观察组平均住院时间短于对照组,不耐受、面部压伤、鼻腔出血及胃肠胀气发生率低于对照组（P均 0.0 5）,见表4。讨论治疗7 d后目前,临床治疗AECOPD合并I型呼吸衰竭主要包括 10.1：基础支持治疗：使用支气管扩张药物、呼吸兴奋剂、祛痰药物、静脉或吸入激素、抗感染治疗7 d后等;氧气治疗：经鼻导管给予1 2 L/min的持续低氧流量吸氧,通常血氧提升太快，会抑制缺氧对呼吸中枢的反射性兴奋作用,降低通气量,进一步增加治疗7 d后二氧化碳潴留；机械通气：包括有创与无创,其中有创机械通气是通过气管插管或气管切开建立人工气道,将人与呼吸机连接给予呼吸支持治疗；无创通气模式不需要建立人工气道，使用相对简便、灵活，且并发症较少，容易被患者接受。HFNC作为一种心率(次/min)106.25 11.3493.35 8.72*86.52 8.67*#101.76 9.58104.72 10.56 85.86 6.73*91.82 9.69*:82.34 6.45*#82.28 7.23*#呼吸频率(次/min)31.64 4.3927.67 4.25*21.57 3.13*#30.84 5.5526.36 4.18*19.35 3.08*#384组别对照组观察组注：与本组治疗前比较，*P0.05;与本组治疗1 d后比较,P0.05;与对照组同时间比较,P0.05组别鼻腔出血对照组45观察组45注：与对照组比较，*P0.05无创氧疗方式,是由高流量输出装置、鼻塞系统及加温加湿系统组装而成，利用密封鼻导管输送高流量气体，通过流速大于患者自主吸气流速，保证气体充分，满足自主呼吸流速要求，从而快速地改善氧合，保障吸氧浓度，适用于临床诸多呼吸衰竭未行气管插管疾病 12 陈照家等 13 研究表明,HFNC治疗AECOPD合并型呼吸衰竭动脉血气分析指标均优于NPPV。本研究结果显示,NPPV与HFNC治疗均可改善AE-COPD 合并 型呼吸衰竭患者的临床症状,但 HFNC治疗在改善心率及呼吸频率方面更具优势。呼吸衰竭的基本特点是低氧血症、呼吸性酸中毒及其导致的代谢障碍和脏器功能障碍,NPPV可及时、合理地纠正上述紊乱，为原发病和诱发因素的治疗提供时间和条件，无需建立人工气道 14。HFNC兼顾了普通面罩和鼻塞的优点，供氧性能稳定，通过密闭导管输送空氧混合高流量（最大可达6 0 L/min）气体以产生一定的气道正压,降低呼吸阻力，减轻呼吸肌疲劳，促进肺部气体交换，增加功能性残气量，减少呼出气体再吸人，改善氧合，进而大大提升整体区域性呼气末肺阻抗，改善心率、呼吸频率及通气功能 15,16 COPD作为一种气道炎性疾病,在其各个阶段中均存在不同程度的炎症反应 17 。同时,肺功能损伤及缺氧状态也会产生全身性炎症反应，加剧病情进展。本研究结果显示,治疗7 d后,观察组患者CRP、I L-6、T NF-水平均低于对照组,提示HFNC治疗可有效缓解机体炎症反应。可能是因为HFNC适宜的温度及湿度有利于氧气滋润患者气道，保护气道纤毛上皮细胞功能,改善氧合反应,进而降低炎症反应。本研究还发现,治疗1d、7 d 后,观察组 SGRQ内科急危重症杂志2 0 2 3年第2 9 卷第5期表32 组患者生存质量及舒适度比较（分，s）SGRQ评分例治疗前4568.35 10.644569.13 11.72例GCQ评分治疗1d后治疗7 d后63.85 9.92*47.26 8.43*#59.72 9.25*42.39 8.14*#表42 组住院时间与不良反应比较住院时间d,(xs)11.34 2.129.26 1.07*治疗前51.44 2.4650.82 2.39不良反应 例(%)不耐受面部压伤4(8.89)9(20.00)0*1(2.22)*评分低于对照组,GCQ评分高于对照组,且观察组住院时间短于对照组，不良反应发生率均少于对照组，提示HFNC治疗在提高患者生存质量、舒适度、缩短住院时间及降低不良反应方面具有明显优势 18 。HFNC可以提供恒定氧浓度以及舒适的温湿度,不仅能够有效避免气道变冷、水分流失以减少对鼻部的刺激，同时还极大程度的防止呼吸道分泌物聚积,降低院内感染风险。充分加温湿化的气流会减少气流阻力，提高气道传导功能,预防支气管痉挛,从而提高患者舒适度和生活质量,减少住院时间及不良事件发生率 19.2 0 参考文献1 Ritchie AI,Wedzicha JA.Definition causes pathogenesis and conse-quences of chronic obstructive pulmonary disease exacerbations J.Clin Chest Med,2020,41(3):421-438.2洗少静,马义铭,陈燕.慢性阻塞性肺疾病急性加重期的病原学特征及危险因素研究现状 J.内科急危重症杂志,2 0 2 1,2 7（5）：353-358.3Rajdev K,Spanel AJ,McMillan S,et al.Pulmonary barotrauma in CO-VID-19 patients with ARDS on invasive and non-invasive positivepressure ventilation J.J Intensive Care Med,2021,36(9):1013-1017.4农凌波，余裕恒，张容，等.无创正压通气在重症加强治疗病房危重患者预氧合中的应用 J.中国呼吸与危重监护杂志,2 0 2 1,2 0(1):17-21.5 Rochwerg B,Einav S,Chaudhuri D,et al.The role for high flow nasalcannula as a respiratory support strategy in adults:a clinical practiceguideline J.Intensive Care Med,2020,46(12):2226-2237.6 Lee CC,Mankodi 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