2017+ERS／ATS急性呼吸衰竭无创通气治疗ppt.ppt

2017 ERS/ATS急性呼吸衰竭无急性呼吸衰竭无创通气指南解读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(populationinterventioncomparisonoutcome)范式对11个临床相关问题进行了解答。推荐意见整理如下：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?RecommendationWe 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.)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 0.643.35)and decrease the need for intubation(RR 0.41,95%CI 0.180.72).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.最近的几项研究表明双相气道正压NIV不减少死亡率（RR 1.46,95CI 0.64-3.35），不减少对插管的需要（RR 041,95CI 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-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.)We recommend a trial of bilevel NIV in patients con-sidered to require endotracheal intubation and mechanical ventilation,unless the patient is immediately deteriorating.(Strong recommendation,moderatecertainty of evidence.)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急性加重导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）（强烈推荐，高质量证据）。我们建议在认为需要气管内插管的患者中进行试验性双相气道正压NIV机械通气，除非患者立即恶化（强烈推荐，中等质量证据）。实施考虑：当pH值7.35，PaCO245mmHg，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.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）。In 2008,GRAYet al.43 published the largest multicentre trial from 26 emergency departments,in which1069 patients were randomised to CPAP,bilevel NIV or standard oxygen therapy.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.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 4448 that have incorporated the data from GRAYet al.43as well as other new trials,have been published.They consistently conclude that:1)NIV decreases the need for intubation,2)NIV is associated with a reduction in hospital mortality,3)NIV isnot associated with increased myocardial infarction(a concern raised by the first study comparing NIVand CPAP 49),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 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 0.451.70;moderate certainty)decreased the need for intubation(RR 0.31,95%CI 0.170.55;low certainty)We suggest that CPAP or bilevel NIV be used for patients with ARF due to cardiogenic pulmonaryoedema in the pre-hospital setting.(Conditional recommendation,low certainty of evidence.)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；适度确定性）减少了插管的需要（RR 0.31，95%CI 0.17-0.55；低确定性）。Question 3:Should NIV be used in ARF due to acute asthma?Recommendation Given the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for ARF due to asthma.NIV has an unclear effect on mortality,intubation(RR 4.48,95%CI 0.2389.23;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）。Question 4:Should NIV be used for ARF in immunocompromised patients?Recommendation We suggest early NIV for immunocompromised patients with ARF.(Conditional recommendation,moderate certainty of evidence.)问题4：NIV是否用于免疫缺陷患者的ARF？推荐意见：我们建议免疫功能低下的ARF患者早期使用NIV（条件性推荐，中等质量证据）。one recent RCT 67 showed benefits of high-flow nasal cannula oxygen therapy over bilevel NIV with regard to intubation and mortality.高流量鼻套管氧疗在插管率和死亡率的改善上高于 Bilevel NIV。and more study is required to determine whether this modality has advantages over NIV in immunocompromised patients with ARF.Question 5:Should NIV be used in de novo ARF?RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for de novo ARF.问题5：NIV是否用于新发的急性呼吸衰竭？推荐意见：鉴于证据的不确定性，无法就由于新发的ARF使用NIV提出建议。Question 6:Should NIV be used in ARF in the post-operative setting?RecommendationWe suggest NIV for patients with post-operative ARF.(Conditional recommendation,moderate certainty of evidence.)问题6：NIV是否用于手术后ARF的患者中？推荐意见：建议在手术后ARF患者使用NIV（条件性推荐，中等质量证据）。Question 7:Should NIV be used in patients with ARF receiving palliative care?RecommendationWe suggest offering NIV to dyspnoeic patients for palliation in the setting of terminal cancer or other terminal conditions.(Conditional recommendation,moderate certainty of evidence.)问题7：NIV是否用于接受姑息治疗的ARF患者？推荐意见：建议将NIV提供给癌症终末期或其他疾病终末期的呼吸困难患者（条件性推荐，中等质量证据）。Question 8:Should NIV be used in ARF due to chest trauma?RecommendationWe suggest NIV for chest trauma patients with ARF.(Conditional recommendation,moderate certainty of evidence.)问题8：NIV是否用于由于胸部创伤导致的ARF？推荐意见：建议胸部创伤引起的ARF患者中使用NIV。（条件性推荐，中等质量证据）。Question 9:Should NIV be used in ARF due to pandemic viral illness?RecommendationGiven the uncertainty of evidence we are unable to offer a recommendation for this question 问题9：NIV是否用于由于流行性病毒性疾病引起的ARF？推荐意见：鉴于证据的不确定性，无法就此提出建议。Question 10:Should NIV be used in ARF following extubation from invasive mechanical ventilation?问题10：NIV是否用于有创机械通气拔管后的ARF？Question 10a:Should NIV be used to prevent respiratory failure post-extubation?RecommendationsWe suggest that NIV be used to prevent post-extubation respiratory failure in high-risk patientspost-extubation.(Conditional recommendation,low certainty of evidence.)We suggest that NIV should not be used to prevent post-extubation respiratory failure in non-high-riskpatients.(Conditional recommendation,very low certainty of evidence.)问题10a：NIV是否用于预防拔管后的呼吸衰竭？推荐意见：建议NIV用于预防拔管后有呼吸衰竭高风险的患者呼吸衰竭（条件性推荐，低质量证据）。建议NIV不应用于防止非呼吸衰竭高风险的拔管后患者（条件性推荐，低质量证据）。Question 10b:Should NIV be used in the treatment of respiratory failure that develops post-extubation?RecommendationWe suggest that NIV should not be used in the treatment of patients with established post-extubation respiratory failure.(Conditional recommendation,low certainty of evidence.)问题10b：NIV是否应用于治疗拔管后发生的呼吸衰竭？推荐意见：建议NIV不应用于治疗已确定的拔管后呼吸衰竭的患者（条件性推荐，低质量证据）。Question 11:Should NIV be used to facilitate weaning patients from inva-sive mechanical ventilation?RecommendationsWe suggest NIV be used to facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure.(Conditional recommendation,moderate certainty of evidence.)We do not make any recommendation for hypoxaemic patients.问题11：NIV是否用于帮助有创机械通气的患者脱机？推荐意见：建议NIV用于帮助高碳酸血症呼吸衰竭患者的机械通气脱机（条件性推荐，中等质量证据）。对低氧血症患者不做任何推荐Thanks for listening