经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响.pdf

J Clin Pathol Res2023,43(7)http:/ 临床与病理杂志经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响孙津津（池州市人民医院急诊内科，安徽 池州 247000）摘要 目的：通过与无创机械通气(non-invasive mechanical ventilation，NIV)对比，探讨经鼻高流量湿化氧疗(high-flow nasal cannula，HFNC)对急性呼吸衰竭(acute respiratory failure，ARF)患者呼吸循环参数、凝血指标和并发症的影响。方法：选取2018年9月至2020年8月池州市人民医院收治的ARF患者作为研究对象。根据氧疗方法不同将90例ARF患者分为HFNC组(n=45)与NIV组(n=45)，HFNC组予以HFNC治疗，NIV组予以NIV治疗。比较2组治疗前后呼吸循环参数呼吸频率(respiratory rate，RR)、脉搏血氧饱和度(pulse oxygen saturation，SpO2)、动脉二氧化碳分 压(arterial partial pressure of carbon dioxide，PaCO2)和 氧 合 指 数(arterial partial pressure of oxygen/fraction of inspiratory oxygen，PaO2/FiO2)、凝血功能指标D-二聚体、纤维蛋白原(fibrinogen，Fib)、舒适度评分、耐受性评分、并发症发生率和预后情况。结果：与治疗前相比，治疗48 h后2组RR降低(均P0.05)，PaO2、PaCO2和PaO2/FiO2水平增高(均P0.05)。与治疗前相比，治疗48 h后2组D-二聚体、Fib水平均降低(均P0.05)。相比NIV组，HFNC组舒适度评分、耐受性评分均显著降低(均P0.05)。HFNC并发症发生率为11.11%，显著低于NIV组的31.11%(P0.05)。HFNC组48 h肺部感染率低于NIV组(P0.05)。结论：对于ARF的治疗，HFNC在改善呼吸循环参数和血液高凝状态方面的效果相当，但HFNC有更好的耐受性及较低的并发症发生率，安全性更好。关键词 急性呼吸衰竭；经鼻高流量湿化氧疗；无创机械通气；呼吸循环参数；凝血功能；并发症Effects of nasal high-flow humidified oxygen therapy on respiratory and circulatory parameters,coagulation parameters and complications in patients with acute respiratory failureSUN Jinjin(Emergency Medicine,People s Hospital of Chizhou,Chizhou Anhui 247000,China)DOI：10.11817/j.issn.2095-6959.2023.222610收稿日期(Date of reception)：2022-12-05第一作者(First author)：孙津津，Email:,ORCID:0009-0008-1920-697X通信作者(Corresponding author)：孙津津，Email:,ORCID:0009-0008-1920-697X1356经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响 孙津津 ABSTRACT Objective:To investigate the effects of high-flow nasal cannula(HFNC)on respiratory and circulatory parameters,coagulation parameters and complications in patients with acute respiratory failure(ARF)by comparing with non-invasive ventilation(NIV).Methods:Patients with ARF admitted to Chizhou People s Hospital from September 2018 to August 2020 were selected as the research objects.Ninety patients with ARF were divided into a HFNC group(n=45)and a NIV group(n=45)according to different oxygen therapies.The HFNC group was treated with HFNC,and the NIV group was treated with NIV.The respiratory and circulatory parameters respiratory rate(RR),pulse oxygen saturation(SpO2),arterial partial pressure of carbon dioxide(PaCO2),and oxygenation index(PaO2/FiO2),coagulation function indexes D-dimer,fibrinogen(Fib),comfort score,tolerance score,complication rate and prognosis in the 2 groups before and after the treatment were compared.Results:After 48 h of treatment,the RR in the 2 groups was lower than that before the treatment(P0.05),and the levels of PaO2,PaCO2 and PaO2/FiO2 were higher than those before the treatment(all P0.05).After 48 h of treatment,the levels of D-dimer and Fib in the 2 groups were lower than those before the treatment(both P0.05).Compared with the NIV group,the scores of comfort and tolerance in the HFNC group were significantly lower(all P0.05).The incidence rate of complications in HFNC group was 11.11%,which was significantly lower than 31.11%in the NIV group(P0.05).The 48 h pulmonary infection rate in the HFNC group was lower than that in the NIV group(P0.05).Conclusion:For the treatment of ARF,HFNC has the same effect in improving respiratory and circulatory parameters and blood hypercoagulation state,but HFNC has better tolerance,lower incidence of complications and better safety.KEY WORDS acute respiratory failure;high-flow nasal cannula;non-invasive mechanical ventilation;respiratory cycle parameters;coagulation function;complications急性呼吸衰竭(acute respiratory failure，ARF)是多种原因导致肺通气功能障碍，引起低氧血症，进而导致机体生理与代谢紊乱的一种临床综合征，其病情进展迅速，有较高的死亡风险1。改善肺通气功能与低氧血症是 ARF 治疗之关键。无创机械通气(non-invasive ventilation，NIV)是治疗ARF的有效手段，能够快速改善机体氧交换，纠正低氧血症，但耐受性差，易出现胃胀、口干等多种并发症2-3。经鼻高流量湿化氧疗(high-flow nasal cannula，HFNC)作为一种新型无创氧疗方式，有加温、加湿功能，在改善机体氧合状况的同时，能够为患者提供良好的气道舒适感，利于提高患者的治疗依从性，降低拔管后再插管率4-5。但也有研究6认为，HFNC对于呼吸衰竭患者氧合能力的改善有限。为进一步明确HFNC与NIV的优劣，本研究以ARF患者为研究对象，比较两种氧疗方式的疗效和安全性。1 对象与方法 1.1 对象选取2018年9月至2020年8月池州市人民医院收治的90例ARF患者。纳入标准：1)符合ARF诊断标准7；2)年龄18 岁；3)氧合指数(arterial partial 1357临床与病理杂志,2023,43(7)http:/pressure of oxygen/fraction of inspiratory oxygen，PaO2/FiO2)200 mmHg(1 mmHg=0.133 kPa)；4)行NIV或HFNC治疗。排除标准：1)伴严重心肝肾功能障碍者；2)有慢性呼吸疾病史者；3)心源性肺水肿；4)有无创通气禁忌证者；5)需气管插管行有创机械通气者；6)血流动力学不稳定者；7)意识改变引起自主呼吸受限者；8)俯卧位通气者。根据氧疗方法不同将患者分为HFNC组(n=45)与NIV组(n=45)。本研究获得池州市人民医院医学伦理委员会审批通过(审批号：20180620003)。1.2 治疗方法HFNC组：仪器采用ARIVO2高流量湿化氧疗系统(新西兰费雪派克医疗保健公司)，起始参数：氧流量设定为 60 L/min，氧浓度设定为 90%，湿度为100%，吸入温度为 37，根据脉搏血氧饱和度(pulse oxygen saturation，SpO2)进行参数的调整，维持SpO293%。至少使用2 d，当患者基础疾病好转后，逐步下调HFNC参数，当流量低于40 L/min，且氧浓度低于40%时，更换为鼻导管吸氧(3 L/min)，若病情加重、达到插管指征则行气管插管。NIV 组：仪器采用飞利浦无创呼吸机(V60 型；美国飞利浦伟康公司)，采用S/T模式，起始氧浓度设定为 30%100%，呼吸频率(respiratory rate，RR)为 1520 次/min，吸气压、呼气压分别为 1018、48 cmH2O(1 cmH2O=0.098 kPa)，维持 SpO293%。至少使用 2 d，当患者基础疾病好转后，逐步下调呼吸机参数，当吸气压为 8 cmH2O，呼气压为4 cmH2O，则更换为鼻导管吸氧(3 L/min)，若病情加重、达到插管指征8则行气管插管。1.3 观察指标1)呼吸与循环参数。记录2组治疗前和治疗48 h后的 RR、SpO2、动脉二氧化碳分压(arterial partial pressure of carbon dioxide，PaCO2)和PaO2/FiO2。2)凝血功能。记录2组治疗前和治疗48 h后D-二聚体、纤维蛋白原(fibrinogen，Fib)水平，其中D-二聚体的检测方法为胶乳增强免疫透射比浊法，Fib的检测方法为凝固法。3)舒适度与耐受性。治疗48 h后，参照Triuvnopati等9方法对患者氧疗舒适度、耐受性进行评估，均采用15分评分法，得分越高说明患者舒适度、耐受性越差。4)并发症。记录2组并发症发生情况，包括胃胀气、口干等。5)预后情况。记录2组气管插管率、48 h肺部感染和28 d全因病死率。1.4 统计学处理采用SPSS 26.0统计学软件分析数据。计量资料(PaO2、PaO2/FiO2等均满足正态分布)用均数标准差(xs)表示，2组之间差异分析用成组t检验，同组前后差异分析用配对t检验；计数资料用例(%)表示，2组之间差异分析用2检验或Fisher确切概率法。P0.05，表1)。2.2 呼吸与循环参数治疗前，2组RR、PaO2、PaCO2和PaO2/FiO2水平均相当(均P0.05)；治疗48 h后，2组RR相比治疗前均降低(均P0.05)，PaO2、PaCO2和PaO2/FiO2水平相比治疗前均增高(均P0.05，表2)。表1 2组一般资料比较(n=45)Table 1 Comparison of general data between the 2 groups(n=45)组别HFNC组NIV组t/2P性别/例男25270.1820.670女2018年龄/岁61.3511.5460.7812.410.2260.822BMI/(kgm2)24.873.1225.242.860.5860.559ARF病因(肺炎/脓毒症/其他)/例28/9/826/12/70.5690.752基础疾病/例(%)高血压8(17.78)10(22.22)0.2780.598糖尿病6(13.33)7(15.56)0.0900.764高脂血症6(13.33)4(8.89)0.4500.502APACHE II评分14.783.2415.122.870.5270.600计量资料以均数标准差(xs)表示。BMI：体重指数；ARF：急性呼吸衰竭；APACHE II：急性生理与慢性健康评分II；HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。1358经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响 孙津津 2.3 凝血功能治疗前，2组D-二聚体、Fib水平均相当(均P0.05)；治疗48 h后，2组D-二聚体、Fib水平相比治疗前均降低(均P0.05，表3)。2.4 舒适度与耐受度相比NIV组，HFNC组舒适度评分、耐受性评分均显著降低(均P0.05，表4)。2.5 并发症相比NIV组，HFNC组并发症发生率显著降低(P0.05，表5)。2.6 预后情况HFNC 组 48 h 肺部感染率低于 NIV 组(P0.05，表6)。表2 2组治疗前后呼吸与循环参数比较(n=45，xs)Table 2 Comparison of respiratory and circulatory parameters before and after the treatment between the 2 groups(n=45,xs)组别HFNC组NIV组时间点治疗前治疗48 h后治疗前治疗48 h后RR/(次min1)28.352.0424.613.1228.172.1624.722.87PaO2/mmHg52.754.3692.3610.5852.873.9492.7810.61PaCO2/mmHg35.743.4239.123.2535.813.5638.762.96PaO2/FiO2/mmHg141.2926.58244.3913.67143.3425.12241.7812.651 mmHg=0.133 kPa。RR：呼吸频率；PaO2：脉搏血氧饱和度；PaCO2：动脉二氧化碳分压；PaO2/FiO2：氧合指数；HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。表3 2组凝血功能指标变化比较(n=45，xs)Table 3 Comparison of changes in coagulation function indexes between the 2 groups(n=45,xs)组别HFNC组NIV组时间点治疗前治疗48 h后治疗前治疗48 h后D-二聚体/(mgL1)1.520.411.260.35*1.540.461.200.32*Fib/(gL1)4.430.363.930.28*4.380.423.910.33*与同组治疗前相比，*P0.05。Fib：纤维蛋白原；HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。表4 2组舒适度与耐受度评分比较(n=45，xs)Table 4 Comparison of comfort and tolerance scales between the 2 groups(n=45,xs)组别HFNC组NIV组tP舒适度/分1.560.372.640.5910.4030.001耐受性/分1.590.412.250.536.6070.001HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。1359临床与病理杂志,2023,43(7)http:/3 讨 论 ARF是临床急危重症之一，病情进展迅速，病死率较高。氧疗是ARF的基本治疗手段，能够促进肺复张，快速改善患者氧合状况10。选择适宜的呼吸支持手段是ARF治疗的关键问题之一，也是临床研究的热点。NIV是利用鼻罩、面罩等连接患者，通过对通气压力进行调节，促使萎缩肺泡的复张，使肺有效容积提高，改善通气功能，纠正低氧血症11。HFNC是新型的氧疗手段，通过予以加温、加湿的高流量气体吸入，维持呼气末正压达到一定水平，利于肺复张，改善气体交换；高流量的空氧混合气体能够对咽部死腔予以持续冲刷，能够促进肺部纤毛运输系统功能恢复，改善氧合功能12。方国强等13研究表明，HFNC对慢性阻塞性肺疾病所致呼吸衰竭患者的氧合状况的改善效果与NIV相当。卢健聪等14研究显示，HFNC具有与NIV相似的氧疗效果。本研究中，治疗48 h后，2组RR相比治疗前降低，PaO2、PaCO2和PaO2/FiO2水平相比治疗前增高，2组对比差异无统计学意义，这与先前的报道13-14类似，提示HFNC治疗ARF具有相同的氧合改善效果，该结论也从2组具有相当的气管插管率和28 d病死率的预后结果得到进一步证实。研究15表明，呼吸衰竭患者伴随血液高凝状态，原因在于缺氧状态可引起肾代谢异常，对Fib的清除减少，同时低氧状态还能够对微血管造成直接损伤，使得凝血系统激活，引起纤溶亢进，从导致D-二聚体、Fib的表达增高。无创通气通过改善通气，纠正缺氧，能够减轻缺氧状态诱发血管内皮损伤，抑制凝血系统激活，促进肾脏对Fib等清除，缓解纤溶亢进，从而使得血清D-二聚体、Fib水平降低，有效改善高凝状态16。目前关于HFNC与NIV对患者凝血功能指标的影响对比尚缺乏报道。本研究结果显示：治疗48 h后，2组D-二聚体、Fib水平相比治疗前均降低，且2组差异无统计学意义，提示NIPPV能够改善ARF患者高凝状态，效果与NIV相当。尽管NIV对呼吸衰竭的救治效果肯定，但也存在胃胀气、口干、皮肤破损等诸多并发症问题17。而HFNC通过对吸入气体进行加温、加湿，能够提供接近人体生理的呼吸道气体，可减轻吸入气体对呼吸系统上皮细胞的损伤，从而减轻患者不适感受18。加温、加湿作用可减小高流量气体对鼻咽腔的刺激，使得鼻黏膜损伤减轻，利于气道通畅19。得到预加温、加湿的高流量气体还可减小呼吸做功，从而使得呼吸机疲劳得到缓解20。李雯莉等21研究显示：表6 2组预后情况比较(n=45)Table 6 Comparison of prognosis between the 2 groups(n=45)组别HFNC组NIV组2P气管插管/例(%)4(8.89)9(20.00)2.2480.13448 h肺部感染/例(%)2(4.44)8(17.78)4.0500.04428 d全因死亡/例(%)3(6.67)5(11.11)0.714*Fisher确切概率法。HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。表5 2组并发症比较(n=45)Table 5 Comparison of complications between the 2 groups(n=45)组别HFNC组NIV组2P胃胀气/例(%)1(2.22)4(8.89)口干/例(%)3(6.67)5(11.11)面部压伤/例(%)0(0.00)2(4.44)鼻/例(%)1(2.22)3(6.67)合计/例(%)5(11.11)14(31.11)5.4040.020HFNC：经鼻高流量湿化氧疗；NIV：无创机械通气。1360经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响 孙津津 HFNC能够有效改善低氧性呼吸衰竭症状，并且相比NIV 有更好的舒适度。本研究中，相比 NIV 组，HFNC组舒适度和耐受性评分以及并发症均显著降低，提示HFNC 治疗ARF 患者有着较好的耐受性，安全性更高。本研究还显示：HFNC组48 h内肺部感染发生率显著低于NIV组，究其原因可能在于高流量系统对吸入气体予以充分湿化、加温处理，能够缓解气道痉挛，有助于肺部纤毛的运动功能提高，使得黏膜纤毛清除功能得到改善，这利于气道分泌物的清除，促进痰液排出，从而降低肺部感染的风险22。综上，本研究发现：HFNC治疗ARF具有与NIV相当的氧疗效果，能够有效改善血液高凝状态，且可提高患者舒适度和耐受性，安全性更高。但本研究纳入例数较少，关于HFNC的疗效和安全性仍有待大样本量的研究进一步验证。利益冲突声明：作者声称无任何利益冲突。参考文献1王志翊,翁杰,侯若南,等.急性呼吸衰竭患者死亡风险列线图模型的构建J.中华急诊医学杂志,2020,29(11):1445-1449.https:/doi.org/10.3760/cma.j.issn.1671-0282.2020.11.011.WANG Zhiyi,WEN Jie,HOU Ruonan,et al.Development of a nomogram to predict the mortality risk in patients with acute respiratory failureJ.Chinese Journal of Emergency Medicine,2020,29(11):1445-1449.https:/doi.org/10.3760/cma.j.issn.1671-0282.2020.11.011.2李录,方保民.无创通气治疗急性呼吸衰竭失败的危险因素分析J.国际呼吸杂志,2021,41(1):69-73.https:/doi.org/10.3760/131368-20200422-00324.LI Lu,FANG Baomin.Analysis of risk factors for failure of non-invasive ventilation in the treatment of acute respiratory failureJ.International Journal of Respiration,2021,41(1):69-73.https:/doi.org/10.3760/131368-20200422-00324.3Cinesi Gmez C,Peuelas Rodrguez,Lujn Torn ML,et 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