2018/10/22,1,正确认识无创正压通气在呼吸衰竭治疗中的地位,解放军总医院呼吸病中心 解立新 xielx301hospital.com.cn,http:/www.301hospitalrespirology.com.cn,2018/10/22,2,Preface,Never the tube! Try the mask!,Crit Care Med. 2007;35(3):977-978.,Noninvasive positive pressureventilation (NPPV) has become a standard therapy for the treatment of acute respiratory failure (ARF) in select populations and is increasingly being used in the critical care and acute care setting,2018/10/22,3,解立新. 中国医刊.2006;41:16-19,2018/10/22,4,解立新. 中国医刊.2006;41:16-19,正压机械通气的目的,正压机械通气能够解决肺的通气和部分换气功能 能够有效改善和维持最适氧合和促进二氧化碳排出，维持生命支持的氧的需要，为疾病的恢复赢得时机 在进行正压机械通气的同时，应采取有效的措施尽量减小机械通气相关副作用,5,Preface,6,对无创通气应用的把握,在与非机械通气治疗的对比中动态把握应用指征 在与有创通气的对比中动态把握应用指征 关键词： 对比 动态 孰更有效/好用？ 代价、副作用更小？,无创通气,有创通气,非机械通气,2018/10/22,7,Preface,Respir Care 2007;52(5):568 578.,Failure risk charts for NPPV,2018/10/22,8,Interface of NIV,J Aerosol Med. 2007;20(1):S85S99.,2018/10/22,9,Interface of NIV,J Aerosol Med. 2007;20(1):S85S99.,2018/10/22,10,理论上讲, 具有完善监测与报警功能的大型多功能呼吸机(critical care ventilator) 以及专用无创呼吸机均可用于NPPV 对于应用密闭性能较好的全面罩和头罩可尝试应用传统的有创多功能呼吸机进行NPPV 而应用密闭性能较差的鼻罩和口鼻面罩简易应用漏气补偿效果较好的专用无创呼吸机进行NPPV治疗,Ventilator selection,2018/10/22,11,临床应用,2018/10/22,12,急性低氧性呼吸衰竭,2018/10/22,13,ALI/ARDS,ARDS是临床最为常见的重症呼吸衰竭疾患，病情发展快，病死率较高，也是临床研究的热点和难点问题 由于ARDS是以顽固性进行性低氧血症为主要表现，机械通气治疗通过促进肺泡复张和维持肺泡和周围毛细血管的氧降梯度从而改善氧合为针对疾病的病因治疗争取宝贵的时间,2018/10/22,14,ALI/ARDS (cont),Noninvasive ventilation for acute respiratory distress syndrome: Breaking down the final frontier?,Crit Care Med. 2007; 35(1):288 289,NIPPV should be tried very cautiously or not at all in patients with ALI who have shock, metabolic acidosis or profound hypoxemia.,Critical Care 2006, 10:R79,2018/10/22,15,ALI/ARDS (cont),Crit Care Med. 2007; 35(1):18 25,A multiple-center survey on the use in clinical practice of NPPV as a first-line intervention for ARDS,NPPV:79 Intubation：68,2018/10/22,16,ALI/ARDS (cont),Crit Care Med. 2007; 35(1):18 25,A multiple-center survey on the use in clinical practice of NPPV as a first-line intervention for ARDS,2018/10/22,17,ALI/ARDS (cont),Crit Care Med.2007; 35(1):18 25,In expert centers, NPPV applied as first-line intervention in ARDS avoided intubation in 54% of treated patients. In patients with SAPS 34, those with a PaO2/FIO2 175 after 1 hr of NPPV will likely benefit from continuation of NPPV,2018/10/22,18,ALI/ARDS (cont),Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study,Critical Care 2006, 10:R79,2018/10/22,19,ALI/ARDS (cont),Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study,Critical Care 2006, 10:R79,在对没有合并休克的的ALI患者就氧合指数、代谢性酸碱指数和APACHEIII进行多元逐步回归分析，其中代谢性酸中毒（OR:1.27）和严重低氧血症（OR:1.03）是预测NPPV失败的主要决定因素 NIPPV治疗失败的患者其病死率远高于APACHEIII预测的病死率（68% vs. 39%，p 16 years, Pulmonary edema shown by Chest radiograph, RR20 breaths/min, pH92%,2018/10/22,28,Preface,N Engl J Med. 2008;359:142-51.,Conclusions: In patients with ACPE, NIV induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy , but has no effect on short-term mortality.,NIV refers to all modalities that assist ventilation without the use of an endotracheal tube but rather with a sealed face-mask. NIV with positive end-expiratory pressure (PEEP) should be considered as early as possible in every patient with acute cardiogenic pulmonary oedema and hypertensive AHF as it improves clinical parameters including respiratory distress NIV with PEEP improves LV function by reducing LV afterload NIV should be used with caution in cardiogenic shock and right ventricular failure,