Controversy and application of noninvasive ventilation as a weaning technique_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

LI Jian

Department of Respiratory Medicine ，Affiliated hospital of Jiangsu University。Zhengjiang，jiangsu，212001，China;

Corresponding?author：

Keywords：

無創通氣; 機械通氣; 撤機; 應用

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建立人工氣道實施機械通氣是治療嚴重呼吸衰竭過程中挽救患者生命最常用的措施之一，然而通過人工氣道的機械通氣也增加了相關并發癥發生的機會，如呼吸機相關性肺炎（VAP）等[1]。多數患者在應用呼吸機進行通氣支持治療中，當呼吸衰竭及其病因的病情緩解或明顯改善時就可以解除人工氣道和終止通氣支持，但20%~30%的患者需要逐漸解除呼吸機的通氣支持，謂之撤機（Weaning）[1]。盡管文獻中撤機的定義略有不同，但主要指的是需要逐步減弱及停止通氣支持和解除人工氣道的一個時間過程。有慢性呼吸功能不全的患者撤機尤為困難，撤機困難患者的撤機時間可占總機械通氣時間的40%[2]。機械通氣時間延長與VAP發生率和病死率增加相關。一般來說，機械通氣時間 gt;3 d，VAP的發生率增加；機械通氣時間 gt;5 d，并發的VAP為晚發性醫院獲得性肺炎（HAP），其感染的病原體多為耐多藥細菌，治療難度加大，病死率高于早發性HAP。因此，對于機械通氣患者來說，一旦建立人工氣道實施有創通氣，就應該積極創造條件，盡快撤機，去除人工氣道。然而過快地降低和停止通氣支持以及過早的氣管拔管，可導致撤機失敗和再插管。因此時機不成熟的撤機和延時撤機同樣可造成機械通氣時間過長，導致VAP發生率和病死率升高，以及醫療費用增加[2]。撤機的模式和方法有多種，但最佳的撤機方式仍有爭議[1]。近年來無創通氣（NIV）作為一種撤機方式用于臨床已引起人們的興趣和關注，但至今臨床研究所得結論并未達到一致，NIV是否可以作為一種常規撤機方式用于臨床尚無定論。本文通過總結近年來相關的臨床研究，評價NIV用于機械通氣撤機的可行性和利弊，探討需進一步優化研究方案來解決的有關問題。

Citation： LI Jian. Controversy and application of noninvasive ventilation as a weaning technique. Chinese Journal of Respiratory and Critical Care Medicine, 2008, 08(3): 233-236. doi: Copy

1.	Ferrer M，Bernadich O，Nava S，et al.Noninvasive ventilation after intubation and mechanical ventilation.Eur Respir J，2002，19：959-965.
2.	Meade M，Guyatt G，Griffith L，et al.Introduction to a series of systematic reviews of weaning from mechanical ventilation.Chest，2001，120：396s-399s.
3.	Liesching T，Kwok H，Hill NS.Acute applications of noninvasive positive pressure ventilation.Chest，2003，124：699-713.
4.	Mehta S，Hill NS.Noninvasive ventilation.Am J Respir Crit Care Med，2001，163：540-577.
5.	Udwadia ZF，Santis GK，Steven MH，et al.Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency.Thorax，1992，47：715-718.
6.	Restrick LJ，Scott AD，Ward EM，et al.Nasal intermittent positive-pressure ventilation in weaning intubated patients with chronic respiratory disease from assisted intermittent，positive-pressure ventilation.Respir Med，1993，87：199-204.
7.	Gregoretti C，Beltrame F，Lucangelo U，et al.Physiologic evaluation of non-invasive pressure support ventilation in trauma patients with acute respiratory failure.Intensive Care Med，1998，24：785-790.
8.	Kilger E，Briegel J，Haller M，et al.Effects of noninvasive positive pressure ventilatory support in non-COPD patients with acute respiratory insufficiency after early extubation.Intensive Care Med，1999，25：1374-1380.
9.	Vitacca M，Ambrosino N，Clin E，et al.Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autononmous breathing.Am J Respir Crit Care Med，2001，164：638-641.
10.	Solh AAE，Aquilina A，Pineda L，et al.Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients.Eur Respir J，2006，28：588-595.
11.	Windisch W，Storre JH，Matthys H，et al.Weaning from mechanical ventilatian by long-term nasal positivre pressure ventilation in two patients with acute respiratory distress syndrome associated with pneumococcal sepsis.Respiration，2002，69：464-467.
12.	Goodenberger DM，Couser JI，May JJ，et al.Successful discontinuation of ventilation via tracheostomy be substitution of nasal positive pressure ventilation.Chest，1992，102：1277-1279.
13.	Nava S，Ambrosino N，Chini E，et al.Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease：a randomized controlled trial.Ann Intern Med，1998，128：721-728.
14.	Girault C，Daudethun I，Chevron V，et al.Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure：a prospective，randomized controlled study.Am J Respir Crit Care Med，1999，120：86-92.
15.	Ferrer M，Esquinas A，Arancibia F，et al.Noninvasive ventilation during persistent weaning failure：a randomized controlled trial.Am J Respir Crit Care Med，2003，168：70-76.
16.	王辰，商鳴宇，黃克武，等.有創與無創序貫性機械通氣治療慢性阻塞性肺疾病所致嚴重呼吸衰竭的研究.中華結核和呼吸雜志，2000，23：212-216.
17.	Jiang JS，Kao SJ，Wang SN.Effect of early application of biphasic positive airway pressure on the outcome of extubation in ventilator weaning.Respirology，1999，4：161-165.
18.	Keenan SP，Powers C，Mccormack DG，et al.Noninvasive positive-pressure ventilation for postextubation respiratory distress：a randomized controlled trial.JAMA，2002，287：3238-3244.
19.	Esteban A，Frutos-Vivar F，Ferguson ND，et al.Noninvasive positive-pressure ventilation for respiratory failure after extubafion.N Engl J Med，2004，350：2452-2460.
20.	Truwit JD，Bernard GR.Noninvasive ventilation-don’t push too hard.N Engl J Med，2004，350：2512-2515.
21.	Hilbert G，Gruson D，Portel L，et al.Noninvasive pressure support ventilation in COPD patients with psotextubation hypercapnic respiratory insufficiency.Eur Respir J，1998，11：1349-1353.
22.	Burns KEA，Adhikari NKJ，Meade MO.A meta-analysis of noninvasive weaning to facilitate liberation from mechanical ventilation.Can J Anaesth，2006，53：305-315.
23.	Jacka MJ.Ventilatory weaning for Goldilocks.Can J Anaesth，2006，53：222-225.
24.	Navalesi P.Weaning and noninvasive ventilation：the odd couple.Am J Respir Crit Care Med，2003，168：5-6.
25.	Ferrer M，Valencia M，Nicolas JM，et al.Early noninvasive ventilation averts extubation failure in patients at risk：a randomized trial.Am J Respir Crit Care Med，2006，173：164-170.
26.	Nava S，Gregoretti C，Fanfulla F，et al.Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patient.Crit Care Med，2005，33：2465-2470.

1. Ferrer M，Bernadich O，Nava S，et al.Noninvasive ventilation after intubation and mechanical ventilation.Eur Respir J，2002，19：959-965.
2. Meade M，Guyatt G，Griffith L，et al.Introduction to a series of systematic reviews of weaning from mechanical ventilation.Chest，2001，120：396s-399s.
3. Liesching T，Kwok H，Hill NS.Acute applications of noninvasive positive pressure ventilation.Chest，2003，124：699-713.
4. Mehta S，Hill NS.Noninvasive ventilation.Am J Respir Crit Care Med，2001，163：540-577.
5. Udwadia ZF，Santis GK，Steven MH，et al.Nasal ventilation to facilitate weaning in patients with chronic respiratory insufficiency.Thorax，1992，47：715-718.
6. Restrick LJ，Scott AD，Ward EM，et al.Nasal intermittent positive-pressure ventilation in weaning intubated patients with chronic respiratory disease from assisted intermittent，positive-pressure ventilation.Respir Med，1993，87：199-204.
7. Gregoretti C，Beltrame F，Lucangelo U，et al.Physiologic evaluation of non-invasive pressure support ventilation in trauma patients with acute respiratory failure.Intensive Care Med，1998，24：785-790.
8. Kilger E，Briegel J，Haller M，et al.Effects of noninvasive positive pressure ventilatory support in non-COPD patients with acute respiratory insufficiency after early extubation.Intensive Care Med，1999，25：1374-1380.
9. Vitacca M，Ambrosino N，Clin E，et al.Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autononmous breathing.Am J Respir Crit Care Med，2001，164：638-641.
10. Solh AAE，Aquilina A，Pineda L，et al.Noninvasive ventilation for prevention of post-extubation respiratory failure in obese patients.Eur Respir J，2006，28：588-595.
11. Windisch W，Storre JH，Matthys H，et al.Weaning from mechanical ventilatian by long-term nasal positivre pressure ventilation in two patients with acute respiratory distress syndrome associated with pneumococcal sepsis.Respiration，2002，69：464-467.
12. Goodenberger DM，Couser JI，May JJ，et al.Successful discontinuation of ventilation via tracheostomy be substitution of nasal positive pressure ventilation.Chest，1992，102：1277-1279.
13. Nava S，Ambrosino N，Chini E，et al.Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease：a randomized controlled trial.Ann Intern Med，1998，128：721-728.
14. Girault C，Daudethun I，Chevron V，et al.Noninvasive ventilation as a systematic extubation and weaning technique in acute-on-chronic respiratory failure：a prospective，randomized controlled study.Am J Respir Crit Care Med，1999，120：86-92.
15. Ferrer M，Esquinas A，Arancibia F，et al.Noninvasive ventilation during persistent weaning failure：a randomized controlled trial.Am J Respir Crit Care Med，2003，168：70-76.
16. 王辰，商鳴宇，黃克武，等.有創與無創序貫性機械通氣治療慢性阻塞性肺疾病所致嚴重呼吸衰竭的研究.中華結核和呼吸雜志，2000，23：212-216.
17. Jiang JS，Kao SJ，Wang SN.Effect of early application of biphasic positive airway pressure on the outcome of extubation in ventilator weaning.Respirology，1999，4：161-165.
18. Keenan SP，Powers C，Mccormack DG，et al.Noninvasive positive-pressure ventilation for postextubation respiratory distress：a randomized controlled trial.JAMA，2002，287：3238-3244.
19. Esteban A，Frutos-Vivar F，Ferguson ND，et al.Noninvasive positive-pressure ventilation for respiratory failure after extubafion.N Engl J Med，2004，350：2452-2460.
20. Truwit JD，Bernard GR.Noninvasive ventilation-don’t push too hard.N Engl J Med，2004，350：2512-2515.
21. Hilbert G，Gruson D，Portel L，et al.Noninvasive pressure support ventilation in COPD patients with psotextubation hypercapnic respiratory insufficiency.Eur Respir J，1998，11：1349-1353.
22. Burns KEA，Adhikari NKJ，Meade MO.A meta-analysis of noninvasive weaning to facilitate liberation from mechanical ventilation.Can J Anaesth，2006，53：305-315.
23. Jacka MJ.Ventilatory weaning for Goldilocks.Can J Anaesth，2006，53：222-225.
24. Navalesi P.Weaning and noninvasive ventilation：the odd couple.Am J Respir Crit Care Med，2003，168：5-6.
25. Ferrer M，Valencia M，Nicolas JM，et al.Early noninvasive ventilation averts extubation failure in patients at risk：a randomized trial.Am J Respir Crit Care Med，2006，173：164-170.
26. Nava S，Gregoretti C，Fanfulla F，et al.Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patient.Crit Care Med，2005，33：2465-2470.

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