Objective To analyze the risk factors of treatment failure by noninvasive positive pressure ventilation (NPPV) in patients with acute respiratory failure (ARF) due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and explore the best time that NPPV be replaced by invasive ventilation when NPPV failure occurs. Methods The data of patients with ARF due to AECOPD who were treated with NPPV from January 2013 to December 2015 were retrospectively collected. The patients were divided into two groups: the NPPV success group and the NPPV failure group (individuals who required endotracheal intubation or tracheotomy at any time). The Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ score was analyzed; the Glasgow Coma Scale score, respiratory rate (RR), pH value, partial pressure of oxygen (PaO2), PaO2/fraction of inspired oxygen (FiO2) ratio, and partial pressure of carbon dioxide were also analyzed at admission, after 2 hours of NPPV, and after 24 hours of NPPV. Results A total of 185 patients with ARF due to AECOPD were included. NPPV failed in 35.1% of the patients (65/185). Multivariate analysis identified the following factors to be independently associated with NPPV failure: APACHEⅡscore≥30 [odds ratio (OR)=20.603, 95% confidence interval (CI) (5.309, 80.525), P<0.001], RR at admission≥35 per minute [OR=3.723, 95%CI (1.197, 11.037), P=0.020], pH value after 2 hours of NPPV<7.25 [OR=2.517, 95%CI (0.905, 7.028), P=0.070], PaO2 after 2 hours of NPPV<60 mm Hg (1 mm Hg=0.133 kPa) [OR=3.915, 95%CI (1.374, 11.508), P=0.010], and PaO2/FiO2 after 2 hours of NPPV<200 mm Hg [OR=4.024, 95%CI (1.542, 11.004), P=0.010]. Conclusion When patients with ARF due to AECOPD have a higher severity score, have a rapid RR at admission, or fail to improve in terms of pH and oxygenation after 2 hours of NPPV, the risk of NPPV failure is higher.
Objective To evaluate the rescue intubation induced by ketamine and midazolam in patients with acute respiratory failure.Methods 81 patients with acute respiratory failure admitted between June 2010 and June 2012 were recruited in the study. They were randomly divided to a MF group to receive 0. 05 mg/kg of midazolam + 1 to 2 μg/kg of fentanyl ( n =41) , and aMK group to received 0. 05 mg/kg of midazolam + 0. 5 to 1 mg/kg of ketamine ( n =40) for rescue intubation. The APACHEⅡ score on initial24 hours after admission in ICU, length of ICU stay, and 28-day mortality were recorded. The differences in arterial blood pressure, heart rate, respiration rate, and blood oxygen saturation before intubation and 10 minutes after intubation were compared. Incidences of hypotension and other adverse events and difficult intubation were also recorded.Results The midazolamdose in the MK group was significantly less than that in the MF group ( P lt; 0. 01) . The blood pressure in both groups decreased. The systolic blood pressure dropped most significantly in the MF group ( P lt;0. 05) . The incidence of hypotension was 41. 5% in the MF group, significantly higher than that in the MK group ( 20. 0% , P lt;0. 05) . The incidence of hypotension had no correlation with midazolamdosage ( P gt;0. 05) . There was no significant difference in adverse events except for the arrhythmia between two groups. The length of ICU stay and 28-day mortality were similar in both groups ( P gt; 0. 05) . The incidence of difficult tracheal intubation was nearly 50% in both groups.Conclusions In patients with respiratory failure, rescue intubation induced by ketamine can reduce the dose of midazolam and reduce the incidence of hypotension without more complications. The optimal dose of ketamine in induced tracheal intubation requires further study.
Acute poisoning is characterized by a sudden and rapid onset, most poisons lack specific antidotes. Even with the full use of blood purification, mechanical ventilation, and various drugs, it is often difficult to change the fatal outcome of critically ill patients. In recent years, extracorporeal membrane oxygenation (ECMO) has gradually gained attention and exploratory application in the treatment of acute poisoning due to its significant cardiopulmonary function support, veno-venous ECMO is used for severe lung injury after poisoning, acute respiratory distress syndrome and respiratory failure due to ineffective mechanical ventilation, and it can also be used to assist the removal of residual poisons in the lungs. Veno-arterial ECMO is commonly employed in patients with circulatory failure following poisoning, fatal cardiac arrhythmias, and arrest of cardiac and respiratory. The application of veno-arterio-venous ECMO has also been reported. The mode of ECMO necessitates timely adjustments according to the evolving illness, while ongoing exploration of additional clinical indications is underway. This review analyzes and evaluates the application scope and effectiveness of ECMO in acute poisoning in recent years, with a view to better exploring and rationalizing the use of this technology.
Objective To investigate the physiological effects of different oxygen injection site on ventilatory status and oxygenation during noninvasive positive pressure ventilation ( NPPV) with portable noninvasive ventilators. Methods A prospective crossover randomized study was performed. Oxygen injection site was randomized into the outlet of the ventilator, the connection site between mask and circuit, and the mask under the condition of leak port immobilized in the mask. Oxygen flow was retained in the baseline level at the initial 5 to 10 minutes, and adjusted to obtain arterial oxygen saturation measured by pulse oximetry ( SpO2 ) ranging from 90% to 95% after SpO2 remains stable. SpO2 at the initial 5 to 10 minutes, oxygen flow, ventilatory status, oxygenation, hemodynamics and dyspnea indexes at0. 5 hour, 1 hour, and 2 hours of NPPV were compared between different oxygen injection sites. Results 10 patients were recruited into the study. Under the condition of the same oxygen flow, SpO2 with oxygen injection site in the outlet of the ventilator was significantly higher than that with oxygen injection site in the connection site between mask and circuit [ ( 98.9 ±0.9) % vs. ( 96.9 ±1.1) % , P =0. 003] , whereas SpO2 with oxygen injection site in the connection site between mask and circuit was significantly higher than that with oxygen injection site in the mask [ ( 96.9 ±1.1) % vs. ( 94.1 ±1.6) %, P = 0.000] . Oxygen flow with oxygen injection site in the mask was statistically higher than that with oxygen injection site at other sites ( P lt; 0.05) . Arterial oxygen tension/ oxygen flow with oxygen injection site in the outlet of the ventilator was significantly higher than that with oxygen injection site in the connection site between mask and circuit ( 67.9 ±31.1 vs. 37.0 ±15.0, P =0.007) , and than that with oxygen injection site in the mask ( 67.9 ± 31.1 vs. 25.0 ±9.1, P = 0.000) . pH, arterial carbon dioxide tension, hemodynamics and dyspnea indexes were not significantly different between different oxygen injection sites ( P gt; 0.05) .Conclusions When portable noninvasive ventilator was applied during NPPV, oxygen injection site significantly affects improvement of oxygenation, and shows a trend for affecting ventilatory status and work of breathing. When the leak port was immobilized in the mask, the nearer oxygen injection site approaches the outlet of the ventilator, the more easily oxygenation is improved and the lower oxygen flow is demanded.
摘要:目的：探讨纤支镜经口引导气管插管在慢阻肺合并重度呼吸衰竭救治中的临床应用价值。方法：237例慢阻肺合并重度呼吸衰竭患者,随机分为纤支镜经口引导气管插管组(纤支镜组)125例和喉镜经口引导气管插管组(喉镜组)112例,分别在纤支镜和喉镜引导下按常规进行气管插管术。结果：纤支镜组和喉镜组一次获得插管成功率分别为984%和920%(P＜005),平均插管时间分别为（613±391） min 和（926±415） min(P＜005)。纤支镜组有5例患者出现咽喉部少量出血,并发症发生率为40%;喉镜组共有12例发生并发症,并发症发生率为107%(P＜005),其中齿、舌、咽或喉部损伤6例,反射性呕吐致误吸2例,单侧肺通气1例,插入食管2例,心跳呼吸骤停1例。结论：纤支镜经口引导气管插管在慢阻肺合并重度呼吸衰竭救治中是一种简便快速、成功率高和并发症少的有效方法,值得临床推广应用。Abstract: Objective: To evaluate the efficacy of endotracheal intubation under fiberoptic bronchoscope through mouth in severe respiratory failure. Methods:Two hundreds and thirtyseven cases of severe respiratory failure were divided into two groups at random (fiberoptic bronchoscope group and laryngoscope group), 125 cases were intubated through mouth under fiberoptic bronchoscope, the others were intubated through mouth by laryngoscope. Results: The successful rates of endotracheal intubation were 98.4% and 92.0% in two groups respectively (P ＜005), the mean intubation timewere (613±391) min and (926±415) min respectively ( P ＜ 005), 4 cases in fiberoptic bronchoscope group appeared a little blood in throat, the complication rate was 32% 12 cases in the laryngoscope group had complications, the complication rate was 107%( P＜ 005). Among it, 6 cases had the injury of tooth, tongue, gullet and larynx.The cases of reflexvomiting were 2,pulmonary ventilation by single lung were 1, intubation in esophagus were 2, cardiopulmonary arrest were 1.Conclusions:Endotracheal intubation under fiberoptic bronchoscope through mouth was accurate, the fewer complications and effective for patients, and could be used widely in clinical applications.
Objective To explore the predictive value of serum procalcitonin (PCT), D-dimer (D-D) and decoy receptor 3 (DcR3) for prognosis of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and respiratory failure undergoing non-invasive ventilation (NIV). Methods A total of 95 patients with AECOPD and respiratory failure undergoing basic treatment and NIV in the hospital were retrospectively enrolled between September (n=65) 2017 and February 2021. According to prognosis after treatment, they were divided into a good prognosis group and a poor prognosis group (n=30). The general data of all patients were collected. The influencing factors of prognosis were analyzed by multivariate logistic regression model. The levels of DcR3, PCT and D-D were detected by enzyme-linked immunosorbent assay, colloidal gold colorimetry and immunoturbidimetry. The patients condition was assessed by scores of acute physiology chronic health evaluation scoring system Ⅱ (APACHEⅡ). The partial pressure of arterial oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2) were recorded. And the above indexes between the two groups were compared. The relationship between DcR3, PCT, D-D and APACHEⅡ score, PaO2, PaCO2 was analyzed by Pearson correlation analysis. The prognostic value of DcR3, PCT and D-D was analyzed by receiver operating characteristic (ROC) curve. Results There was no significant difference in gender, GOLD grading or underlying diseases between the poor prognosis group and the good prognosis group (P>0.05), but there were significant differences in age, DcR3, PCT, D-D, APACHEⅡ score, PaO2 and PaCO2 after treatment (P<0.05). DcR3, PCT, D-D, APACHEⅡ score and PaCO2 in the poor prognosis group were higher than those in the good prognosis group, while PaO2 was lower than that in the good prognosis group (P<0.05). Logistic regression analysis showed that DcR3 ≥5.50 ng/mL (OR=21.889), PCT ≥ 5.00 μg/L (OR=3.782), D-D ≥3.00 μg/L (OR=4.162) and APACHEⅡ score ≥20 points (OR=2.540) were all influencing factors of prognosis (P<0.05). The results of Pearson correlation analysis showed that DcR3, PCT and D-D were positively correlated with APACHEⅡ score and PaCO2, while negatively correlated with PaO2 (P<0.05). The results of ROC curve analysis showed that area under ROC curve of DcR3, PCT and D-D for predicting the prognosis were 0.745 (95%CI 0.631 - 0.859), 0.691 (95%CI 0.579 - 0.803) and 0.796 (95%CI 0.696 - 0.895), respectively (P<0.05). Conclusion The serum DcR3, PCT and D-D levels are related to disease progression in patients with AECOPD and respiratory failure after NIV, which have good predictive efficiency for prognosis and can be applied as important biological indexes to evaluate prognosis and guide treatment.
During the new coronavirus disease 2019 (COVID-19) pandemic, there has been controversy over whether emergency surgical management should be performed or not in the patients with COVID-19. Stanford type A aortic dissection is a very urgent life-threatening disease, and guidelines recommend surgical treatment for patients with type A aortic dissection in the first instance. However, intraoperative extracorporeal circulation can be fatal to patients recovering from COVID-19. During the pandemic, extracorporeal membrane oxygenation (ECMO) has played an important role in supporting COVID-19 patients with acute respiratory failure. This article reports a successful V-V ECMO treatment for a Stanford type A aortic dissection patient, who suffered respiratory failure caused by COVID-19 after emergency surgery.
Objective To investigate the efficacy and prognostic risk factors of high flow nasal cannula (HFNC) in elderly patients with respiratory failure. Methods Clinical data of 172 elderly patients with respiratory failure admitted to 363 Hospital from April 2020 to August 2022 were retrospectively collected. The patients were divided into an observation group (n=86) and a control group (n=86) according to treatment method. The observation group (54 males, 32 females), mean 68.67±2.36 years old, received HFNC oxygen therapy. The control group (52 males, 34 females), mean 68.12±2.14 years old, received conventional oxygen therapy. According to the prognosis after HFNC treatment, the observation group was subdivided into a poor prognosis group (n=21) and a good prognosis group (n=65). The clinical effects of different treatment methods in the two groups were analyzed, and the risk factors affecting prognosis of elderly patients with respiratory failure treated by HFNC were analyzed by multivariate logistic regression. A line graph model was constructed, and the model was verified by receiver operator characteristic curve and cumulative gain graph. Results Repeated measures ANOVA was conducted on the oxygen therapy indicators of the two groups of patients. The results showed that pH, PaO2, PaCO2, and respiratory rate all have statistical significance in terms of time effect (F=423.25, P<0.001; F=326.25, P<0.001; F=128.79, P<0.001; F=323.16, P<0.001), inter-group effect (F=128.79, P<0.001; F=205.46, P<0.001; F=310.52, P<0.001; F=123.15, P<0.001), and interactive effect (F=111.06, P<0.001; F=198.76, P<0.001; F=134.28, P<0.001; F=112.47, P<0.001). This indicated that the impact of time on pH, PaO2, PaCO2, and respiratory rate differs depending on the treatment method. The scores of acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), the level of brain natriuretic peptide (BNP), the heart rate before treatment, the posterior root of tongue fall, the initial HFNC flow and the duration of HFNC in the poor prognosis group were significantly higher than those in the good prognosis group. Initial PaO2/FiO2 was significantly lower than that in the good prognosis group (P<0.05). Multiple factor analysis showed that APACHEⅡ score>17 points, BNP level>150 ng/L before treatment, heart rate >105 times/min before treatment, posterior root of tongue drop, initial HFNC flow>55 L/min, initial PaO2/FiO2<150 mmHg were independent influencing factors for poor prognosis of elderly patients with respiratory failure treated by HFNC. The histogram model showed that the total score of the above 6 indicators is 284, corresponding to a probability of poor prognosis of 71.6%, which proved that the prediction ability of this model is good. Conclusions The application of HFNC in elderly patients with respiratory failure has a significant effect. APACHEⅡ score, BNP level before treatment, heart rate before treatment, posterior root of tongue fall, initial HFNC flow, initial PaO2/FiO2 are all risk factors affecting the prognosis, which should be paid attention to in clinic to improve the therapeutic effect.
ObjectiveTo explore the value of three brief scales (BAP-65 class, DECAF score, and CAPS) on assessing the severity of acute exacerbation in patients with chronic obstructive pulmonary disease(COPD) complicated by hypercapnic respiratory failure. MethodsTwo hundred and forty-four cases with acute exacerbation of COPD complicated by hypercapnic respiratory failure, admitted in West China Hospital from August 2012 to December 2013, were analyzed retrospectively.The scores of each scale were calculated.The areas under the receiver operating characteristic curves (AUROC) of each scale for hospital mortality, mechanical ventilation use, mortality of patients requiring mechanical ventilation, invasive mechanical use were analyzed and compared. ResultsThe AUROCs of BAP-65 class, DECAF score and CAPS for hospital mortality were 0.731, 0.765, and 0.711; for mechanical ventilation were 0.638, 0.702, and 0.617; for mortality of patients requiring mechanical ventilation were 0.672, 0.707, and 0.677; for invasive mechanical ventilation use were 0.745, 0.732, and 0.627(BAP-65 vs.CAPS, P < 0.05).Mortality and mechanical ventilation use increased as the three scales escalated.In the patients whose BAP-65 or DECAF score were more than 4 points, the hospital mortality was nearly 50%, and about 95% of the patients underwent mechanical ventilation. ConclusionsThe BAP-65 class, DECAF score, and CAPS of patients on admission have predictive values on assessing the severity of acute exacerbation in patients with COPD complicated by hypercapnic respiratory failure, especially the simple and practical BAP-65 class and DECAF score.
Objective To systematically review the efficacy of noninvasive positive pressure ventilation (NPPV) by helmet in adults with acute respiratory failure. Methods Randomized controlled trials (RCTs) or cohort studies about noninvasive positive pressure ventilation (NPPV) by helmet in adults with acute respiratory failure were retrieved in PubMed, The Cochrane Library (Issue 11, 2016), Web of Science, EMbase, CBM, CNKI and WanFang Data databases from inception to November 2016. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Stata 12.0 software was then used to perform meta-analysis. Results A total of eight studies were included. The results of meta-analysis showed that, NPPV by helmet could significantly reduce the carbon dioxide partial pressure (cohort study: SMD=–0.46, 95%CI –0.75 to –0.18, P=0.001), tracheal intubation rate (RCT: OR=0.36, 95%CI 0.17 to 0.77, P=0.008) and hospital mortality (RCT: OR=0.48, 95%CI 0.24 to 0.98, P=0.044), improve the positive end expiratory pressure (RCT: SMD=1.27, 95%CI 0.87 to 1.67, P<0.05) and respiratory status (RCT: SMD=–0.45, 95%CI –0.81 to –0.08,P=0.017). There was no significant difference in the duration of NPPV(cohort study: OR=–0.20, 95%CI –0.50 to 0.09, P=0.177; RCT: OR=–0.24, 95%CI –0.86 to 0.38, P=0.445). Conclusion NPPV by helmet can reduce the carbon dioxide partial pressure, tracheal intubation rate, hospital mortality and improve the positive end expiratory pressure, respiratory status. But the effects in the duration of NPPV and oxygenation index are uncertain. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify above conclusion.