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：

无创通气; 机械通气; 撤机; 应用

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建立人工气道实施机械通气是治疗严重呼吸衰竭过程中挽救患者生命最常用的措施之一，然而通过人工气道的机械通气也增加了相关并发症发生的机会，如呼吸机相关性肺炎（VAP）等[1]。多数患者在应用呼吸机进行通气支持治疗中，当呼吸衰竭及其病因的病情缓解或明显改善时就可以解除人工气道和终止通气支持，但20%~30%的患者需要逐渐解除呼吸机的通气支持，谓之撤机（Weaning）[1]。尽管文献中撤机的定义略有不同，但主要指的是需要逐步减弱及停止通气支持和解除人工气道的一个时间过程。有慢性呼吸功能不全的患者撤机尤为困难，撤机困难患者的撤机时间可占总机械通气时间的40%[2]。机械通气时间延长与VAP发生率和病死率增加相关。一般来说，机械通气时间 gt;3 d，VAP的发生率增加；机械通气时间 gt;5 d，并发的VAP为晚发性医院获得性肺炎（HAP），其感染的病原体多为耐多药细菌，治疗难度加大，病死率高于早发性HAP。因此，对于机械通气患者来说，一旦建立人工气道实施有创通气，就应该积极创造条件，尽快撤机，去除人工气道。然而过快地降低和停止通气支持以及过早的气管拔管，可导致撤机失败和再插管。因此时机不成熟的撤机和延时撤机同样可造成机械通气时间过长，导致VAP发生率和病死率升高，以及医疗费用增加[2]。撤机的模式和方法有多种，但最佳的撤机方式仍有争议[1]。近年来无创通气（NIV）作为一种撤机方式用于临床已引起人们的兴趣和关注，但至今临床研究所得结论并未达到一致，NIV是否可以作为一种常规撤机方式用于临床尚无定论。本文通过总结近年来相关的临床研究，评价NIV用于机械通气撤机的可行性和利弊，探讨需进一步优化研究方案来解决的有关问题。

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，商鸣宇，黄克武，等.有创与无创序贯性机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的研究.中华结核和呼吸杂志，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，商鸣宇，黄克武，等.有创与无创序贯性机械通气治疗慢性阻塞性肺疾病所致严重呼吸衰竭的研究.中华结核和呼吸杂志，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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