Myocardial dysfunction in sepsis: check a BNP!
Myocardial dysfunction in sepsis: check a BNP!
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脓毒症心肌功能障碍：检查 BNP！
DOI：
10.1097/pcc.0b013e3181849f5d
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发表时间：
2008
期刊：
影响因子：
--
通讯作者：
Aneja,Raj
中科院分区：
文献类型：
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作者：
Aneja,Raj
Betamax, is here to stay. However, noninvasive positive pressure ventilation (NIV) could offer adjunctive support for adults and children with respiratory failure, long ago replacing negative pressure “iron lungs” as technology advanced. However, NIV has become a significant tool for use in adults with a variety of disorders, as an alternative to immediate endotracheal tube intubation (1). NIV is generally delivered either by continuous positive airway pressure or by bilevel positive airway pressure (BiPAP), although most adult studies have focused on use of BiPAP. Early efforts centered on use of NIV in patients primarily with hypoventilation syndromes and chronic obstructive pulmonary disease, but interest and experience grew to include its use in hypoxemic respiratory insufficiency, a setting where it would seem to be less likely to be of benefit. A large body of randomized clinical trials and subsequent meta-analysis have demonstrated the benefits of NIV both in improving mortality in adults with chronic obstructive pulmonary disease (2) and in decreasing intubation need in acute hypoxemic respiratory failure (3, 4). NIV would seem to offer similar potential benefits for children (4). Augmentation of spontaneous effort would theoretically have significant impact on improving functional residual capacity and decreasing the heightened risk of infants for atelectasis. However, NIV could also have potential difficulties because of an infant’s more limited inspiratory reserve and because of the need for greater sedation to maintain NIV in children. As with many areas of critical care therapeutics, however, experience with NIV and clinical trials to test efficacy have lagged in children (5) compared with studies in adults. Several relatively large case series have provided encouraging support for use in children with both hypoxemic (6–8) and hypercarbic respiratory failure (8, 9). Although suggestive of decreased need for intubation with NIV, none of these series offered prospective comparison groups.In this issue of Pediatric Critical Care Medicine, Yanez et al.(10) report results from the first published pediatric randomized trial of NIV in pediatric respiratory insufficiency. The investigators enrolled 50 children with evidence of moderate to severe respiratory distress in two pediatric intensive care units in Chile. Patients were randomized in a centralized fashion between the units to either standard therapy or the addition of BiPAP delivered via a full face mask. Patient groups were well randomized with no significant differences in age, disease, or severity of hypoxemia between groups. Patients receiving NIV had significant improvements in physiologic variables of heart rate and respiratory rate coincident with NIV compared with control patients. Of greater importance, significantly fewer NIV patients (28%; relative risk of intubation 0.47) required intubation than did standard therapy patients (60%; p 0.0045). This success rate in avoidance of intubation of NIV patients is comparable with that seen in some of the other pediatric NIV case series [57%(11), 77%(8), and 89%(6)]. Although the results of this study are encouraging, several limitations must be noted. Patients entered into the study had diverse disease processes, including both hypoxemic and hypercarbic respiratory insufficiency. As previous adult studies have shown outcome differences that may vary by disease process, it is difficult to be certain that benefits occurred equally in study patients with pneumonia as for those with bronchiolitis. In contrast to other studies, all NIV patients used full face masks for BiPAP delivery. Although BiPAP was originally designed for nasal mask delivery, use of full face masks in fact has …
