Intrahospital transport of a patient with acute exacerbation of chronic obstructive pulmonary disease under noninvasive ventilation
Intrahospital transport of a patient with acute exacerbation of chronic obstructive pulmonary disease under noninvasive ventilation
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无创通气下慢性阻塞性肺疾病急性加重患者的院内转运
DOI：
10.1007/s00134-005-2626-0
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发表时间：
2005
影响因子：
38.9
通讯作者：
G. Kreymann
中科院分区：
文献类型：
--
作者：
S. Kluge;H. Baumann;G. Kreymann
先生：无创正压通气 (NPPV) 越来越多地用于 ICU 中急性呼吸衰竭患者。 NPPV 对于慢性阻塞性肺疾病急性加重的患者尤其有利，因为它可以降低死亡率、气管插管的需要以及住院时间[1]。 ICU 患者经常需要转移到其他地点，例如放射科或导管实验室 [2]。旧式运输呼吸机无法实现 NPPV，因为这些呼吸机无法为 NPPV 提供足够的通气模式。最新一代的转运呼吸机具有多种优势，包括新的通气模式（双水平气道正压模式、压力支持自主呼吸）。还可以提供精确浓度的氧气，并且监测和报警功能比过去更加复杂。我们报告了一名 68 岁女性因慢性阻塞性肺病加重导致呼吸功能不全入住我们 ICU 的病例。面罩吸氧5l/min时氧饱和度为90%，血气分析显示呼吸性酸中毒（pH 7.21，pCO 2 70.8 mmHg），胸部X线检查结果正常。治疗开始时使用氧气、吸入β-肾上腺素能激动剂、抗胆碱能支气管扩张剂、皮质类固醇和抗生素。由于持续性呼吸窘迫，随后开始 NPPV。患者的心电图显示 V1-V4 导联 ST 段抑制显着，进一步的实验室检查显示肌钙蛋白升高 2.24 µg/l (− 0.1)，超声心动图显示左心室功能明显下降。经过仔细考虑患者对无创通气的良好耐受性、配合能力和血流动力学稳定性，决定将其在 NPPV 下转移至导管实验室，以排除明显的冠状动脉狭窄。佩戴全面罩的 NPPV 继续使用转运呼吸机（Oxylog 3000，Dräger，德国）使用双水平气道正压模式，吸气压力为 21 cmH 2 O，PEEP 为 5 cmH 2 O，呼吸频率为 25 次呼吸/分钟，吸入氧分数为 0.4。在这些设置下，潮气量平均为 500 毫升。一名重症监护医生和一名护士陪同患者并进行监测。在整个转运和心导管检查过程中，SaO 2 始终保持高于 90%，患者清醒且合作。血管造影显示冠状血管正常，无明显狭窄。心室造影证实左心室功能明显下降，这一发现与急性心肌炎的诊断最为一致。 80 分钟后，患者顺利返回 ICU。重复血气分析显示 PCO 2 水平为 60 mmHg。
Sir: Noninvasive positive pressure ventilation (NPPV) is being used increasingly in patients with acute respiratory failure in the ICU setting. NPPV appears particularly advantageous in patients with acute exacerbations of chronic obstructive pulmonary disease as it decreases mortality, the need for endotracheal intubation, and the length of hospital stay [1]. ICU patients frequently require transportation to alternative locations, such as the radiology department or the catheter laboratory [2]. NPPV was not possible with older transport ventilators as these did not provide adequate ventilation modes for NPPV. Transport ventilators of the latest generation offer several advantages, including new ventilation modes (bilevel positive airway pressure mode, pressure-supported spontaneous breathing). Precise concentrations of oxygen can also be delivered, and both monitoring and alarm features are far more sophisticated than in the past.We report the case of a 68-year-old woman admitted to our ICU because of respiratory insufficiency due to exacerbated chronic obstructive pulmonary disease. Oxygen saturation under 5l/min oxygen by a face mask was 90%, and blood gas analysis showed respiratory acidosis (pH 7.21, pCO 2 70.8 mmHg), while chest radiography findings were normal. Treatment was started with oxygen, inhaled β-adrenergic agonists, anticholinergic bronchodilators, corticosteroids, and antibiotics. NPPV was then initiated because of persistent respiratory distress. The patient’s electrocardiogram was remarkable for ST segment suppression in leads V1–V4, and further laboratory work up revealed elevated troponin of 2.24 µg/l (− 0.1), and echocardiography showed markedly reduced left ventricular function. After careful consideration of the patient’s good tolerance of the noninvasive ventilation, ability to cooperate, and hemodynamic stability the decision was made to transfer her under NPPV to the catheter laboratory to rule out significant coronary stenosis. NPPV with a full-face mask was continued with a transport ventilator (Oxylog 3000, Dräger, Germany) using the bilevel positive airway pressure mode with an inspiratory pressure of 21 cmH 2 O, a PEEP of 5 cmH 2 O, a respiratory rate of 25 breaths/min, and fraction of inspired oxygen of 0.4. At these settings the tidal volume averaged 500 ml. A critical care physician and a nurse accompanied the patient and performed monitoring. Throughout the transport and cardiac catheterization SaO 2 consistently remained higher than 90%, and the patient was awake and cooperative. Angiography demonstrated normal coronary vessels with no significant stenosis. Ventriculography confirmed markedly reduced left ventricular function, a finding most consistent with a diagnosis of acute myocarditis. After 80 min the patient returned to the ICU without an incident. Repeat blood gas analysis showed a PCO 2 level of 60 mmHg.