TREATMENT OF SEVERE CARDIOGENIC PULMONARY-EDEMA WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DELIVERED BY FACE MASK
TREATMENT OF SEVERE CARDIOGENIC PULMONARY-EDEMA WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DELIVERED BY FACE MASK
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DOI：
10.1056/nejm199112263252601
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发表时间：
1991-12-26
影响因子：
158.5
通讯作者：
BAGGOLEY, CJ
中科院分区：
文献类型：
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作者：
BERSTEN, AD;HOLT, AW;BAGGOLEY, CJ
背景资料。严重的心源性肺水肿是呼吸衰竭的常见原因，许多患有这种情况的患者需要气管插管和机械通气。我们调查了使用面罩进行持续正压治疗是否具有生理益处，并将减少插管和机械通气的需要。我们随机将39名因严重心源性肺水肿而发生呼吸衰竭的患者随机分为两组，一组接受氧气治疗，另一组接受经面罩输送的氧气加持续气道正压治疗。不可能使调查人员对指定的治疗视而不见。在接下来的24小时内进行生理测量，并跟踪患者出院。30分钟后，接受氧气加持续正压的患者的呼吸频率和动脉二氧化碳分压下降得更多。30分钟平均(+/-SD)呼吸频率，单纯氧气组从32+/-6次/分钟降至33+/-9次/分钟，氧气组从35+/-8次/分钟降至27+/-6次/分钟(P=0.008)；动脉血二氧化碳分压从+/-17毫米汞柱降至62+/-14毫米汞，氧气组由58+/-8毫米汞降至46+/-4毫米汞(P<；0.001)。接受持续正压治疗的患者动脉血pH值(氧分压从7.15+/-0.11升至7.18+/-0.18；氧分压+持续正压从7.18±0.08升至7.28±0.06；P<；0.001)和动脉血氧分压/吸入氧分数的比值(单纯氧分压从136+/-4升至126+/-47；氧分压+持续正压从138+/-32升至206+/-126；P=0.01)。然而，24小时后，两个治疗组之间在这些呼吸指数中的任何一个都没有显著差异。7例(35%)患者仅接受氧气治疗，而未接受氧气加持续气道正压治疗的患者需要插管和机械通气(P=0.005)。然而，两组患者的住院病死率(单纯吸氧4例；吸氧加持续气道正压通气2例；P=0.36)和住院时间均无显著差异。重症心源性肺水肿患者经面罩持续气道正压治疗可早期改善生理功能，减少插管和机械通气的需要。这项短期研究不能确定持续气道正压是否有任何长期益处，也不能确定一项更大规模的研究是否会显示治疗组之间的死亡率差异。
Background. Severe cardiogenic pulmonary edema is a frequent cause of respiratory failure, and many patients with this condition require endotracheal intubation and mechanical ventilation. We investigated whether continuous positive airway pressure delivered by means of a face mask had physiologic benefit and would reduce the need for intubation and mechanical ventilation.Methods. We randomly assigned 39 consecutive patients with respiratory failure due to severe cardiogenic pulmonary edema to receive either oxygen alone or oxygen plus continuous positive airway pressure delivered through a face mask. It was not possible to blind the investigators to the assigned treatment. Physiologic measurements were made over the subsequent 24 hours, and the patients were followed to hospital discharge.Results. After 30 minutes, both respiratory rate and arterial carbon dioxide tension had decreased more in the patients who received oxygen plus continuous positive airway pressure. The mean (+/- SD) respiratory rate at 30 minutes decreased from 32 +/- 6 to 33 +/- 9 breaths per minute in the patients receiving oxygen alone and from 35 +/- 8 to 27 +/- 6 breaths per minute in those receiving oxygen plus continuous positive airway pressure (P = 0.008); the arterial carbon dioxide tension decreased from 64 +/- 17 to 62 +/- 14 mm Hg in those receiving oxygen alone and from 58 +/- 8 to 46 +/- 4 mm Hg in those receiving oxygen plus continuous positive airway pressure (P < 0.001). The patients receiving continuous positive airway pressure also had a greater increase in the arterial pH (oxygen alone, from 7.15 +/- 0.11 to 7.18 +/- 0.18; oxygen plus continuous positive airway pressure, from 7.18 +/- 0.08 to 7.28 +/- 0.06; P < 0.001) and in the ratio of arterial oxygen tension to the fraction of inspired oxygen (oxygen alone, from 136 +/- 4 to 126 +/- 47; oxygen plus continuous positive airway pressure, from 138 +/- 32 to 206 +/- 126; P = 0.01). After 24 hours, however, there were no significant differences between the two treatment groups in any of these respiratory indexes. Seven (35 percent) of the patients who received oxygen alone but none who received oxygen plus continuous positive airway pressure required intubation and mechanical ventilation (P = 0.005). However, no significant difference was found in in-hospital mortality (oxygen alone, 4 of 20 patients; oxygen plus continuous positive airway pressure, 2 of 19; P = 0.36) or the length of the hospital stay.Conclusions. Continuous positive airway pressure delivered by face mask in patients with severe cardiogenic pulmonary edema can result in early physiologic improvement and reduce the need for intubation and mechanical ventilation. This short-term study could not establish whether continuous positive airway pressure has any long-term benefit or whether a larger study would have shown a difference in mortality between the treatment groups.