Chronic obstructive pulmonary disease with respiratory failure of mechanical ventilation strategy

Chronic obstructive pulmonary disease with respiratory failure of mechanical ventilation strategy
Chronic obstructive pulmonary disease (COPD) with respiratory failure is the Department of Respiratory Medicine of the most common reasons for the use of mechanical ventilation, but there is nothing wrong application of more or unsatisfactory Department. COPD with respiratory failure complicated disease, bronchial - lung infection, airway obstruction, respiratory muscle fatigue, multiple organ dysfunction, such as staggered there. How to become more rational, economic and efficient use of mechanical ventilation, is the need seriously to consider and explore the issue of [1,2]. After years of clinical practice and research, we believe that effective anti-infection treatment, and so on the basis of the following aspects of mechanical ventilation strategy to improve, you can compare large extent on the merger of COPD acute respiratory failure in the treatment of Changed.

1, COPD with respiratory failure on the plane indications

Generally speaking, to the morning, indications of relative relaxation. For COPD with cases of respiratory failure, it is difficult to have a completely standards or "point" to decide whether to use mechanical ventilation. The main decision is based on the condition of dynamic change, that is, patients with ventilation and the recent trend of changes in lung infection. If the general condition is still active after treatment or further ease the increase should be timely applications include mechanical ventilation, an effective means of blocking and correct bad ventilation, respiratory muscle fatigue and poor drainage, such as sputum key link in the pathophysiology , The disease quickly so that the relative ease into the state. If the condition in the stage of development can not be effectively controlled and to be more serious condition, it will significantly increase the complexity of the treatment and prognosis difficult and adverse impact.

For serious infection, airway secretions number of cases to the establishment of the use of artificial airway followed by mechanical ventilation methods, the so-called invasive mechanical ventilation. By the establishment of artificial airway sputum way to ensure the full drainage and ventilation effect. The infection is not very serious, less airway secretions and respiratory muscle fatigue prominent patients, may also consider the use of non-invasive nasal masks or nasal mask mechanical ventilation. Now that the early application of non-invasive ventilation to improve respiratory muscle fatigue, thus facilitating and improving ventilation function Katan ability to have a positive effect.

Second, COPD patients the choice of mode of mechanical ventilation and parameters of the conditioning

COPD patients for the use of mechanical ventilation, a very important principle is to "help rather than replace," that is, as long as the patients have some degree of breathing independently, that is, to use auxiliary ventilation, and improved conditions in the integrated mechanical ventilation after the lower level of support , A gradual increase in patients with breathing independently bear the burden of ventilation. Auxiliary mode from breathing independently trigger some form of mechanical ventilation, patients of respiratory muscles supporting Work, which would enable patients with independent ventilation in the capacity of training and rehabilitation, after an earlier and more successfully weaning prepared. Assist mode include synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), synchronized intermittent mandatory ventilation + pressure support ventilation (SIMV + PSV), two-phase positive airway pressure (Biphasic Positive Airway Pressure, BIPAP), the proportion supporting Ventilation (PAV), and so on. One application SIMV + PSV and PSV models have more practical experience and has been advocating. PSV in particular suction occurred inspiratory flow and objectives of capacity, breath in the three aspects of coordination with the patient, from the perspective of its mechanical ventilation Work more physical, better support for the model, on the plane early to consider the application Or with the use of low frequency SIMV to facilitate the timely mobilization of independent respiratory function. BIPAP and PAV are explored in the model, has a certain According to the preliminary clinical application.

COPD, airway resistance increase compliance and reduce the lung, breath extend the time constant, pervasive breath is not complete, closed gas depression, lung dynamic over-inflated status and endogenous PEEP, the adjustment in the ventilator Attention should be paid as much as possible breath longer time to promote breath, specific measures include increasing the suction flow rate, adjusted suction wave, shortened breath, bronchial expansion, ruled out calls valve dysfunction and, if necessary, sedation patients to choose large-caliber Endotracheal tube (diameter of not less than 7.5 mm); peak in monitoring airway pressure and pressure platform to ensure that it does not increase the premise, plus a certain amount of exogenous PEEP, can help reduce inspiratory Trigger threshold, to reduce endogenous PEEP caused by the suction power consumption to increase and promote breathing independently and mechanical ventilation and coordination between the patient's comfort; To avoid inspiratory lung volume at the end of high tidal volume should not be Too large, should enable the airway platform in the lower 30 cmH2O, best limited to the respiratory rate 20 times / points, as the ventilation when the blood level of carbon dioxide, as long as the maintenance period to ease the level or slightly higher, arterial blood pH value of not less than To 7.30.

COPD patients on the plane after weaning should always consider the possibility of problems and extubation. T-day trip to the PSV or low-level test to detect every possible opportunity. Early extubation of the following methods COPD mechanical ventilation should be regarded as an important strategy to improve.

Third, on a non-invasive mechanical ventilation support COPD patients early extubation weaning strategy:

COPD cases have occurred from severe respiratory failure and requires the use of mechanical ventilation for two main reasons: One is the bronchial - lung infection increase and the other is COPD acute airway obstruction heavier, and had been in a state of fatigue due to respiratory muscle Heavier load, infection poisoning, acid-base balance, electrolyte imbalance, and other functions result of deterioration in-pump failure. COPD is more than two cases on the reasons for the plane, as well as COPD patients weaning the main influence and consideration. COPD in the past on the plane, the short term can often control infection, but because of airway obstruction and respiratory muscle fatigue state and independent ventilation function can not meet the needs of the body, still rely on mechanical ventilation, mechanical ventilation extension of the time, and in the extension of The process of mechanical ventilation, because of the artificial airway, prone to ventilator-associated pneumonia (VAP), the treatment process occurred repeatedly, the weaning process has occurred repeatedly and delay or even ventilator-dependent state.

In fact, the artificial airway in the establishment of effective drainage sputum and reasonable use of antibiotics, bronchial - lung infection can often be more quickly in 3-5 days time under control, clinical performance to reduce the volume of sputum, Viscosity thinning, sputum color to white, the temperature dropped, reduced white blood cell count, on the chest film bronchial - lung infection shadow faded, this stage we can call it "lung infection control window" (Pulmonary Infection Control Window, PIC window). The emergence of infection control window means that patients have been the principal focus on bad ventilation function, airway secretions drainage problem has been relegated to a secondary position, we can take to improve ventilation in patients, especially respiratory muscle fatigue solution to the problem of stability And to further improve conditions. Such a judgement reminds us of the possibility of a lung infection control window of time after the removal of tracheal tube, using nasal masks or nasal mask of non-invasive mechanical ventilation to assist ventilation, and as timely removal of the artificial airway , Is expected to effectively avoid the artificial airway caused by lower respiratory tract infections and ventilator-associated pneumonia.

Based on this consideration, we in Beijing's Chaoyang Hospital respiratory intensive care unit (RICU) on a trial basis in the machine after about five days, once the window of a lung infection control after the removal of endotracheal tube, and then switch to non-invasive mechanical ventilation, to continue To help patients with respiratory muscle fatigue solve, the problem of bad ventilation, and this method before the same conditions but with continued use of the artificial airway mechanical ventilation to the traditional methods of weaning compared. The results showed that using non-invasive ways to help patients with early extubation method can not only significantly reduce the use of invasive mechanical ventilation time, the total of mechanical ventilation, that is invasive and non-invasive ventilation of the time clearly than ever the simple application Invasive mechanical ventilation reduce the time, the incidence of respiratory-related pneumonia was significantly reduced, patients and well tolerated, weaning high success rate. This can also greatly reduce the time and living ICU reduce medical costs.

This is actually bronchial pulmonary infection and ventilation dysfunction / respiratory muscle fatigue on the impact of these two aircraft and weaning the problem in two stages to take a different approach to resolve: the first phase, that is, on the plane early, when Infection and ventilation dysfunction both by the presence of the artificial airway invasive ventilation method is quick to resolve serious infection and bad ventilation problems, and when entering the second phase, that is, when the infection, if effective control, ventilation bad form to use machinery The main reason for ventilation, the timely removal of artificial airway to avoid possible after the relevant infection, use of non-invasive mechanical ventilation to continue to address the failure or respiratory muscle dysfunction problems, after the gradual removal of ventilator.

The lung infection is not obvious but the ventilation serious obstacles to accept the invasive ventilation in patients with COPD, ventilation should be resumed as soon as possible after switching to non-invasive ventilation to prevent ventilator-associated pneumonia occurred improve treatment.

Italy and France the recent two studies showed similar results [3,4], confirmed early extubation sequential use of non-invasive ventilation in the validity and clinical application.

Such invasive and non-invasive mechanical ventilation sequential strategy, the key is to promptly and accurately identify and control invasive and non-invasive mechanical ventilation of the switch points, or lung infection control windows or ventilation function in the non-invasive ventilation The initial tolerance; right to operate non-invasive mechanical ventilation is to guarantee the success of the sequential treatment another important aspect.

Invasive and non-invasive mechanical ventilation of the sequential approach is effective for COPD disease characteristics and laws of mechanical ventilation strategy, can effectively improve treatment and reduce medical costs, a very good clinical practical value, is advocated by weaning strategy. Its application is expected to a greater extent on improving the treatment of COPD with respiratory failure in the face.

Fourth, non-invasive mechanical ventilation in COPD acute respiratory failure of the merger of the status of

Non-invasive mechanical ventilation has the advantage of being free of artificial airway and its related complications, ventilator-associated pneumonia and the incidence of low reservations about the normal swallowing, eating, coughing, speaking function to retain the upper airway physiological temperature, wet and Immune function; need tranquilizers; patients from both physical and psychological make it easier weaning; can be stopped, and long-term or household use. And the artificial airway of invasive mechanical ventilation compared with the primary function can not be for lack of an effective drainage and ventilation effect of instability in the sputum. In addition, non-invasive ventilation mask the shortcomings of other nose / nasal mask discomfort; pressure red facial skin; eye injury; nose masks / nasal mask leakage, such as gastrointestinal Flatulence.

At present, non-invasive ventilation COPD with respiratory failure is an important means of treatment, its main role is supporting-pump feature, ease respiratory muscle fatigue [5,6]. Non-invasive ventilation can be a reasonable application of a considerable part of the successful treatment of COPD acute respiratory failure in patients with the merger, so that from intubation; will have to have a mechanical ventilation of these cases may also play a role in helping early extubation. In principle, for mild cases, the indication of non-invasive ventilation to relax and to help correct when respiratory muscle fatigue, thereby improving the-pump feature and promote Katan. Even for less severe diseases, in the past no indication of mechanical ventilation cases, may also consider more active use of early non-invasive mechanical ventilation to effectively ease the respiratory muscle fatigue, to prevent the condition from deteriorating further. For severe cases, the indication of non-invasive ventilation to strictly, so as not to delay the rescue time. Especially for heavier infection and airway secretions number of cases, although application of non-invasive ventilation was also alleviate the condition, but we should not be reluctant to use non-invasive ventilation, but should be timely adopted by the artificial airway of mechanical ventilation methods More conducive to speedy and effective infection control and correct ventilation failure, in a relatively short period of time to ease the condition, then you can use these to the non-invasive method of mechanical ventilation as soon as possible to help extubation.