经鼻高流量氧疗治疗急性呼吸衰竭的随机对照试验_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

 冯晓东 , 张贵良 , 曾利华 , 杨天民 , 邓飞 , 叶万辉

绵竹市人民医院•四川大学华西医院绵竹医院重症医学科（四川绵竹 618200）;

Corresponding author：

冯晓东, Email: 770795373@qq.com

Keywords：

经鼻高流量氧疗; 无创通气; 28 天气管插管率; 90 天全因死亡率; 急性呼吸衰竭

DOI：

10.7507/1671-6205.202002113

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目的评价经鼻高流量氧疗治疗急性呼吸衰竭的临床效果。方法选择重症医学科收治的急性呼吸衰竭患者，用随机数字表法分为标准氧疗组、经鼻高流量氧疗组、无创通气组三组，分别给予面罩吸氧、经鼻高流量氧疗、无创正压机械通气治疗。观察患者 28 天气管插管率、90 天全因死亡率、治疗 48 h 后氧合状况。结果共纳入 116 例患者，其中经鼻高流量氧疗组 40 例，标准氧疗组 39 例，无创通气组 37 例。经鼻高流量氧疗组患者 28 天气管插管率明显低于标准氧疗组（22.5% 比 51.3%，OR=0.28，95%CI 0.10～0.73）和无创通气组（22.5% 比 48.6%，OR=0.31，95%CI 0.12～0.82）；三组 90 天全因死亡率差异无统计学意义（分别为 15.0%、25.6% 和 24.3%，P=0.456）。治疗 48 h 后，高流量氧疗组 PaO₂ 较标准氧疗组、无创通气组显著升高（P=0.006），高流量氧疗组比标准氧疗组提高 PaO₂/FiO₂ 更有优势（OR=4.02，95%CI 1.64～9.85），但高流量氧疗与无创通气 PaO₂/FiO₂ 差异无统计学意义（P>0.05），三组患者 PaCO₂、pH、呼吸频率差异无统计学意义（P>0.05）。结论与标准氧疗、无创通气相比，经鼻高流量氧疗能显著降低急性呼吸衰竭患者 28 天气管插管率，且有降低患者 90 天全因死亡率的趋势。经鼻高流量氧疗提高患者氧合比标准氧疗更有优势，和无创通气效果相当。

Citation： 冯晓东, 张贵良, 曾利华, 杨天民, 邓飞, 叶万辉. 经鼻高流量氧疗治疗急性呼吸衰竭的随机对照试验. Chinese Journal of Respiratory and Critical Care Medicine, 2020, 19(5): 489-494. doi: 10.7507/1671-6205.202002113 Copy

1.	Lee CC, Mankodi D, Shaharyar S, et al. High flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation in adults with acute hypoxemic respiratory failure: a systematic review. Respir Med, 2016, 121: 100-108.
2.	Corley A, Caruana LR, Barnett AG, et al. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth, 2011, 107(6): 998-1004.
3.	Austin MA, Wills KE, Blizzard L, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ, 2010, 341: c5462.
4.	Messika J, Ben Ahmed K, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care, 2015, 60(2): 162-169.
5.	Frat JP, Brugiere B, Ragot S, et al. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care, 2015, 60(2): 170-178.
6.	Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med, 2015, 372(23): 2185-2196.
7.	Thille AW, Contou D, Fragnoli C, et al. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Crit Care, 2013, 17(6): R269.
8.	Koga Y, Kaneda K, Fujii N, et al. Comparison of high-flow nasal cannula oxygen therapy and non-invasive ventilation as first-line therapy in respiratory failure: a multicenter retrospective study. Acute Med Surg, 2019, 7(1): e461.
9.	Williams R, Rankin N, Smith T, et al. Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa. Crit Care Med, 1996, 24(11): 1920-1929.
10.	李洁, 张煜, 詹庆元. 人工气道的湿化. 中国呼吸与危重监护杂志, 2006, 5(6): 473-477.
11.	Groves N, Tobin A. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care, 2007, 20(4): 126-131.
12.	Gotera C, Díaz Lobato S, Pinto T, et al. Clinical evidence on high flow oxygen therapy and active humidification in adults. Rev Port Pneumol, 2013, 19(5): 217-227.
13.	Möller W, Celik G, Feng S, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985), 2015, 118(12): 1525-1532.
14.	Plotnikow GA, Thille AW, Vasquez DN, et al. Effects of high-flow nasal cannula on end-expiratory lung impedance in semi-seated healthy subjects. Respir Care, 2018, 63(8): 1016-1023.
15.	吕珊, 安友仲. 主动温湿化的经鼻高流量氧疗在成人患者中的应用. 中华危重病急救医学, 2016, 28(1): 84-88.
16.	倪忠, 秦浩, 李洁, 等. 中华医学会呼吸病学分会呼吸治疗学组. 新型冠状病毒肺炎患者经鼻高流量氧疗使用管理专家共识. 中国呼吸与危重监护杂志, 2020, 19(2): 110-115.
17.	Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med, 2014, 190(3): 282-288.
18.	Song HZ, Gu JX, Xiu HQ, et al. The value of high-flow nasal cannula oxygen therapy after extubation in patients with acute respiratory failure. Clinics (Sao Paulo), 2017, 72(9): 562-567.
19.	Tiruvoipati R, Lewis D, Haji K, et al. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care, 2010, 25(3): 463-468.
20.	朱正方, 刘煜昊, 王启星, 等. 经鼻高流量氧疗用于机械通气脱机拔管后序贯治疗的初步评价. 中华危重病急救医学, 2017, 29(9): 778-782.
21.	Leite MR, Ramos EM, Kalva-Filho CA, et al. Effects of 12 weeks of aerobic training on autonomic modulation, mucociliary clearance, and aerobic parameters in patients with COPD. Int J Chron Obstruct Pulmon Dis, 2015, 10: 2549-2557.
22.	Roca O, Riera J, Torres F, et al. High-flow oxygen therapy in acute respiratory failure. Respir Care, 2010, 55(4): 408-413.
23.	Chanques G, Constantin JM, Sauter M, et al. Discomfort associated with underhumidified high-flow oxygen therapy in critically ill patients. Intensive Care Med, 2009, 35(6): 996-1003.
24.	Dysart K, Miller TL, Wolfson MR, et al. Research in high flow therapy: mechanisms of action. Respir Med, 2009, 103(10): 1400-1405.
25.	Macé J, Marjanovic N, Faranpour F, et al. Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: a before-after study. Am J Emerg Med, 2019, 37(11): 2091-2096.
26.	Nseir S, Zerimech F, Fournier C, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med, 2011, 184(9): 1041-1047.
27.	Estes RJ, Meduri GU. The pathogenesis of ventilator-associated pneumonia: Ⅰ. Mechanisms of bacterial transcolonization and airway inoculation. Intensive Care Med, 1995, 21(4): 365-383.
28.	Quenot JP, Ladoire S, Devoucoux F, et al. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med, 2007, 35(9): 2031-2036.
29.	Rosenthal VD, Bat-Erdene I, Gupta D, et al. International nosocomial infection control consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module. Am J Infect Control, 2020, 48(4): 423-432.
30.	Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol, 2012, 33(3): 250-256.
31.	Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 2013, 13(8): 665-671.

1. Lee CC, Mankodi D, Shaharyar S, et al. High flow nasal cannula versus conventional oxygen therapy and non-invasive ventilation in adults with acute hypoxemic respiratory failure: a systematic review. Respir Med, 2016, 121: 100-108.
2. Corley A, Caruana LR, Barnett AG, et al. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth, 2011, 107(6): 998-1004.
3. Austin MA, Wills KE, Blizzard L, et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ, 2010, 341: c5462.
4. Messika J, Ben Ahmed K, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care, 2015, 60(2): 162-169.
5. Frat JP, Brugiere B, Ragot S, et al. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care, 2015, 60(2): 170-178.
6. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med, 2015, 372(23): 2185-2196.
7. Thille AW, Contou D, Fragnoli C, et al. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Crit Care, 2013, 17(6): R269.
8. Koga Y, Kaneda K, Fujii N, et al. Comparison of high-flow nasal cannula oxygen therapy and non-invasive ventilation as first-line therapy in respiratory failure: a multicenter retrospective study. Acute Med Surg, 2019, 7(1): e461.
9. Williams R, Rankin N, Smith T, et al. Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa. Crit Care Med, 1996, 24(11): 1920-1929.
10. 李洁, 张煜, 詹庆元. 人工气道的湿化. 中国呼吸与危重监护杂志, 2006, 5(6): 473-477.
11. Groves N, Tobin A. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care, 2007, 20(4): 126-131.
12. Gotera C, Díaz Lobato S, Pinto T, et al. Clinical evidence on high flow oxygen therapy and active humidification in adults. Rev Port Pneumol, 2013, 19(5): 217-227.
13. Möller W, Celik G, Feng S, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985), 2015, 118(12): 1525-1532.
14. Plotnikow GA, Thille AW, Vasquez DN, et al. Effects of high-flow nasal cannula on end-expiratory lung impedance in semi-seated healthy subjects. Respir Care, 2018, 63(8): 1016-1023.
15. 吕珊, 安友仲. 主动温湿化的经鼻高流量氧疗在成人患者中的应用. 中华危重病急救医学, 2016, 28(1): 84-88.
16. 倪忠, 秦浩, 李洁, 等. 中华医学会呼吸病学分会呼吸治疗学组. 新型冠状病毒肺炎患者经鼻高流量氧疗使用管理专家共识. 中国呼吸与危重监护杂志, 2020, 19(2): 110-115.
17. Maggiore SM, Idone FA, Vaschetto R, et al. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med, 2014, 190(3): 282-288.
18. Song HZ, Gu JX, Xiu HQ, et al. The value of high-flow nasal cannula oxygen therapy after extubation in patients with acute respiratory failure. Clinics (Sao Paulo), 2017, 72(9): 562-567.
19. Tiruvoipati R, Lewis D, Haji K, et al. High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients. J Crit Care, 2010, 25(3): 463-468.
20. 朱正方, 刘煜昊, 王启星, 等. 经鼻高流量氧疗用于机械通气脱机拔管后序贯治疗的初步评价. 中华危重病急救医学, 2017, 29(9): 778-782.
21. Leite MR, Ramos EM, Kalva-Filho CA, et al. Effects of 12 weeks of aerobic training on autonomic modulation, mucociliary clearance, and aerobic parameters in patients with COPD. Int J Chron Obstruct Pulmon Dis, 2015, 10: 2549-2557.
22. Roca O, Riera J, Torres F, et al. High-flow oxygen therapy in acute respiratory failure. Respir Care, 2010, 55(4): 408-413.
23. Chanques G, Constantin JM, Sauter M, et al. Discomfort associated with underhumidified high-flow oxygen therapy in critically ill patients. Intensive Care Med, 2009, 35(6): 996-1003.
24. Dysart K, Miller TL, Wolfson MR, et al. Research in high flow therapy: mechanisms of action. Respir Med, 2009, 103(10): 1400-1405.
25. Macé J, Marjanovic N, Faranpour F, et al. Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: a before-after study. Am J Emerg Med, 2019, 37(11): 2091-2096.
26. Nseir S, Zerimech F, Fournier C, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Respir Crit Care Med, 2011, 184(9): 1041-1047.
27. Estes RJ, Meduri GU. The pathogenesis of ventilator-associated pneumonia: Ⅰ. Mechanisms of bacterial transcolonization and airway inoculation. Intensive Care Med, 1995, 21(4): 365-383.
28. Quenot JP, Ladoire S, Devoucoux F, et al. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med, 2007, 35(9): 2031-2036.
29. Rosenthal VD, Bat-Erdene I, Gupta D, et al. International nosocomial infection control consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module. Am J Infect Control, 2020, 48(4): 423-432.
30. Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol, 2012, 33(3): 250-256.
31. Melsen WG, Rovers MM, Groenwold RH, et al. Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis, 2013, 13(8): 665-671.

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经鼻高流量氧疗治疗急性呼吸衰竭的随机对照试验

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