危重病患者预先使用高流量鼻导管
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Proactive Use of High-Flow Nasal Cannula With Critically Ill Subjects
背景与目的：建议使用高流量鼻导管（HFNC）可能是急性缺氧性呼吸衰竭患者的一线治疗方法。本研究的目的是确定拟使用HFNC是否减少ICU患者的非计划插管和不良结果的发生。
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方法：该研究前瞻性评估分别接受两种使用HFNC方案的2个组。对照组为在方案前阶段接受HFNC的受试者的回顾性选择。组1（n = 88）接受机械通气> 24小时，并按照严格的标准直接拔管后给予HFNC。组2(n=83)为当患者需氧量增加（>4L/min）时，给予HFNC。
结果：组1与对照组相比，在死亡率、住院时间或ICU住院天数方面没有差异，但是革兰氏阴性肺部感染发生率（30％比9％，P =0.001）和使用支气管扩张剂治疗（81％比61％，P=0.008）明显减少。不同组间拔管失败率几乎相同，但试验组的再次插管时间较短（24 vs 13 h，P = 0.19）。组2在插管率或死亡率方面与对照组相比没有显著差异，但通过试验方案管理的受试者在ICU天数（4比3天，P = 0.03）和住院天数（12比8天，P =0.007）明显减少。当HFNC治疗无效时，HFNC时间较短（33比24h，P=0.10）且插管时间更快（19比9h，P=0.08）。
结论：HFNC时拔管导致组1患者的肺部感染和支气管扩张剂治疗显著下降，但并未减少住院时间或拔管失败率。当早期使用HFNC和按照试验方案（如组2）时，患者ICU和住院时间缩短，并且在需要加强呼吸支持治疗时更快地启动HFNC。
Keith D Lamb RRT RRT-ACCS, Sarah K Spilman MA, Trevor W Oetting RRT,Julie A Jackson RRT RRT-ACCS, Matthew W Trump DO, and Sheryl M Sahr MD MSc
Proactive Use of High-Flow Nasal Cannula With Critically
Ill Subjects
Respir Care 2018;63(3):259 –266. © 2018 Daedalus Enterprises
BACKGROUND:It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population.
METHODS:The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n 88) received mechanical ventilation for > 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n 83) were placed on HFNC when oxygen requirements escalated (>4 L/min).
RESULTS: Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P .001) and use of bronchodilator therapy (81% vs 61%, P .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P .03) and hospital days (12 vs 8 d, P .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P .10) and faster time to intubation when HFNC failed (19 vs 9 h, P .08).
CONCLUSIONS:Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.
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