A.急性高CAPNIC呼吸衰竭A1.COPD急性加重:建议:NIV应用于急性或慢性呼吸道酸中毒患者的COPD急性加重(pH=7.25-7.35)。(1A)在开始有创机械通气(IMV)之前,COPD急性加重(pH<7.25和PaCO2≥45)的患者应尝试NIV,但需要立即插管的患者除外。(2A).pH越低,NIV失效的机会越高。(2B)NIV不应在COPD急性加重的正常或轻度高二氧化碳患者中常规使用,无酸中毒(pH>7.35)。(2B)A2。由于胸壁畸形/神经肌肉疾病引起的ARF的NIV:建议:NIV可用于由于胸壁畸形/神经肌肉疾病引起的ARF患者。(PaCO2≥45)(UPP)A3。由于肥胖通气不足综合征(OHS)引起的ARF中的NIV:建议:当OHS患者出现急性高碳酸血症或慢性呼吸衰竭(pH45)时,NIV可用于AHRF。(3B)NIV/CPAP可用于肥胖,在没有酸中毒的情况下,患有OHS和/或右心衰竭的高碳酸血症患者。(UPP)B.
■B1。急性心源性肺水肿的NIV:建议在ARF的住院患者中使用NIV,因为心源性肺水肿.(1A).NIV应用于急性心力衰竭/心源性肺水肿患者,急诊室本身。(1B)CPAP和BiPAP模式对心源性肺水肿患者均安全有效。(1A).然而,心源性肺水肿伴高碳酸血症应首选BPAP(NIV-PS)。(3A)B2。急性低氧性呼吸衰竭的NIV:建议:在轻度早期急性低氧性呼吸衰竭(P/F比<300和>200mmHg)中,NIV可用于常规氧疗,在密切监督下。(2B)我们强烈建议不要在P/F比值<150的急性低氧血症衰竭患者中进行NIV试验。(2A)B3。由于胸部创伤引起的ARF中的NIV:建议:NIV可用于创伤性连ail胸,并充分缓解疼痛。(3B)B4。免疫功能低下宿主的NIV:建议:在早期ARF的免疫功能低下患者中,我们可以考虑NIV而不是常规氧气。(2B).B5.姑息治疗中的NIV:建议:我们强烈建议在姑息治疗中使用NIV来减少呼吸困难。(2A)B6。术后病例的NIV:建议:术后急性呼吸衰竭患者应使用NIV。(2A)B6a。腹部手术中的NIV:建议:NIV可用于腹部手术后的ARF患者。(2A)B6b。减重手术中的NIV:建议:NIV可用于先前存在OSA或OHS的减重手术后患者。(3A)B6c。NIV在胸外科手术:建议:在心胸手术,建议急性呼吸衰竭患者术后使用NIV,以改善氧合并减少再插管的机会.(2A)NIV不应用于接受食道手术的患者。(UPP)B6d。肺移植后的NIV:建议:NIV可用于缩短断奶时间并避免肺移植后再次插管。(2B)B7。手术期间的NIV(ETI/支气管镜检查/TEE/内窥镜检查):建议:NIV可用于插管前的预氧合。(2B)具有适当接口的NIV可以在支气管镜/内窥镜检查期间用于ARF患者以改善氧合。(3B)B8。病毒性肺炎ARDS中的NIV:建议:NIV不能被认为是H1N1肺炎急性呼吸衰竭患者的首选治疗方法。然而,在选定的单器官受累患者中使用NIV可能是合理的,在严格控制的环境中进行密切监控。(2B)B9。NIV和肺结核急性加重:建议:对急性肺结核患者谨慎使用NIV,有效的感染控制预防措施,以防止空气传播。(3B)B10。高危患者计划拔管后的NIV:建议:我们建议NIV可用于使高危患者脱离有创机械通气,因为它可降低再次插管率。(2B)B11。NIV用于拔管后呼吸窘迫:建议:我们建议不应使用NIV治疗来控制高危患者拔管后的呼吸窘迫。(2B)C.
■建议:模式的选择主要取决于疾病的病因和严重程度等因素,患者和操作者对呼吸的熟悉程度和经验。(UPP)我们建议在辅助模式下使用流量触发而不是压力触发,因为它提供了更好的患者呼吸机同步性。尤其是COPD患者,流量触发已被发现有利于自动PEEP。(3B)D.
■D1。镇静:建议:非药物方法使患者平静(让患者放心,适当的环境)在服用镇静剂之前应始终尝试。(UPP)在NIV患者中,镇静可以在非常密切的监测下使用,并且仅在ICU环境中使用,并注意NIV失败的迹象。(UPP)E.
方法:建议:我们建议在危重患者中使用便携式双层呼吸机或专门设计的ICU呼吸机进行无创通气。(UPP)具有泄漏补偿功能的重症监护呼吸机和双水平呼吸机在降低WOB方面同样有效,RR,PaCO2(3B)目前,口鼻面罩是急性呼吸衰竭无创通气最优选的接口。(3B)F.
■建议:我们建议从NIV断奶可以通过该单元的标准化协议驱动方法来完成。(2B)如何引用这篇文章:ChawlaR,DixitSB,ZirpeKG,ChaudhryD,KhilnaniGC,MehtaY,etal.ISCM在成人ICU急性呼吸衰竭中使用无创通气的指南。印度J暴击护理医学2020;24(补编1):S61-S81。
A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B.
UNASSIGNED: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C.
UNASSIGNED: Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D.
UNASSIGNED: D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E.
METHODS: Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non-invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F.
UNASSIGNED: Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM
Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61-S81.