| BackgroundAcute left heart failure is clinical syndrome mainly caused by pulmonary congestion, pulmonary edema is the worst performance in acute left heart failure. While acute left heart failure, there is sharp decline in cardiac output and there is increased in heart load, and significantly increased the left ventricular end-diastolic pressure and pulmonary venous hypertension, resulting in pulmonary interstitial and alveolar edema with complicated of acute respiratory failure. When hypoxia can not be improved in time, then causing the irreversible organs damage in the body, the disease will progress rapidly and lead to death. Therefore, maintaining a normal blood oxygen levels in patients is important. Currently, mechanical ventilation is one of the most effective way in the treatment of respiratory failure. Non-invasive ventilation (non-invasive ventilation, NIV) is being increasingly recognized by clinicians by its convenient and reliable efficacy.Non-invasive ventilation is the general term a series of methods with increased alveolar ventilation without intubation, including nasal mask positive pressure ventilation (NPPV), external negative pressure ventilation. Early last century, the invention of negative pressure ventilation in vitro saved countless lives of polio patients. However, due to the external negative pressure ventilation equipment is huge, the operation are complicated, since the 50s of last century, it is gradually being abandoned, endotracheal intubation and tracheostomy positive pressure breathing machine connected to mechanical ventilation become the preferred means of therapy. With the better understanding of serious adverse reactions of invasive ventilation, such as ventilation vassociated pneumonia (VAP), resulting in tracheal injury, making the non-invasive ventilation technology to regain attention, especially the implementation of continuous positive airway pressure mask ventilation (CPAP) and intermittent positive pressure ventilation (IPPV) began to use more. Currently, we are talking about N1V mainly refers to positive pressure ventilation via nasal mask. In the 1990s, large-scale domestic and international randomized study confirmed the effectiveness of NPPV, compliance and economic practicability, which can reduce serious complications of mechanical ventilation, improve the long-term prognosis, obey the subjective views of patients, so that NIPPV is a first-line treatment in left heart failure in patients.The BiPAP breathing machine as a means of noninvasive ventilation, has been successfully applied to various types of pulmonary respiratory failure in patients and have a good results. In recent years with the maturity and continuous improvement of non-invasive ventilation technology and its has received increasing attention of application in the cardiovascular diseased field. There are many reported nasal mask mechanical ventilation(BiPAP) can applied to left heart failure various causes, including the patients of coronary heart disease. It was also reported that give a reasonable noninvasive ventilation early in patients with acute pulmonary edema may reduce the time of increased the SaO2 to physiological levels, rapid relief the symptoms of hypoxia and reduce mortality. The advantages of BiPAP ventilator, including increased intrathoracic pressure, reducing left ventricular load, increased intrathoracic pressure that reduces venous blood return, reduce cardiac preload and ease pulmonary bleeding; positive pressure ventilation can increase alveolar pressure, improvement of ventilation/perfusion ratio, reduce pulmonary edema; positive pressure ventilation can quickly correct the hypoxemia and acidosis,let the effect of the drug in anti-heart failure can be did, to prevent hypoxia-induced cardiac respiratory arrest; without trauma,the operate is easy and the patient can be accept easyly.In the past, about the intervention timing of invasive ventilation in the treatment of acute left heart failure, we must consider the intervention of invasive ventilation when the diagnosis of acute heart failure are clear, the condition of acute left heart failure are with KillipⅡstate level and above, respiratory muscle fatigue and respiratory distress can not be alleviated, there refractory hypoxemia, hypercapnia and severe acidosis, but the timing of intervention of BiPAP non-invasive ventilation in acute left heart failure need early considered when have KillipⅡacute left heart failure combined oxygenation dysfunction.However, BiPAP non-invasive ventilation in the treatment of acute left heart failure, the majority reported that about general summary article, there are no strong selective, prospective in that reported, the relatively controlled study are small and there is a certain controversy in the application. In addition,because of less equipment, less operating, lack of knowledge and other reasons, so that there is limited application in the primary hospital.ObjectiveThe main purpose of this project is to further explore the adjuvant treatment of BiPAP non-invasive ventilation in acute left heart failure combined hypoxemia, and compared with the treat efficacy of non-invasive ventilation BiPAP and conventional treatment in acute left heart failure combined hypoxemia,in order to lay the application foundation of non-invasive ventilation BiPAP.Methods1. General InformationAccording to the fifth edition of the scientific diagnostic criteria for acute heart failure, collected 34 patients with acute left ventricular failure from respiratory department of our hospital from June 2008 to September 2010. These patients were divided into two groups, there are 18 cases in BiPAP treatment group,16 patients in control group.The difference of two groups in gender, age, underlying heart disease and others have not statistically significant (P>0.05).2. The diagnosis of acute left heart failure①rapid breathing difficulties;②cyanosis, orthopnea, lungs and the distribution of scattered wheeze and could be heard. The medium-sized blisters in the end of bilateral lung could be heard and bilateral symmetric distribution. Apex could be heard and diastolic gallop;③chest X-ray:the brightness of lungs are decrease, the markings of the lungs are increased significantly, thickening, and bilateral costophrenic angle of the outer visible KilayA line, B line, hilum By thick film, there Butterfly;④exclude neurogenic pulmonary and respiratory difficulties.3. Exclusion criteria of noninvasive ventilation①coma;②multiple organ failure, heart failure end;③acute myocardial infarction with hypotension.4. Efficacy criterion①markedly:After 30 min treat,the cyanosis disappeared, heart palpitations, shortness of breath and difficulty breathing and other symptoms were relieved, heart rate, heart rate, blood pressure and respiration were returned to normal, pulmonary rales were decreased or disappeared, arterial blood gas PaO2> 90 mmHg;②effective:After treatment 30min cyanosis and difficulty breathing are alleviate, respiration rate, heart rate, blood pressure, SaO2 or PaO2 and other indicators were improved;③invalid:If the symptoms do not improve or even insevere, consciousness are appeared, blood gas and other indicators deteriorated (arterial partial pressure of oxygen PaO2≤55mmHg, peripheral oxygen saturation SaO2≤85%, arterial blood PH value decreased to≤7.2), endotracheal intubation immediately and diverted to invasive positive pressure ventilation. Cardiac arrest or spontaneous breathing rhythm arrhythmia, or irregular breathing and breathing pauses all this belong to the ineffective treatment.5. Therapeutic methodAll patients were given ECG testing, continuous respiratory function tests, all patients were treat by cardiac, diuretic, vasodilator and other conventional drug treatment, and to give non-invasive BiPAP ventilation. treatment group are given Oxygen by nasal catheter, and then give access oxygen by BiPAP breathing machine,the oxygen supply are limit by not to leak, in the treatment process let the patients have a comfortable psychological, so that patients can inhale oxygen efficiency; the control group were treated with normal oxygen supply way, firstly, connected oxygen mask on the side of the hole, then connect the BiPAP ventilator. Respirator use method:BiPAP Harmany II non-invasive ventilator produced by American Respironics, ventilation mode S/T, inspiratory pressure (IPAP) 16cmH2O start and gradually add to 20cmH2O, expiratory pressure (EPAP) 6cmH2O, backup respiratory rate 16 times/min, oxygen flow 6L/min, based on transcutaneous oxygen saturation (SpO2) to adjust the IPAP and EPAP, for SpO2≥90%. Arterial blood was collected after 1h and analysis, and comprehensive observation for vital signs, consciousness, pulmonary rales and other indicators, the condition of patients did not improve then given a intubation and converted to invasive ventilation. In the whole process, observe the patient closely and the indicators of ventilator. 6. Outcome measuresThe general conditions of patients (gender, age, height, respiratory rate); observed clinical symptoms closely before and after the change of oxygen supply, such as vital signs, consciousness, pulmonary rales, etc., testing respiratory rate momently, blood pressure, heart rate, arterial partial pressure of oxygen (PaO2), oxygen saturation (SaO2); the patients condition did not improve that then give intubation and converted to invasive ventilation, record the number of patients need for tracheal intubation or tracheostomy of invasive ventilation.7. Statistical analysisData analysis by SPSS13.0 software, the results of measurement data showed by x±s, the compare between the two groups used t test. count data parameters showed by percentage, using chi-square test, take P<0.05 as significant.Results1. Gender, age, underlying heart disease, blood gas analysis of the two groups of patients included in the study,the different have no significant (P>0.05).2. Before treatment,the two groups, PaO2, SaO2,HR,RRwas no significant difference (P>0.05), after 1h,6h, PaO2, SaO2,HR,RR increased significantly in the treatment group 1h, although PaO2, SaO2,HR,RR also increased in control group, but the PaO2, SaO2,HR,RR was significant difference after 1 hour and 6hour in the two groups (P <0.01).3. The treatment group,2 patients (10%) requiring endotracheal intubation while 8 patients (50.0%) requiring endotracheal intubation the control group, the rate of endotracheal intubation in two group are significant difference (P<0.01) 4. There were no death case in the BiPAP non-invasive ventilation group and control group.Conclusions Use BiPAP non-invasive ventilation and conventional method to treat acute left heart failure combined hypoxemia, after 1h,6h later of the treatment, PaO2, SaO2 was significantly increased in the BiPAP noninvasive ventilation group and the heart rate, respiratory rate decreased to normal levels, the PaO2, SaO2 of conventional treatment group was increased and the heart rate, respiratory rate also declined, after 1h,6h, the PaO2, SaO2 of BiPAP non-invasive ventilation compared with the conventional treatment are increased significantly, heart rate, respiratory rate are significantly reduced. There are only 2 patients required endotracheal intubation in the treatment group while there are 8 patients in the control group, the difference of endotracheal intubation group was significant. In addition,80% of BiPAP noninvasive ventilation can be wean within 24 to 48 in the treatment group, this study confirms that the BiPAP non-invasive ventilation in the treatment of acute left heart failure combined hypoxemia are obvious. |
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