经鼻高流量氧疗期间的喂养实践：当前证据及对呼吸治疗的临床意义

文献信息

中文摘要

背景： 经鼻高流量氧疗（HFNC）作为一种无创呼吸支持方式，正日益广泛地应用于急性和重症监护环境。尽管营养管理是呼吸衰竭患者照护中不可或缺的组成部分，但目前尚缺乏针对接受HFNC患者喂养的既定指南，临床决策差异很大，反映出对HFNC影响吞咽功能、气道保护和误吸风险方面持续存在的不确定性。方法：本叙述性综述发现，HFNC可能改变吞咽生物力学，尤其是在流量>40 L/min时，可能增加呛咳和误吸的风险。关于误吸风险的证据异质性较大，主要来自健康志愿者和儿童毛细支气管炎队列。成人证据仅限于回顾性研究；其中规模最大的一项研究发现，肠内喂养并未增加呼吸功能恶化。大多数机构缺乏正式的喂养方案，实践由临床医生个人判断驱动。结果：共识领域包括血流动力学稳定患者早期肠内喂养的安全性，以及避免仅因使用HFNC而常规长期停止营养。分歧持续存在于常规吞咽评估、喂养期间的最佳流量阈值以及口服与管饲的优先顺序方面。结论：接受HFNC患者的安全喂养需要多学科、个体化的方法，在呼吸支持与营养充足性之间取得平衡。需要前瞻性多中心研究来确定安全流量阈值、验证床旁评估工具并建立标准化喂养指南，尤其是在成人和危重症人群中。

英文摘要

High-flow nasal cannula (HFNC) therapy is increasingly used as a noninvasive respiratory support modality across acute and critical care settings. Although nutritional management is integral to the care of patients with respiratory failure, established guidelines for feeding patients receiving HFNC are lacking, and clinical decisions vary widely, reflecting persistent uncertainty about HFNC's effects on swallowing function, airway protection, and aspiration risk. This narrative review found that HFNC may alter swallowing biomechanics, particularly at flow rates >40 L/min, potentially increasing the risk of choking and aspiration. Evidence on aspiration risk is heterogeneous, deriving largely from healthy volunteers and pediatric bronchiolitis cohorts. Adult evidence is limited to retrospective studies; the largest found no increase in respiratory deterioration with enteral feeding. Most institutions lack formal feeding protocols, and practice is driven by individual clinician judgment. Areas of consensus include the safety of early enteral feeding in hemodynamically stable patients and the avoidance of routine prolonged withholding of nutrition based solely on HFNC use. Disagreement persists regarding routine swallowing assessment, optimal flow thresholds during feeding, and the prioritization of oral versus tube feeding. Safe feeding in patients receiving HFNC requires a multidisciplinary, individualized approach that balances respiratory support against nutritional adequacy. Prospective multicenter studies are needed to define safe flow thresholds, validate bedside assessment tools, and establish standardized feeding guidelines, particularly in adult and critically ill populations.