无创呼吸治疗：贯穿急性期、慢性期、家庭及姑息治疗环境的以生理学为导向的方法

文献信息

中文摘要

无创呼吸治疗已从一种用于在特定类型的急性呼吸衰竭中避免气管插管的策略，演变为涵盖急性期治疗、慢性呼吸衰竭、睡眠呼吸障碍、家庭呼吸支持、肺康复和姑息治疗的更广泛框架。该术语现在包括常规氧疗、经鼻高流量氧疗、持续气道正压通气、双水平无创通气、家庭无创通气、家庭高流量治疗以及针对睡眠相关呼吸障碍的正压通气治疗。本综述提出一种以生理学为导向的方法。临床医生不应仅根据疾病选择设备，而应识别主要的生理问题：氧合受损、肺泡通气不足、上气道阻塞、呼吸做功增加、呼吸肌疲劳、分泌物清除受损，或需要以舒适为导向的支持。在急性期治疗中，无创通气已明确用于COPD急性加重所致的急性高碳酸血症性呼吸衰竭和急性心源性肺水肿，而在急性低氧血症性呼吸衰竭患者中，经鼻高流量氧疗、持续气道正压通气和无创通气需要更谨慎地选择。在慢性期治疗中，家庭无创通气和家庭高流量治疗应被理解为长期呼吸照护体系的组成部分，而不是简单的设备处方。实际成功取决于合适的接口选择、漏气控制、湿化、患者与设备的同步性、气道清除、患者教育以及安全监测。以生理学为导向且以患者为中心的框架可能改善无创呼吸治疗在连续照护过程中的合理使用。

英文摘要

Noninvasive respiratory therapy has evolved from a strategy used to avoid endotracheal intubation in selected forms of acute respiratory failure into a broader framework encompassing acute care, chronic respiratory failure, sleep-disordered breathing, home respiratory support, pulmonary rehabilitation, and palliative care. The term now encompasses conventional oxygen therapy, high-flow nasal cannula therapy, continuous positive airway pressure, bilevel noninvasive ventilation, home noninvasive ventilation, home high-flow therapy, and positive airway pressure therapy for sleep-related breathing disorders. This review proposes a physiology-oriented approach. Rather than selecting a device solely according to the disease, clinicians should identify the dominant physiological problem: impaired oxygenation, alveolar hypoventilation, upper-airway obstruction, increased work of breathing, respiratory muscle fatigue, impaired secretion clearance, or the need for comfort-oriented support. In acute care, noninvasive ventilation is well established for acute hypercapnic respiratory failure due to COPD exacerbations and for acute cardiogenic pulmonary edema, whereas high-flow nasal cannula therapy, continuous positive airway pressure, and noninvasive ventilation require more careful selection in patients with acute hypoxemic respiratory failure. In chronic care, home noninvasive ventilation and home high-flow therapy should be understood as components of long-term respiratory care systems rather than as simple device prescriptions. Practical success depends on appropriate interface selection, leak control, humidification, patient-device synchrony, airway clearance, patient education, and safe monitoring. A physiology-oriented and patient-centered framework may improve the appropriate use of noninvasive respiratory therapy across the continuum of care.