切换至 "中华医学电子期刊资源库"

第五届中国出版政府奖音像电子网络出版物奖提名奖

中国科技核心期刊

中国科学引文数据库(CSCD)来源期刊

中华重症医学电子杂志

指南与规范    

机械通气患者雾化治疗指南
中华医学会重症医学分会重症呼吸学组   
  • 收稿日期:2021-06-30 接受日期:2021-07-08 出版日期:2021-07-09 发布日期:2021-07-09
  • 通讯作者: 邱海波, E-mail:haiboq2000@163.com
  • Received:2021-06-30 Accepted:2021-07-08 Online:2021-07-09 Published:2021-07-09
       重症患者50%~70%需要接受机械通气治疗[1-2],雾化治疗是机械通气时常同步应用的集束化气道管理方法之一。雾化(气溶胶吸入疗法)是将支气管扩张剂、激素或抗菌药物等制成气溶胶,以气溶胶或雾的形式输送入气道和肺,从而达到治疗疾病或者缓解症状的目的[3-4]。雾化不同于湿化,湿化是指在一定的温度控制下,应用湿化器将水分散成水蒸汽,以一定的速度喷入呼吸道,达到湿润气道黏膜,稀释痰液,保持呼吸道黏液纤毛系统的正常运动和廓清功能的一种物理疗法[5]。
       机械通气雾化治疗时,气溶胶从雾化装置中产生输送入呼吸机管路,并在正压的作用下输送抵达下呼吸道,整个过程受到多种复杂因素的影响,规范雾化治疗中的各个环节有利于提高雾化药物的输送效率和保障治疗效果。既往调查表明,我国机械通气患者雾化治疗仍不规范,各医疗机构在雾化实施方面也存在较大的差异[6]。为规范临床机械通气患者雾化治疗行为,中华医学会重症医学分会依据国内外最新的研究进展及专家意见,归纳和构建了10个在机械通气患者雾化治疗临床实践中常见的重要问题,并采用目前国际广泛使用的循证医学方法--GRADE(Grades of Recommendation,Assessment,Development,and Evaluation,即推荐分级评估、制定和评价)方法制定了本指南(指南制定方法见附件1)。
[1] Liu L, Gao Z, Yang Y, et al. Economic variations in patterns of care and outcomes of patients receiving invasive mechanical ventilation in China: a national cross-sectional survey [J]. J Thorac Dis, 2019, 11(7): 2878-2889.
[2] Du B, An Y, Kang Y, et al. Characteristics of critically ill patients in ICUs in mainland China [J]. Crit Care Med, 2013, 41(1): 84-92.
[3] Stein SW, Thiel CG. The history of therapeutic aerosols: a chronological review [J]. J Aerosol Med Pulm Drug Deliv, 2017, 30(1): 20-41.
[4] Dhanani J, Fraser JF, Chan HK, et al. Fundamentals of aerosol therapy in critical care [J]. Crit Care, 2016, 20(1): 269.
[5] Plotnikow GA, Accoce M, Navarro E, et al. Humidification and heating of inhaled gas in patients with artificial airway. A narrative review [J]. Rev Bras Ter Intensiva, 2018, 30(1): 86-97.
[6] Zhang Z, Xu P, Fang Q, et al. Practice pattern of aerosol therapy among patients undergoing mechanical ventilation in mainland China: A web-based survey involving 447 hospitals [J]. PLoS One, 2019, 14(8): e0221577.
[7] Moustafa IOF, ElHansy MHE, Al Hallag M, et al. Clinical outcome associated with the use of different inhalation method with and without humidification in asthmatic mechanically ventilated patients [J]. Pulm Pharmacol Ther, 2017, 45: 40-46.
[8] Galindo-Filho VC, Alcoforado L, Rattes C, et al. A mesh nebulizer is more effective than jet nebulizer to nebulize bronchodilators during non-invasive ventilation of subjects with COPD: A randomized controlled trial with radiolabeled aerosols [J]. Respir Med, 2019, 153: 60-67.
[9] Galindo-Filho VC, Ramos ME, Rattes CS, et al. Radioaerosol pulmonary deposition using mesh and jet nebulizers during noninvasive ventilation in healthy subjects [J]. Respir Care, 2015, 60(9): 1238-1246.
[10] Dhand R. How should aerosols be delivered during invasive mechanical ventilation? [J]. Respir Care, 2017, 62(10): 1343-1367.
[11] Phipps PR, Gonda I. Droplets produced by medical nebulizers. Some factors affecting their size and solute concentration [J]. Chest, 1990, 97(6): 1327-1332.
[12] Hess D, Fisher D, Williams P, et al. Medication nebulizer performance. Effects of diluent volume, nebulizer flow, and nebulizer brand [J]. Chest, 1996, 110(2): 498-505.
[13] Ari A, Atalay OT, Harwood R, et al. Influence of nebulizer type, position, and bias flow on aerosol drug delivery in simulated pediatric and adult lung models during mechanical ventilation [J]. Respir Care, 2010, 55(7): 845-851.
[14] Sutherasan Y, Ball L, Raimondo P, et al. Effects of ventilator settings, nebulizer and exhalation port position on albuterol delivery during non-invasive ventilation: an in-vitro study [J]. BMC Pulm Med, 2017, 17(1): 9.
[15] Dugernier J, Ehrmann S, Sottiaux T, et al. Aerosol delivery during invasive mechanical ventilation: a systematic review [J]. Crit Care, 2017, 21(1): 264.
[16] Moustafa IOF, Ali MRA, Al Hallag M, et al. Lung deposition and systemic bioavailability of different aerosol devices with and without humidification in mechanically ventilated patients [J]. Heart Lung, 2017, 46(6): 464-467.
[17] Moraine JJ, Truflandier K, Vandenbergen N, et al. Placement of the nebulizer before the humidifier during mechanical ventilation: Effect on aerosol delivery [J]. Heart Lung, 2009, 38(5): 435-439.
[18] 冉碧勤, 谭道琼. 有创呼吸机不同雾化器位置的气道疗效对比 [J]. 中国继续医学教育, 2017, 9(4): 247-248.
[19] 江源源, 胡蕾, 刘敏, 等. 不同雾化位置对机械通气患者气道治疗的影响 [J]. 巴楚医学, 2019, 2(3): 99-102+115.
[20] 温敏, 郑凤梅, 李桂贤, 等. 雾化器不同位置对机械通气病人气道疗效的观察 [J]. 全科护理, 2011, 9(15): 1324-1325.
[21] Ari A, Areabi H, Fink JB. Evaluation of aerosol generator devices at 3 locations in humidified and non-humidified circuits during adult mechanical ventilation [J]. Respir Care, 2010, 55(7): 837-844.
[22] Mouloudi E, Katsanoulas K, Anastasaki M, et al. Bronchodilator delivery by metered-dose inhaler in mechanically ventilated COPD patients: influence of tidal volume [J]. Intensive Care Med, 1999, 25(11): 1215-1221.
[23] Dugernier J, Reychler G, Wittebole X, et al. Aerosol delivery with two ventilation modes during mechanical ventilation: a randomized study [J]. Ann Intensive Care, 2016, 6(1): 73.
[24] Mouloudi E, Prinianakis G, Kondili E, et al. Bronchodilator delivery by metered-dose inhaler in mechanically ventilated COPD patients: influence of flow pattern [J]. Eur Respir J, 2000, 16(2): 263-268.
[25] 王琳, 关纯, 秦贤, 等. 不同模式与参数设置下机械通气时雾化吸入对呼吸力学指标的影响 [J]. 中华危重病急救医学, 2018, 30(11): 1036-1040.
[26] Mouloudi E, Katsanoulas K, Anastasaki M, et al. Bronchodilator delivery by metered-dose inhaler in mechanically ventilated COPD patients: influence of end-inspiratory pause [J]. Eur Respir J, 1998, 12(1): 165-169.
[27] 徐小雅, 江美芳, 王永生, 等. 氧气驱动雾化吸入联合无创呼吸机治疗在COPD合并呼吸衰竭患者中的应用及护理 [J]. 四川医学, 2013, 34(7): 1099-1101.
[28] 曾宇红, 姚赟, 沈佩雷, 等. 经无创呼吸机雾化吸入治疗AECOPD合并Ⅱ型呼吸衰竭的临床观察 [J]. 药品评价, 2016, 13(20): 47-49.
[29] 郄国玲, 韩江玲, 张换春, 等. 不同雾化方式在慢性阻塞性肺疾病患者无创通气中的疗效观察 [J]. 护士进修杂志, 2014, 29(11): 1014-1016.
[30] 彭晓卉. 无创呼吸机联合氧气驱动雾化吸入治疗慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭的临床疗效 [J]. 临床合理用药杂志, 2018, 11(9): 113-114.
[31] 粟玲, 沈瑶, 杨叶梦, 等. 无创机械通气串联雾化吸入治疗老年慢性阻塞性肺疾病急性加重期合并Ⅱ型呼吸衰竭的临床观察 [J]. 老年医学与保健, 2020, 26(2): 245-249.
[32] 李登媛, 周向东. 无创通气联合不同时机雾化吸入治疗AECOPD合并Ⅱ型呼吸衰竭患者的疗效对比 [J]. 现代医药卫生, 2016, 32(6): 833-835.
[33] Nava S, Karakurt S, Rampulla C, et al. Salbutamol delivery during non-invasive mechanical ventilation in patients with chronic obstructive pulmonary disease: a randomized, controlled study [J]. Intensive Care Med, 2001, 27(10): 1627-1635.
[34] 彭磊, 宋燕燕, 王祺东, 等. 无创正压通气串联雾化吸入治疗对AECOPD合并2型呼吸衰竭患者的疗效分析 [J]. 系统医学, 2017, 2(7): 57-60.
[35] 孙文欣, 庄凤艳, 万梅. 两种时机应用氧气驱动雾化吸入在无创正压通气治疗COPD患者中的疗效观察 [J]. 中国继续医学教育, 2015, 7(20): 137-138.
[36] 武玉斌, 吴祖凤. 不同雾化方式在Ⅱ型呼吸衰竭的疗效观察 [J]. 安徽医药, 2015, 19(04): 806-808.
[37] 俞亦好, 戴新建. 2种雾化吸入法的效果比较 [J]. 中国实用护理杂志, 2009, (8): 36-37.
[38] Abdelrahim ME, Plant P, Chrystyn H. In-vitro characterisation of the nebulised dose during non-invasive ventilation [J]. J Pharm Pharmacol, 2010, 62(8): 966-972.
[39] Branconnier MP, Hess DR. Albuterol delivery during noninvasive ventilation [J]. Respir Care, 2005, 50(12): 1649-1653.
[40] Calvert LD, Jackson JM, White JA, et al. Enhanced delivery of nebulised salbutamol during non-invasive ventilation [J]. J Pharm Pharmacol, 2006, 58(11): 1553-1557.
[41] Chatmongkolchart S, Schettino GP, Dillman C, et al. In vitro evaluation of aerosol bronchodilator delivery during noninvasive positive pressure ventilation: effect of ventilator settings and nebulizer position [J]. Crit Care Med, 2002, 30(11): 2515-2519.
[42] Dai B, Kang J, Sun LF, et al. Influence of exhalation valve and nebulizer position on albuterol delivery during noninvasive positive pressure ventilation [J]. J Aerosol Med Pulm Drug Deliv, 2014, 27(2): 125-132.
[43] Haw A, McPeck M, Cuccia AD, et al. Face mask leak determines aerosol delivery in noninvasive ventilation [J]. Respir Care, 2021, 66(1): 95-103.
[44] Michotte JB, Jossen E, Roeseler J, et al. In vitro comparison of five nebulizers during noninvasive ventilation: analysis of inhaled and lost doses [J]. J Aerosol Med Pulm Drug Deliv, 2014, 27(6): 430-440.
[45] Peng Y, Dai B, Hu CX, et al. Which nebulizer position should be avoided? an extended study of aerosol delivery and ventilator performance during noninvasive positive pressure ventilation [J]. Respiration, 2018, 95(3): 145-153.
[46] Boe J, Dennis JH, O'Driscoll BR, et al. European Respiratory Society Guidelines on the use of nebulizers [J]. Eur Respir J, 2001, 18(1): 228-242.
[47] van Meenen DMP, van der Hoeven SM, Binnekade JM, et al. Effect of on-demand vs routine nebulization of acetylcysteine with salbutamol on ventilator-free days in intensive care unit patients receiving invasive ventilation: a randomized clinical trial [J]. Jama, 2018, 319(10): 993-1001.
[48] Wu SH, Shyu LJ, Li CH, et al. Better airway resistance reduction profile in intubated COPD patients by personalized bronchodilator dosing: A pilot randomized control trial [J]. Pulm Pharmacol Ther, 2018, 49: 134-139.
[49] Routine nebulized ipratropium and albuterol together are better than either alone in COPD. The COMBIVENT Inhalation Solution Study Group [J]. Chest, 1997, 112(6): 1514-1521.
[50] Singh D, Agusti A, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019 [J]. Eur Respir J, 2019, 53(5).
[51] Beltaief K, Msolli MA, Zorgati A, et al. Nebulized terbutaline and ipratropium bromide versus terbutaline alone in acute exacerbation of chronic obstructive pulmonary disease requiring noninvasive ventilation: a randomized double-blind controlled trial [J]. Acad Emerg Med, 2019, 26(4): 434-442.
[52] Riise GC, Qvarfordt I, Larsson S, et al. Inhibitory effect of N-acetylcysteine on adherence of Streptococcus pneumoniae and Haemophilus influenzae to human oropharyngeal epithelial cells in vitro [J]. Respiration, 2000, 67(5): 552-558.
[53] Pérez-Giraldo C, Rodríguez-Benito A, Morán FJ, et al. Influence of N-acetylcysteine on the formation of biofilm by Staphylococcus epidermidis [J]. J Antimicrob Chemother, 1997, 39(5): 643-646.
[54] Kashef N, Karami S, Djavid GE. Phototoxic effect of hypericin alone and in combination with acetylcysteine on Staphylococcus aureus biofilms [J]. Photodiagnosis Photodyn Ther, 2015, 12(2): 186-192.
[55] Arshad Q, Asghar S, Shafqat E, et al. Role of N-Acetylcysteine in clearance of secretions in mechanical ventilated patients [J]. 2019.
[56] Masoompour SM, Anushiravani A, Tafaroj Norouz A. Evaluation of the effect of nebulized N-Acetylcysteine on respiratory secretions in mechanically ventilated patients: randomized clinical trial [J]. Iran J Med Sci, 2015, 40(4): 309-315.
[57] 鲍洁. N-乙酰半胱氨酸在ARDS中的应用评价 [J]. 医药论坛杂志, 2015, 36(12): 137-138.
[58] Abdellatif S, Trifi A, Daly F, et al. Efficacy and toxicity of aerosolised colistin in ventilator-associated pneumonia: a prospective, randomised trial [J]. Ann Intensive Care, 2016, 6(1): 26.
[59] Hassan NA, Awdallah FF, Abbassi MM, et al. Nebulized Versus Ⅳ Amikacin as adjunctive antibiotic for hospital and ventilator-acquired pneumonia postcardiac surgeries: a randomized controlled trial [J]. Crit Care Med, 2018, 46(1): 45-52.
[60] Kollef MH, Ricard JD, Roux D, et al. A randomized trial of the Amikacin Fosfomycin Inhalation System for the Adjunctive Therapy of Gram-negative ventilator-associated pneumonia: IASIS trial [J]. Chest, 2017, 151(6): 1239-1246.
[61] Liu C, Zhang YT, Peng ZY, et al. Aerosolized Amikacin as adjunctive therapy of ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria: a single-center randomized controlled Trial [J]. Chin Med J (Engl), 2017, 130(10): 1196-1201.
[62] Lu Q, Yang J, Liu Z, et al. Nebulized ceftazidime and amikacin in ventilator-associated pneumonia caused by Pseudomonas aeruginosa [J]. Am J Respir Crit Care Med, 2011, 184(1): 106-115.
[63] Moradi Moghaddam O, Niakan Lahiji M, Talebi-Taher M, et al. Effect of inhaled colistin on the treatment of ventilator-associated pneumonia due to multi-drug resistant acinetobacter [J]. Tanaffos, 2019, 18(1): 66-73.
[64] Niederman MS, Chastre J, Corkery K, et al. BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with Gram-negative pneumonia [J]. Intensive Care Med, 2012, 38(2): 263-271.
[65] Niederman MS, Alder J, Bassetti M, et al. Inhaled amikacin adjunctive to intravenous standard-of-care antibiotics in mechanically ventilated patients with Gram-negative pneumonia (INHALE): a double-blind, randomised, placebo-controlled, phase 3, superiority trial [J]. Lancet Infect Dis, 2020, 20(3): 330-340.
[66] Rattanaumpawan P, Lorsutthitham J, Ungprasert P, et al. Randomized controlled trial of nebulized colistimethate sodium as adjunctive therapy of ventilator-associated pneumonia caused by Gram-negative bacteria [J]. J Antimicrob Chemother, 2010, 65(12): 2645-2649.
[67] Stokker J, Karami M, Hoek R, et al. Effect of adjunctive tobramycin inhalation versus placebo on early clinical response in the treatment of ventilator-associated pneumonia: the VAPORISE randomized-controlled trial [J]. Intensive Care Med, 2020, 46(3): 546-548.
[68] Hallal A, Cohn SM, Namias N, et al. Aerosolized tobramycin in the treatment of ventilator-associated pneumonia: a pilot study [J]. Surg Infect (Larchmt), 2007, 8(1): 73-82.
[69] 王昕华, 赵弘卿. 抗生素不同给药方式治疗呼吸机相关性肺炎的临床观察 [J]. 中国药业, 2015, 24(23): 46-48.
[70] 岳新召. 雾化吸入阿米卡星治疗呼吸机相关性肺炎的疗效及可行性研究 [J]. 临床合理用药杂志, 2016, 9(15): 38-39-42.
[71] 张文. 妥布霉素雾化吸入联合静脉使用抗生素治疗呼吸机相关性肺炎有效性和安全性观察 [J]. 中国社区医师, 2020, 36(14): 64-66.
[72] Khorvash F, Yaghoubi S, Farsaei S, et al. Comparison of two therapeutic approaches for the management of ventilator-associated pneumonia due to multidrug-resistant Acinetobacter: a randomized clinical trial study [J]. J Immunoassay Immunochem, 2020, 41(1): 97-105.
[73] Montgomery AB, Vallance S, Abuan T, et al. A randomized double-blind placebo-controlled dose-escalation phase 1 study of aerosolized amikacin and fosfomycin delivered via the PARI investigational eFlow® inline nebulizer system in mechanically ventilated patients [J]. J Aerosol Med Pulm Drug Deliv, 2014, 27(6): 441-448.
[1] 张成, 黄怀, 沈丹彤, 古菁, 叶水林, 邢然然, 钱绮雯, 李新亚, 叶云霞. 膈肌超声对脑卒中后机械通气患者脱机的评估研究[J]. 中华医学超声杂志(电子版), 2019, 16(11): 832-837.
[2] 宫丹丹, 徐爽, 姜晓东, 于健. 右美托咪定抑制脓毒症患者炎症反应的可能机制及剂量相关性研究[J]. 中华危重症医学杂志(电子版), 2021, 14(01): 10-14.
[3] 周元, 杨秀滨. 非体外循环冠状动脉旁路移植术后机械通气时间延长的危险因素及预后分析[J]. 中华危重症医学杂志(电子版), 2020, 13(03): 181-187.
[4] 胡马洪, 孟建标, 焦燕娜, 赖志珍, 刘梅, 庞丽莎, 徐敏荣, 张微, 王铁钧, 张庚. 布托啡诺与丙泊酚对急性呼吸衰竭行无创机械通气躁动患者镇静作用的比较研究[J]. 中华危重症医学杂志(电子版), 2020, 13(03): 188-194.
[5] 肖爱兵, 宋佳, 龚仕金, 王敏佳, 胡伟航, 鲁海燕. 膈肌超声预测ICU机械通气患者拔管结局的临床研究[J]. 中华危重症医学杂志(电子版), 2019, 12(04): 250-255.
[6] 刘卫明, 齐建雄, 孙妙艳, 金同新, 林燕梅, 罗德成. 有创-无创序贯机械通气联合纳美芬治疗重度Ⅱ型呼吸衰竭临床分析[J]. 中华肺部疾病杂志(电子版), 2020, 13(6): 0-0.
[7] 李立, 代兴, 郁静. 肺部超声联合膈肌运动度在机械通气患者拔管中的临床应用[J]. 中华肺部疾病杂志(电子版), 2020, 13(5): 0-0.
[8] 张晓雪, 杨志旭, 盖小荣. 气道分泌物淀粉酶水平对呼吸机相关肺炎风险的预测[J]. 中华肺部疾病杂志(电子版), 2020, 13(5): 0-0.
[9] 王斌, 黄学文, 黄学琴, 徐智. 联合应用机械通气、肌松剂、硫酸镁抢救高原危重哮喘持续状态一例[J]. 中华肺部疾病杂志(电子版), 2019, 12(03): 395-397.
[10] 孙晓林, 马四清, 潘世琴, 孙丽娟, 路艳萍, 张霞. 集束化干预策略对高原ICU机械通气患者呼吸机相关性肺炎的预防效果[J]. 中华重症医学电子杂志, 2021, 07(01): 33-38.
[11] 刘伟明, 侯晓红, 丁敏, 闫晶, 王桂莲, 刘敏, 王玉萍, 刘霞. 院内转运流程在新型冠状病毒肺炎机械通气患者中的应用[J]. 中华重症医学电子杂志, 2021, 07(01): 81-83.
[12] 蔡书翰, 杨晓, 张婧, 胡波, 彭志勇. 重症新型冠状病毒肺炎的病理生理和基于心肺功能保护的呼吸支持策略[J]. 中华重症医学电子杂志, 2020, 06(04): 393-397.
[13] 张斌, 曹薇, 吴秀, 刘运安, 赵媛, 张青青, 王胜昱. 综合脱机指数预测机械通气脱机价值的Meta分析[J]. 中华重症医学电子杂志, 2019, 05(03): 243-248.
[14] 吴亮, 龚仕金, 虞意华, 王敏佳, 徐靓, 叶聪, 徐玲芸, 林昌标. 体外膈肌起搏对老年神经调节辅助通气患者预后的改善作用[J]. 中华老年病研究电子杂志, 2020, 07(04): 27-31.
[15] 美克拉依·阿不都克里木, 木塔里甫·买合木提, 张大权. 外科重症监护室呼吸机相关性肺炎发生与胃食管反流的相关性研究[J]. 中华胃食管反流病电子杂志, 2020, 07(03): 164-166.
阅读次数
全文


摘要