Yogun Bakimda Noninvaziv Yontemlerle Solunum Destegi

.: PREFACE
Ön Söz
Preface
Prof. Dr. Zehra Nur BAYKARA
Kocaeli Üniversitesi Tıp Fakültesi, Anesteziyoloji ve Reanimasyon ABD, Yoğun Bakım BD, Kocaeli
Article Language: TR
Pozitif basınçlı ventilasyonun gelişimi; şüphesiz ki tıp tarihindeki önemli gelişmelerden birisi oldu. Akut solunum yetmezliklerinde yaşam kurtarıcı olabileceğinin görülmesi ve bu açıdan negatif basınç ventilasyonuna üstünlüğünün farkedilmesi, modern yoğun bakım ünitelerinin kuruluşunu hızlandıran en önemli katalizörlerden birisi oldu.1 1960'lı yılların başından itibaren yaygın olarak kullanılmaya başlanan pozitif basınç ventilasyonu uzun seneler sadece havayoluna bir tüp yerleştirilerek (endotrakeal tüp ya da trakeostomi kanülü) invaziv olarak uygulandı. Birçok durumda yaşam kurtarıcı olan invaziv mekanik ventilasyonun kullanılmaya başlamasından kısa bir süre sonra yan etkileri de farkedilmeye başlandı.1,2 Bunların bir kısmı inspirium sırasında havayoluna pozitif basınç uygulamasına bağlı olarak ortaya çıkan etkiler olsa da, bir kısmı da pozitif basınç ventilasyonunun invaziv yolla uygulanması nedeniyle ortaya çıkan yan etkilerdi.2 Havayolu aracının yerleştirilmesi sırasında, ya da uzun süreli olarak havayolunda kalması nedeniyle ortaya çıkabilen yan etkiler morbidite ve bazı durumlarda mortalite artışına neden olabiliyordu. Bu durum, pozitif basınç ventilasyonunun noninvaziv yöntemlerle uygulanmasına olanak sağlayan yöntem arayışına neden oldu. Bu arayışlar sonucu geliştirilen noninvaziv mekanik ventilasyon (NIV), uygun hasta gruplarında ilk seçenek olarak kullanılmaya başlandı. Randomize kontrollü çalışmalar, metaanalizler, geniş kohort çalışmalar NIV'un invaziv mekanik ventilasyonla karşılaştırıldığında daha az enfeksiyöz komplikasyona neden olduğunu gösteren güçlü kanıtlar sundu.3-5 Seçilmiş hasta gruplarında uygulandığında morbidite ve mortalite azalmasına, hastane yatış süresinde kısalmaya neden olabiliyordu.6,7 Bugün NIV, kronik obstrüktif akciğer hastalığı (KOAH)'a bağlı olarak ortaya çıkan, asidozun da eşlik ettiği akut hiperkapnik solunum yetmezliği, kalp yetmezliğine bağlı akut akciğer ödemi, postoperatif solunumyetmezliği, immün yetersizliği olan hastalardaki akut solunum yetmezlikleri, ve palyatif bakım hastalarında ortaya çıkan solunum yetmezliklerinde, kontrendikasyonun olmadığı durumlarda, önerilen mekanik ventilasyon yöntemidir.8 Buna karşın nonhiperkapnik akut solunum yetmezliğinde faydası kesin değildir, tedavi yetmezliği ve sonrasında entübasyon gereksinimi olabilir ki bu durum mortalite artışı ile ilişkili bulunmuştur. NIV'un başarısızlığında altta yatan hastalık yanında arayüzün (maske, nazal yastıkçık, ağız maskesi, vb.) hastaya uygun olmayışı, hastanın koopere olamayışı, ve sağlık ekibinin tecrübesi de rol oynar.

2004'ten itibaren erişkin hastalarda kullanılmaya başlayan ve gittikçe popülaritesi artan yüksek akımlı nazal oksijen (HFNO) tedavisinde ise nemlendirilmiş ve ısıtılmış oksijen/hava karışımı (FiO2 0.21-100), yüksek akımla (60 L'ye kadar), bir nazal kanül yardımıyla hastaya verilir.9 Yüksek akımla özellikle proksimal havayolunda ölü boşluğun yıkanması (washout) yoluyla dakika ventilasyonunun daha yüksek fraksiyonunun alveolar gaz değişimine katkıda bulunması, nazofarinks basıncını artırarak ''PEEP'' etkisi oluşturması, özellikle yüksek akım hızlarında (>30 L) ve ağız kapalı pozisyonda verilen oksijen konsantrasyonunun tahmin edilebilir olması, solunum eforunu azaltması, konvansiyonel oksijen verme sistemlerine göre hastaya verilen oksijen/ hava karışımının daha iyi ısıtılıp, nemlendirilebilmesi HFNO'ini oksijen veren sistemler arasında benzersiz kılmaktadır.7 Nazal kanül yoluyla uygulandığı için, NIV'daki arayüzlerle kıyaslandığında hasta toleransı genel olarak daha yüksektir. Ancak; şu ana kadar yapılan HFNO ÖN SÖZ ile ilgili çalışmalar genellikle gözlemsel çalışmalar ya da heterojen hasta grubunu içeren randomize çalışmalardır.10 Daha geniş ve randomize kontrollü çalışmalara ihtiyaç vardır. Buna karşın HFNO'nin genel olarak yoğun bakım ünitelerinde hüsnü kabulle karşılandığını söylemek mümkündür. En sık akut nonhiperkapnik hipoksik solunum yetmezliği, postoperatif solunum yetmezliği, preoksijenasyon ve entübasyon işlemi sırasında, ekstübasyon sonrası ve fiberoptik bronkoskopi sırasında kullanılmaktadır.9

Şüphesiz ki yoğun bakımcılar mümkün olsa solunum desteği gerektiren tüm hastalarına noninvaziv yolla solunum desteği sunmak ister. Bu, şu an için mümkün görünmüyor. İleride teknolojik gelişmeler buna imkân sağlayabilir mi, bilmiyoruz. Ancak yoğun bakım ünitelerinde noninvaziv yöntemlerle solunum desteği gittikçe artan oranda kullanılıyor ve bu oran gittikçe artacak gibi görünüyor. HFNO'nin her zaman solunum desteği sağlamada NIV kadar başarılı olmasa da, bazı durumlarda NIV'a alternatif bir yöntem olabileceği görülüyor. Bir taraftan HFNO'nin farklı hasta gruplarında kullanımı test edilirken, bir taraftan da NIV'da yeni modlar geliştirildiğini, arayüzlerin hasta konforunu artıracak şekilde modifiye edilmeye çalışıldıklarını görüyoruz.11 Bu yöntemleri uygularken kaçınılmaz görünen entübasyon ve invaziv mekanik ventilasyon gereksinimini geciktirmemek ve uygun indikasyonlarda kullanmak şüphesiz ki önemli noktalar.

Bu kitapta bu iki noninvaziv solunum destek yönteminin entübasyon gereksinimini önlemedeki etkinlikleri ve weaning stratejisi olarak kullanımları iki ayrı derlemede analiz edildi. Bunun yanısıra noninvaziv solunum destek yöntemlerinde hasta seçimi, endikasyonlar, ekipman özellikleri, sedasyon gereksinimi, travma ve KOAH'da kullanımları masaya yatırıldı. Evde noninvaziv yöntemlerle solunum desteği ve noninvaziv solunum destek yöntemleriyle hasta transferi güncel literatür eşliğinde gözden geçirildi. NIV ve HFNO uygulanan hastalarda aerosol tedavisi/nemlendirme ve nutrisyon da iki ayrı derlemede ele alındı.

Türkçe literatüre katkıda bulunacağını düşündüğüm bu kitapta yer alan derlemeleri ben şahsen büyük bir zevkle okudum. Emeği geçen hocalarımıza teşekkür ediyorum. Sizlerin de beğeneceğini umuyorum...

Prof. Dr. Zehra Nur BAYKARA
Editör

KAYNAKLAR
1. Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis. 1988;137(6):1463-93.
2. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70(1):65-76.
3. Nourdine K, Combes P, Carton MJ, Beuret P, Cannamela A, Ducreux JC. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med. 1999;25(6):567-73.
4. Girou E, Brun-Buisson C, Taillé S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. 2003;290(22):2985-91.
5. Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283(2):235-41.
6. Tomii K, Seo R, Tachikawa R, Harada Y, Murase K, Kaji R, et al. Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU. Respir Med. 2009;103(1):67-73.
7. Curley GF, Laffy JG, Zhang H, Slutsky AS. Noninvasive respiratory support for acute respiratory failure-high flow nasal cannula oxygen or non-invasive ventilation? J Thorac Dis. 2015;7(7):1092-7.
8. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2). pii: 1602426.
9. Nishimura M. High-flow nasal cannula oxygen therapy in adults. J Intensive Care. 2015;3(1): 15.
10. https://www.uptodate.com/contents/heated-and-humidified-high-flow-nasal-oxygen-in-adults-practical-considerations-and-potentialapplications.
11. Longhini F, Pan C, Xie J, Cammarota G, Bruni A, Garofalo E, et al. New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study. Crit Care. 20177;21(1):170.

Anahtar Kelimeler: Noninvaziv mekanik ventilasyon; yüksek akımlı nazal oksijen tedavisi
There is no doubt that the development of positive pressure ventilation was one of the most important developments in medical history. The fact that it could be life-saving in acute respiratory failure, and the recognition of its superiority to negative pressure ventilation in this respect, was one of the most important catalysts that accelerated the establishment of modern intensive care units.1 Positive pressure ventilation, which has been used commonly since the early 1960s, was, for many years, an invasive procedure when a tube was placed in the airway; either an endotracheal tube or a tracheostomy cannula. In many cases the side effects began to be noticed shortly after the use of invasive mechanical ventilation, which is life-saving.1,2 Although some of these were adverse effects due to positive pressure application to the airway during inspirium, others were related to the intubation of the airway.2 Side effects that might occur during the placement of the airway device or due to its prolonged stay in the airway might cause morbidity, and in some cases, increased mortality. This situation led to the search for a method which would allow positive pressure ventilation using noninvasive methods. Noninvasive Mechanical Ventilation (NIV), which was developed as a result of this research, was used as the first option in suitable patient groups. Randomized controlled trials, meta-analyses, and extensive cohort studies presented strong evidence that NIV caused fewer infectious complications when compared to invasive mechanical ventilation.3-5Moreover, previous studies have shown that NIV decreases mortality rates of selected patients with acute respiratory failure, and may shorten length of stay at hospital.6,7 Today, in the absence of contraindications, NIV is the recommended method of mechanical ventilation in acute hypercapnic respiratory failure associated with chronic obstructive pulmonary disease (COPD) and accompanied by acidosis, acute pulmonary edema due to heart failure, postoperative respiratory failure, acute respiratory failure in immunocompromised patients, and in respiratory failure in nursing patients.8 However, its benefit in non-hypercapnic acute respiratory failure is uncertain, and there may be treatment failure and subsequent intubation requirement, which are associated with increased mortality. When there is failure of NIV significant factors have been identified which include, in addition to the underlying disease, the interface, consisting of the mask, nasal cushion, mouth mask, and so on not being suitable for the patient, the patient being unable to cooperate, and the experience of the medical team.

In the treatment of High-flow Nasal Oxygen Treatment (HFNO), which has been used in adult patients since 2004 and is increasingly popular, a dampened and heated oxygen/air mixture (FiO2 0.21-100) is given to the patient with the help of a nasal cannula with a high flow (up to 60 L.dk-1).7 HFOT is unique among oxygen-giving systems because of the following characteristics: HFOT has a high flow, especially the higher fraction of minute ventilation through the wash-out of the dead space in the proximal airway contributes to the exchange of alveolar gas; increasing in nasopharynx pressure which creates PEEP effect; the ability to estimate the oxygen concentration given in the closed mouth position especially at high flow rates (>30 L); reducing respiration effort; and heating and dampening of the oxygen/air mixture. Since it is administered through a nasal cannula, patient tolerance is generally higher when compared to the interfaces used for NIV. However, studies conducted on HFNO so far are usually observational studies or randomized trials that involve a heterogeneous patient group.10 Wider and more randomized controlled trials are needed in this respect. However, in Intensive Care Units, HFOT has been welcomed. It is most frequently used in acute non-hypercapnic hypoxic res ÖN SÖZ piratory failure, postoperative respiratory failure, preoxygenation and intubation, after extubation, and during fiberoptic bronchoscopy.9

There is no doubt that intensive care staff would like to apply noninvasive respiratory support to all patients that require respiratory support, if possible. Right now, this does not seem possible for all patients who need respiratory support. We do not know if technological advances will allow this in the future. However, respiratory support is increasingly being used in ICUs with noninvasive methods, and this rate seems likely to increase. In providing respiratory support, although HFNO is not always as successful as NIV in some cases, it seems to be an alternative to NIV. While the use of HFNO is being tested in different patient groups on one hand, we see that new modes are being developed in NIV, and the interfaces are being modified to increase patient comfort on the other.11 It is important not to delay the need for intubation and invasive mechanical ventilation, which seem inevitable, and to use it in appropriate indications when applying these methods.

In this book, the efficiencies of these two noninvasive respiratory support methods in preventing the need for intubation, and their use as a weaning strategy were analyzed in two separate compilations. In addition, patient selection, indications, equipment characteristics, sedation needs, trauma and their use in COPD were discussed in noninvasive respiratory support methods. Patient transfer with noninvasive respiratory support methods and noninvasive respiratory support methods at home were reviewed in the current literature. Aerosol therapy/ moisturization and nutrition in patients undergoing NIV and HFNO were dealt with in two separate reviews.

I personally read with pleasure the compilations in this book, which I think will contribute to Turkish literature. I would like to thank the authors who contributed to it. I hope you will also like it...

Prof. Dr. Zehra Nur BAYKARA
Editor

REFERENCES
1. Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis. 1988;137(6):1463-93.
2. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70(1):65-76.
3. Nourdine K, Combes P, Carton MJ, Beuret P, Cannamela A, Ducreux JC. Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey. Intensive Care Med. 1999;25(6):567-73.
4. Girou E, Brun-Buisson C, Taillé S, Lemaire F, Brochard L. Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema. JAMA. 2003;290(22):2985-91.
5. Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000;283(2):235-41.
6. Tomii K, Seo R, Tachikawa R, Harada Y, Murase K, Kaji R, et al. Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU. Respir Med. 2009;103(1):67-73.
7. Curley GF, Laffy JG, Zhang H, Slutsky AS. Noninvasive respiratory support for acute respiratory failure-high flow nasal cannula oxygen or non-invasive ventilation? J Thorac Dis. 2015;7(7):1092-7.
8. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2). pii: 1602426.
9. Nishimura M. High-flow nasal cannula oxygen therapy in adults. J Intensive Care. 2015;3(1): 15.
10. https://www.uptodate.com/contents/heated-and-humidified-high-flow-nasal-oxygen-in-adults-practical-considerations-and-potentialapplications.
11. Longhini F, Pan C, Xie J, Cammarota G, Bruni A, Garofalo E, et al. New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study. Crit Care. 20177;21(1):170.

Keywords: High flow nasal oxygen; noninvasive ventilation

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Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com