Abstract: Objective　To evaluate the therapeutic efficacy of high-flow nasal cannula（HFNC） and noninvasive positive-pressure ventilation（NPPV） in patients with acute exacerbations of chronic obstructive pulmonary disease（AECOPD） and various APACHE Ⅱ scores after extubation.Methods　We enrolled 120 patients with AECOPD undergoing tracheal intubation in the Department of Critical Care Medicine，Wuhan First Hospital from December 2014 to November 2016.All patients were assigned to either Group A（APACHE Ⅱ score <12），B（APACHE Ⅱ score of 12 to 24） or C（APACHE Ⅱ score >24） according to the APACHE Ⅱ score，with 40 cases in each group.The patients in each group were then divided into Subgroups Ⅰ（undergoing HFNOT，n=20） and Ⅱ（undergoing NPPV，n=20） using a random number table.The patients' general characteristics were recorded，along with the respiratory parameters and the incidence of endpoints and complications.Results　There were no interactionswith pH value，oxygenation index（OI），partial pressure of carbon dioxide（PaCO2），respiratory rate（RR） and blood lactic acid（Lac） concentration in Group A in terms of the treatment option and duration（P>0.05），and the main effect was not significant in relation to pH value，OI，PaCO2，RR or blood Lac concentration in terms of the treatment option and duration（P>0.05）．In addition，there was no significant difference in the occurrence rate of re-intubation and atelectasis between Subgroups Ⅰ and Ⅱ in Group A（P>0.05），and a significantly lower incidence rate of abdominal distention was seen in Subgroup Ⅰ compared with Subgroup Ⅱ（P<0.05）．In Group B，there were no interactions with pH value，OI，RR or blood Lac concentration in terms of the treatment option and duration（P>0.05），and an interaction was seen with PaCO2（P<0.05），while the main effect was not significant in relation to pH value，OI，RR or blood Lac concentration in terms of the treatment option and duration（P>0.05），but significant in relation to PaCO2（P<0.05）．In addition，the occurrence rate of re-intubation was not significant difference in Subgroup Ⅰ and Subgroup Ⅱ（P>0.05），and a significantly lower incidence rate of abdominal distention and atelectasis was seen in Subgroup Ⅰ compared with Subgroup Ⅱ（P<0.05）．In Group C，there were no interactions with pH value or blood Lac concentration in terms of the treatment option and duration（P>0.05），and there were interactions with OI，PaCO2 and RR（P<0.05）．The main effect was not significant in relation to pH value or blood Lac concentration（P>0.05），but significant in relation to OI，PaCO2 and RR（P<0.05），in terms of the treatment option and duration.Moreover，the occurrence rate of re-intubation was significantly higher in Subgroup Ⅰ than in Subgroup Ⅱ（P<0.05），and a significantly lower incidence rate of abdominal distention and atelectasis was seen in Subgroup Ⅰ compared with Subgroup Ⅱ（P<0.05）．Conclusion　There was no significant difference in the preventive efficacy of sequential therapy with HFNC and NPPV for respiratory failure in elderly AECOPD patients with APACHE Ⅱ scores of <24 after extubation；however，the preventive efficacy of HFNC was inferior to NPPV for respiratory failure in elderly AECOPD patients with APACHE Ⅱ scores of > 24 after extubation.

Key words: Pulmonary disease, chronic obstructive；Positive-pressure respiration；Respiration, artificial；APACHE

摘要： 目的　观察经鼻高流量氧疗（HFNC）与无创正压通气（NPPV）在不同急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分老年慢性阻塞性肺疾病急性加重期（AECOPD）患者拔管后的治疗效果。方法　选取2014年12月—2016年11月于武汉市第一医院重症医学科行气管插管的符合研究标准的120老年例AECOPD患者为研究对象。根据APACHEⅡ评分的高低将患者分为A组（APACHEⅡ评分<12分）、B组（APACHEⅡ评分12~24分）、C组（APACHEⅡ评分>24分），各40例；每组患者采用随机数字表法再分为亚组Ⅰ（HFNC治疗）、亚组Ⅱ（NPPV治疗），各20例。收集患者一般资料，记录呼吸指标、终点事件及并发症发生情况。结果　A组的治疗方法与时间在pH值、氧合指数（OI）、动脉血二氧化碳分压（PaCO2）、呼吸频率（RR）、血乳酸（Lac）上不存在交互作用（P>0.05），治疗方法、时间在pH值、OI、PaCO2、RR、Lac上主效应不显著（P>0.05）；亚组Ⅰ、亚组Ⅱ再次插管及肺不张发生率比较，差异无统计学意义（P>0.05）；亚组Ⅰ腹胀发生率低于亚组Ⅱ（P<0.05）。B组的治疗方法与时间在pH值、OI、RR、Lac上不存在交互作用（P>0.05），在PaCO2上存在交互作用（P<0.05）；治疗方法、时间在pH值、OI、RR、Lac上主效应不显著（P>0.05），在PaCO2上主效应显著（P<0.05）；亚组Ⅰ、Ⅱ再次插管发生率比较，差异无统计学意义（P>0.05），亚组Ⅰ腹胀、肺不张发生率低于亚组Ⅱ（P<0.05）。C组的治疗方法与时间在pH值、Lac上不存在交互作用（P>0.05），在OI、PaCO2、RR上存在交互作用（P<0.05）；治疗方法、时间在pH值、Lac上主效应不显著（P>0.05），在OI、PaCO2、RR上主效应显著（P<0.05）；亚组Ⅰ再次插管发生率高于亚组Ⅱ（P<0.05），腹胀和肺不张发生率低于亚组Ⅱ（P<0.05）。结论　在APACHE Ⅱ评分<24分时，HFNC和NPPV序贯氧疗预防老年AECOPD拔管后呼吸衰竭的效果无差别；APACHE Ⅱ评分>24分时，HFNC预防老年AECOPD拔管后呼吸衰竭的效果劣于NPPV。

关键词: 肺疾病, 慢性阻塞性, 正压呼吸, 呼吸, 人工, 急性病生理学和长期健康评价