Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
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Prediction of Intubation after Bronchoscopy with Non-invasive Positive Pressure Ventilation Support in Patients with Acute Hypoxemic Respiratory Failure

급성 저산소혈증 환자에서 비침습적 양압환기 적용 하 기관지경 검사 후 기관 삽관의 예측 인자

  • Song, Jae-Uk (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kim, Su-A (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Choi, E Ryoung (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Kim, Soo Min (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Choi, Hee Jung (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Lim, So Yeon (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Park, So Young (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Suh, Gee Young (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Jeon, Kyeongman (Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • 송재욱 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 김수아 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 최이령 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 김수민 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 최희정 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 임소연 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 박소영 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 서지영 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과) ;
  • 전경만 (성균관대학교 의과대학 내과학교실 삼성서울병원 호흡기내과)
  • Received : 2009.06.05
  • Accepted : 2009.06.24
  • Published : 2009.07.30
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Abstract

Background: Non-invasive positive pressure ventilation (NPPV) ensures adequate gas exchange during bronchoscopy in spontaneously breathing, hypoxemic patients, thus avoiding endotracheal intubation. However, in some patients, endotracheal intubation is eventually required after bronchoscopy. This study investigated the incidence of intubation and predictors of a need for emergency intubation prior to NPPV bronchoscopy initiation. Methods: On a retrospective basis, we reviewed the medical records of 36 patients (median age, 55 years; interquartile range [IQR], 43~65 years) with acute hypoxemic respiratory failure who required NPPV during bronchoscopy between January 2005 and October 2007. Results: All patients were hypoxemic (median $PaO_2/FiO_2$ ratio 155; IQR 90~190), but tolerated bronchoscopy with NPPV support. SOFA score and SAPS II score immediately before NPPV initiation were 4 (3~7) and 36 (30~42), respectively. Seventeen (47%) patients needed endotracheal intubation at a median time of 22 (2~50) hours after bronchoscopy. Patients who needed intubation after bronchoscopy had a higher in-hospital mortality (11 [65%] vs. 4 [21%], p=0.017). Upon multiple logistic regression analysis, the need for intubation after bronchoscopy was independently associated with a $P_aO_2/FiO_2$ ratio (OR, 0.961; 95% CI, 0.924~0.999; p=0.047) immediately before NPPV initiation for bronchoscopy. Conclusion: The severity of the hypoxemia immediately prior to NPPV initiation for bronchoscopy was associated with the need for intubation after bronchoscopy in patients with hypoxemic respiratory failure.

연구배경: 급성 호흡부전 환자에서 기관지경 검사 시비침습적 양압환기를 적용하면 저산소혈증의 악화 없이 안전하게 검사를 시행할 수 있으나 일부 환자에서는 저산소혈증의 악화로 기계 환기가 필요하게 된다. 본 연구는 저산소혈증으로 비침습적 양압환기 적용 하에 기관지경 검사를 시행한 환자들에서 검사 후 기관 삽관의 빈도 및 예측 인자를 알아보고자 하였다. 방 법: 2005년 1월부터 2007년 10월까지 삼성서울병원 내과계 중환자실에서 기관지경 검사를 받은 환자 210명 중 저산소혈증으로 비침습적 양압환기 적용 하에 기관지경 검사를 시행한 36명의 환자를 대상으로 후향적 조사를 시행하였다. 결 과: 36명의 환자(남:여, 18:18)들의 중앙연령은 55세(사분위 범위, 43~65세)였다. 기관지경 검사 전 SOFA 점수는 4점(3~7점), SAPSII 점수는 37점(30~42점)이었고 P/F ratio는 중앙값 155 (90~190)이었다. 기관지경 검사 후 17명(47%)에서 기관 삽관이 시행되었고, 시술 후 삽관까지 걸린 시간의 중앙값은 22시간(2~50시간) 이었다. 36명의 환자 중 15명(42%)이 사망하였고, 기관 삽관이 필요했던 경우 그렇지 않은 경우보다 병원 내 사망률이 높았다(11 [65%] vs. 4 [21%], p=0.017). 다중 로지스틱 회기분석 결과 기관지경 검사 전의 P/F ratio만이 기관지경 검사 후 기관 삽관과 독립적으로 관련이 있었다(OR, 0.961; 95% CI, 0.924~0.999; p=0.047). 결 론: 급성 호흡부전 환자에서 기관지경 검사 시 저산소혈증의 악화를 방지하기 위해 비침습적 양압환기를 적용할 때 적절한 환자 선택이 중요하며, 중증 저산소혈증환자에서는 기관 삽관을 대비하여 검사 후 집중적인 감시가 필요할 것으로 사료된다.

Keywords

References

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