每日一题_2022.5.11

A 27-year-old man with viral pneumonia is significantly short of breath, with negative sputum and blood cultures. He is hemodynamically stable, but is having difficulty bringing up his secretions. Arterial blood gas analysis on 6-liter nasal cannula shows pH 7.35, partial arterial carbon dioxide pressure 39 mm Hg, partial arterial oxygen pressure 51 mm Hg, with oxygen saturation of 87%.

Which of the following is the most appropriate next step in management?

A. Intubate for hypoxic respiratory failure.

B. Start noninvasive ventilation for hypoxic respiratory failure. 

C. Start 3% saline nebulizations to loosen his secretions.

D. Start nasal high-flow oxygen therapy.

E. Start broad-spectrum antibiotics.

答案解析：

该患者患有缺氧性呼吸衰竭，已证明有限的干预措施可用于降低这种常见疾病的死亡率。在一项随机对照试验中显示，与无创通气相比，高流量鼻氧治疗（通过鼻插管输送加热和湿化氧气）可降低缺氧性呼吸衰竭患者的90天死亡率。高流量氧疗对上呼吸道产生正压效应，耐受性优于其他形式的通气。如果患者需要机械通气来支持他通过病毒性肺炎，那么这将是正确的选择，但在机械通气前尝试无创通气及其伴随疾病是合理的。关于无创通气是否降低缺氧性呼吸衰竭患者死亡率的文献喜忧参半。在之前引用的试验中，高流量氧疗优于无创通气。雾化吸入松动分泌物和广谱抗生素均未显示可降低病毒性肺炎的死亡率。

正确答案：D