153例极/超低出生体重儿初始无创持续气道正压通气失败的不良预后及关联性因素分析
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摘要
目的探讨对极/超低出生体重(VLBW/ELBW)儿行初始无创持续气道正压通气失败的不良预后及关联性因素。方法纳入2016年1月1日至2017年9月30日,胎龄<32.0周且出生体质量<1.50 kg,出生后30 min内给予无创持续气道正压通气的VLBW/ELBW儿153例,按照无创持续气道正压通气的结局分为成功组(n=126)和失败组(n=27)。采用回顾性队列研究方法,分析两组间的危险因素和近期预后,包括存活率、肺出血、气胸、颅内出血、晚发型脓毒症(LOS)、新生儿坏死性小肠结肠炎(NEC)、支气管肺发育不良(BPD)、早产儿视网膜病(ROP)、宫外生长迟缓(EUGR)等,并对失败组进行死因分析。结果危险因素分析中,单因素分析发现两组间胎龄、出生体质量、围产期窒息和早发型脓毒症(EOS)差异有统计学意义(P<0.05),多因素Logistics回归分析发现出生体质量、围产期窒息与初始无创持续气道正压通气失败有统计学意义的关联(P<0.05),出生体质量截断值为1.17 kg(敏感性0.78,特异性0.71,曲线下面积0.80,P<0.001)。近期预后分析中,两组间的死亡率、肺出血、LOS及ROP发病率差异有统计学意义,其中与肺出血、死亡率关联性最大;失败组的死因顺位前2位依次为肺出血、颅内出血,肺出血致死者胎龄29.6(26.8, 30.3)周、出生体质量0.80(0.74, 1.11)kg。结论 VLBW/ELBW儿初始无创持续气道正压通气失败率17.6%,低出生体质量(<1.17 kg)及围产期窒息为VLBW/ELBW儿初始无创持续气道正压通气失败的主要预测因素;初始无创持续气道正压通气失败是该组人群死亡、肺出血、LOS及ROP的独立危险因素;肺出血和颅内出血是初始无创持续气道正压通气失败的主要直接死亡原因,其中出生体质量≤0.80 kg的ELBW儿肺出血致死发生率高。
Objective To analysis the cause and adverse outcome of initial noninvasive continuous positive airway pressure failure in very/extremely low weight(VLBW/ELBW) infants. Methods A total of 153 VLBW/ELBW infants with the birth wight <1.50 kg and gestational age<32.0 weeks in Shandong Provincial Hospital Affiliated to Shandong University from January 1,2016 to September 30,2017 w ere enrolled. The infants w ere divided into noninvasive-S group( n = 126),in w hich the noninvasive support w as successful,and noninvasive-F group( n = 27),in w hich the noninvasive support w as failed. In-hospital outcomes,including survival rate,pneumorrhagia,pneumothorax,intracranial hemorrhage,late-onset sepsis( LOS),neonatal necrotizing enterocolitis( NEC),bronchopulmonary dysplasia( BPD),retinopathy of prematurity( ROP) and extrauterine growth retardation( EUGR),were compared between the tw o groups. Logistic regression models w ere used to further investigate the perinatal factors associated w ith noninvasive failure and its correlation w ith the adverse outcomes during hospitalization of the infants. Results The gestation age,birth w eight,perinatal asphyxia and EOS w ere statistical different betw een the tw o groups( P<0.05),and the Logistic regression analysis show ed that birth w eight and perinatal asphyxia w ere associated w ith noninvasive failure( P<0.05).The ROC analysis show ed that birth w eight <1.17 kg w as the most significant cutoff value for the development of noninvasive failure w ith sensibility being 0.78,specificity being 0.71,and area under the curve being 0.80,P<0.001. Logistic regression analysis for short-outcome show ed that the death rate,pneumorrhagia,LOS and ROP w ere statistical different betw een the tw o groups( P<0.05). The tw o crucial causes of death w ere pneumorrhagia and intracranial hemorrhage in noninvasive-F group,and the gestational age of the dead infants caused by pneumorrhagia w as 29. 6( 26. 8,30.3) w eeks and birth w eight w as 0.80( 0.74,1.11) kg. Conclusion The rate of noninvasive failure w as 17.6% in VLBW/ELBW infants,and low er birth w eight( <1.17 kg) and perinatal asphyxia are associated w ith noninvasive failure. Noninvasive failure in preterm infants is associated w ith death,pneumorrhagia,LOS,and ROP. The leading causes of death are pneumorrhagia,especially for the infants w ith birth w eight ≤0.80 kg,and intracranial hemorrhage.
Objective To analysis the cause and adverse outcome of initial noninvasive continuous positive airway pressure failure in very/extremely low weight(VLBW/ELBW) infants. Methods A total of 153 VLBW/ELBW infants with the birth wight <1.50 kg and gestational age<32.0 weeks in Shandong Provincial Hospital Affiliated to Shandong University from January 1,2016 to September 30,2017 w ere enrolled. The infants w ere divided into noninvasive-S group( n = 126),in w hich the noninvasive support w as successful,and noninvasive-F group( n = 27),in w hich the noninvasive support w as failed. In-hospital outcomes,including survival rate,pneumorrhagia,pneumothorax,intracranial hemorrhage,late-onset sepsis( LOS),neonatal necrotizing enterocolitis( NEC),bronchopulmonary dysplasia( BPD),retinopathy of prematurity( ROP) and extrauterine growth retardation( EUGR),were compared between the tw o groups. Logistic regression models w ere used to further investigate the perinatal factors associated w ith noninvasive failure and its correlation w ith the adverse outcomes during hospitalization of the infants. Results The gestation age,birth w eight,perinatal asphyxia and EOS w ere statistical different betw een the tw o groups( P<0.05),and the Logistic regression analysis show ed that birth w eight and perinatal asphyxia w ere associated w ith noninvasive failure( P<0.05).The ROC analysis show ed that birth w eight <1.17 kg w as the most significant cutoff value for the development of noninvasive failure w ith sensibility being 0.78,specificity being 0.71,and area under the curve being 0.80,P<0.001. Logistic regression analysis for short-outcome show ed that the death rate,pneumorrhagia,LOS and ROP w ere statistical different betw een the tw o groups( P<0.05). The tw o crucial causes of death w ere pneumorrhagia and intracranial hemorrhage in noninvasive-F group,and the gestational age of the dead infants caused by pneumorrhagia w as 29. 6( 26. 8,30.3) w eeks and birth w eight w as 0.80( 0.74,1.11) kg. Conclusion The rate of noninvasive failure w as 17.6% in VLBW/ELBW infants,and low er birth w eight( <1.17 kg) and perinatal asphyxia are associated w ith noninvasive failure. Noninvasive failure in preterm infants is associated w ith death,pneumorrhagia,LOS,and ROP. The leading causes of death are pneumorrhagia,especially for the infants w ith birth w eight ≤0.80 kg,and intracranial hemorrhage.
引文
[1] Glass HC, Costarino AT, Stayer SA, et al. Outcomes for extremely premature infants[J]. Anesth Analg, 2015, 120(6): 1337-1351.
[2] SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Finer NN, Carlo WA, et al. Early CPAP versus surfactant in extremely preterm infants[J]. N Engl J Med, 2010, 362(21): 1970-1979.
[3] 范雪, 陈娟. 早产儿初始持续气道正压通气失败的危险因素分析[J]. 华西医学, 2017, 32(4): 586-588.
[4] Meneses J, Bhandari V, Alves JG, et al. Noninvasive ventilation for respiratory distress syndrome: a randomized controlled trial[J]. Pediatrics, 2011, 127(2): 300-307.
[5] Dargaville PA, Aiyappan A, De Paoli AG, et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences[J]. Neonatology, 2013, 104(1): 8-14.
[6] De Jaegere AP, van der Lee JH, Canté C, et al. Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation[J]. Acta Paediatr, 2012, 101(4): 374-379.
[7] 邵肖梅, 叶鸿瑁, 邱小汕. 实用新生儿学[M]. 4版.北京:人民卫生出版社, 2011: 396, 408, 479, 702.
[8] Jobe AH, Bancalari E. Bronchopulmonary dysplasia[J]. Am J Respir Crit Care Med, 2001, 163(7): 1723-1729.
[9] Verani JR, McGee L, Schrag SJ, et al. Prevention of perinatal group B streptococcal disease-revised guidelines from CDC, 2010[J]. MMWR Recomm Rep, 2010, 59(RR-10): 1-36.
[10] 陈栋, 刘兆娥, 于永慧, 等. 超未成熟儿和超低出生体重儿早期存活率及影响因素分析[J]. 中华新生儿科杂志, 2017, 32(6): 401-405. CHEN Dong, LIU Zhaoe, YU Yonghui, et al. The early survival rate and its influencing factors of extremely premature and extremely low birth weight infants[J]. Chinese Journal of Neonatology, 2017, 32(6): 401-405.
[11] Buch P, Makwana AM, Chudasama RK, et al. Usefulness of Downe score as clinical assessment tool and bubble CPAP as primary respiratory support in neonatal respiratory distress syndrome[J]. Journal of Pediatric Sciences, 2013, 5(1): e176.
[12] Hameed NN, Abdul Jaleel RK, Saugstad OD. The use of continuous positive airway pressure in preterm babies with respiratory distress syndrome: a report from Baghdad, Iraq[J]. J Matern Fetal Neonatal Med, 2014, 27(6): 629-632.
[13] Dargaville PA, Gerber A, Johansson S, et al. Incidence and outcome of CPAP failure in preterm infants[J]. Pediatrics, 2016, 138(1): e20153985. doi:10.1542/peds.2015-3985.
[14] Sweet DG, Carnielli V, Greisen G, et al. European consensus guidelines on the management of respiratory distress syndrome-2016 update[J]. Neonatology, 2017, 111(2): 107-125.
[15] 中国医师协会新生儿科医师分会. 早产儿呼吸窘迫综合征早期防治专家共识[J].发育医学电子杂志, 2017, 5 (3): 129-131.
[16] Eichenwald EC, Committee on Fetus and Newborn, American Academy of Pediatrics. Apnea of prematurity[J]. Pediatrics, 2016, 137(1): 1-7.
[17] 中国新生儿复苏项目专家组. 中国新生儿复苏指南(2016年北京修订)[J]. 中华围产医学杂志, 2016, 19(7): 481-486.
[18] Sweet DG, Carnielli V, Greisen G, et al. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants: 2013 update[J]. Neonatology, 2013, 103(4): 353-368.
[19] Committee on Fetus and Newborn, American Academy of Pediatrics. Respiratory support in preterm infants at birth[J]. Pediatrics, 2014, 133(1): 171-174.
[20] Soll RF, Edwards EM, Badger GJ, et al. Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009[J]. Pediatrics, 2013, 132(2): 222-228.
[21] Tagliaferro T, Bateman D, Ruzal-Shapiro C, et al. Early radiologic evidence of severe respiratory distress syndrome as a predictor of nasal continuous positive airway pressure failure in extremely low birth weight newborns[J]. J Perinatol, 2015, 35(2): 99-103.
[22] Pillai MS, Sankar MJ, Mani K, et al. Clinical prediction score for nasal CPAP failure in pre-term VLBW neonates with early onset respiratory distress[J]. J Trop Pediatr, 2011, 57(4): 274-279.
[23] 仇杰, 臧丽娇, 庄根苗, 等. 不同胎龄围生期窒息与多器官功能损伤的相关性[J]. 山东大学学报(医学版), 2016, 54(9): 64-68.QIU Jie, ZANG Lijiao, ZHUANG Genmiao, et al. Correlation between multiorgan damage and perinatal asphyxia occurred at different gestational ages[J]. Journal of Shandong University (Health Sciences), 2016, 54(9): 64-68.
[24] 刘颖钏, 邬方彦, 印学蕾. 超低出生体重儿122例早期生存质量分析[J]. 中华新生儿科杂志, 2018(1): 39-44.LIU Yingchuan, WU Fangyan, YIN Xuelei. The study of quality of life of extremely low birth weight infants: an early life report of 122 cases[J]. Chinese Journal of Neonatology, 2018(1): 39-44.
[2] SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Finer NN, Carlo WA, et al. Early CPAP versus surfactant in extremely preterm infants[J]. N Engl J Med, 2010, 362(21): 1970-1979.
[3] 范雪, 陈娟. 早产儿初始持续气道正压通气失败的危险因素分析[J]. 华西医学, 2017, 32(4): 586-588.
[4] Meneses J, Bhandari V, Alves JG, et al. Noninvasive ventilation for respiratory distress syndrome: a randomized controlled trial[J]. Pediatrics, 2011, 127(2): 300-307.
[5] Dargaville PA, Aiyappan A, De Paoli AG, et al. Continuous positive airway pressure failure in preterm infants: incidence, predictors and consequences[J]. Neonatology, 2013, 104(1): 8-14.
[6] De Jaegere AP, van der Lee JH, Canté C, et al. Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation[J]. Acta Paediatr, 2012, 101(4): 374-379.
[7] 邵肖梅, 叶鸿瑁, 邱小汕. 实用新生儿学[M]. 4版.北京:人民卫生出版社, 2011: 396, 408, 479, 702.
[8] Jobe AH, Bancalari E. Bronchopulmonary dysplasia[J]. Am J Respir Crit Care Med, 2001, 163(7): 1723-1729.
[9] Verani JR, McGee L, Schrag SJ, et al. Prevention of perinatal group B streptococcal disease-revised guidelines from CDC, 2010[J]. MMWR Recomm Rep, 2010, 59(RR-10): 1-36.
[10] 陈栋, 刘兆娥, 于永慧, 等. 超未成熟儿和超低出生体重儿早期存活率及影响因素分析[J]. 中华新生儿科杂志, 2017, 32(6): 401-405. CHEN Dong, LIU Zhaoe, YU Yonghui, et al. The early survival rate and its influencing factors of extremely premature and extremely low birth weight infants[J]. Chinese Journal of Neonatology, 2017, 32(6): 401-405.
[11] Buch P, Makwana AM, Chudasama RK, et al. Usefulness of Downe score as clinical assessment tool and bubble CPAP as primary respiratory support in neonatal respiratory distress syndrome[J]. Journal of Pediatric Sciences, 2013, 5(1): e176.
[12] Hameed NN, Abdul Jaleel RK, Saugstad OD. The use of continuous positive airway pressure in preterm babies with respiratory distress syndrome: a report from Baghdad, Iraq[J]. J Matern Fetal Neonatal Med, 2014, 27(6): 629-632.
[13] Dargaville PA, Gerber A, Johansson S, et al. Incidence and outcome of CPAP failure in preterm infants[J]. Pediatrics, 2016, 138(1): e20153985. doi:10.1542/peds.2015-3985.
[14] Sweet DG, Carnielli V, Greisen G, et al. European consensus guidelines on the management of respiratory distress syndrome-2016 update[J]. Neonatology, 2017, 111(2): 107-125.
[15] 中国医师协会新生儿科医师分会. 早产儿呼吸窘迫综合征早期防治专家共识[J].发育医学电子杂志, 2017, 5 (3): 129-131.
[16] Eichenwald EC, Committee on Fetus and Newborn, American Academy of Pediatrics. Apnea of prematurity[J]. Pediatrics, 2016, 137(1): 1-7.
[17] 中国新生儿复苏项目专家组. 中国新生儿复苏指南(2016年北京修订)[J]. 中华围产医学杂志, 2016, 19(7): 481-486.
[18] Sweet DG, Carnielli V, Greisen G, et al. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants: 2013 update[J]. Neonatology, 2013, 103(4): 353-368.
[19] Committee on Fetus and Newborn, American Academy of Pediatrics. Respiratory support in preterm infants at birth[J]. Pediatrics, 2014, 133(1): 171-174.
[20] Soll RF, Edwards EM, Badger GJ, et al. Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009[J]. Pediatrics, 2013, 132(2): 222-228.
[21] Tagliaferro T, Bateman D, Ruzal-Shapiro C, et al. Early radiologic evidence of severe respiratory distress syndrome as a predictor of nasal continuous positive airway pressure failure in extremely low birth weight newborns[J]. J Perinatol, 2015, 35(2): 99-103.
[22] Pillai MS, Sankar MJ, Mani K, et al. Clinical prediction score for nasal CPAP failure in pre-term VLBW neonates with early onset respiratory distress[J]. J Trop Pediatr, 2011, 57(4): 274-279.
[23] 仇杰, 臧丽娇, 庄根苗, 等. 不同胎龄围生期窒息与多器官功能损伤的相关性[J]. 山东大学学报(医学版), 2016, 54(9): 64-68.QIU Jie, ZANG Lijiao, ZHUANG Genmiao, et al. Correlation between multiorgan damage and perinatal asphyxia occurred at different gestational ages[J]. Journal of Shandong University (Health Sciences), 2016, 54(9): 64-68.
[24] 刘颖钏, 邬方彦, 印学蕾. 超低出生体重儿122例早期生存质量分析[J]. 中华新生儿科杂志, 2018(1): 39-44.LIU Yingchuan, WU Fangyan, YIN Xuelei. The study of quality of life of extremely low birth weight infants: an early life report of 122 cases[J]. Chinese Journal of Neonatology, 2018(1): 39-44.