新生儿先天性膈疝及肺保护性通气策略
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摘要
目的探讨新生儿先天性膈疝的肺保护性通气策略。方法选择2013至2018年在浙江省台州医院进行手术的60例先天性膈疝患儿,按照不同的通气策略分为A、B两组;A组使用常频呼吸机和高频震荡呼吸机,B组联合使用体外膜肺氧合呼吸机和常频呼吸机,同时根据病情的严重程度又将患儿分为轻症组和重症组,比较各组患儿术前的通气时间、手术死亡率、术后并发症(包括脱机困难、复张性水肿、气胸和肺部感染)及预后情况。结果 A、B两组轻症患儿的术前通气时间比较差异无统计学意义(P>0.05),B组重症患儿的术前通气时间显著低于A组(t=3.112,P<0.05)。B组轻症患儿的复张性水肿和气胸的发生率均显著低于A组(P值分别为0.035、0.023),肺部感染率显著高于A组(P=0.023);B组重症患儿的死亡率、复张性水肿和气胸的发生率均显著低于A组(P值分别为0.007、0.003、0.001),脱机困难和肺部感染的发生率均显著高于A组(P值分别为0.000、0.004)。A、B两组轻症患儿手术后1年的肺功能各参数比较差异均无统计学意义(均P>0.05);B组重症患儿的潮气量(VT)、呼吸频率(RR)、达峰时间比(TPIEF/TE)均显著低于A组(P值分别为0.009、0.008、0.043),B组重症患儿的分钟通气量(MV)、达峰容积比(VPEF/VE)均显著高于A组(P值分别为0.003、0.047)。结论使用体外膜肺氧合呼吸机进行肺保护性通气相比高频震荡呼吸机能够提高重症新生先天性膈疝患儿的生存机会,并且有利于肺部功能的恢复,但是仍然存在脱机困扰和肺部感染率高的问题。
Objective To explore the pulmonary protective ventilation strategies of congenital diaphragmatic hernia in neonates. Methods Sixty neonates with congenital diaphragmatic hernia who came to Taizhou Hospital for surgery from 2013 to 2018 were selected. According to the different ventilation strategies, they were divided into two groups. Cases in group A used conventional ventilator and high-frequency shock ventilator, and cases in group B used extracorporeal membrane oxygenation ventilator combined with conventional ventilator. Meanwhile, the cases were divided into mild group and severe group according to the severity of disease. The preoperative ventilation time, operative mortality, postoperative complications(including off-line difficulty, reexpansion pulmonary edema, pneumothorax and pulmonary infection) and prognosis were compared among different groups. Results There was no statistically significant difference in preoperative ventilation time between group A and B in cases with mild disease. The preoperative ventilation time of severe patients in group B was significantly lower than that in group A(t=3.112,P<0.05). The incidences of reexpansion pulmonary edema and pneumothorax were remarkably lower in group B than in group A(P value was 0.035 and 0.023, respectively), and the pulmonary infection rate was significantly higher in group B(P=0.023). The mortality and incidence of reexpansion pulmonary edema and pneumothorax were remarkably lower in severe cases in group B than in group A(P value was 0.007, 0.003 and 0.001, respectively), but the incidence of off-line difficulty and pulmonary infection were significantly higher(P value was 0.000 and 0.004, respectively). The difference in parameters of lung function one year after surgery was not significant between two groups of mild cases(P>0.05). Tidal volume(VT), respiration rate(RR), and TPIEF/TE in severe cases in group B were significantly lower than in group A(P value was 0.009, 0.008 and 0.043, respectively), while MV and VPEF/VE in group B were higher than in group A(P value was 0.003 and 0.047, respectively). Conclusion Compared with the high-frequency shock ventilator, extracorporeal membrane oxygenation ventilator can improve the survival chance of cases with severe congenital diaphragmatic hernia, and is beneficial to the recovery of pulmonary function. But it still has the problems of off-line disturbance and high pulmonary infection rate.
Objective To explore the pulmonary protective ventilation strategies of congenital diaphragmatic hernia in neonates. Methods Sixty neonates with congenital diaphragmatic hernia who came to Taizhou Hospital for surgery from 2013 to 2018 were selected. According to the different ventilation strategies, they were divided into two groups. Cases in group A used conventional ventilator and high-frequency shock ventilator, and cases in group B used extracorporeal membrane oxygenation ventilator combined with conventional ventilator. Meanwhile, the cases were divided into mild group and severe group according to the severity of disease. The preoperative ventilation time, operative mortality, postoperative complications(including off-line difficulty, reexpansion pulmonary edema, pneumothorax and pulmonary infection) and prognosis were compared among different groups. Results There was no statistically significant difference in preoperative ventilation time between group A and B in cases with mild disease. The preoperative ventilation time of severe patients in group B was significantly lower than that in group A(t=3.112,P<0.05). The incidences of reexpansion pulmonary edema and pneumothorax were remarkably lower in group B than in group A(P value was 0.035 and 0.023, respectively), and the pulmonary infection rate was significantly higher in group B(P=0.023). The mortality and incidence of reexpansion pulmonary edema and pneumothorax were remarkably lower in severe cases in group B than in group A(P value was 0.007, 0.003 and 0.001, respectively), but the incidence of off-line difficulty and pulmonary infection were significantly higher(P value was 0.000 and 0.004, respectively). The difference in parameters of lung function one year after surgery was not significant between two groups of mild cases(P>0.05). Tidal volume(VT), respiration rate(RR), and TPIEF/TE in severe cases in group B were significantly lower than in group A(P value was 0.009, 0.008 and 0.043, respectively), while MV and VPEF/VE in group B were higher than in group A(P value was 0.003 and 0.047, respectively). Conclusion Compared with the high-frequency shock ventilator, extracorporeal membrane oxygenation ventilator can improve the survival chance of cases with severe congenital diaphragmatic hernia, and is beneficial to the recovery of pulmonary function. But it still has the problems of off-line disturbance and high pulmonary infection rate.
引文
[1]洪小杨,周更须,刘宇航,等.体外膜肺氧合在儿科心肺功能衰竭救治中的临床应用[J].临床儿科杂志,2015,33(1):5-8.
[2]汲玮,黄悦.儿童呼吸机相关性肺损伤及肺保护性通气策略研究进展[J].临床儿科杂志,2015,33(8):743-746.
[3]陈文科,侯昉,刘文英.先天性膈疝的诊治进展[J].中华妇幼临床医学杂志(电子版),2015,11(4):530-534.
[4]肖斌,刘敏,徐畅.先天性膈疝继发新生儿持续肺动脉高压的研究进展[J].中国当代儿科杂志,2015,17(9):1013-1019.
[5]岳梅枝.呼吸机肺保护性通气与序贯通气治疗老年重症肺炎合并呼吸衰竭的疗效比较[J].医学综述,2014,20(16):3043-3045.
[6]胡华琨,李强,彭夕华,等.允许性高碳酸血症在新生儿胸腔镜先天性膈疝修补术中的应用[J].临床麻醉学杂志,2014,30(8):766-769.
[7]Chen Weicheng,Huang Kuoyang,Yao Chihwei,et al.The modified SAVE score:predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department[J].Critical Care (London,England),2016,20(1):233-235.
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[9]Peer Syed M,Ramakrishnan Karthik,Wade James R,et al.Rapid response extracorporeal membrane oxygenation deployment-surgical technique[J].World Journal Pediatric Congenital Heart Surgery,2016,7(6):23-26.
[10]Zanella Alberto,Salerno Domenico,Scaravilli Vittorio,et al.A mathematical model of oxygenation during venovenous extracorporeal membrane oxygenation support[J].Journal Critical Care,2016,36(2):321-324.
[11]Putnam Luke R,Gupta Vikas,Tsao Kuojen,et al.Factors associated with early recurrence after congenital diaphragmatic hernia repair[J].Journal Pediatric Surgery,2017,52(6):143-147.
[12]Bartko Philipp E,Wiedemann Dominik,Schrutka Lore,et al.Impact of right ventricular performance in patients undergoing extracorporeal membrane oxygenation following cardiac surgery[J].Journal American Heart Association,2017,6(8):23-27.
[13]Vaja Ricky,Bakr Ahmed,Sharkey Annabel,et al.The use of extracorporeal membrane oxygenation in neonates with severe congenital diaphragmatic hernia:a 26-year experience from a tertiary centre[J].European Journal Cardio-thoracic Surgery,2017,52(3):113-121.
[14]梁军,庞晓军,杜正隆.体外膜肺氧合疗法研究进展[J].现代预防医学,2011,38(5):999-1000.
[15]Gloria Pelizzo,Maria Chiara Mimmi,Jose Luis Peiro,et al.Congenital diaphragmatic hernia:endotracheal fluid phospholipidic profile following tracheal occlusion in an experimental model[J].Journal Perinatal Medicine,2017,45(2):23-26.
[16]Christiana Farkouh-Karoleski,Tasnim Najaf,Julia Wynn,et al.A definition of gentle ventilation in congenital diaphragmatic hernia:a survey of neonatologists and pediatric surgeons[J].Journal Perinatal Medicine,2017,45(9):113-117.
[17]李菊花,康鹏讲,张茹,等.iNO联合高频震荡通气并西地那非口服对难治性PPHN的作用[J].中国妇幼健康研究,2015,26(4):729-731.
[18]王璐,张晋楚,孙柏平.小儿迟发型膈疝的临床分析[J].中国妇幼健康研究,2013,24(5):692-694.
[19]杜岚岚,梁树,王柱,等.iNO联合HFOV对新生儿持续肺动脉高压的疗效分析[J].中国妇幼健康研究,2017,28(12):1633-1635.
[2]汲玮,黄悦.儿童呼吸机相关性肺损伤及肺保护性通气策略研究进展[J].临床儿科杂志,2015,33(8):743-746.
[3]陈文科,侯昉,刘文英.先天性膈疝的诊治进展[J].中华妇幼临床医学杂志(电子版),2015,11(4):530-534.
[4]肖斌,刘敏,徐畅.先天性膈疝继发新生儿持续肺动脉高压的研究进展[J].中国当代儿科杂志,2015,17(9):1013-1019.
[5]岳梅枝.呼吸机肺保护性通气与序贯通气治疗老年重症肺炎合并呼吸衰竭的疗效比较[J].医学综述,2014,20(16):3043-3045.
[6]胡华琨,李强,彭夕华,等.允许性高碳酸血症在新生儿胸腔镜先天性膈疝修补术中的应用[J].临床麻醉学杂志,2014,30(8):766-769.
[7]Chen Weicheng,Huang Kuoyang,Yao Chihwei,et al.The modified SAVE score:predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department[J].Critical Care (London,England),2016,20(1):233-235.
[8]Ng G W,Yuen H J,Sin K C,et al.Clinical use of venoarterial extracorporeal membrane oxygenation[J].Hong Kong Medical Journal,2017,23(3):123-126.
[9]Peer Syed M,Ramakrishnan Karthik,Wade James R,et al.Rapid response extracorporeal membrane oxygenation deployment-surgical technique[J].World Journal Pediatric Congenital Heart Surgery,2016,7(6):23-26.
[10]Zanella Alberto,Salerno Domenico,Scaravilli Vittorio,et al.A mathematical model of oxygenation during venovenous extracorporeal membrane oxygenation support[J].Journal Critical Care,2016,36(2):321-324.
[11]Putnam Luke R,Gupta Vikas,Tsao Kuojen,et al.Factors associated with early recurrence after congenital diaphragmatic hernia repair[J].Journal Pediatric Surgery,2017,52(6):143-147.
[12]Bartko Philipp E,Wiedemann Dominik,Schrutka Lore,et al.Impact of right ventricular performance in patients undergoing extracorporeal membrane oxygenation following cardiac surgery[J].Journal American Heart Association,2017,6(8):23-27.
[13]Vaja Ricky,Bakr Ahmed,Sharkey Annabel,et al.The use of extracorporeal membrane oxygenation in neonates with severe congenital diaphragmatic hernia:a 26-year experience from a tertiary centre[J].European Journal Cardio-thoracic Surgery,2017,52(3):113-121.
[14]梁军,庞晓军,杜正隆.体外膜肺氧合疗法研究进展[J].现代预防医学,2011,38(5):999-1000.
[15]Gloria Pelizzo,Maria Chiara Mimmi,Jose Luis Peiro,et al.Congenital diaphragmatic hernia:endotracheal fluid phospholipidic profile following tracheal occlusion in an experimental model[J].Journal Perinatal Medicine,2017,45(2):23-26.
[16]Christiana Farkouh-Karoleski,Tasnim Najaf,Julia Wynn,et al.A definition of gentle ventilation in congenital diaphragmatic hernia:a survey of neonatologists and pediatric surgeons[J].Journal Perinatal Medicine,2017,45(9):113-117.
[17]李菊花,康鹏讲,张茹,等.iNO联合高频震荡通气并西地那非口服对难治性PPHN的作用[J].中国妇幼健康研究,2015,26(4):729-731.
[18]王璐,张晋楚,孙柏平.小儿迟发型膈疝的临床分析[J].中国妇幼健康研究,2013,24(5):692-694.
[19]杜岚岚,梁树,王柱,等.iNO联合HFOV对新生儿持续肺动脉高压的疗效分析[J].中国妇幼健康研究,2017,28(12):1633-1635.