新生儿呼吸衰竭的呼吸机治疗探讨
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摘要
目的:1.探讨呼吸机治疗新生儿呼吸衰竭的效果、并发症及其相关因素。2.分析其它措施对机械通气患儿的辅助治疗作用。
方法:回顾性分析2002年7月～2004年12月在我科新生儿重症监护病房(neonatal intensive care unit, NICU)行呼吸机治疗的86例呼吸衰竭新生儿资料,探讨机械通气及相关措施的应用,比较肺透明膜病(HMD)患儿治愈组与未愈组围生期因素、入院时体温、呼吸机参数、呼吸机相关性肺炎(VAP)、静脉营养天数、肺表面活性物质(PS)和盐酸氨溴索(沐舒坦)的应用等差异。
结果:1.呼吸机治疗新生儿呼吸衰竭的治愈率为71%;呼吸机相关性肺炎的发生率为30.2%,肺炎克雷伯菌和铜绿假单胞菌是呼吸机相关性肺炎常见的致病菌。2.HMD治愈组与未愈组5分钟Apgar评分、呼吸机初调参数及最高参数中的吸入氧浓度(FiO2)、呼吸频率(RR)、呼气末正压(PEEP)、吸气时间(Ti)等无显著性差异(P>0.05);而胎龄、出生体重、1分钟Apgar评分、宫内窘迫、最高参数中的吸气峰压(PIP)、呼吸机相关性肺炎、静脉营养应用天数、PS和沐舒坦的应用等方面,治愈组与未愈组之间存在显著的差异(P<0.05)。3.HMD患儿PS应用组呼吸机参数最高PIP、最高FiO2及其维持时间明显低于未用组(P<0.05);HMD患儿沐舒坦治疗组与未治疗组相比,前者上机期间平均每天吸痰次数明显少于后者(P<0.05)。
结论:呼吸机是治疗新生儿呼吸衰竭的主要手段,呼吸机相关性肺炎是机械通气的主要并发症。加强围生期高危因素的预防,及时防治并发症,合理使用呼吸机,同时应用PS、静脉营养和沐舒坦等辅助措施可提高新生儿呼吸衰竭的治愈率。
Objective: To evaluate the effects of mechanical ventilation and other life-support procedures on neonatal respiratory failure, and to analyze corresponding complications and related high risk factors.
Methods: Eighty-six neonates with respiratory failure were treated by ventilator in our NICU from July 2002 to December 2004. The application of ventilator and related remedies was explored. The differences of perinatal risk factors, temperature, ventilator parameters, incidence of ventilator associated pneumonia, use of surfactant, parenteral nutrition and mucosolvan were compared.
Results: 1.The percentage of curing of critical newborn by ventilator was 71%, and the most common complication was ventilator associated pneumonia(VAP) with an incidence 30.2%. The most familiar bacterium were klebsiella pneumoniae and pseudomonoas. 2.There was no significant difference(P>0.05) in Apgar Score at 5 min, initial parameters of ventilator between the cured group and the uncured group of HMD, nor was FiO2, respiratory rate(RR), positive end-expiratory pressure(PEEP), time of inspiration(Ti) among the highest parameters. But the significant difference of the two groups was observed in gestational age, birth weight, fetal hypoxia, Apgar Score at 1 min, peak inspiratory pressure(PIP) of the highest parameter, complication with VAP, the use of surfactant, parenteral nutrition and mucosolvan(P<0.05). 3. PIP, FiO2 and duration of FiO2 among the highest parameters in surfactant treatment group of HMD were significantly lower than that of non surfactant treatment group(P<0.05). The frequency of aspirating sputum in mucosolvan treatment group of HMD was significantly less than non mucosolvan treatment group(P<0.05).
Conclusions: Assisted mechanical ventilation is an important procedure in the treatment of neonatal respiratory failure. Reinforing the prognostic of perinatal high risk fators, timely prevention and treatment of complication, proper using of respirator, combined with the use of surfactant, parenteral nutrition and mucosolvan can improve the percentage of curing of respiratory failure.
方法:回顾性分析2002年7月～2004年12月在我科新生儿重症监护病房(neonatal intensive care unit, NICU)行呼吸机治疗的86例呼吸衰竭新生儿资料,探讨机械通气及相关措施的应用,比较肺透明膜病(HMD)患儿治愈组与未愈组围生期因素、入院时体温、呼吸机参数、呼吸机相关性肺炎(VAP)、静脉营养天数、肺表面活性物质(PS)和盐酸氨溴索(沐舒坦)的应用等差异。
结果:1.呼吸机治疗新生儿呼吸衰竭的治愈率为71%;呼吸机相关性肺炎的发生率为30.2%,肺炎克雷伯菌和铜绿假单胞菌是呼吸机相关性肺炎常见的致病菌。2.HMD治愈组与未愈组5分钟Apgar评分、呼吸机初调参数及最高参数中的吸入氧浓度(FiO2)、呼吸频率(RR)、呼气末正压(PEEP)、吸气时间(Ti)等无显著性差异(P>0.05);而胎龄、出生体重、1分钟Apgar评分、宫内窘迫、最高参数中的吸气峰压(PIP)、呼吸机相关性肺炎、静脉营养应用天数、PS和沐舒坦的应用等方面,治愈组与未愈组之间存在显著的差异(P<0.05)。3.HMD患儿PS应用组呼吸机参数最高PIP、最高FiO2及其维持时间明显低于未用组(P<0.05);HMD患儿沐舒坦治疗组与未治疗组相比,前者上机期间平均每天吸痰次数明显少于后者(P<0.05)。
结论:呼吸机是治疗新生儿呼吸衰竭的主要手段,呼吸机相关性肺炎是机械通气的主要并发症。加强围生期高危因素的预防,及时防治并发症,合理使用呼吸机,同时应用PS、静脉营养和沐舒坦等辅助措施可提高新生儿呼吸衰竭的治愈率。
Objective: To evaluate the effects of mechanical ventilation and other life-support procedures on neonatal respiratory failure, and to analyze corresponding complications and related high risk factors.
Methods: Eighty-six neonates with respiratory failure were treated by ventilator in our NICU from July 2002 to December 2004. The application of ventilator and related remedies was explored. The differences of perinatal risk factors, temperature, ventilator parameters, incidence of ventilator associated pneumonia, use of surfactant, parenteral nutrition and mucosolvan were compared.
Results: 1.The percentage of curing of critical newborn by ventilator was 71%, and the most common complication was ventilator associated pneumonia(VAP) with an incidence 30.2%. The most familiar bacterium were klebsiella pneumoniae and pseudomonoas. 2.There was no significant difference(P>0.05) in Apgar Score at 5 min, initial parameters of ventilator between the cured group and the uncured group of HMD, nor was FiO2, respiratory rate(RR), positive end-expiratory pressure(PEEP), time of inspiration(Ti) among the highest parameters. But the significant difference of the two groups was observed in gestational age, birth weight, fetal hypoxia, Apgar Score at 1 min, peak inspiratory pressure(PIP) of the highest parameter, complication with VAP, the use of surfactant, parenteral nutrition and mucosolvan(P<0.05). 3. PIP, FiO2 and duration of FiO2 among the highest parameters in surfactant treatment group of HMD were significantly lower than that of non surfactant treatment group(P<0.05). The frequency of aspirating sputum in mucosolvan treatment group of HMD was significantly less than non mucosolvan treatment group(P<0.05).
Conclusions: Assisted mechanical ventilation is an important procedure in the treatment of neonatal respiratory failure. Reinforing the prognostic of perinatal high risk fators, timely prevention and treatment of complication, proper using of respirator, combined with the use of surfactant, parenteral nutrition and mucosolvan can improve the percentage of curing of respiratory failure.
引文
1. 段慧娟. 654-2 治疗新生儿呼吸衰竭 60 例疗效分析[J]. 吉林医学,2004,25(8):62 .
2. 刘兴泽, 邓春芳. 大剂量东莨菪碱治疗新生儿呼吸衰竭的疗效观察[J]. 2004,17 (2):145-146 .
3. Keith J, Barrington, March B, et al. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubati- on of very low birth weight infants[J]. Pediatric,2001,107:638 .
4. Kinsella JP, Parker TA, Lvy DD, et al. Noninvasive delivery of inhaled nitric oxide ther- apy for late pulmonary of hypertention in newborn infants with congenital diaphragmatic hernia[J]. Pediatr,2003,142(4):397-401 .
5. Chotigeat U, Khorana M, Kanjanapatakul W. Outcome of neonates with persistent pulm- onary hypertension of the newborn treated with inhaled nitric oxide[J]. J Med Assoc Thai, 2002,85 (7):800-807 .
6. Truog WZ, Castor CA, Sheffield MJ. Neonatal nitric oxide use: predictors of response a- nd financial implications[J]. J Perinatol,2003,23(2):128-132 .
7. Sadiq HF, Mantych G, Benawra RS, et al. Inhaled nitric oxide in the treatment of moderate persistent pulmonary hypertention of the newborn:a randomized controlled,mu- lticenter trial[J]. Perinatol,2003,23(2):98-103 .
8. Steinhom RH, Albert G, Swartz DD, et al. Recombinant human superoxide dismutase e- nhances the effect of inhaled nitric oxide in persistent pulmonary hypertension[J]. Am J Kespir Crit Care Med,2001,164(5):834-839 .
9. Perreault T. ECMO or no ECMO:Do no harm[J]. An Esp Pediatr,2002,57:1-4 .
10. Stevens TP, chess PR, Mcconnochie KM, et al. Survival in early and late-term infants wi- th congenital diaphragmatic hemia treated with extracorporeal membrane oxygenation[J]. Pediatrics,2002,110 (3):590-596 .
11. Hirchl RB, Philip WF, Glick L, et al. A prospective, randomized pilot trial of perfluoro- carbon-induced lung growth in newborns with congenital diaphragmatic hernia[J].Pediatr Surg,2003,38(3):283-289 .
12. Avi Nahum. Partial liquid ventilation[J]. Clin Pulm Med, 2003,10(2):93-99 .
13. Haeberle H A, Nesti F, Dietrih H J, et al. Perflubron reduces lung inflammation in respir- ratory syncytial virus infection by inhibiting chemokine expression and nuclear factor K- appa B activation[J]. Am J kespir crit care Med,2002,165:1433-1438 .
14. Merz U, Klosterhalfen B, Hausler M, et al. Partial liquid ventilation redues release of le- ukotriene B4 and interleukin-6 in brochoalveolar lavage in surfactant depleted newborn pigs[J]. Pediatr Res,2002,51:183-189 .
15. Von der Hardt K, Kandler MA, Fink L,et al. Laser-assisted miro dissection and real-time PCR detect antiimflammatory effect of perfluorocarbon[J]. Am J Physiol lung cell Mol Physiol,2003,285(1):L55-L62 .
16. 陈丽, 王鸿娟, 文秋生, 等. 应用呼吸机治疗新生儿呼吸衰竭存活儿近期随访观察[J]. 中华儿科杂志,2001,39(1):55-56 .
17. 中华医学会儿科学分会新生儿学组. 新生儿常频机械通气常规[J]. 中华儿科杂志,2004,42(5):356-357 .
18. 周小光, 肖昕, 农绍汉, 等. 新生儿机械通气治疗学[M]. 第 1 版. 北京:人民卫生出版社,2004.149 .
19. 王斌. 新生儿呼吸衰竭的临床管理[J]. 实用儿科临床杂志,2003,18(6):419-422 .
20. Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, et al. Ventilator associated pneumo- nia in extremely preterm-neonates in a neonatal intensive care unit:characteristics, risk f- actors, and outcomes[J]. Pediatrics,2003,112 (6pt1):1283-1289 .
21. Elward Am, Warren Dk, Fraser VJ. Ventilator-associated pneumonia in pediatric in tensi- ve care unit patients:risk factors and outcomes[J]. Pediatrics,2002.109(5):758-764 .
22. Morehead RS, Pinto SJ. Ventilator-associated pneumonia[J]. Arch Intern Med,2000,160 (3):1926-1936 .
23. Ewig S, Bauer T, Torres A. The pulmonary physician in critical care nosocomial pneumonia [J]. Thorax,2002,57:366-371 .
24. Kollef MH. Prenention of hospital-associated pneumonia and ventilator-associated pneumonia[J]. Crit Care Med,2004,32(6):1396-1405 .
25. Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator associated pneumonia rates through a staff education programme[J]. Hosp Infect,2004,57(3):223-227 .
26. Stoller JK, Orens DK, Fatica C, et al. Weekly versus daily hanges of inline suction cathet- ers:impact on rates of ventilator associated pneumonia and associated costs[J]. Respir care, 2003,48:494-499 .
27. Bouza E, Perez A, Munoz P, et al. Ventilator associated pneumonia after heart surgery:a prospective analysis and the value of surveillance[J]. Crit Care Med,2003,31:1964-1970.
28. Shorr AF, O Malley PG. Continuous subglottic suctioning for the prevention of ventilator associated eumonia:potential economic implication[J]. Chest, 2001,119:228-235 .
29. 金汉珍, 黄德珉, 官希吉, 等. 实用新生儿学[M]. 第 3 版. 北京:人民卫生出版社,2003.91 .
30. 陆长东, 何爱兰, 杨黎焱, 等. 肺表面活性物质对新生儿肺透明膜病呼吸力学的影响[J]. 中华急诊医学杂志,2004,13(6):370-372 .
31. Figueras-Aloy J, Quero J, Carbonell-Estrany X, et al. Early administration of the second dose of surfactant(beractant) in the treatment of severe hyaline membrane disease[J].A- cta Paediatr,2001,Mar;90(3):296-301 .
32. Schrama AJJ, Beaufort AJ, Sukul YRM, et al. Phospholipase A2 is present in meconium and inhibits the activity of pulmonary surfatant;an in vitro study[J]. Acta Padiatr,2001,90: 412-416 .
33. Wiswell TE, Knight GR, Finer NN, et al. A multienter, randomized, controlled trial comparing surfaxin(lucinactant) lavage with standard care for treatment of meconium aspiration syndrome[J]. Pediatrics,2002,109(6):1081-1087 .
34. Oh MH, Bae CW. Inhibitory effect of meconium on pulmonary surfactant function tested in vitro using the stable microbubble test[J]. Eur J Pediatr, 2000,159 (10):770-774 .
35. KUPCZYK M, KUNA P. Mucolytics in acute and chronic respiratory tract disorders. I. Pathophysiology and mechanisms of action[J]. Pol Merkuriusz Lek,2002,12(69):248- 252 .
36. KUPCZYK M, KUNA P. Mucolytics in acute and chronic respiratory tract disorders. II. Uses for treatment and antioxidant properties[J]. Pol Merkuriusz Lek,2002,12(69):248- 252 .
37. AIBARA M, DOBASHI K, AKIYAMA M, et al. Effects of N-acetylcsteine and ambroxol on the production of IL-12 and IL-10 in human alveolar macrophages[J]. Respiration, 2000,67 (6):662-671 .
38. 方凤. 肺表面活性物质在新生儿呼吸系统疾病中的临床应用[J]. 实用儿科临床杂志,2003,18 (5):335 .
39. 林广裕, 曾虹, 卢君, 等. 出生后不同时间应用沐舒坦预防早产儿肺透明膜病的临床观察[J]. 中华急诊医学杂志,2003, 2(4):252-254 .
40. Hohlagschwandtner M, Husslein P, Klebermass K, et al. Perinatal mortality and mobidity comparison between maternal transport, neonatal transport and inpatient antenatal treat- ment[J]. Arch Gynecol Obset, 2001,265(3):113-118 .
2. 刘兴泽, 邓春芳. 大剂量东莨菪碱治疗新生儿呼吸衰竭的疗效观察[J]. 2004,17 (2):145-146 .
3. Keith J, Barrington, March B, et al. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubati- on of very low birth weight infants[J]. Pediatric,2001,107:638 .
4. Kinsella JP, Parker TA, Lvy DD, et al. Noninvasive delivery of inhaled nitric oxide ther- apy for late pulmonary of hypertention in newborn infants with congenital diaphragmatic hernia[J]. Pediatr,2003,142(4):397-401 .
5. Chotigeat U, Khorana M, Kanjanapatakul W. Outcome of neonates with persistent pulm- onary hypertension of the newborn treated with inhaled nitric oxide[J]. J Med Assoc Thai, 2002,85 (7):800-807 .
6. Truog WZ, Castor CA, Sheffield MJ. Neonatal nitric oxide use: predictors of response a- nd financial implications[J]. J Perinatol,2003,23(2):128-132 .
7. Sadiq HF, Mantych G, Benawra RS, et al. Inhaled nitric oxide in the treatment of moderate persistent pulmonary hypertention of the newborn:a randomized controlled,mu- lticenter trial[J]. Perinatol,2003,23(2):98-103 .
8. Steinhom RH, Albert G, Swartz DD, et al. Recombinant human superoxide dismutase e- nhances the effect of inhaled nitric oxide in persistent pulmonary hypertension[J]. Am J Kespir Crit Care Med,2001,164(5):834-839 .
9. Perreault T. ECMO or no ECMO:Do no harm[J]. An Esp Pediatr,2002,57:1-4 .
10. Stevens TP, chess PR, Mcconnochie KM, et al. Survival in early and late-term infants wi- th congenital diaphragmatic hemia treated with extracorporeal membrane oxygenation[J]. Pediatrics,2002,110 (3):590-596 .
11. Hirchl RB, Philip WF, Glick L, et al. A prospective, randomized pilot trial of perfluoro- carbon-induced lung growth in newborns with congenital diaphragmatic hernia[J].Pediatr Surg,2003,38(3):283-289 .
12. Avi Nahum. Partial liquid ventilation[J]. Clin Pulm Med, 2003,10(2):93-99 .
13. Haeberle H A, Nesti F, Dietrih H J, et al. Perflubron reduces lung inflammation in respir- ratory syncytial virus infection by inhibiting chemokine expression and nuclear factor K- appa B activation[J]. Am J kespir crit care Med,2002,165:1433-1438 .
14. Merz U, Klosterhalfen B, Hausler M, et al. Partial liquid ventilation redues release of le- ukotriene B4 and interleukin-6 in brochoalveolar lavage in surfactant depleted newborn pigs[J]. Pediatr Res,2002,51:183-189 .
15. Von der Hardt K, Kandler MA, Fink L,et al. Laser-assisted miro dissection and real-time PCR detect antiimflammatory effect of perfluorocarbon[J]. Am J Physiol lung cell Mol Physiol,2003,285(1):L55-L62 .
16. 陈丽, 王鸿娟, 文秋生, 等. 应用呼吸机治疗新生儿呼吸衰竭存活儿近期随访观察[J]. 中华儿科杂志,2001,39(1):55-56 .
17. 中华医学会儿科学分会新生儿学组. 新生儿常频机械通气常规[J]. 中华儿科杂志,2004,42(5):356-357 .
18. 周小光, 肖昕, 农绍汉, 等. 新生儿机械通气治疗学[M]. 第 1 版. 北京:人民卫生出版社,2004.149 .
19. 王斌. 新生儿呼吸衰竭的临床管理[J]. 实用儿科临床杂志,2003,18(6):419-422 .
20. Apisarnthanarak A, Holzmann-Pazgal G, Hamvas A, et al. Ventilator associated pneumo- nia in extremely preterm-neonates in a neonatal intensive care unit:characteristics, risk f- actors, and outcomes[J]. Pediatrics,2003,112 (6pt1):1283-1289 .
21. Elward Am, Warren Dk, Fraser VJ. Ventilator-associated pneumonia in pediatric in tensi- ve care unit patients:risk factors and outcomes[J]. Pediatrics,2002.109(5):758-764 .
22. Morehead RS, Pinto SJ. Ventilator-associated pneumonia[J]. Arch Intern Med,2000,160 (3):1926-1936 .
23. Ewig S, Bauer T, Torres A. The pulmonary physician in critical care nosocomial pneumonia [J]. Thorax,2002,57:366-371 .
24. Kollef MH. Prenention of hospital-associated pneumonia and ventilator-associated pneumonia[J]. Crit Care Med,2004,32(6):1396-1405 .
25. Salahuddin N, Zafar A, Sukhyani L, et al. Reducing ventilator associated pneumonia rates through a staff education programme[J]. Hosp Infect,2004,57(3):223-227 .
26. Stoller JK, Orens DK, Fatica C, et al. Weekly versus daily hanges of inline suction cathet- ers:impact on rates of ventilator associated pneumonia and associated costs[J]. Respir care, 2003,48:494-499 .
27. Bouza E, Perez A, Munoz P, et al. Ventilator associated pneumonia after heart surgery:a prospective analysis and the value of surveillance[J]. Crit Care Med,2003,31:1964-1970.
28. Shorr AF, O Malley PG. Continuous subglottic suctioning for the prevention of ventilator associated eumonia:potential economic implication[J]. Chest, 2001,119:228-235 .
29. 金汉珍, 黄德珉, 官希吉, 等. 实用新生儿学[M]. 第 3 版. 北京:人民卫生出版社,2003.91 .
30. 陆长东, 何爱兰, 杨黎焱, 等. 肺表面活性物质对新生儿肺透明膜病呼吸力学的影响[J]. 中华急诊医学杂志,2004,13(6):370-372 .
31. Figueras-Aloy J, Quero J, Carbonell-Estrany X, et al. Early administration of the second dose of surfactant(beractant) in the treatment of severe hyaline membrane disease[J].A- cta Paediatr,2001,Mar;90(3):296-301 .
32. Schrama AJJ, Beaufort AJ, Sukul YRM, et al. Phospholipase A2 is present in meconium and inhibits the activity of pulmonary surfatant;an in vitro study[J]. Acta Padiatr,2001,90: 412-416 .
33. Wiswell TE, Knight GR, Finer NN, et al. A multienter, randomized, controlled trial comparing surfaxin(lucinactant) lavage with standard care for treatment of meconium aspiration syndrome[J]. Pediatrics,2002,109(6):1081-1087 .
34. Oh MH, Bae CW. Inhibitory effect of meconium on pulmonary surfactant function tested in vitro using the stable microbubble test[J]. Eur J Pediatr, 2000,159 (10):770-774 .
35. KUPCZYK M, KUNA P. Mucolytics in acute and chronic respiratory tract disorders. I. Pathophysiology and mechanisms of action[J]. Pol Merkuriusz Lek,2002,12(69):248- 252 .
36. KUPCZYK M, KUNA P. Mucolytics in acute and chronic respiratory tract disorders. II. Uses for treatment and antioxidant properties[J]. Pol Merkuriusz Lek,2002,12(69):248- 252 .
37. AIBARA M, DOBASHI K, AKIYAMA M, et al. Effects of N-acetylcsteine and ambroxol on the production of IL-12 and IL-10 in human alveolar macrophages[J]. Respiration, 2000,67 (6):662-671 .
38. 方凤. 肺表面活性物质在新生儿呼吸系统疾病中的临床应用[J]. 实用儿科临床杂志,2003,18 (5):335 .
39. 林广裕, 曾虹, 卢君, 等. 出生后不同时间应用沐舒坦预防早产儿肺透明膜病的临床观察[J]. 中华急诊医学杂志,2003, 2(4):252-254 .
40. Hohlagschwandtner M, Husslein P, Klebermass K, et al. Perinatal mortality and mobidity comparison between maternal transport, neonatal transport and inpatient antenatal treat- ment[J]. Arch Gynecol Obset, 2001,265(3):113-118 .