肺表面活性物质治疗急性呼吸窘迫综合征研究现状

肺表面活性物质（pulmonary surfactant,PS）是急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）的治疗手段之一,但治疗效果尚不明确。相关研究表明,不同种类的PS、给药剂量、给药方式等因素均可能影响PS使用效果。该文对PS治疗ARDS的研究现状进行概述。     

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目的探讨新生儿常见肺部疾病支气管肺泡灌洗液肺表面活性蛋白A(BALSPA)水平及其与临床的关系。方法收集2000年1月至2003年2月在广州市儿童医院新生儿重症监护室住院的需行机械通气治疗的新生儿重症肺炎、胎粪吸入综合征(MAS)、急性呼吸窘迫综合征(ARDS)以及新生儿呼吸窘迫综合征(RDS)患儿共57例。测定其BALSPA水平,监测血气、PaO2/FiO2水平。结果重症肺炎组与MAS组患儿BALSPA水平无明显差异,但MAS组患儿PaO2、PaCO2及PaO2/FiO2水平较重症肺炎组明显降低(P值<0.01,<0.05,<0.05);ARDS及RDS组患儿BALSPA水平均较上述两组低(P值均<0.001),而RDS组患儿BALSPA水平较ARDS组低(P<0.001),但ARDS组患儿PaO2水平较RDS组患儿低(P<0.05)。PS治疗组患儿的病死率较非PS治疗组明显降低(P=0.049),其PaO2/FiO2与BALSPA水平密切相关(r=0.741,P=0.000)。结论与重症肺炎患儿比较胎粪吸入综合征患儿BALSPA水平无明显降低;ARDS及RDS患儿BALSPA水平明显降低;BALSPA水平能反映新生儿肺损伤的严重程度,对于新生儿肺部疾病预后的判断有一定意义。     

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??Objective To analyze the clinical characteristics and prognosis of pneumonia complicated with acute respiratory distress syndrome??ARDS?? in pediatric hematological patients in order to improve the clinical treatment level. Methods The data of clinical symptoms??laboratory result??treatment??prognosis and risk factors of 35 hematological children with pneumonia and ARDS admitted between March 2012 and January 2015 in Department of Pediatrics??Sun Yat-sen Memorial Hospital??Sun Yat-sen University were retrospectively analyzed. Results The 35 hematological children with pneumonia and ARDS had high fever??71.4%????cough??85.7%????shortness of breath??88.6%????cyanosis??74.3%????three concave sign positive??74.3%?? and lung rale??65.7%??. The level of PaO2/FiO2 decreased??chest X-ray showed patchy or patchy infiltrates??and diffuse exudation and large consolidation in severe cases. A total of 29 strains of pathogens were isolated??including 22 strains of gram-negative bacteria. In 35 ARDS children??23 cases died??65.7%????and the main cause of death was MODS??in 12 cases??52.2%??. The death cause was related to no remission in primary disease??MODS??shock??severe chest infiltration and the use of mechanical ventilation??P??0.05????but not to the way of mechanical ventilation??P??0.05??. Logistic regression analysis showed that MODS and shock were the independent risk factors of death??P??0.05??. Conclusion The hematological children with pneumonia and ARDS should get more attention for its high mortality. It can be diagnosed early according to the clinical symptoms and signs??the blood gas analysis and chest X-ray. MODS and shock are the independent risk factors of death.     

新生儿急性呼吸窘迫综合征研究进展

新生儿急性呼吸窘迫综合征（ARDS）是新生儿常见的临床危重症,是新生儿致死、致残的主要原因之一。新生儿ARDS病因及发病机制复杂,与各种病理因素导致的继发性肺表面活性物质（PS）缺乏有关,具有炎症性特点。新生儿ARDS作为一种临床综合征,与其他疾病难以鉴别。该病的治疗目前缺乏特效手段,仍是以呼吸支持、PS替代、体外膜肺氧合治疗、营养支持及液体管理等对症及综合治疗为主。该文就新生儿ARDS的病因分类、临床特点、诊断治疗策略等方面的研究进展做一综述。     

不同机械通气方式联合肺表面活性物质对新生儿急性肺损伤/急性呼吸窘迫综合征疗效比较

目的 比较高频振荡通气+肺表面活性物质 （HFOV+PS）、常频机械通气+肺表面活性物质 （CMV+PS）、常频机械通气 （CMV）3种治疗方式对新生儿急性肺损伤/急性呼吸窘迫综合征 （ALI/ARDS）的临床疗效。方法 纳入ALI/ARDS新生儿136例 （ALI73例,ARDS63例）,其中HFOV+PS组45例,CMV+PS组53例,CMV组38例,前两组应用肺表面活性物质气管内滴入 （70~100mg/kg）。分别检测机械通气0h、12h、24h、48h、72h的PaO2、PaCO2、PaO2/FiO2、氧合指数 （OI）、呼吸指数 （RI）。结果 机械通气12h、24h、48h时HFOV+PS组的PaO2高于CMV+PS组和CMV组,PaCO2低于CMV+PS组和CMV组 （P < 0.05）;在机械通气12h、24h、48h、72h时HFOV+PS组PaO2/FiO2高于CMV+PS组和CMV组,OI、RI低于CMV+PS组和CMV组 （P < 0.05）;HFOV+PS组机械通气时间、用氧时间均低于CMV+PS组和CMV组 （P < 0.05）;3组气漏、颅内出血发生率及治愈率比较差异无统计学意义。结论 与单纯CMV以及CMV联合PS治疗相比,HFOV联合PS更可改善ALI/ARDS新生儿的肺功能,缩短通气时间及用氧时间,且不增加并发症的发生。     

肺表面活性物质联合布地奈德对急性呼吸窘迫综合征极低出生体质量儿肺功能的影响

目的 探讨肺表面活性物质(PS)联合布地奈德对急性呼吸窘迫综合征(ARDS)极低出生体质量儿肺功能的影响,并评价联合用药的治疗效果.方法 2010年8月-2011年3月南京市妇幼保健院收治的胎龄<34周、出生体质量<1 500 g、出生4 h内发生ARDS的早产儿30例,随机分为PS组和PS+布地奈德组.PS+布地奈德组(男9例,女6例)使用PS和布地奈德混合剂(每70 mg PS中加入0.25 mg布地奈德),剂量:PS 70 mg·kg-1,布地奈德0.25 mg·kg-1.PS组(男8例,女7例)单使用PS,70 mg·kg-1,出生30～60 min内由气管内滴入.监测2组患儿血气及肺功能.结果 PS+布地奈德组患儿动脉血气pH值第2、5、6天明显高于PS组(Pa<0.05),二氧化碳分压[pa(CO2)]第3、4、6天明显降低(Pa<0.05),氧合指数(OI)第3、4、6天明显升高(Pa<0.05);肺功能监测2组胸肺总顺应性(Crs)升高、呼吸道阻力(Raw)下降、潮气量(TV)增加,第5、6天与PS组比较有显著差异(Pa<0.05).结论 使用PS联合布地奈德对ARDS极低出生体质量儿能较快改善肺功能,尽早撤离呼吸机,减少肺损伤,减少早产儿支气管肺发育不良的发生.     

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??Hemofiltration and renal replacement therapy are usually preferred as adjunct therapy for sepsis to improve hemodynamics and fluid balance??as well as to remove noxious molecules and inflammatory factors. It is well known that continuous renal replacement therapy??CRRT?? is an important adjunct therapy for sepsis-associated kidney injury. Recently?? blood purification is widely used to treat septic shock?? acute respiratory distress syndrome??ARDS???? severe acute pancreatitis and electrolyte imbalance. Currently?? there are four differentpatternsofblood purification used including continuous veno-venous hemofiltration??CVVH???? high volume hemofiltration??HVHF???? continuous veno-venous hemodiafiltration??CVVHDF?? and plasma exchange??PE?? in pediatric sepsis. However??there is no standard recommendation for blood purification model and the optimal timing in pediatric sepsis.     

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??Abstract??Objective To evaluate the efficacy of low molecular weight heparin in patients with sepsis . Methods??A total of 24 patients with sepsis were randomly divided into LMWH treatment group and control group. Both groups were examined TAT??AT-??PC??PS??PLT??PT??APTT??Fbg??D-d??FDP and severity score. Results??PC and PS in these two groups were increased after treatments??and those of LMWH treatment group were increased more significantly than those of control group?? there was a significant difference between these two groups ??P < 0.001??. TAT in these two groups fell after treatments??and that of LMWH treatment group fell more significantly than that of control group?? but there was no statistic difference between these two groups ??P > 0.05??. Severity score in these two groups was increased after 2 days′treatment?? severity score in LMWH treatment group was increased more significantly than that of control?? there was a significant difference between these two groups ??P < 0.05??. Conclusion??Low dosage of low molecular weight heparin treatment in patients with sepsis is effective on improving function of hemorrhagic-coagulation and the clinical condition without complications of bleeding.     

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??Clinical and electroencephalographic characteristics of Panayiotopoulos syndrome.????CHEN Chun-hong??WU Hu-sheng??LV Jun-lan. Neurology and Rehabilitation Center??Beijing Children’s Hospital Affiliated to Capital University of Medical Sciences??Beijing 100045??China
Abstract??Objective??To summarize the clinical characteristics and electroencephalographic features of Panayiotopoulos syndrome ??PS?? and to gain better understanding of it. Methods??The clinical data of 8 patients with PS in Neurology and Rehabiliation Center Beijing Children's Hospital affiliated to Capital University of Medical Sciences were analyzed from Apr. 2008 to Dec. 2009. Results??Of the 8 patients??the age of first seizure was from two years and nine months to five years and eleven months??four years in average. Of all the patients??there personal history ?? pregnancy??birth??neonatal period and psychomotor development?? was normal except that two patients had febrile seizures. All patients had ictal vomiting??which was the first apparent symptom??3 patients had pallor and general fatigue??3 patients had nausea and felt uncomfortable??one had dizziness and nausea and one had incontinence of faeces. These autonomic manifestations were followed by seizure symptoms??6 patients manifestated deviation of the eyes?? 2 patients had eyes turned upward??2 patients had ipsilateral head deviation which occurred in 6 of them simultaneously with eye deviation??one patient had unilateral limb jerk??two patients had generalized convulsion and 7 patients had unconsciousness. The duration of seizures were 2 to 3 minutes in one patient??10 to 20 minutes in 6 patients and 2 hours in one. EEG studies showed that occipital spikes were observed in 4 patients??frontal spikes in 2 patients ??centrotemporal spikes in one patient and EEG was normal in one patient. Conclusion??Panayiotopoulos syndrome is an age-related benign idiopathic epilepsy syndrome occurring in early and mid-childhood??it is characterized by seizures??often with predominantly autonomic symptoms??espically emesis??followed by unilateral deviation of the eyes or head??with unconsciousness and generalized convulsion. The EEG mainly reveals multifocal discharge that may appear in any area??often in occipital region. It is emphasized that clinical manifestations are more important in diagnosing PS.     

肺表面活性物质在儿童急性呼吸窘迫综合征的应用

肺表面活性物质(pulmonary surfactant,PS)是由Ⅱ型肺泡上皮细胞合成分泌的脂质蛋白混合物,主要功能是降低肺泡气-液界面表面张力.急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)时多种原因引起PS的量和质出现变化,导致其功能异常.外源性PS替代治疗可以改善儿童ARDS肺部气体交换,但提高存活率作用不肯定.这可能与ARDS病因、PS成分、给药方法、时机、剂量及次数等不同有关.目前不推荐PS作为儿童ARDS的常规治疗方法.