无创高频通气技术在早产儿的应用

无创高频通气（NIHFV）是利用鼻塞、鼻咽管或面罩替代气管插管进行高频通气的一种新兴无创通气支持模式。NIHFV结合了经鼻持续气道正压通气（NCPAP）和高频通气（HFV）的优点,具有持续维持肺泡稳定,更有利于清除CO2,压力伤更小,不需要同步技术等优势。小样本研究表明NIHFV可作为其他无创通气失败后的营救性治疗从而避免和延迟气管插管,但是目前临床资料有限,需要进一步的多中心、大样本、随机对照研究。     

新生儿无创正压通气

无创正压通气是主要采取经鼻或口鼻面罩作为连接方式进行的机械通气,目的 是减少有创通气的严重并发症.有经鼻持续呼吸道正压和间歇正压通气模式.主要应用于急性呼吸窘迫综合征初始治疗、气管插管拔管后和早产儿呼吸暂停.     

3岁及3岁以下呼吸衰竭患儿拔除气管插管后行无创通气支持和吸氧治疗对比:前瞻性随机对照临床试

目的无创正压通气（ noninvasive positive-pressure ventila-tion,NIV）对预防患儿因呼吸衰竭再次气管插管的作用并不明确。本研究旨在评估气管拔管失败率,建立随机方案,并分析开展有说服力的随机对照研究来比较NIV和吸氧对呼吸衰竭患儿拔管后48 h内再次插管的预防作用。     

新生儿重症湿肺高危因素分析

目的 探讨新生儿重症湿肺的临床特征及需要机械辅助通气治疗的影响因素.方法 对167例新生儿湿肺进行回顾性分析,观察其临床特征、预后,分析需要机械辅助通气治疗的影响因素.结果 167例患儿中早产儿69例(41.2%).161例(96.4%)患儿入院时存在呼吸衰竭,72例(43.1%)需行气管插管机械通气.辅助通气组111例(气管插管72例,经鼻呼气末正压通气39例),非辅助通气组56例.两组患儿在年龄、出生体重、剖宫产率、性别比方面差异无显著性.全部患儿中24例合并心脏疾病,28例合并缺氧缺血性脑病,51例合并吸入性肺炎.湿肺患儿中胎龄<34周(OR=3.398,95%CI:1.113～10.369)及合并心脏疾病(OR=4.122,95%CI:1.173～14.481)者,需辅助通气的危险增加.是否有重度窒息、是否合并缺氧缺血性脑病及吸入性肺炎,未被证实是湿肺患儿需辅助通气的影响因素.结论 早产儿重症湿肺发生率较高,湿肺患儿胎龄<34周及合并心脏疾病时需要机械辅助通气的危险增加.     

儿童睡眠呼吸暂停低通气综合征及无创正压通气治疗的研究进展

儿童睡眠呼吸暂停低通气综合征在流行病学、病因学、诊断、临床表现、病理生理及治疗方面与成人有很大差异，大多数患儿手术切除扁桃体及／或腺样体效果良好，但仍有部分患儿需家庭无创机械通气治疗。本文就儿童睡眠呼吸暂停低通气综合征及应用无创通气治疗的研究进展进行综述。     

新生儿无创辅助呼吸支持介绍

随着新生儿微创辅助通气时代的到来及“开肺策略”的提出,新生儿的无创通气技术理念在世界范围内的NICU得到普及。该文复习了近年来新生儿无创通气技术的有关文献并作简要综述。持续气道正压通气（CPAP）主要原理为在呼气末予以压力支持的一种通气模式,又称之为持续扩张压或呼气末正压通气,经过世界范围内多年的临床实践,CPAP已被证实是一种有效的对患有呼吸系统疾病的新生儿实施呼吸支持的辅助通气模式。由于CPAP价格相对便宜,且易于在临床应用,因此更适合于在发展中国家推广。CPAP辅助通气,除可显著地改善患儿机体的氧合外,对有不同程度气道阻塞的患儿,它可以减轻气道塌陷,因此有助于减少患儿呼吸暂停的发生。文献研究表明,对于32周以下的早产儿,早期应用CPAP可减少患儿气管插管机械通气的机率。该文将试图介绍几种不同的CPAP应用装置和几种不同的CPAP应用方法。虽然对于早期应用CPAP是否能够降低新生儿死亡率及患病率目前尚不十分清楚,但临床实践已经表明,与有创通气比较,CPAP对患儿的损伤小,是一种较为舒适的通气模式,早期应用CPAP还可减少肺泡表面活性物质的使用频率。另外,该文还介绍CPAP的应用指征、优点及其局限性,CPAP的衍生模式如经鼻间歇正压辅助通气以及infant flow CPAP装置等。     

无创正压通气在儿科重症监护病区中应用

无创正压通气(NPPV)是机械通气的一种形式，是指使用鼻／面罩而不经气管插管或切开增加肺泡通气的正压通气方法。20世纪90年代以来，临床随机对照研究进一步证实了NPPV的有效性和可依从性，在成人各种急性呼吸衰竭的治疗中占有重要位置，渐成为急性呼吸衰竭患者的一线治疗方法。但是，国内在儿科临床应用上至今未见报道。现总结近年来我院儿科重症监护病区(PICU)应用NPPV治疗儿科急性呼吸衰竭的情况，报告如下。     

早产极低出生体质量儿撤机后两种鼻塞式辅助通气方式的临床疗效比较

目的 比较在呼吸机撤机后的早产儿中应用鼻塞式同步间歇指令通气(nSIMV)和鼻塞式持续气道正压通气(nCPAP)的临床疗效.方法 52例需要使用气管插管、SIMV通气的早产儿,出生体质量<1 500 g,孕周<34周,当呼吸机参数降至FiO2<0.4,频率<20次/min,给予氨茶碱负荷量后拔除气管插管.患儿随机分为nSIMV组和nCPAP组.观察记录患儿撤机后72 h的临床情况.结果 两组患儿出生孕周、出生体质量、气管插管上机时间比较差异均无显著性(P>0.05).nSIMV组与nCPAP组比较,撤机失败率低、严重呼吸暂停较少、高碳酸血症和低氧血症发生率低,组间比较差异均有显著性(P<0.05).喂养不耐受、坏死性小肠结肠炎、呼吸机相关性肺炎、败血症、支气管肺发育不良和住院时间的组间比较差异无显著性(P>0.05).结论 nSIMV能更有效地对早产极低出生体质量儿撤机后进行呼吸支持.这一无创辅助通气方式将有更广阔的应用前景.     

头盔无创支持通气在小儿先天性心脏病术后应用的安全性和有效性评价

目的：通过总结32例应用无创头盔进行无创压力支持通气患儿的临床结果,分析其应用的安全性和显效特点,并为先天性心脏病( congenital heart disease,CHD)术后患儿无创通气( non-invasive ventilation,NIV)适应证的合理选择提出依据。方法2015年7月至2015年12月期间我院心胸外科1岁以上CHD术后患儿,NIV实施后1 h临床改善的患儿定义为早期有效组( Group-E),否则为非早期有效组( Group-NE)。记录入选患儿的一般资料、疾病诊断、需要NIV主要原因、ICU停留时间、ICU并发症、病死率以及住院天数。结果共入选使用头盔NIV者32例,18例(56.25％)为Group-E,14例(43.75％)为Group-NE。 Group-E中15例避免再次气管插管,持续有效率为83.33％(15/18),而Group-NE中6例避免再次气管插管,持续有效率为42.86％(6/14),差异有统计学意义(P＝0.02)。两组NIV 1 h(NIV-1h)结果显示,心率、呼吸频率和血乳酸水平Group-E明显低于Group-NE,pH值、PaO2/FiO2和舒适度评分 Group-E优于 Group-NE。结束 NIV(NIV-end)时,PaCO2水平 Group-E 明显低于Group-NE,而两组的氧合指标差异不明显。分析组内变化,Group-E在基线状态( NIV-base)、NIV-1h和NIV-end时各指标基本呈进行性改善趋势,而Group-NE不同时间点差异基本无统计学意义,并且在NIV-end时表现高碳酸血症和镇静过度趋势。两组呼吸机相关性肺炎的发生率分别为33.33％(6/18)和71.43％(10/14),差异有统计学意义(χ2＝4.571,P＝0.03)。 Group-E总体机械通气时间明显少于Group-NE[(136.72±151.49)h比(252.79±155.33)h,P<0.05]。结论头盔NIV在CHD术后能够被患儿良好耐受并避免气管插管,早期改善的患儿临床结果更具优势,机械通气时间和相关并发症减少。早期改善可作为是否继续使用NIV有价值的参考指标。     

新生儿无创神经辅助通气支持的临床应用

神经辅助通气(neurally adjusted ventilatory assist,NAVA)是呼吸的时间和程度都由患者控制的一种呼吸模式,持续监测患儿的呼吸节律,以膈肌电活动信号(electrical activity of diaphragm,Edi)作为辅助通气的信号,使得不考虑漏气时无创辅助通气的同步得以实现.无创NAVA的优势在于改善人机同步,可靠的呼吸监测,自主调节呼吸.理论上,这些优点使无创NAVA成为呼吸衰竭新生儿有效理想的呼吸支持方式.无创NAVA作为一种新兴的呼吸支持模式用于降低新生儿气管插管率,实现早期拔管,可作为一种新型的持续正压通气模式.     

�޴���Ƶͨ���������������Ӧ��

??Non-invasive high-frequency ventilation??NIHFV?? is a newer form of non-invasive ventilation??NIV?? which uses nasopharyngeal tubes??short nasal prongs or masks instead of endotracheal tube to deliver high frequency ventilation. NIHFV offers the advantages of invasive high frequency ventilation??no need for synchronisation??high CO2 removal??less volume/barotrauma?? and nasal CPAP??non-invasive interface??increase in functional residual capacity allowing oxygenation to improve??. Clinical pilot studies show NIHFV can be used as a rescue therapy after failure of other NIV modes to help prevent or delay intubation. However??the data is limited. Further multi-center??prospective??randomized??controlled trials are needed.     

Current methods of non-invasive ventilatory support for neonates

Non-invasive ventilatory support can reduce the adverse effects associated with intubation and mechanical ventilation, such as bronchopulmonary dysplasia, sepsis, and trauma to the upper airways. In the last 4 decades, nasal continuous positive airway pressure (CPAP) has been used to wean preterm infants off mechanical ventilation and, more recently, as a primary mode of respiratory support for preterm infants with respiratory insufficiency. Moreover, new methods of respiratory support have been developed, and the devices used to provide non-invasive ventilation (NIV) have improved technically. Use of NIV is increasing, and a variety of equipment is available in different clinical settings. There is evidence that NIV improves gas exchange and reduces extubation failure after mechanical ventilation in infants. However, more research is needed to identify the most suitable devices for particular conditions; the NIV settings that should be used; and whether to employ synchronized or non-synchronized NIV. Furthermore, the optimal treatment strategy and the best time for initiation of NIV remain to be identified. This article provides an overview of the use of non-invasive ventilation (NIV) in newborn infants, and the clinical applications of NIV.     

A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure

OUTCOMES: To compare the benefits of noninvasive ventilation (NIV) plus standard therapy vs. standard therapy alone in children with acute respiratory failure; assess method effectiveness in improving gas exchange and vital signs; and assess method safety. DESIGN: Prospective, randomized, controlled study. SITE: Two pediatric intensive care units in Santiago, Chile, at Clínica Santa María and Clínica Dávila, respectively. PATIENTS AND METHODS: Fifty patients with acute respiratory failure admitted to pediatric intensive care units were recruited; 25 patients were randomly allocated to noninvasive inspiratory positive airway pressure and expiratory positive airway pressure plus standard therapy (study group); the remaining 25 were given standard therapy (control group). Both groups were comparable in demographic terms. INTERVENTIONS AND MEASUREMENTS: The study group received NIV under inspiratory positive airway pressure ranging between 12 cm and 18 cm H2O and expiratory positive airway pressure between 6 cm and 12 cm H2O. Vital signs (cardiac and respiratory frequency), Po2, Pco2, pH, and Po2/Fio2 were recorded at the start and 1, 6, 12, 24, and 48 hrs into the study. RESULTS: Heart rate and respiratory rate improved significantly with NIV. Heart rate and respiratory rate were significantly lower after 1 hr of treatment compared with admission (p = 0.0009 and p = 0.004, respectively). The trend continued over time, heart rate being significantly lower than control after the first hour and heart rate after 6 hrs. With NIV, Po2/Fio2 improved significantly from the first hour. The endotracheal intubation was significantly lower (28%) in the NIV group than in the control group (60%; p = 0.045). CONCLUSIONS: NIV improves hypoxemia and the signs and symptoms of acute respiratory failure. NIV seems to afford these patients protection from endotracheal intubation.     

Clinical practice

The most important goal of introducing noninvasive ventilation (NIV) has been to decrease the need for intubation and, therefore, mechanical ventilation in newborns. As a result, this technique may reduce the incidence of bronchopulmonary dysplasia (BPD). In addition to nasal CPAP, improvements in sensors and flow delivery systems have resulted in the introduction of a variety of other types of NIV. For the optimal application of these novelties, a thorough physiological knowledge of mechanics of the respiratory system is necessary. In this overview, the modern insights of noninvasive respiratory therapy in newborns are discussed. These aspects include respiratory support in the delivery room; conventional and modern nCPAP; humidified, heated, and high-flow nasal cannula ventilation; and nasal intermittent positive pressure ventilation. Finally, an algorithm is presented describing common practice in taking care of respiratory distress in prematurely born infants.     

Usefulness of Heliox in the management of a serious airway obstruction caused by a subglottic hemangioma

Heliox therapy, alone or combined with noninvasive ventilation, has successfully been used in the treatment of infants and children with respiratory disease such as airway obstruction. We describe the case of a 1-month-old infant with severe upper respiratory airway obstruction (approximately 80 %) secondary to multiple cervical hemangiomatosis effectively treated with either Heliox alone or combined with nasal continuous positive airway pressure. This treatment provided symptomatic relief and facilitated diagnosis and subsequent application of specific treatment; the patient was free of signs of respiratory distress and the use of aggressive treatments such as endotracheal intubation or tracheal cannulation was avoided. Heliox can constitute a multipurpose, safe and useful tool in the noninvasive management of infants and children with serious obstructive respiratory disease.     

Aerosolized surfactants

PURPOSE OF REVIEW: To present existing data on the potential use of aerosolized surfactants for treatment of neonatal respiratory distress syndrome in the era of noninvasive ventilatory support. RECENT FINDINGS: Current surfactant therapy requires endotracheal intubation and application of positive pressure ventilation. Instillation of the drug itself can be complicated by 'peridosing adverse events' including, but not limited to, desaturations, bradycardias, changes in blood pressure, drug reflux and even the need for reintubations. Increasing use of noninvasive ventilatory support for neonatal respiratory distress syndrome has motivated clinicians and researchers to look for alternate ways of introducing surfactants to patients. Aerosolized surfactants have been tested in animal models of respiratory distress syndrome. In addition, four small clinical studies have been performed to date. The effectiveness of this form of treatment requires further study, however, which will need to include optimizing the dose of aerosolized surfactant, choosing particle size, developing the best delivery system, and using a surfactant formulation that maintains its activity once aerosolized. SUMMARY: Aerosolized surfactants for neonatal respiratory distress syndrome may prevent the need for endotracheal intubation. Appropriately designed randomized controlled studies are required to determine if this form of surfactant administration is as effective and safe as tracheal instillation.     

双水平正压通气和持续气道正压通气在早产儿呼吸窘迫综合征中应用的比较

目的：对患有新生儿呼吸窘迫综合征（RDS）的早产儿早期使用双水平正压通气（DuoPAP）和经鼻持续气道正压通气（NCPAP）模式在降低有创呼吸支持率和支气管肺发育不良（BPD）发生率方面进行比较分析。方法：该试验为单中心随机对照试验,将胎龄30~35 周患有RDS生后6 h内的早产儿随机分为早期使用DuoPAP组（n=34）和早期使用 NCPAP组（n=33）,若这两种方式不能维持则使用气管内插管、呼吸机辅助呼吸,肺表面活性物质作为急救药物。观察患儿生后24 h、48 h及72 h内的总插管有创呼吸支持率、支气管肺发育不良（BPD）发生率及使用无创呼吸支持后1、12、24、48、72 h 二氧化碳分压（PaCO2）、氧分压（PaO2）及氧合指数（OI）。结果：DuoPAP组48 h内、72 h内总插管有创呼吸支持率明显低于NCPAP组（P0.05）。DuoPAP组OI无创呼吸支持后1、12、24、48、72 h均高于NCPAP组（均P<0.05）。DuoPAP组PaCO2在无创呼吸支持后1、12、24 h明显小于NCPAP组（P<0.05）;DuoPAP组PaO2在无创呼吸支持后1、12 h 明显大于NCPAP组（P<0.05）。结论：早期使用DuoPAP与NCPAP相比,可明显降低RDS患儿插管有创呼吸支持率,值得推广。     

Non-invasive ventilatory support in neonates: An evidence-based update

Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.     

A review of non-invasive ventilation support in neonates

Non-invasive ventilation (NIV) is a mode of respiratory support commonly used on the neonatal unit. Since the advent of NIV, it has evolved from being used as a mode of respiratory support to wean infants from mechanical ventilation (MV) to a primary mode of respiratory support. Newer methods of NIV support such as nasal bilevel positive airway pressure (BiPAP) and humidified high flow nasal cannula oxygen therapy (HHFNC) have emerged in attempts to reduce intubation rates and subsequent MV in preterm infants. There is ongoing debate about the role of nasal continuous positive airway pressure (NCPAP) in reducing ventilator induced lung injury, its timing and use as a primary mode of ventilation in the very low birth weight and extreme preterm infants.This review gives an overview of the current understanding and practices of the different modes of NIV in the neonatal unit.