高频振荡通气与常频机械通气治疗新生儿气胸的临床对照研究

【摘要】 目的 研究高频振荡通气（High frequency oscillatorg ventilation，HFOV）与常频机械通气(Conventional menchanical ventilation，CMV)治疗新生儿气胸的临床疗效，寻找更适合与优越性的通气方法。方法 选取新生儿病房在2013年10月~2016年2月收治的80例需要机械通气治疗的气胸新生儿。按治疗方法分为两组，观察组40例采用高频振荡通气（HFOV）治疗；对照组40例则采用常频机械通气（CMV）治疗。观察两组患儿在不同时期的血气分析指标及肺功能恢复时间，两组患儿治疗疗效与有无并发症。结果 两组患儿一般资料及原发病构成比较，差异无统计学意义（P＞005）。两组患儿在治疗前氧分压（PaO2）、二氧化碳分压（PaCO2）、氧合指数（OI）、动脉/肺泡氧分压（a/APO2）的比较，差异无统计学意义（P＞005）。两组患儿治疗4、8、12、24、48h后，观察组和对照组各时段PaO2值均较治疗前上升（P＜005）；PaCO2值较治疗前下降（P＜005）；OI值较治疗前明显下降（P＜005）；a/APO2值较治疗前升高（P＜005）。但观察组治疗4、8、12、24、48h时后PaO2、PaCO2、OI、a/APO2值改善情况明显优于对照组，（P＜005）。观察组呼吸机平均使用时间为（37±13）/d明显短于对照组的（71±18）/d（P＜005）。观察组X线胸片恢复时间为（41±19）/d明显短于对照组的（95±23）/d（P＜005）。治疗过程中两组患者无明显并发症情况发生（P＞005）。结论 HFOV和CMV两种通气治疗新生儿气胸均有明显效果，但HFOV的临床治疗疗效更好，检测血气分析指标及肺功能改善更明显，且安全性更高，无明显并发症，更适合治疗新生儿气胸。     

Combination of high frequency oscillatory ventilation and interventional lung assist in severe acute respiratory distress syndrome

Background

The combination of high-frequency oscillatory ventilation (HFOV) and extracorporeal carbon dioxide removal with the interventional lung assist (iLA) in severe acute respiratory distress syndrome (ARDS) represents a novel treatment option.

Methods

The study used a retrospective single-center analysis of 21 consecutive adult patients with severe ARDS, ventilated with HFOV/iLA. Efficiency, side effects, and outcome of combined treatment are presented as median (interquartile range).

Measurements and Main Results

The following were used to determine patient characteristics: sequential organ failure assessment score, 14; simplified acute physiology score II, 41; and Murray score, 4. The duration of combined treatment was 6 days. The blood flow through the iLA was 1.9 L/min.The Pao₂/inspired fraction of oxygen ratio increased from 61 (47-86) to 98 (67-116) within 2 hours and to 106 (70-135) mm Hg at 24 hours. Paco₂ decreased from 58 (50-76) to 37 (29-47) mm Hg at 2 hours with normalization of pH 7.28 (7.16-7.36) to 7.43 (7.33-7.49) after 2 hours associated with hemodynamic stabilization. In 6 patients, complications due to iLA treatment were observed, and in 3 patients, complications associated with HFOV were seen. Weaning from HFOV/iLA was successful in 10 patients. The 30-day mortality rate was 43%, and hospital mortality rate was 57%.

Conclusion

The combination of HFOV/iLA is an option in severe pulmonary failure if conventional ventilation fails and pumpdriven extracorporeal membrane oxygenation therapy is not available.     

Successful treatment of a patient with ARDS after pneumonectomy using high-frequency oscillatory ventilation

High frequency oscillatory ventilation (HFOV) was used in a patient who developed the acute respiratory distress syndrome 5 days following a right pneumonectomy for bronchogenic carcinoma. When conventional pressure-controlled ventilation failed to maintain adequate oxygenation, HFOV dramatically improved oxygenation within the first few hours of therapy. Pulmonary function and gas exchange recovered during a 10-day period of HFOV. No negative side effects were observed. Early use of HFOV may be a beneficial ventilation strategy for adults with acute pulmonary failure, even in the postoperative period after lung resection. Received: 3 February 1999/Final revision received: 2 June 1999/Accepted: 1 July 1999     

Pathologic features of various ventilatory strategies

Five pathologic findings have been found to be associated with ventilatory-induced lung injury in the premature baboon model of hyaline membrane disease. They are: (1) tracheal and major bronchial lesions, (2) small airway changes, (3) inflation pattern aberrations, (4) bronchoalveolar hemorrhage, and (5) air leak problems. The use of immediate high frequency oscillatory ventilation (HFOV) prevents the bronchiolar overdistension (small airway), atelectasis (inflation pattern), and air leak problems. The lesions in the trachea and large bronchi of prematures all show injury secondary to prolonged intubation, but after HFOV the lesions are no worse than those seen in PPV-treated tracheas. HFOV does increase the incidence of bronchoalveolar hemorrhages, and this lesion plus some of the non-pulmonary complications will require further investigation.     

Comparison of conventional mandatory ventilation and high frequency oscillatory ventilation for treatment of acute lung injury induced by steam inhalation injury

This study compared pathophysical indexes, respiratory mechanics, circulatory parameters and lung injury scores of acute lung injury (ALI) induced by steam inhalation injury in a New Zealand rabbit model with different ventilatory strategies: a control group which consisted of lower tidal volume (VT 6 ml/kg) and high positive end-expiratory pressure (PEEP) (9 cmH₂O); treatment group which was high frequency oscillatory ventilation (HFOV). Eighteen rabbits were anaesthetized, sedated, neuromuscular-blocked and ventilated with above two modes at our animal laboratory of burn center. After induction of acute lung injury by steam inhalation, animals were randomizedly assigned to receive either conventional mechanical ventilation (CMV) or high frequency oscillatory ventilation and were grouped as CMV and HFOV group. As a result, HFOV attenuated the decrease in oxygenation and pulmonary compliance, alleviated lung tissue damage and inflammatory response. Therefore, HFOV may be a preferable option for treatment of acute lung injury induced by steam inhalation injury.     

高频振荡通气治疗婴幼儿心脏术后急性肺水肿的临床观察和护理

目的探讨高频振荡通气（HFOV）对婴幼儿心脏病术后急性肺水肿的临床治疗效果及护理。方法24例心脏术后急性肺水肿病例分为两组,A组为高频振荡通气,B组为常频呼吸机通气,两组均采用相同的护理措施。结果HFOV较常频呼吸机通气更有效改善婴幼儿心脏术后急性肺水肿患儿的通气,提高氧分压。结论HFOV是治疗婴幼儿心脏术后急性肺水肿的有效方法,疗效显著,安全性好,值得,临床推广应用的新型机械通气模式。     

To ventilate,oscillate, or cannulate?

Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.     

A case of severe ARDS caused by novel swine‐origin influenza (A/H1N1pdm) virus: A successful treatment with direct hemoperfusion with polymyxin B‐immobilized fiber

In 2009, a 35‐year‐old female with Down syndrome was admitted to our hospital because of severe pneumonia caused by an infection with the novel swine‐origin influenza (A/H1N1pdm) virus (S‐OIV). A chest X‐ray on admission revealed bilateral infiltration shadows. Although mechanical ventilation was administered because of the development of ARDS, the hypoxemia continued to progressed. We observed evidence of alveolar hemorrhage on evaluation of the patient using bronchofiberscopy. The bacterial examination was negative. Despite intensive care, including respiratory management with high‐frequency oscillatory ventilation (HFOV), the patient's hypoxemia and hypotension progressed. We concluded that a cytokine storm due to the influenza infection with SIRS caused shock status, resulting in septic shock. We subsequently treated the patient with direct hemoperfusion with polymyxin B‐immobilized fiber (PMX‐DHP). The hypoxemia improved immediately. She was free from mechanical ventilation and discharged from the hospital by the 17th day of her hospitalization. PMX‐DHP seems to improve hypoxemia in patients with severe ARDS who cannot maintain sufficient respiratory control under mechanical ventilation. This case is the first report about severe and life‐threatening ARDS due to the novel influenza, in which PMX‐DHP showed beneficial effects. J. Clin. Apheresis 2010. © 2010 Wiley‐Liss, Inc.