双水平气道正压对OSAHS患者预后及血管内皮功能的影响

目的 分析双水平气道正压双水平气道正压通气(bi-level positive airway pressure,BiPAP)对阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)患者血管内皮功能及预后的影响。 方法 将100例OSAHS患者纳入研究，随机分为观察及对照组，各50例。观察组行BiPAP ，对照组行常规治疗，比较两组多导睡眠监测(polysomnography，PSG)检查指标（低通气指数、呼吸暂停指数、呼吸暂停及低通气时间、90%以下血氧饱和度次数、90%以下血氧饱和度时间）、心肺功能［脑钠肽(brainnatriureticpeptide,BNP)、右心室Tei指数、左心室Tei指数、一秒用力呼气容积占用力肺活量的百分比(forced expiratory volume in one second/forced vital capacity，FEV1/FVC)、一秒用力呼气容积占预计值的百分比(FEV1占预计值%)］、血管内皮功能［内皮素1(endothelin-1,ET-1)、一氧化氮(nitric oxide,NO)、凝血酶Ⅲ(antithrombin Ⅲ,AT-Ⅲ)］及生活质量。 结果 观察组低通气指数、呼吸暂停指数、呼吸暂停及低通气时间、90%以下血氧饱和度次数及时间指标均显著低于对照组（P＜0.05）。观察组治疗后BNP以及Tei指数显著低于治疗前及对照组治疗后，FEV1/FVC、FEV1占预计值%显著高于治疗前及对照组治疗后(P＜0.05)。观察组治疗后ET-1、AT-Ⅲ低于治疗前及对照组治疗后，NO高于治疗前及对照组治疗后（P＜0.05）。观察组治疗后生活质量各项目评分高于对照组（P＜0.05）。 结论 BiPAP治疗能够改善OSAHS患者的预后情况及血管内皮功能，效果确切。     

A multidisciplinary approach for prenatal diagnosis of FRASER SYNDROME-report of a novel variant in FRAS1

ObjectiveWith this case report, we would like to highlight the importance of a multidisciplinary approach and atypical findings of congenital high airway obstruction sequence (CHAOS), anhydramnios, and renal dysgenesis in the prenatal diagnosis of Fraser syndrome (FS).Case reportA 25-year-old primigravida at 19 weeks of routine anomaly scan revealed abnormal sonographic findings such as fetal bilateral dysplastic small kidneys and gross oligohydramnios. The further detailed evaluation revealed that both fetal lungs were hyperechogenic with prominent (dilated) trachea and bronchi suggestive of CHAOS. Based on these findings, a diagnosis of FS was suspected. The couple was counseled and the pregnancy was terminated. The postmortem evaluation and novel homozygous variant in the FRAS1 gene confirmed the diagnosis of FS.ConclusionThe diagnosis and counseling of the patient were supported by a well-coordinated, multidisciplinary approach involving an obstetrician, a fetal medicine specialist, a medical geneticist, and a fetal pathologist.     

呼吸机自动测量气道阻断压与标准测量方法的一致性

目的 验证呼吸机自动测量的气道阻断压(airway occlusion pressure,P0.1)与标准测量方法的一致性,以及不同触发形式对自动测量结果的影响。方法 选择采用非阻断自动测量P0.1的呼吸机,分别进行模拟肺和临床试验。调节全自动自主呼吸模拟肺,模拟具有不同呼吸努力和呼吸力学特征的48种状态,应用待检测呼吸机,以压力支持通气模式为模拟肺进行通气。临床研究部分纳入15例接受压力支持通气的成年患者。两部分研究均随机交叉应用压力和流量触发,采集呼吸机自动监测的P0.1后,采用标准呼气末气道阻断法进行P0.1测量,作为标准参考值。采用Bland-Altman检验分析P0.1呼吸机监测值与标准参考值的一致性,计算残差(呼吸机监测值-标准参考值)和95%一致性区间,比较不同触发形式对残差的影响。结果 在模拟肺验证中,P0.1呼吸机监测值与标准参考值之间的残差(95%一致性区间)在压力和流量触发下分别为0.04(－0.63~0.70)和－0.54(－1.44~0.36)cmH₂O(1 cmH₂O=0.098 kPa),两者相比差异具有统计学意义(P<0.001)。临床观察获得了相似的结果,压力和流量触发时的残差(95%一致性区间)分别为－0.11(－0.73~0.52)和－0.54(－1.50~0.59)cmH₂O,差异无统计学意义(P>0.05),表明呼吸机监测值与标准参考值间存在一致性。结论 压力触发时,呼吸机非阻断法自动测量的P0.1与标准方法具有良好的一致性。而流量触发明显低估P0.1,建议自动监测时切换到压力触发。     

Major complications of airway management: a prospective multicentre observational study

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with ‘predicted easy’ airways were rare (approximately 1 in 14,200), but 45 times more common in those with ‘predicted difficult’ airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.     

经鼻导管高流量吸氧与经鼻气道正压通气在重症毛细支气管炎呼吸支持中的应用价值比较

目的：比较经鼻导管高流量吸氧（HFNC）与经鼻气道正压通气（nCPAP）在重症毛细支气管炎呼吸支持中的应用价值，为临床治疗方案的选择提供参考。方法：选取2016年12月至2018年12月我院儿科收治的重症毛细支气管炎患儿90例，采用随机数字表法分为观察组和对照组各45例。两组患儿入院后均给予常规综合治疗以保证呼吸道通畅，在此基础上观察组采用HFNC治疗，对照组采用nCPAP治疗，比较两组患儿治疗前和治疗24 h后呼吸频率、经皮血氧饱和度（TcSO2）、呼吸窘迫评分体系（CSS）评分、动脉血氧分压（PaO2）等呼吸相关指标及治疗前后临床症状体征改善情况。结果：两组患儿治疗24 h后呼吸频率、CSS评分均降低，且观察组降低程度更大，TcSO2、PaO2于治疗24 h后升高，观察组升高幅度较对照组明显；治疗后两组患儿咳嗽及肺部湿啰音、肺部炎症情况均改善，观察组症状体征消失时间早于对照组，差异均有统计学意义（P<0.05）。结论：重症毛细支气管炎患儿采用HFNC治疗可明显改善通气功能和临床症状，治疗效果优于nCPAP治疗，可扩大样本量进一步观察。