早产儿呼吸窘迫综合征的呼吸支持策略及研究进展

新生儿呼吸窘迫综合征（respiratory distress syndrome，RDS）多见于早产儿，胎龄越小，发病率越高。近年的大规模随机对照研究突出了产房内开始的持续气道正压通气（continuous positive airway pressure，CPAP）在RDS防治中的重要作用，对于生后有自主呼吸的早产儿，产房内应用CPAP优于气管插管，而顶防性应用肺表面活性物质（pulmonary surfactant，PS）不再具有优势。2013版欧洲新生儿RDS防治指南推荐有患RDS风险的早产儿生后均应立即接受CPAP支持，初设呼气末正压至少6cmH2O（1cmn20=0．098kPa）；对于患RDS的早产儿，最理想的处理是生后CPAP以及早期解救性PS应用。而需要气管插管的早产儿应尽早接受PS替代治疗。不能耐受CPAP的患儿更换通气模式为无创正压通气可能降低拔管失败率。目前有多种策略来缩短机械通气时间并增加无创通气的成功率。患RDS的极早产儿应常规接受咖啡因治疗以提高撤机成功率，并降低支气管肺发育不良的发生率。生后1～2周后仍不能脱离呼吸机者，需接受小剂量递减地塞米松治疗，但应避免生后1周内应用地塞米松以及较大剂量应用。

Respiratory support in preterm infants with respiratory distress syndrome

Neonatal respiratory distress syndrome （RDS） is most common in premature infants, the smaller the gestational age, the higher the incidence. Continuous positive airway pressure （CPAP） started in the delivery room has been shown in multicentre randomized controlled trials to reduce the need for mechani- cal ventilation（MV） and surfactant. The European Consensus Guidelines on the Management of Neonatal Re- spiratory Distress Syndrome in Preterm Infants - 2013 Update recommended that CPAP should be started from birth in all babies at risk of RDS and a starting pressure of at least 6 cmH20（ 1 cmH20 s0. 098 kPa） should be applied. CPAP with early rescue surfactant should be considered the optimal management for babies with RDS. Using CPAP immediately after birth with subsequent selective surfactant administration may be considered as an alternative to routine intubation with prophylactic or early surfactant administration in pre- term infants. If endotracheal intubation is needed, early administration of surfactant is preferable. Nasal inter- mittent positive pressure ventilation may reduce the risk of extubation failure in babies failing on CPAP. Sev- eral strategies have been employed specifically to improve the success of noninvasive ventilation and shorten the duration of MV. Caffeine should be used to facilitate weaning from MV and to reduce bronchopulmonary dysplasia. A short tapering course of low- or very low-dose dexamethasone should be considered to facilitate extubation in babies who remain on MV after 1 ~ 2 weeks. Very early steroid treatment and txeatment with high doses cannot be recommended.