极/超早产儿的生存现状和呼吸管理进展

极/超早产儿由于肺发育不成熟,病死率和支气管肺发育不良的发生率较高,呼吸管理和患儿的生存率及生存质量密切相关.合理的产前皮质激素促肺成熟、肺表面活性物质(pulmonary surfactant,PS)的应用和机械通气策略有助于改善极/超早产儿的预后.采用无创技术进行呼吸支持,特别是生后立即给予持续气道正压通气而后根据病情选择性给予PS作为预防性给予PS的替代呼吸支持策略已受到普遍推荐.新的机械通气策略与模式如高频振荡通气、神经调节辅助呼吸和目标容量通气是否具有更大的优势仍需要进一步的研究证实.     

鼻塞式CPAP在50例极低出生体重儿的临床应用分析

目的　探讨鼻塞式持续气道正压 (CPAP)对极低出生体重儿的呼吸支持作用。方法　对 5 0例伴呼吸衰竭的极低出生体重儿应用鼻塞式CPAP治疗资料进行分析。结果　 2 8～ 32周组 2 2例 ,其中用机械通气 +鼻塞式持续气道正压 (NCPAP)治疗 11例 ,机械通气 0 .33～ 2 0d ,平均 4.37d ,用NCPAP 1～ 30d ,平均 8.30d ,单纯用NCPAP 11例 ,18h～ 2 9.0d ,平均 6 .45d。 2 2例全部存活 ,仅 1例发生支气管肺发育不良。 2 4～ <2 8周组 2 8例 ,机械通气 +NCPAP 2 7例 ,单用NCPAP 1例 ,机械通气 0 .5～ 170d ,平均 2 6 .8d ,用NCPAP 2 4～ 6 6d ,平均44 .7d ,存活率 89.3% ,支气管肺发育不良 12例 ,发生率 42 .85 %。结论　NCPAP对自主呼吸强 ,孕龄≥ 2 8周的早产儿呼吸衰竭常可单独使用 ,不必机械通气 ,对于病情危重或孕龄 <2 8周者可作为机械通气撤离后继续给予呼吸支持的一种令人满意的方法。     

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呼吸支持与超低出生体重儿(extremely low birthweight infant,ELBWI)的生存率有关。由于肺保护通气策略的广泛应用,使ELBWI呼吸衰竭死亡率显著下降;随着肺表面活性物质(PS)时代的到来,常规的机械通气呼吸支持手段显得不如20世纪80年代那么重要,但通气模式对于这些非常微小的ELBWI的治疗成功率关系仍然非常密切。     

《中国实用儿科杂志》2018年第5期重点内容介绍 重点选题:早产儿呼吸支持相关问题

正早产儿呼吸支持的几个重要里程碑神经调节辅助通气技术在早产儿呼吸支持中的应用出生后糖皮质激素预防和治疗早产儿支气管肺发育不良的评价无创高频通气技术在早产儿的应用LISA/MIST技术与早产儿呼吸系统疾病的预后早产儿目标血氧饱和度范围的争议     

机械通气在儿童危重哮喘治疗中的应用

目的 探讨危重哮喘患儿应用机械通气治疗的临床疗效.方法 回顾性总结10年间28例危重哮喘患儿应用气管插管机械通气的临床资料,分析其通气方式、好转率、病死率、机械通气治疗前后血气分析指标的变化.结果 在通气模式上,采用容量辅助/控制模式12例,同步间歇指令通气联合压力支持16例.撤机模式均为同步间歇指令通气联合压力支持,此外根据病情还适当应用肺保护性通气、低呼气末正压通气、肺开放等通气策略.患儿病情好转出院率96.4%,病死率5.6%.结论 机械通气是危重哮喘患儿十分重要的抢救治疗手段.把握适应证、采用正确的通气策略、配合及时有效的呼吸管理和综合治疗是治疗成功的关键.     

新生儿常见肺疾病的呼吸支持策略

新生儿呼吸支持技术应针对新生儿呼吸系统疾病不同的病理生理学特点,进行个体化治疗。以最适合的呼吸支持策略,尽可能减少其风险,达到最佳的治疗效果。本文阐述极（超）低出生体重儿的呼吸管理,胎粪吸入综合征、持续性肺动脉高压、难治性支气管肺发育不良、肺气漏、肺出血等不同肺疾病的病理生理特点、肺呼吸力学变化及机械通气管理的原则和选择。     

机械通气

呼吸支持广泛应用于儿童呼吸衰竭的抢救,目前应用最为成熟和广泛的呼吸支持方法为经气管插管常频机械通气,机械通气是否正确与合理应用,与治疗效果密切相关.     

持续呼吸道正压通气在新生儿呼吸系统疾病中的应用

持续呼吸道正压通气(CPAP)能使肺泡在呼气末保持一定压力,增加功能残气量,防止肺泡萎陷,从而改善通气和换气功能。CPAP主要用于出现呼吸困难、两肺充气不良的新生儿,适应证主要有早期或轻中度新生儿呼吸窘迫综合征、早产儿呼吸暂停、新生儿湿肺、机械通气撤离后过度肺水肿等。CPAP为鼻塞法,避免气管插管、减少机械通气,是一种简便、适宜的新生儿呼吸支持技术。     

《2019年欧洲呼吸窘迫综合征管理指南》解读

在《2016年欧洲呼吸窘迫综合征（RDS）管理指南》基础上,2019年版指南依据最新循证医学证据和医学文献,进行了补充和更新,使RDS管理策略不断优化。内容涉及早产发生风险的预测及产前糖皮质激素的规范使用、产房管理更加循证化、肺保护性通气策略的出生后早期应用,仍强调肺表面活性物质的替代治疗是RDS治疗至关重要的环节,无创呼吸支持能降低早产儿慢性肺疾病的发生率,产前糖皮质激素的使用和咖啡因的应用均显著降低了机械通气时间。此外,适宜的温度调控,精确的液体和营养管理,维持良好的血液灌注以及谨慎使用抗生素均能改善早产儿的预后。     

严重肺部感染的呼吸支持疗法

呼吸功能障碍及呼吸衰竭是儿童严重呼吸道感染常见问题,维持呼吸道通畅、合理使用机械通气、保证氧合是重要支持治疗措施.现重点介绍严重呼吸道感染的概念、人工呼吸道建立与管理、常规通气肺保护及急性肺损伤/急性呼吸窘迫综合征通气策略.     

Automated respiratory support in newborn infants

A considerable proportion of premature infants requires mechanical ventilatory support and supplemental oxygen. Due to their immaturity, exposure to these forms of respiratory support contributes to the development of lung injury, oxidative stress and abnormal retinal development. These conditions are associated with poor long-term respiratory and neurological outcome. Mechanically ventilated preterm infants present with frequent fluctuations in ventilation and gas exchange. Currently available ventilatory modes and manual adjustment to the ventilator or supplemental oxygen cannot effectively adapt to these recurrent fluctuations. Moreover, the respiratory support often exceeds the infant's real needs. Techniques that adapt the mechanical ventilatory support and supplemental oxygen to the changing needs of preterm infants are being developed in order to improve stability of gas exchange, to minimise respiratory support and to reduce personnel workload. This article describes the preliminary evidence on the application of these new techniques in preterm infants and animal models.     

Mechanical ventilatory support in preterm infants

A large proportion of premature infants presents with acute respiratory failure after birth and require mechanical ventilatory support. In addition to conventional mechanical ventilation, an increasing number of these infants are currently supported by newer modes including synchronized, volume targeted and noninvasive mechanical ventilation. While these new modes have improved weaning from mechanical ventilation they have not had a consistent impact on respiratory outcome or other morbidities. This is a review of the different modes of invasive and noninvasive mechanical ventilation used to support premature infants with respiratory failure.     

Theophylline treatment in the extubation of infants weighing less than 1,250 grams: a controlled trial

The role of theophylline in weaning infants weighing less than 1,250 g at birth from mechanical ventilation was evaluated. Infants were randomized into control or theophylline treatment groups when they required minimal ventilatory support (peak inspiratory pressure 12 cm H2O, positive end-expiratory pressure 2 cm H2O, rate 12 breaths per minute, and FiO2 less than 0.3), and they were extubated 24 hours later. Infants required reintubation if they had (1) PaCO2 greater than 55 mm Hg and pH less than 7.20, (2) FiO2 greater than 0.5, or (3) apnea associated with a heart rate less than 100 beats per minute that required frequent stimulation (more than 20 episodes during a 16-hour period). Among 32 infants (birth weight less than 1,000 g) who reached minimal ventilatory support before seven days after delivery, 13 of 18 (72%) control infants required reintubation, whereas only four of 14 (28%) theophylline-treated infants required reintubation. On the other hand, among infants (birth weight less than 1,000 g) who reached minimal ventilatory support after seven days following delivery, only one of six (17%) of the control group required reintubation and no improvement could be seen with theophylline treatment. Similarly, among control infants (birth weight 1,001 to 1,250 g), only ten of 45 (23%) required reintubation after reaching low intermittent manditory ventilation settings. In summary, most infants recovering from respiratory distress syndrome who had birth weights (1) greater than 1,000 g or (2) less than 1,000 g and who were older than seven days could be successfully extubated from minimal ventilatory support without theophylline treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

早期微量喂养改善极低出生体重儿宫外生长与预后的半随机对照试验

目的观察早期微量喂养对极低出生体重儿(VLBWI)生后6周宫外生长与预后的影响。方法选择2007年1月至2009年1月无锡市儿童医院与南京医科大学附属南京儿童医院NICU收治的出生体重(1500g且需要辅助通气和静脉营养的VLBWI为研究对象,根据单双病床号分为早期微量喂养组和对照组。早期微量喂养组:在静脉营养的同时从生后第3天开始经鼻饲管给予早产儿配方乳0.5～1mL.h-1,直至辅助通气结束;对照组:仅予静脉营养直至辅助通气结束。监测生后6周内的能量摄入、生长状况、脓毒症(血培养阳性)发生率、肝功能、喂养耐受情况、辅助通气时间、住院时间和喂养相关并发症的发生率。结果早期微量喂养组18例,对照组22例进入分析。早期微量喂养组入组时胎龄、出生体重和新生儿临床危险指数评分与对照组差异均无统计学意义。①早期微量喂养组生后6周内总能量摄入显著高于对照组,平均差异为261.1kJ.kg-1,P=0.03。②早期微量喂养组生后6周时点体重增长值显著高于对照组,两组差异为120g,P=0.02;头围增长值显著高于对照组,平均差异为0.6cm,P=0.04;中臂围两组差异为0.30cm,P=0.48;三头肌皮肤皱褶厚度两组差异为0.22mm,P=0.51。③两组生后6周内肝功能指标与黄疸持续时间差异无统计学意义;早期微量喂养组生后6周内脓毒症发生率显著低于对照组,P=0.03。④早期微量喂养组需要静脉营养的时间显著少于对照组,P=0.03;过渡到完全肠内营养的时间显著少于对照组,P=0.03。⑤早期微量喂养组需氧时间显著少于对照组,P=0.02;平均住院时间显著少于对照组,P=0.03。⑥两组生后6周内各种喂养相关并发症(腹胀、呕吐、坏死性小肠结肠炎和吸入性肺炎)的发生率差异无统计学意义。结论早期微量喂养可改善VLBWI生后6周宫外生长状况。     

Interaction between surfactant and ventilatory support in newborns with primary surfactant deficiency

The interaction between exogenous surfactant and various modes of ventilatory support in terms of timing, quality and quantity can influence both short- and long-term outcomes of immature infants. Alterations to the pulmonary surfactant system can occur with all forms of mechanical ventilation. Experimental data suggest possible interaction between ventilatory support and exogenous surfactant even during the first breaths in the delivery room. The adverse effect on surfactant function at this time can increase the need for and duration of ventilatory support. The logical approach to ventilatory support is to be minimally aggressive with optimal recruitment of the lungs to avoid ventilator-induced lung injury. Nasal continuous positive airway pressure (CPAP) in combination with early prophylactic surfactant administration may be an effective and less damaging method capable of reducing the need of artificial ventilation, but its benefit has not been proven in extremely preterm infants less than 28 weeks' gestation. Because of unproven efficacy of nasal CPAP in extremely premature infants, the population most at risk for adverse pulmonary and neurologic outcome, this paper focuses on the comparison of conventional and high-frequency oscillatory ventilation (HFOV) with respect to alteration of surfactant function, and short- and long-term outcomes, in both human and experimental trials. Though the two most recent large clinical trials provide reassurance with respect to the safety of first-intention high-frequency ventilation, the reduction in the risk of chronic lung disease appears to be only modest or absent. Recent laboratory investigations suggest that the key element of HFOV, namely optimization of volume, can, under some circumstances, be replicated with low tidal volume conventional ventilation and high positive end-expiratory pressure. Recent introduction of patient-triggered volume-targeted conventional ventilation into clinical practice offers the promise of a practical means of providing gentle conventional ventilation capable of minimizing ventilator-induced lung injury. Ultimately, well-designed comparative clinical trials with long-term outcomes are essential to accurately quantify risks and benefits of any new approach to mechanical ventilation. Without such data, these experimental results should not be extrapolated into clinical practice, because of the multifactorial pathophysiology of the development of chronic pulmonary disease in extremely premature infants and the risk of unanticipated adverse effects.     

Incidence of apnoea and bradycardia in preterm infants following triple antigen immunization

Ninety-seven preterm infants were immunized with diphtheria-tetanus-pertussis (DTP) prior to discharge from hospital. The mean gestational age at birth was 28.1 weeks (range 24-34) and the mean age at immunization was 80.6 days (range 44–257). Nineteen (20%) infants developed apnoea or bradycardia within 24 h of immunization. The infants who developed apnoea and/or bradycardia had a younger gestational age at birth than those who did not (P= 0.03), were artificially ventilated for longer (P= 0.01) and were more likely to have a diagnosis of chronic lung disease (P= 0.006). In the majority of infants these events were not clinically significant. Two infants who developed concurrent upper respiratory tract infections required additional oxygen and one of them was treated with oral theophylline. In general, it is safe practice to immunize preterm infants with DTP unless otherwise contraindicated. However, it is recommended that cardiorespiratory function is monitored after immunization in very preterm infants who had prolonged ventilatory support and/or chronic lung disease.     

Mechanical ventilation strategies

Although only a small proportion of full term and late preterm infants require invasive respiratory support, they are not immune from ventilator-associated lung injury. The process of lung damage from mechanical ventilation is multifactorial and cannot be linked to any single variable. Atelectrauma and volutrauma have been identified as the most important and potentially preventable elements of lung injury. Respiratory support strategies for full term and late preterm infants have not been as thoroughly studied as those for preterm infants; consequently, a strong evidence base on which to make recommendations is lacking. The choice of modalities of support and ventilation strategies should be guided by the specific underlying pathophysiologic considerations and the ventilatory approach must be individualized for each patient based on the predominant pathophysiology at the time.     

RESPIRATORY INSUFFICIENCY SYNDROME (RIS) IN PRETERM INFANTS WITH GESTATIONAL AGE OF 32 WEEKS AND LESS

ABSTRACT: Carlsson, J. and Svenningsen, N. W. (Department of Paediatrics, University Hospital, Lund, Sweden). Respiratory insufficiency syndrome (RIS) in preterm infants with gestational age of 32 weeks and less. Neonatal management and follow-up study. Acta Paediatr Scand, 64: 813, 1975.–The clinical entity of respiratory insufficiency syndrome (RIS), i.e. irregular breathing leading to recurrent apnea and bradycardia in an otherwise healthy preterm infant, has been studied in respect of symptomathology and management with intensive case including ventilatory support. During a 4-year period 26 of 103 infants with gestational age 32 weeks and mean birth weight 1304 g (range 710 to 1830 g) developed RIS. In most infants the initial apnea occurred after 2 and before 72 hours post delivery but in some infants later. Because of progressive hypoxemia and acidosis IS of the 26 RIS infants required IPPV treatment. The 76 % survival rate of RIS infants seems to justify intensive care with ventilatory support even in the smallest preterm infants with RIS, especially as the follow-up study performed at 15 months to 3 ½ years of age showed neurological sequelae in only 3 of 20 surviving babies, i.e. 15 % sequelae rate.     

Hepatoblastoma in low birth weight infants: an institutional review

The association between hepatoblastoma and low birth weight documented recently in the literature has yet to be well explained, in particular the suggestion that these patients may have a more aggressive form of the disease. From 1989 to 2003, our institution treated four patients for hepatoblastoma who had birth weights of less than 1,500 g. Notable was 100% patient survival despite bilateral and, in one case, recurrent disease. Speculation regarding the etiology of this subset of hepatoblastoma has included damage to developing hepatocytes induced by oxygen free radicals. Our patients universally had pulmonary disease requiring prolonged supplemental oxygen and ventilatory support. However, our review supports no changes in the standard care of low birth weight infants or in managing those who develop hepatoblastoma.