纤维支气管镜肺泡灌洗治疗急性呼吸窘迫综合征

目的探讨在急性呼吸窘迫综合征中采用纤维支气管镜肺泡灌洗治疗的临床效果。方法选取平江县第一人民医院2012年2月至2014年3月60例急性呼吸窘迫综合征患者,分为对照组与研究组,每组30例。给予对照组患者常规临床治疗,研究组患者在对照组基础上实施纤维支气管镜肺泡灌洗治疗,分析比较两组的治疗效果。结果对照组22例患者治愈,有效率为73.3%;研究组28例患者治愈,有效率为93.3%,显著优于对照组。研究组治疗的机械通气时间、平均住ICU时间及平均住院时间均明显短于对照组,差异有统计学意义(P0.01)。结论在急性呼吸窘迫综合征中采用纤维支气管镜肺泡灌洗治疗方案具有更显著的疗效,有利于改善患者的治愈率,安全性高,值得临床推广及应用。     

支气管肺泡灌洗液炎性因子及肺泡表面活性蛋白与新生儿急性呼吸窘迫综合征的关系

目的 观察急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)新生儿支气管肺泡灌洗液(bronchoalveolar lavage fluid, BALF)炎性因子、肺泡表面活性蛋白(surfactant protein, SP)水平变化,探讨其与新生儿发生ARDS的相关性。方法 需机械通气的ARDS新生儿30例为ARDS组,根据氧合指数分为轻度组(氧合指数4.0～<8.0)11例,中度组(氧合指数8.0～<16.0)12例,重度组(氧合指数≥16.0)7例;因其他疾病需机械通气新生儿25例为对照组。比较ARDS组与对照组应用肺表面活性物质、脓毒症、窒息比率及机械通气时间等。ARDS组于呼吸机上机前、上机24 h时、撤机前,对照组于呼吸机上机前收集BALF,采用ELISA法检测BALF白细胞介素(interleukin, IL)-6、IL-10、IL-17、肿瘤坏死因子-α(tumor necrosis factor-α, TNF-α)、SP-A、SP-D水平;比较上机前ARDS组与对照组及ARDS组上机前、上机24 h时...     

急性呼吸窘迫综合征患者血清和支气管肺泡灌洗液中白介素-1β的变化

目的 :探讨白细胞介素 1β(IL 1β)在急性呼吸窘迫综合征 (ARDS)发病中的作用。方法 :用酶联免疫吸附试验检测了 13例 ARDS患者和 9例健康者支气管肺泡灌洗液 (BAL F)和血清中 IL 1β含量。结果 :ARDS患者 BAL F及血清中 IL 1β含量〔分别为 (14 4 .6 7± 80 .79) ng/ L 和 (4 5 .71± 7.0 9) ng/ L〕明显高于对照组〔分别为 (2 0 .39± 1.87) ng/ L 和 (35 .0 6± 5 .4 6 ) ng/ L,P=0 .0 0 0和 P=0 .0 0 1〕,且 ARDS患者 BAL F中IL 1β含量也明显高于血清 (P=0 .0 0 0 )。结论 :IL 1β参与了 ARDS的发病过程 ,早期测定 ARDS患者肺内细胞因子可能比血液或血浆中更有价值。     

肺泡表面活性物质在急性呼吸窘迫综合征治疗中的应用

目的 观察肺泡表面活性物质对急性呼吸窘迫综合征（ARDS）患者通气、氧合功能的影响。方法 选择我院ICU2002-01-2005-01由各种病因导致的ARDS患者15例。均在人工呼吸机支持下，选用固尔苏（Curosurf）按100mg／kg剂量经纤维支气管镜行肺泡灌洗补充外源性肺泡表面活性物质，并于灌洗前及以后24h内连续观察患者心率、血压、经皮血氧饱和度（TcSaO2），每6h采动脉血进行血气分析调整并记录呼吸机相关参数。结果 肺泡灌洗补充肺泡表面活性物质后6h内PaO2／FiO2明显改善（P〈0．05），12h迭高峰（P〈0.01），以后逐渐下降。结论 肺泡灌洗补充肺泡表面活性物质能够明显缓解临床症状。改善氧合功能，但持续时间相时较短。     

纤维支气管镜在急性呼吸窘迫综合征中的治疗体会

目的 探讨纤维支气管镜(简称纤支镜)肺泡灌洗对机械通气下急性呼吸窘迫综合征(ARDS)患者的治疗效果.方法总结我院ICU近两年来机械通气治疗的40例ARDS患者,其中20例行床旁纤维支气管镜治疗,20例行常规治疗;观察两组治疗后的ICU停留时间、机械通气时间,有效率及ARDS进展率.结果以纤支镜治疗的患者治疗有效率增加,ICU停留时间、机械通气时间均明显缩短,ARDS进展率较单纯常规治疗组明显下降(P<0.05).结论机械通气下ARDS患者使用纤支镜进行肺泡灌洗能达到良好的治疗效果,是一种行之有效的治疗方法.     

急性呼吸窘迫综合征患者肺泡灌洗液细胞凋亡的研究

细胞凋亡被认为在急性呼吸窘迫综合征（ARDS）的发展中起着重要作用。韩国科研人员对31例ARDS患者肺泡灌洗液中细胞凋亡进行了研究，对照组为20例健康成年人。用酶联免疫吸附法（EusA）检测肺泡灌洗液中细胞角蛋白（CK-18）、自细胞介素-8（IL-8）、可溶性脂肪酸（sFas）、可溶性脂肪酸配体（sFasL）、癌生长基因-α（GRO—α）、粒细胞集落刺激因子（G—CSF）、肿瘤坏死因子-α（TNF—α）相关细胞凋亡诱导配体（TRAIL）的含量。     

肺保护性通气对肺内外源性急性呼吸窘迫综合征外周血和肺泡灌洗液中炎性介质影响的比较

目的　观察在肺保护性通气条件下急性呼吸窘迫综合征 (ARDS)模型犬氧合指数以及外周血和肺不同部位 (肺上区、肺下区腹侧和肺下区背侧 )支气管肺泡灌洗液 (BAL F)中炎性介质的变化。方法　健康雄性杂种犬 2 4只 ,随机分为肺内源性 ARDS(ARDSp)实验组、ARDSp 对照组、肺外源性 ARDS(ARDSexp)实验组和 ARDSexp对照组 ,每组 6只。采用静脉注射油酸形成 ARDSexp模型 ,应用十六烷磺基丁二酸钠盐气管内吸入形成 ARDSp模型。实验组肺损伤后进行肺保护性通气〔潮气量 8ml/ kg,呼气末正压(PEEP) 10 cm H2 O(1cm H2 O=0 .0 98k Pa)〕;对照组则继续进行大潮气量通气。动态观察肺保护性通气条件下 ARDS模型犬外周血和肺不同部位 (如肺尖叶、肺心叶和肺膈叶 ) BAL F中的炎性介质 ,如肿瘤坏死因子α(TNFα)、白细胞介素 (IL 1β,IL 6 )的变化。结果　肺损伤后 ARDS模型犬氧合指数均显著恶化 ,外周血中炎性介质明显升高 (P均 <0 .0 5 ) ,ARDSp模型犬肺尖叶和心叶 BAL F中炎性介质水平明显高于 ARDSexp模型犬 (P均 <0 .0 5 )。应用肺保护性通气治疗后 ,实验组犬氧合指数有不同程度改善 ,炎性介质水平有不同程度下降 ;但 ARDSp实验组的治疗效果不如 ARDSexp实验组。结论　 ARDSexp和 ARDSp的肺不同部位炎性介质释放和氧合     

纤维支气管镜下温生理盐水灌洗肺绵羊急性呼吸窘迫综合征模型的研究

在对急性呼吸窘迫综合征（ARDS）的研究中，传统的整肺温生理盐水支气管肺泡灌洗。造成类似于淹溺所致ARDS模型的方法临床上仍在广泛应用。为了建立稳定、可重复性好的早期ARDS模型，我们采用了纤维支气管镜支气管肺泡灌洗技术，研究此方法建立ARDS模型的可行性，并探讨肺泡灌洗法对绵羊血流动力学及肺力学的影响。     

急性呼吸窘迫综合征

急性呼吸窘迫综合征(ARDS)是一组继发于内外科疾患的以急性肺损伤为特征的临床综合征，本文就ARDS的定义、临床特征、流行病学特点以及发病机制方面的进展作一综述。     

Distribution and function of alveolar cells in multiply injured patients with trauma-induced ARDS

To determine whether alveolar cells are involved in the pathogenesis of adult respiratory distress syndrome (ARDS), we assessed the distribution and function of alveolar cells from 30 polytraumatized patients with trauma-induced respiratory failure, 5 of whom also had lung contusion. Cells were obtained by bronchoalveolar lavage performed daily begining on the day of trauma and continuing for 14 days. Neutrophils constituted about 60% of lavage cells in ARDS patients with lung contusion 0–2 days after polytrauma and about 50% in ARDS patients without lung contusion. In ARDS patients with lung contusion the neutrophil fraction decreased to 52% 3–6 days after trauma and to 40% 7–14 days after trauma. In patients without lung contusion the neutrophil fraction increased to 77% and then decreased to 60% at these times. Total cell counts in ARDS patients with lung contusion were more than twice as high as in patients without lung contusion 0–2 days after trauma. The difference in total cell counts decreased during days 3–6 and disappeared by day 7. In all patients morphologically altered alveolar cells were observed 4 days and more after trauma. In non-survivors significantly more altered cells were found. The chemiluminescence-response pattern of the alveolar cells was enhanced throughout the study and correlated with the neutrophil fraction (r=0.6). The neutrophil fraction also correlated with the pulmonary vascular resistance during the first two days after trauma (r=0.53). We conclude that alveolar cells are involved in the pathogenesis of trauma-induced ARDS and that the alveolar cell distribution is different in patients with and without lung contusion during the development of posttraumatic respiratory failure.Part of this paper was presented as a poster at the VII^th International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium, March 1987     

Association of PEEP with two different inflation volumes in ARDS patients: effects on passive lung deflation and alveolar recruitment

Objective: To assess the effects of the association of positive end-expiratory pressure (PEEP) with different inflation volumes (V_T's) on passive lung deflation and alveolar recruitment in ARDS patients.¶Design: Clinical study using PEEP with two different V_T's and analyzing whether passive lung deflation and alveolar recruitment (Vrec) depend on end-inspired (EILV) or end-expired (EELV) lung volume in mechanically ventilated ARDS patients.¶Setting: Medical intensive care unit in a university hospital.¶Patients and participants: Six mechanically ventilated consecutive supine patients with ARDS.¶Interventions: Time-course of thoracic volume decay during passive expiration and Vrec were investigated in six ARDS patients ventilated on PEEP with baseline V_T (V_T,b) and 0.5V_T (0.5V_T,b), and on zero PEEP (ZEEP) with V_T,b. Time constants of the fast (τ ₁) and slow (τ ₂) emptying compartments, as well as resistances and elastances were also determined.¶Measurements and results: (a) the bi-exponential model best fitted the volume decay in all instances. The fast compartment was responsible for 84 ± 7 (0.5V_T,b) and 86 ± 5 % (V_T,b) on PEEP vs 81 ± 6 % (V_T,b) on ZEEP (P:ns) of the exhaled V_T, with τ ₁ of 0.50 ± 0.13 and 0.58 ± 0.17 s vs 0.35 ± 0.11 s, respectively; (b) only τ ₁ for V_T,b on PEEP differed significantly (P < 0.02) from the one on ZEEP, suggesting a slower initial emptying; (c) for the same PEEP, Vrec was higher with a higher volume (V_T,b) than at a lesser one (0.5V_T,b), reflecting the higher V_T.¶Conclusions: In mechanically ventilated ARDS patients: (a) the behavior of airway resistance seems to depend on the degree of the prevailing lung distension; (b) alveolar recruitment appears to be more important when higher tidal volumes are used during mechanical ventilation on PEEP; (c) PEEP changes the mechanical properties of the respiratory system fast-emptying compartment.     

iPSC-MSC来源的外泌体对LPS刺激肺泡巨噬细胞产生炎性因子的影响

目的探讨i PSC-MSC来源的外泌体(exosome,Exo)对LPS刺激的肺泡巨噬细胞释放炎性因子的作用。方法采用旋转超滤法提纯i PSC-MSC外泌体,以无外泌体培养基培养肺泡巨噬细胞NR8383,分别给予Exo(50μg/ml)、LPS(50ng/ml)、LPS(50ng/ml)+Exo(50μg/ml)培养24h,以不含Exo和LPS培养为对照组,利用酶联免疫标记法(ELISA)检测各组上清液中TNF-α、IL-1β、IL-6蛋白浓度。结果提取物经透射电镜观察为圆形或半圆形囊泡,直径40~100nm,表达Exo标志物CD9和CD63;LPS组上清液中TNF-α、IL-1β和IL-6的浓度(435.38±36.31pg/ml、319.76±39.14pg/ml和408.33±43.44pg/ml)与空白对照组(37.48±8.75pg/ml、33.51±7.88pg/ml和37.73±8.46pg/ml)和Exo组(38.71±9.14pg/ml、32.05±6.81pg/ml和42.84±6.54pg/ml)比较显著上调(P0.01);LPS+Exo组TNF-α、IL-1β和IL-6的浓度(369.30±32.74pg/ml、249.23±36.77pg/ml和328.91±46.45pg/ml)与LPS组相比,明显减少(P0.05);空白对照组与Exo组的TNF-α、IL-1β和IL-6的浓度无显著性差异。结论成功富集Exo;i PSC-MSC来源的Exo可抑制LPS诱导的肺泡巨噬细胞表达炎性因子。     

Alveolar macrophage chemotaxis in fire victims with smoke inhalation and burns injury

In vitro migration of alveolar macrophages was studied in 24 fire victims and 19 controls; all subjects were cigarette smokers. Unstimulated (P = 0.01) and stimulated migration towards casein-(P = 0.01) and zymosan-activated serum (P = 0.002) of macrophages from smoke inhalation patients (SI) (n = 19) was increased when compared to control subjects (CS). Migration of alveolar macrophages from patients with burns without smoke inhalation (burns only, BO) was not increased. Patients with smoke inhalation and no burns (smoke only, SO) (n = 9) had increased migration when compared to controls but this was not statistically significant. Patients with smoke inhalation and burns (SB) (n = 10) had increased unstimulated migration (P = 0.01) and increased migration towards casein (P less than 0.005), ZAS (P less than 0.002) and F-met-leu-phe (P less than 0.05) when compared to controls (CS). Lavage fluid from the fire victims displayed chemotactic activity towards normal human neutrophils and its analysis for the components of the complement cascade proved positive (Clq, Clr, Factor B and C3). These data suggest that activation of alveolar macrophages may contribute to the development of pathophysiological changes in patients with smoke inhalation (SI) and particularly those with smoke inhalation and burns (SB).     

肺结核合并结核性肛瘘1例

肺结核合并结核性肛瘘１例邓仲贵四川省第四人民医院内科（６１００００）患者，男，２０岁，农民，因低热、盗汗、咳嗽伴肛周脓肿破溃溢大便半年。于１９９５年６月６日收入我院外科治疗。病员于半年前因低热盗汗咳嗽到当地医院就诊，未进行胸透及查痰，诊断为“上感”，...     

高频振动通气在急性呼吸窘迫综合征治疗中的作用

目的　评估高频振动通气 (high frequencypercussiveventilation ,HFPV)在成人ARDS治疗中的有效性和安全性 ,探索ARDS治疗的新途径。方法　临床观察 93例ICU条件下使用HFPV的ARDS病人 ,对常规通气 (conventionalventilation ,CV)和HFPV下的PaO2 /FiO2 、PaCO2 、DO2 、VO2 、Qs/Qt、PEEP/CPAP、PAWP等氧代谢、血流动力学指标和呼吸参数的变化进行统计分析。结果　 93例病人中 ,存活 6 6例 ,死亡2 7例 ,死亡率为 2 9 0 % (除外 7例未死于ICU者 ,实际死亡率为 2 1 5 % )。使用HFPV前后PaO2 /FiO2 、PaC O2 、DO2 、VO2 、Qs/Qt的变化为 (77 6± 2 0 0 )和 (2 0 8 7± 70 8)、 (471 2± 114 7)和 (6 0 1 3± 14 0 9)、(10 7 6± 34 3)和 (14 6 4± 2 3 3)、 (35 7± 2 0 5 )和 (2 4 5± 6 5 ) (P <0 0 5 )。X ray胸片双肺阴影减轻或消失 ,同时可看到病人鼻腔口腔有不等量的混浊液体从呼吸道溢出。结论　HFPV在ARDS治疗中是有效和安全的。临床应用HFPV能明显改善氧代谢 ,提高PaO2 /FIO2 。早期应用和合理化管理能明显降低ARDS的病死率     

Noninvasive pressure-support ventilation in immunocompromised children with ARDS: a feasibility study

Objective  To verify the feasibility of non-invasive ventilation (NIV) in immunocompromised children affected by ARDS. Setting  University Hospital PICU. Patients  Twenty-three consecutive immunocompromised children treated with NIV for ARDS. Interventions  All consecutive patients received NIV through a face-mask or a helmet. Results  No differences were found regarding admission data and severity scores between NIV responders and non-responders. Early and sustained improvement in PaO₂/FiO₂ ratio were observed in 82 and 74% of cases, respectively. 13 out of 23 patients (54.5%) avoided intubation and were discharged from the PICU; ten patients required intubation: two of them survived and eight patients died (two refractory hypoxemia, three septic shock, three multi-organ failure). PICU and intra-hospital mortality was significantly higher for NIV-nonresponders (P < 0.001). PICU stay was significantly shorter for NIV responders (P = 0.03). NIV responders had significantly lower heart and respiratory rate at the end of treatment (P < 0.001 and P = 0.048, respectively). Conclusions  NIV administration is feasible and well tolerated in immunocompromised children with ARDS. A short NIV trial can be used to verify the usefulness of the technique. A randomized controlled trial is needed to confirm the efficacy of NIV in immunocompromised children requiring ventilatory support for ARDS. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Partial results from this study were presented at the 9th European Pediatric and Neonatal Ventilation Conference (EPNV 2008), held in Montreux (Switzerland), April 2008.     

微小RNA-146a在脂多糖诱导肺泡巨噬细胞中的表达

目的 观察脂多糖(LPS)诱导对NR8383肺泡巨噬细胞微小RNA-146a(miRNA-146a)表达的影响.方法 将体外培养的肺泡巨噬细胞株NR8383分成LPS刺激组和磷酸盐缓冲液(PBS)对照组,培养6 h后,采用酶联免疫吸附法(ELISA)检测细胞培养上清液中肿瘤坏死因子-α(TNF-α)水平,采用实时荧光定量聚合酶链反应(real-time PCR)检测细胞miRNA-146a的表达.结果 LPS刺激组细胞培养上清液中TNF-α含量(ng/L)较PBS对照组明显升高(650.26±40.53比6.23±1.76,P<0.01),细胞miRNA-146a表达水平较PBS对照组上调了约(5.33±0.81)倍(P<0.01).结论 LPS刺激后,miRNA-146a在NR8383细胞中表达增高,其可能参与了NR8383肺泡巨噬细胞的炎症反应调控.     

10例氯气中毒并发ARDS的救治护理

目的总结10例氯气中毒并发ARDS的救治与护理经验。方法采用合理氧疗、抗感染、应用糖皮质激素等方法,对10例氯气中毒并发ARDS患者进行救治与护理。结果 10例患者均得到及时有效的治疗与护理,全部治愈出院。结论早期、足量、短程应用糖皮质激素,雾化吸入,及时止咳化痰,积极预防感染。在面罩吸氧效果不理想的情况下尽早使用呼吸机正压通气,迅速纠正低氧血症是抢救成功的关键措施。加强呼吸道的管理、加强基础护理是减少并发症的有效措施。     

丹参对ARDS大鼠肺损伤的治疗保护和对肺泡巨噬细胞分泌细胞因子的调节作用

目的了解丹参对大鼠血气改变和肺系数的影响以及丹参对肺泡巨噬细胞分泌肿瘤坏死因子(TNF a)、白介素-1(IL-1)的调节作用.方法静注油酸制造ARDS大鼠模型为油酸组,静注生理盐水作对照组,静注油酸同时以丹参灌胃为治疗组.静注油酸及生理盐水6小时后,测定左心PaO2、PaCO2及肺系数.分离培养各组大鼠肺泡巨噬细胞,采用MTT法测定TNF a、IL-1.结果油酸组PaO2值明显低于对照组和治疗组,而PaCO2值明显高于对照组和治疗组(P＜0.001).治疗组血气明显好于油酸组(P＜0.05).油酸组肺系数(1.03±0.06)高于治疗组(0.72±0.05)和对照组(0.64±0.06),P＜0.01.TNF a、IL-1分别为油酸组(72.06±5.64)%、(96.22±11.61)U/ml,对照组(7.75±1.05)%、(21.05±3.11)U/ml,治疗组(35.44±4.55)%、(70.66±8.23)U/ml.油酸组分泌TNFa、IL-1的水平显著高于对照组(P＜0.001),治疗组亦显著高于对照组,但明显低于油酸组(P＜0.001).结论丹参对ARDS有保护性治疗作用,对ARDS大鼠肺泡巨噬细胞过度活化、分泌TNF a、IL-1具有抑制作用.研究对肺泡巨噬细胞分泌细胞因子的调节作用对认识ARDS的发病机制和指导临床治疗有重要意义.