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。     

沐舒坦预防早产儿呼吸窘迫综合征效果观察

早产儿呼吸窘迫综合征 (RDS)是新生儿重症疾病 ,病死率极高 ,2 0世纪 80年代以来 ,广泛采用肾上腺皮质激素产前预防RDS ,取得可喜的成绩 ,但仍有 2 0 %左右的早产儿在使用激素后发生RDS[1] 。自 1998年 2月本院儿科在产前孕母应用肾上腺皮质激素的基础上 ,产后早产儿立即加用沐     

早产儿呼吸窘迫综合征自发性利尿与肺功能关系探讨

目的 探讨早产儿呼吸窘迫综合征（ＲＤＳ）自发性利尿与肺功能及预后的关系。方法 ３１例入院日龄小于２４ｈ,需机械通气的ＲＤＳ患儿,应用床旁肺力学监护仪动态监测、动态顺应性（Ｃｄｙｎ）、潮气量（ＶＴ）,并记录２４ｈ出（Ｏ）入（Ｉ）量和呼吸机各参数。利尿开始时（Ｏ／Ｉ≥１）及最大利尿期的尿量、Ｃｄｙｎ、ＶＴ、ＲＲ、ＰＩＰ、ＭＡＰ、ＦｉＯ２与利尿前８ｈ的资料进行比较。结果 治愈组２５例,开始利尿时间为（４     

鼻塞CPAP治疗早产儿特发性呼吸窘迫综合征19例

为提高早产儿特发性呼吸窘迫综合征（IRD）的治愈率，本文总结了我科NICU自1995年～1996年采用鼻塞持续气道正压（CPAP）氧疗治疗IRDS19例，现报告如下。临床资料一、一般资料：均为本院产科分娩的早产儿，男12例，女7例。平均胎龄31±1．56wk，其中≤30wk7例，～32wk8例。平均     

不同分级的呼吸窘迫综合征早产儿围生期状况分析

目的：对不同分级的呼吸窘迫综合征（RDS）早产儿的围生期状况进行分析,以了解与RDS严重程度相关的高危因素。方法：667例早产RDS患儿根据胸片显示的分级结果分为4个组别,1级217例, 2级225例, 3级126例,4级99例,对各组围生期情况进行回顾性分析。结果：分级不同的RDS早产儿在性别、双胎、双胎之小所占的比例、母亲年龄、产前糖皮质激素应用、有无胎膜早破/胎盘早剥、受孕与分娩方式等方面的差异均无统计学意义（P＞0.05）,但随着RDS分级的加重,患儿出生体重和胎龄在减小,而Apgar评分≤7分的患儿比例及母亲患妊娠高血压疾病的比例在逐渐增大,差异有统计学意义（P＜0.05）。结论：RDS的分级主要与早产程度、出生体重、围生期窒息等高危因素有关。     

沐舒坦防治早产儿呼吸窘迫综合征的疗效观察

目的探讨沐舒坦防治早产儿呼吸窘迫综合征(RDS)的疗效。方法以沐舒坦治疗组为观察组,以单纯综合治疗组为对照组。观察组在综合治疗基础上于生后4h内给以沐舒坦每次7.5mg/kg,每6h1次,疗程3～5d。观察2组早产儿RDS的发病率、临床表现、X线表现、机械通气开始时间、机械通气时间、下机后氧疗时间及死亡率情况。结果2组早产儿RDS的发病率、临床表现、X线表现差异无统计学意义;观察组机械通气开始时间(7.9±0.91)h,对照组(8.2±0.98)h,2组相比差异无统计学意义(P>0.05);观察组机械通气时间(70.5±4.78)h,对照组(83.14±8.31)h,2组相比差异无统计学意义(P>0.05);2组下机后氧疗时间,观察组(18.32±0.64)h,对照组(26.37±0.39)h,差异有统计学意义(P<0.01);2组死亡率相比差异无统计学意义(P>0.05)。结论早产儿生后早期应用沐舒坦,能够促进肺表面活性物质生成和分泌,有利于促进肺发育成熟,促进早产儿RDS临床过程的改善,有利于疾病的恢复。     

早产儿呼吸窘迫综合征自发性利尿与肺功能关系探讨

目的　 探讨早产儿呼吸窘迫综合征 (RDS)自发性利尿与肺功能及预后的关系。 方法 　 31例入院日龄小于 2 4h ,需机械通气的RDS患儿 ,应用床旁肺力学监护仪动态监测、动态顺应性 (Cdyn)、潮气量 (VT) ,并记录 2 4h出 (O)入 (I)量和呼吸机各参数。利尿开始时 (O/I≥ 1)及最大利尿期的尿量、Cdyn、VT、RR、PIP、MAP、FiO2 与利尿前 8h的资料进行比较。 结果 　治愈组 2 5例 ,开始利尿时间为 (41 88± 9 19)h ,最大利尿期为 (6 0 12± 10 95 )h ,与利尿前 8h比较 :开始利尿时 ,肺功能和呼吸机各参数无明显变化 ;而在最大利尿期 ,Cdyn和VT 明显改善 (P <0 0 1) ,呼吸机各参数显著下降 (P <0 0 1)。利尿先于肺功能改善 16～2 8h。死亡组 6例无自发性利尿过程 ,肺功能无改善。 结论 　RDS患者出现自发性利尿后肺功能开始好转 ,当尿量明显增多时 ,肺功能明显改善 ,应迅速下降呼吸机各参数 ,以避免过度通气 ,减少并发症产生。不出现利尿者 ,提示预后欠佳     

容量保证机械通气在呼吸窘迫综合征早产儿中应用

目的 比较容量保证(VG)与压力控制(PC)两种机械通气模式在呼吸窘迫综合征(RDS)早产儿中的应用效果。方法 前瞻性选择2017年03月至2021年04月NICU收治的胎龄<32周或出生体质量<1 500g,需要有创机械通气的RDS早产儿作为研究对象,按简单随机法分为VG组和PC组。比较两组拔管前的呼吸机参数及动脉血气,有创机械通气时间、总呼吸支持时间及平均住院时间,并发症发生率及病死率。结果 最终RDS早产儿79例完成研究,男46例、女33例,平均胎龄(30.1±1.2)周,平均出生体质量(1 239.0±158.0)g,VG组36例、PC组43例。与PC组比较,VG组在拔管前的平均气道压较低,有创机械通气时间、总呼吸支持时间以及平均住院时间均缩短,差异有统计学意义(P<0.05)。结论 在RDS早产儿的机械通气治疗中,VG通气可能是一种更加安全有效的通气方式,但仍需要大样本、多中心的临床试验证实。     

应用肺表面活性物质预防早产儿呼吸窘迫综合征临床观察

目的　 研究应用肺表面活性物质 (PS)预防早产儿呼吸窘迫综合征 (NRDS)的临床价值。 方法 　 14例高危早产儿气管内滴注单剂预防量PS ,与 14例未应用PS的高危早产儿进行前瞻性临床对照研究。 结果 　治疗组血气指标改善较对照组明显 ,治疗组平均住院天数 ( 2 3 3± 6 7)d ,氧疗时间 ( 5 1± 2 2 )d ,机械通气时间 ( 2 6± 1 3 )d ;对照组平均住院天数 ( 2 9 6± 8 5 )d ,氧疗时间 ( 6 9± 2 4)d ,机械通气时间 ( 4 7± 1 5 )d ,两组比较有显著性差异 (P <0 0 5 )。治疗组并发NRDS、死亡及需要机械通气例数也较对照组少 ,但两组差异无统计学意义 (P >0 0 5 )。 结论 　早产儿预防性应用PS不能降低NRDS发病率及病死率 ,但可明显改善患儿血气指标 ,并且缩短住院天数、氧疗时间及机械通气时间 ,早产儿给予PS预防治疗是可行的。     

成人型呼吸窘迫综合征研究进展

成人型呼吸窘迫综合征为继发于某种严重原发疾病的急性呼吸衰竭,具有急起呼吸窘迫、难以纠正的严重低氧血症、肺顺应性下降、X线广泛肺部浸润、肺水肿等临床特征。以前本病有多种名称,目前用得较多的名称仍为Ashbaugh等于1967年首次使用的成人呼吸窘迫综合征(ARDS)。     

早产儿早期血脂代谢特点及与新生儿呼吸窘迫综合征关系探讨

目的：了解早产儿早期血脂代谢特点及其与新生儿呼吸窘迫综合征（RDS）的关系。方法：将100例适于胎龄早产儿按胎龄或出生体重分组,并以40例足月适于胎龄儿作为对照组,于出生后12 h内静脉采血,测定血浆总胆固醇（TC）、甘油三脂（TG）,低密度脂蛋白胆固醇（LDL-C）及高密度脂蛋白胆固醇（HDL-C）水平;另外,分别根据胎龄及出生体重进一步比较发生RDS与未发生RDS早产儿的血脂水平。结果：随胎龄及体重增加,TG水平呈递增趋势,28~30周组及31~33周组早产儿血浆TG水平均明显低于34~36周早产儿及足月儿（P<0.01）;出生体重≤1499 g组及1500~2499 g组早产儿血浆TG水平均明显低于出生体重≥2500 g早产儿及足月儿（P<0.05）,且出生体重≤1499 g组与1500~2499 g组早产儿之间TG水平差异亦有统计学意义（P<0.01）;而各组新生儿HDL-C、LDL-C及TC水平差异无统计学意义。RDS与非RDS早产儿血浆TC、LDL-C及HDL-C水平差异亦无统计学意义;但在胎龄28~30周组,RDS早产儿的TG水平比非RDS早产儿明显降低（P<0.05）;体重≤1499 g RDS早产儿TG水平低于非RDS早产儿（P<0.05）。结论：早产儿血脂水平与胎龄及体重相关,低TG水平可能是胎龄28~30周及体重≤1499 g早产儿出现RDS的原因之一。     

Thrombomodulin serum levels in ventilated preterm babies with respiratory distress syndrome

A soluble form of thrombomodulin (TM), an anticoagulant proteoglycan of the endothelial cell membrane, considered a marker of vascular endothelial damage, was measured in plasma of preterm infants with respiratory distress syndrome (RDS). In these patients, lung immaturity leads to endothelial leak of plasma proteins and to surfactant inhibition. In 18 babies with RDS, plasma TM concentration was significantly elevated compared with values of a matched group of babies without pulmonary disease (276.1 ng/ml vs 141.3 ng/ml) (P<0.05). Furthermore, TM levels of mechanical ventilated babies (IPPV) with severe RDS were higher than those of babies with moderate RDS and treated with nasal CPAP (340.9 ng/ml vs 174.2 ng/ml) (P<0.05). Conclusion These data show that TM can be used as marker of pulmonary endothelial damage in preterm babies treated with mechanical ventilation for RDS and suggest early intervention with exogenous surfactant to limit alveolar protein leakage and surfactant inactivation. Received: 20 February 1997 and in revised form: 7 July 1997 / Accepted: 8 July 1997     

沐舒坦预防早产儿呼吸窘迫综合征的Meta分析

目的：系统评价沐舒坦预防早产儿呼吸窘迫综合征（respiratory distress syndrome,RDS）的有效性及安全性。方法：电子检索Cochrane图书馆、PubMED、EMBASE、中国生物医学文献数据库、中国期刊全文数据库、万方和维普数据库等,手工检索Pediatrics及Pediatric Research中刊载的会议论文。检索沐舒坦预防早产儿RDS的随机对照试验（randomized controlled trial,RCT）文献。应用Cochrane协作网推荐的方法评价文献质量,对同质研究采用RevMan 5.0.17软件进行Meta分析。结果：共纳入6个RCT,其中1篇质量评价为A级,1篇为B级,4篇为C级,包括823例早产儿。Meta分析结果显示,沐舒坦预防组与对照组比较,在RDS发病率(OR=0.24,95%CI［0.15,0.64］,P＜0.01)、支气管肺发育不良（BPD）发病率(OR=0.41,95%CI［0.23,0.75］,P<0.01)、脑室内出血（IVH）发病率(OR=0.39,95%CI［0.24,0.64］,P<0.01)、动脉导管未闭（PDA）发病率(OR=0.33,95%CI ［0.17,0.67］,P<0.01) 及肺部感染发病率(OR=0.24,95%CI［0.14,0.38］,P＜0.01)差异均有统计学意义。所有研究均未报道不良反应的发生。结论：现有证据表明,早产儿早期使用沐舒坦预防性治疗能有效减少RDS、BPD、IVH、PDA及肺部感染的发病率。［中国当代儿科杂志,2010,12（11）：858-863］     

Risk for respiratory distress syndrome in preterm infants born to mothers complicated by placenta previa

This study examined the risk factors for respiratory distress syndrome (RDS) in preterm infants from pregnancies complicated by placenta previa. Forty preterm infants born to mothers with placenta previa between January 1989 and December 1995 in a medical center were enrolled. Each of these patients was matched in gestational age and gender with an infant born immediately after to a mother without placenta previa. Obstetric and neonatal outcome variables were collected. The mean±S.D. gestational age for both groups was 33.0±3.1 weeks. There was no difference in mean birthweight between the placenta previa and control groups (2129±598 vs. 2136±493 g). All the patients in the former and 11 (28%) in the latter were born by cesarean section. About a half of the mothers in both groups received antenatal steroids. Infants from placenta previa pregnancies had a higher incidence (21/40 vs. 10/40, P<0.01) and more severe RDS than controls. Stratified by the status of treatment with antenatal steroid, we found that gestational age was a significant risk factor for RDS in both treated and untreated groups (P<0.01), but placenta previa was an independent risk factor (odds ratio 32; CI 1–4182) by multiple exact logistic regression in antenatal steroid-treated group. We conclude that preterm infants born to mothers with placenta previa had a higher risk for RDS than controls. It played an independent role, in addition to gestational age, only in infants treated with antenatal steroid. We speculate that placenta previa was not directly contributing to RDS, but through other associated risk factors for RDS.     

早期咖啡因治疗对呼吸窘迫综合征早产儿呼吸机需求的影响研究

目的研究早期静脉注射咖啡因对呼吸窘迫综合征(RDS)早产儿的影响。方法通过前瞻性临床对照研究,选择进行机械通气的RDS早产儿59例,分成咖啡因组(n=30)和对照组(n=29)。咖啡因组在生后12~24 h开始使用咖啡因,对照组在计划拔除气管插管前4~6 h开始给予咖啡因(剂量同咖啡因组)。比较两组呼吸机参数,以及呼吸机相关性肺炎(VAP)、呼吸暂停(AOP)等并发症发生情况。结果咖啡因组最高吸气峰压(PIP)、最高吸入氧浓度(Fi O_2)及VAP发生率明显低于对照组(P0.05)。咖啡因组插管时间、NCPAP时间、总需氧时间均明显短于对照组(P0.05),拔管后首次AOP发生时间明显迟于对照组(P0.05),拔管后1~2 d AOP的发生次数也明显少于对照组(P0.01)。结论早期应用咖啡因治疗能减少RDS早产儿对辅助通气的需求,有助于早期拔管及撤离呼吸机,减少VAP及拔管后AOP的发生。     

Evaluation of a practice guideline for the management of respiratory distress syndrome in preterm infants: A quality improvement initiative

BACKGROUND:

The use of mechanical ventilation to treat respiratory distress syndrome in preterm infants has been associated with the development of bronchopulmonary dysplasia. As part of a quality improvement initiative to reduce the incidence of bronchopulmonary dysplasia in preterm infants, a new practice guideline for the management of respiratory distress syndrome was developed and adopted into practice in a neonatal intensive care unit in February 2012.

OBJECTIVE:

To evaluate the effects of implementing the new guideline in regard to the use of mechanical ventilation and surfactant, and the incidence of bronchopulmonary dypslasia.

METHODS:

An historical cohort of very preterm infants (gestational age 26⁰ to 32⁶ weeks) born one year before guideline implementation was compared with a similar cohort of infants born one year following guideline implementation. Data were collected retrospectively from the local neonatal intensive care unit database.

RESULTS:

A total of 272 preterm infants were included in the study: 129 in the preguideline cohort and 143 in the postguideline cohort. Following the implementation of the guideline, the proportion of infants treated with ongoing mechanical ventilation was reduced from 49% to 26% (P<0.001) and there was a trend toward a reduction in bronchopulmonary dysplasia (27% versus 18%; P=0.07). There was no difference in the proportion of infants treated with surfactant (54% versus 50%).

CONCLUSION:

The implementation of the practice guideline helped to minimize the use of ongoing mechanical ventilation in preterm infants.     

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目的 探讨早期、晚期早产儿与足月儿呼吸窘迫综合征(RDS)的发病趋势和临床特征的差异,为临床合理诊治提供依据。方法 2006年1月至2010年12月在郑州大学第三附属医院住院的963例RDS患儿根据胎龄不同分为早期早产儿组(<34周)679例,晚期早产儿组(34～<37周)204例,足月儿组(≥37周)80例,分别对各组患儿的发病率、入院情况、高危因素、临床诊治、预后及并发症进行比较。结果 RDS的发病率逐年增加,均以早期早产儿占多数,晚期早产儿和足月儿RDS比例有增多趋势;RDS患儿男婴超过女婴(P<0.05),且胎龄和体重越大,男婴比例越高;足月儿RDS组产前糖皮质激素使用率明显低于早产儿组;早产儿发生RDS的高危因素主要有胎膜早破、胎盘异常、母亲妊娠高血压疾病,足月儿发生RDS的高危因素主要是择期剖宫产与感染;晚期早产儿与足月儿RDS的临床诊断和应用肺泡表面活性物质(PS)时间均晚于早期早产儿;足月儿RDS应用机械通气比例明显高于早产儿,其临床治愈率高(P<0.05),在死亡率方面与早产儿组无差别;但并发气胸的比例高于早产儿组(P<0.05)。结论 新生儿呼吸窘迫综合征(NRDS)发病率逐年增高,晚期早产儿和足月儿RDS比例有增多趋势;早期、晚期早产儿与足月儿RDS在性别比例、高危因素、起病特点、治疗反应与并发症方面均存在差异,RDS的诊治需要考虑胎龄因素。足月儿RDS多与择期剖宫产、感染有关,发病相对较晚,容易合并气胸,应引起足够重视。     

神经调节辅助通气在早产儿呼吸窘迫综合征中的应用

目的观察神经调节辅助通气(neurally adjusted ventilatory assist,NAVA)对于早产儿呼吸窘迫综合征机械通气中触发同步性、气体交换和呼吸力学的影响。方法 10例呼吸窘迫综合征的早产儿先后给予NAVA和同步间歇指令通气(SIMV)模式通气各60 min,在模式选择顺序上采用随机化处理。比较不同通气模式中患儿生命体征、触发同步性和血气指标、呼吸力学参数。结果 NAVA模式下吸气触发延迟时间较SIMV模式明显缩短(P0.05);2种模式下动脉血pH、PaCO2、PaO2、PaO2/FiO2比较差异均无统计学意义;应用NAVA模式时自主呼吸频率、气道峰压、膈肌电活动信号和呼吸做功均较SIMV模式明显降低(P0.05)。结论对早产儿呼吸窘迫综合征进行机械通气治疗时,与SIMV模式相比,NAVA模式能改善触发同步性,降低气道峰压,并减少膈肌负荷和呼吸做功。     

Inhaled nitric oxide in very preterm infants with severe respiratory distress syndrome

AIM: To test the hypothesis that inhaled nitric oxide therapy can decrease the incidence of bronchopulmonary dysplasia and death in preterm infants with severe respiratory distress syndrome; to evaluate the possible predictive factors for the response to inhaled nitric oxide therapy. METHODS: Preterm infants (less than 30 weeks' gestation) were randomized to receive during the first week of life inhaled nitric oxide, or nothing, if they presented severe respiratory distress syndrome. Then, the treated infants were classified as non responders and responders. RESULTS: Twenty infants were enrolled in the inhaled nitric oxide therapy group and 20 in the control group. Bronchopulmonary dysplasia and death were less frequent in the inhaled nitric oxide group than in the control group (50 vs. 90%, p=0.016). Moreover, nitric oxide treatment was found to decrease as independent factor the combined incidence of death and BPD (OR=0.111; 95% C.I. 0.02-0.610). A birth weight lower than 750 grams had a significant predictive value for the failure of responding to inhaled nitric oxide therapy (OR 12; 95% C.I. 1.3-13.3). CONCLUSION: Inhaled nitric oxide decreases the incidence of bronchopulmonary dysplasia and death in preterm infants with severe respiratory distress syndrome. Birth weight may influence the effectiveness of inhaled nitric oxide therapy in promoting oxygenation improvement in preterm infants.