新生儿急性肺损伤/急性呼吸窘迫综合征

新生儿急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)是由多种原因引起的肺部弥散性损害,以顽固性低氧血症、呼吸窘迫、肺顺应性下降和弥散性渗出为主要特征,ARDS是ALI的严重形式。由于其病死率高,救治此类患儿仍是新生儿科医师面临的严峻挑战。本文对新生儿ALI/ARDS高危因素、发病机制、诊断标准及治疗进展作一介绍。     

脓毒症与急性呼吸窘迫综合征

重症脓毒症常并急性呼吸窘迫综合征，是导致死亡的重要原因，目前认为炎性反应在急性肺损伤或急性呼吸窘迫综合征的发病机制中起主要作用，保护性肺通气策略可应用于儿童急性呼吸窘迫综合征的治疗。     

新生儿急性呼吸窘迫综合征研究进展

新生儿急性呼吸窘迫综合征（ARDS）是新生儿常见的临床危重症,是新生儿致死、致残的主要原因之一。新生儿ARDS病因及发病机制复杂,与各种病理因素导致的继发性肺表面活性物质（PS）缺乏有关,具有炎症性特点。新生儿ARDS作为一种临床综合征,与其他疾病难以鉴别。该病的治疗目前缺乏特效手段,仍是以呼吸支持、PS替代、体外膜肺氧合治疗、营养支持及液体管理等对症及综合治疗为主。该文就新生儿ARDS的病因分类、临床特点、诊断治疗策略等方面的研究进展做一综述。     

肺泡表面活性物质对新生儿急性肺损伤氧合功能的影响

目的 研究肺泡表面活性物质（pulmonary surfactant,PS）对新生儿急性肺损伤、急性呼吸窘迫综合征氧合功能的影响.方法 纳入符合急性肺损伤、急性呼吸窘迫综合征诊断标准的新生儿98例,分为PS治疗组30例及常规治疗组68例,PS治疗组经气管插管注入PS 70 ～ 100 mg/kg,其余治疗同常规治疗组.结果 两组新生儿的性别、胎龄、出生体重、肺损伤程度差异无统计学意义;PS治疗组在急性肺损伤、急性呼吸窘迫综合征治疗后6h、12h、24 h、48 h的PaO3/FiO2、呼吸机有效指数均高于常规治疗组,而氧合指数、呼吸指数均低于常规治疗组,差异有统计学意义（P＜0.05）;PS治疗组在急性肺损伤、急性呼吸窘迫综合征治疗后机械通气时间[（66±13）h、（82 ±26）h]和用氧时间[（86±13）h、（103±25）h）]均较常规治疗组[（80 ±18）h、（101 ±36）h和（104±16）h、（125 ±29） h]缩短,差异有统计学意义（P＜0.05）.结论 应用PS治疗新生儿急性肺损伤、急性呼吸窘迫综合征可改善肺顺应性及氧合功能,缩短机械通气及氧疗时间,有利于改善预后.     

肺表面活性物质临床应用新认识

自1959年Avery发现肺表面活性物质(pulmonary surfactant,PS)缺乏引起早产儿呼吸窘迫综合征以来,1980年日本学者Fuiiwara首先报道用肺表面活性物质治疗早产儿呼吸窘迫综合征取得成功,这一突破性进展引起了医学界的广泛兴趣和关注。长期以来,有关PS缺乏在新生儿呼吸窘迫综合征(NRDS)和急性呼吸窘迫综合征(ARDS)发病中的     

选择性剖宫产儿急性呼吸窘迫综合征发病机制研究进展

新生儿急性呼吸窘迫综合征是新生儿较常见的呼吸道疾病,多见于选择性剖宫产儿,具体发病机制复杂,肺液清除延迟是其主要发病机制,同时胎粪吸入、呼吸反射建立延迟、胎龄、宫缩发动、男性患儿、围生期窒息、母亲有糖尿病或哮喘是其危险因素。     

急性呼吸窘迫综合征的病因与病理

急性呼吸窘迫综合征(ARDS)或称成人呼吸窘迫综合征,在儿童是从新生儿中期至青春期发生的一组以呼吸困难、低氧血症、肺顺应性降低和两肺肺水肿为主征的呼吸衰竭。发病急骤,病情危重,患者一般过去无心肺疾患。本综合征有别于发生在未成熟儿的新生儿呼吸窘迫综合征(NRDS)。     

脓毒症致急性呼吸窘迫综合征的发病机制及乌司他丁的治疗作用

脓毒症是指由感染引起的全身炎症反应综合征,常导致脓毒性休克、多器官功能不全综合征,是儿童最常见的致死原因,是现代儿童危重病医学研究领域的热点和难点.严重脓毒症常并发急性呼吸窘迫综合征,是导致病情恶化及死亡的重要原因.本文就脓毒症所致急性呼吸窘迫综合征的发病机制及乌司他丁的治疗作用作一综述.     

3799例新生儿呼吸道疾病的防治结果(1996年～1998年)

目的 探讨新生儿呼吸道疾病防治方案对新生儿急性呼吸道疾病防治效果。方法 对３７９９例新生儿中呼吸道疾病进行防治调查。结果 总发病率６．５５％,病死率６．２４％;前几位的是窒息＋吸入综合征、呼吸窘迫综合征、肺炎及胎粪吸入综合征,各发病率接近或低于国外近期报道;３ａ重症呼吸道疾病发病率、呼吸道疾病病死率、呼吸机治疗病死率有所下降。结论 此防治方案可有效降低新生儿呼吸道疾病发病及死亡。     

急性肺损伤发病机制研究进展

急性肺损伤/急性呼吸窘迫综合征是指非心源性的各种内外因素导致的急性、进行性、缺氧性呼吸功能不全或呼吸衰竭;肺损伤的病因多种多样,发病机制非常复杂,且尚不明确.该文对其目前相关病因及发病机制研究进行综述.     

Acute respiratory distress syndrome in a child with human parvovirus B19 infection

A 6-year-old girl developed shock and multiple organ dysfunction including acute respiratory distress syndrome in association with parvovirus B19 infection. The diagnosis was based on positive antibodies and the detection of parvovirus 19 DNA in serum, bronchial secretions and skin biopsy. It seems likely, but it was not proved, that the parvovirus infection caused acute respiratory distress syndrome.     

他汀类药物的研究进展及在急性呼吸窘迫综合征中的作用

急性呼吸窘迫综合征是儿童常见重症,威胁儿童的生命健康.其病理机制为肺部组织广泛的炎症反应.他汀类药物已广泛应用于心脑血管疾病的防治,目前研究发现他汀类药物具有抗炎及调节免疫的作用.本文将对他汀类药物的作用机制、在急性肺损伤及急性呼吸窘迫综合征中的作用机制和应用,以及他汀类药物的有效性和安全性进行综述.     

足月儿呼吸窘迫综合征高危因素及防治

近年来,随着择期剖宫产率等因素增加,足月儿呼吸窘迫的发生率也呈上升趋势,已引起广泛关注.本文从母婴两方面重点综述了发生足月儿呼吸窘迫综合征的高危因素及相关机制.发现选择性剖宫产、胎龄、胎儿性别以及某些妊娠合并症均能影响足月儿呼吸窘迫综合征的发病率.并指出一旦呼吸困难加重,要及时使用呼吸支持和尽早使用肺泡表面活性物质,各种综合措施联合使用可减少足月儿呼吸窘迫综合征的病死率.     

What’s new in surfactant?

Surfactant therapy has significantly changed clinical practice in neonatology over the last 25 years. Recent trials in infants with respiratory distress syndrome (RDS) have not shown superiority of any natural surfactant over another. Advancements in the development of synthetic surfactants are promising, yet to date none has been shown to be superior to natural preparations. Ideally, surfactant would be administered without requiring mechanical ventilation. An increasing number of studies investigate the roles of alternative modes of administration and the use of nasal continuous positive airway pressure to minimise the need for mechanical ventilation. Whether children with other lung diseases benefit from surfactant therapy is less clear. Evidence suggests that infants with meconium aspiration syndrome and children with acute lung injury/acute respiratory distress syndrome may benefit, while no positive effect of surfactant is seen in infants with congenital diaphragmatic hernia. However, more research is needed to establish potential beneficial effects of surfactant administration in children with lung diseases other than RDS. Furthermore, genetic disorders of surfactant metabolism have recently been linked to respiratory diseases of formerly unknown origin. It is important to consider these disorders in the differential diagnosis of unexplained respiratory distress although no established treatment is yet available besides lung transplantation for the most severe cases. Conclusion: Research around surfactant is evolving and recent developments include further evolution of synthetic surfactants, evaluation of surfactant as a therapeutic option in lung diseases other than RDS and the discovery of genetic disorders of surfactant metabolism. Ongoing research is essential to continue to improve therapeutic prospects for children with serious respiratory disease involving disturbances in surfactant. Funding: Jasper Been is supported by a Profileringsfonds grant from the Maastricht University Hospital.     

Respiratory distress in neonates

Respiratory distress due to either medical or surgical causes occurs commonly in neonates. It is the most common cause of admission to a neonatal surgical intensive care facility in a tertiary care hospital. The distress can be caused by a variety of clinical conditions; common conditions treated in medical intensive care units are transient tachypnea of the new born, respiratory distress syndrome, pulmonary air leak and pneumothorax. In surgical causes of respiratory distress in neonates the underlying mechanisms include airway obstruction, pulmonary collapse or displacement and parenchymal disease or insufficiency; the common causes are congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congenital lobar emphysema and esophageal atresia with or without tracheo-esophageal fistula. Obstructive lesions of the new born airway include choanal atresia, macroglossis, Pierre-Robin syndrome, lymphangioma, teratoma or other mediastinal masses, cysts, subglottic stenosis and laryngo tracheomalacia. Imaging plays a very major role in the pre-operative diagnosis of these conditions and proper pre-operative resuscitation helps in improving the results of surgery dramatically.     

Interleukin-1 receptor antagonist intron 2 variable number of tandem repeats polymorphism and respiratory failure in children with community-acquired pneumonia

OBJECTIVE: To determine whether the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene is associated with lung injury in children with community-acquired pneumonia. DESIGN: A prospective cohort of children diagnosed with community-acquired pneumonia. SETTING: Two pediatric hospitals. PATIENTS: Eight hundred fifty pediatric patients with community-acquired pneumonia were enrolled. INTERVENTIONS: Genotyping of the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene was performed on DNA isolated from whole blood. MEASUREMENTS AND MAIN RESULTS: The requirement for positive pressure ventilation or the diagnosis of acute lung injury or acute respiratory distress syndrome were the main outcomes of the study. Children (14 days-19 yrs) with community-acquired pneumonia (850) were enrolled; analysis was limited to African American (515) and Caucasian (232) patients. Of the 82 patients requiring positive pressure ventilation, 44 were diagnosed with acute lung injury or acute respiratory distress syndrome. Multivariate logistic regression analyses indicated that children without a copy of the A1 allele of the variable nucleotide tandem repeat polymorphism in intron 2 of the interleukin-1 receptor antagonist gene were more likely to need positive pressure ventilation compared to those with one or two copies of this allele (odds ratio = 2.65, confidence interval, 1.02-6.90). In addition, the absence of the A1 allele also appeared to be associated with the development of community-acquired pneumonia-induced acute lung injury/acute respiratory distress syndrome (odds ratio = 3.1, confidence interval, 0.99-9.67). CONCLUSIONS: In children with community-acquired pneumonia, absence of the A1 allele at the interleukin-1 receptor antagonist intron 2 polymorphic site is associated with increased risk for more severe lung injury, as measured by the need for positive pressure ventilation or the development of acute lung injury or acute respiratory distress syndrome. Conversely, presence of the A1 allele is associated with decreased risk for more severe lung injury in this patient population.     

β2肾上腺素受体激动剂在急性呼吸窘迫综合征中的应用

急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）是危及生命的严重疾病,病情凶险,病死率高.近年来,保护性机械通气策略和保守液体管理技术是ARDS有效的治疗手段,尚缺乏有效的药物治疗.近年来,基础研究显示,β2肾上腺素受体激动剂具有抑制肺部炎症反应、保护肺泡-微血管屏障、刺激肺表面活性物质分泌、促进肺水肿液清除等功能及肺损伤后的防御与修复等作用.本文就β2肾上腺素受体激动剂应用于ARDS的治疗研究进行归纳总结.     

Pulmonary edema in infants and children

PURPOSE OF REVIEW: To provide an overview of the pathogenesis of pulmonary edema and describe recent discoveries related to the clearance of airspace fluid and potential new therapies for this life-threatening disorder. RECENT FINDINGS: It is clinically important to determine the mechanisms responsible for the clearance of fluid from the airspaces. At birth inadequate clearance of fetal lung liquid is one of the two mechanisms leading to respiratory distress syndrome in the premature infant. Adults with heart failure or adult respiratory distress syndrome survive when they had active absorption of airspace fluid, yet have greater morbidity or die when they show no evidence of active fluid clearance. Humans who are susceptible to high-altitude pulmonary edema have less ability to actively transport fluid across their respiratory epithelium. SUMMARY: New approaches to increase the active clearance of fluid from the airspaces, combined with further improvements in the intensive care and monitoring of patients with serious illnesses, will lead to improved care for patients with lung diseases characterized by increased lung water content.     

Surfactant replacement therapy

OBJECTIVE: To analyze and update information about surfactant therapy replacement in newborns with lung diseases. SOURCES: Literature review, including textbooks, meta-analyses, prospective, randomized controlled trials, retrospective assessments and case studies. Literature was reviewed based on the authors clinical and scientific experience regarding surfactant replacement therapy in neonatal lung diseases. SUMMARY OF THE FINDINGS: Surfactant replacement therapy for the neonatal respiratory distress syndrome improves respiratory function, and reduces the need for oxygen supplementation and pressure support ventilation, in addition to minimizing the air leak syndrome. However, the use of surfactant did not prevent the occurrence of other intercurrent diseases such as patent ductus arteriosus, intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, and bronchopulmonary dysplasia. The surfactant treatment decreased neonatal mortality up to 40%. The effectiveness of exogenous surfactant on other respiratory diseases with surface film dysfunction, such as meconium aspiration syndrome, pneumonia, acute respiratory distress syndrome and congenital diaphragmatic hernia has not yet been widely accepted. CONCLUSIONS: Surfactant replacement is now considered the standard treatment for newborns with respiratory distress syndrome. We hope that, in the future, new synthetic surfactant preparations will be more effective in treating other infant respiratory diseases.