肾移植术后肺感染致急性呼吸窘迫综合征的无创机械通气治疗

肾移植术后肺感染是危及患者生命的主要并发症之一．若不能及时有效地给予处理，则病情会迅速发展，出现急性肺损伤（ALI）甚至急性呼吸窘迫综合征（ARDS），其预后极差，常需行机械通气。2002年6月-2004年5月，我科共收治肾移植术后肺感染患者36例。其中并发ALI或ARDS20例，应用无创机械通气（NIPPV）治疗12例，疗效较好，总结如下。     

肾移植术后肺部感染的诊治

目的提高肾移植术后肺部感染的诊疗水平。方法回顾性分析总结36例肾移植术后并发肺部感染患者的临床资料及诊治情况。结果29例患者找到病原体47例次，7例未找到确切的病原体；并发急性肺损伤／急性呼吸窘迫综合征者共20例，其中12例行机械通气治疗，10例（83．3％）治愈；19例患者行纤维支气管镜（纤支镜）介入诊疗，其中16例（84．2％）明确了病原体，12例患者经纤支镜介入治疗后，临床症状均有不同程度改善；本组36例患者中，32例（88．9％）治愈，2例死亡，2例因经济原因放弃治疗自动出院。结论肾移植术后肺部感染患者应积极进行病原学的检测，重视影像学检查的意义；早期经验性治疗能否覆盖可能感染的病原体是治疗能否成功的关键；纤支镜介入诊疗对于提高肾移植术后肺部感染（尤其是莺症肺部感染）的治愈率有重要作用。     

肾移植术后急性呼吸窘迫综合征的护理研究

急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)是肾移植受者死亡的主要原因之一.对本院收治的23例肾移植术后重症肺部感染致ARDS患者进行分析,报告如下.     

特重烧伤后急性肺损伤/急性呼吸窘迫综合征12例分析

目的:探讨特重烧伤后急性肺损伤(ALI)/急性呼吸窘迫综合征(ARDS)的临床特点及治疗方法。方法:回顾分析12例入院时不伴明显呼吸功能障碍的特重烧伤病例发生ALI/ARDS的原因及其治疗效果,分别给予氧疗或机械通气、抗炎、补充胶体、抗感染、手术等治疗。结果:5例经吸氧、药物治疗后痊愈,未行机械通气;7例行机械通气,其中6例痊愈,1例并发肺部感染后死于MODS。结论:特重烧伤可致ALI/ARDS,积极的抗休克、抗感染、手术、抗炎、机械通气等治疗可较有效救治ALI/ARDS。     

无创通气治疗胸外伤后急性肺损伤

急性肺损伤(acute lung injury，ALI)是指严重感染、创伤、休克尤其是重症胸外伤后危及生命的并发症，严重的ALI即为急性呼吸窘迫综合征(ARDS)^[1]。早期ALI如能采取预防性机械通气，有可能使病情逆转，防止ARDS的发生^[2]。通过对10例以胸部外伤为主的早期ALI患者，采取经鼻罩无创通气方法治疗，除l例改为有创通气外，无1例发生ARDS，全部治愈，取得较好的效果。     

肾移植术后肺部感染致急性呼吸窘迫综合征的护理

目的探讨肾移植术后重症肺部感染致急性呼吸窘迫综合征（ARDS）的护理措施。方法回顾性分析24例肾移植术后重症肺部感染致ARDS患者的临床护理措施。结果本组24例患者,15例痊愈出院,2例放弃治疗,7例抢救无效死亡。结论肾移植术后肺部感染致ARDS患者应密切观察病情,严格执行消毒隔离制度,及早提供呼吸支持,加强心理护理、基础护理及营养支持,这些对提高抢救成功率极为关键。     

肾移植术后46例肺部感染病原体及预后分析

背景:肾移植术后肺部感染与许多潜在的病原体有关.目的:分析肾移植术后肺部感染的病原体以及预后因素.设计、时间及地点:病例分析,2008-09在上海交通大学附属第一人民医院呼吸科完成.对象:1999-01/2008-08所有肾移植术后肺部感染患者46例,男37例,女9例.年龄20～65岁.方法:回顾性分析46例肾移植术后肺部感染患者的临床资料.详细记录每位患者的信息,包括:性别、年龄、起病时间,器官移植时间、症状、免疫抑制剂的使用情况、肺部浸润的情况、APACHE评分、是否使用机械通气、疾病的转归等.主要观察指标:①患者的临床特点、病原学诊断和病死率.②患者预后的单因素和多因素分析.结果:细菌仍足最常见的病原体(35%),其他病原体依次为巨细胞病毒(15%)、真菌(11%)、结核(7%)、呼吸道病毒(4%)、卡氏肺孢子菌(2%)、以及蠊缨滴虫(2%).12例死亡.总的病死率为26%.各病原体间病死率无显著差异.呼吸困难,APACHE Ⅱ评分,需要机械通气是影响肾移植术后肺部感染死亡的危险因素.结论:多种病原体参与了肾移植术后肺部感染的发生,包括呼吸道病毒和蠊缨滴虫,而呼吸困难、APACHE Ⅱ评分、需要机械通气是重要的预后因素.     

急性肺损伤/急性呼吸窘迫综合征患者机械通气管理策略

急性肺损伤(acute lung injury,ALI)/急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是临床常见的肺部综合征[1],临床以进行性呼吸困难、低氧血症、肺顺应性下降为特征,病死率为40%~50%。机械通气作为支持呼吸的重要手段,能够缓解呼吸窘迫、改善肺压力-容量关系,为ALI/ARDS患者的病因治疗争取时间、创造条件。本文将重点讨论ALI/ARDS患者的机械通气管理策略。保护性机械通气策略ALI/ARDS患者的临床监护往往面临努力确保足够氧合与减小氧中毒潜在危险两方面的困难选择[2]。20世纪70年代,ALI/ARDS患者机械通气…     

2型糖尿病肺部感染并发ARDS的高危因素及其转归

【目的】探讨2型糖尿病肺部感染后发生急性呼吸窘迫综合征（ARDS）的高危因素及其防治措施。【方法】选取本科近4年来2型糖尿病肺部感染后并发ARDS的23例病例，统计其发病原因、影响因素和疗效、转归。【结果】患者危险因素中有慢性肺部疾病患者18例、心功能不全17例、水电解质紊乱13例、营养状况不良15例、对抗生素的疗效不佳16例；早期给予适量激素治疗、积极的机械通气能改善血气指标（P〈0．05～0．01）；年龄、血糖水平、氧合指数、感染程度与病死率有密切关系。【结论】控制慢性肺部疾患、改善心功能、平衡水电解质紊乱、改善营养状况、合理应用抗生素是控制本病并发ARDS发生的重要手段；早期给予适量激素、积极的机械通气对2型糖尿病肺部感染并发ARDS治疗有积极意义；老龄病人、血糖水平高、氧合指数严重低下、感染程度重预后不佳。     

氯氮平中毒继发急性肺损伤/急性呼吸窘迫综合征的抢救体会

目的:探讨氯氮平中毒继发急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)有效的治疗方法。方法:总结分析16例氯氮平中毒继发ALI/ARDS患者的临床表现和治疗方法。患者在中毒后6～144h出现ALI/ARDS表现,予气管插管、机械通气,抗胆碱药物治疗及血液灌流等综合治疗。结果:本组患者均治愈,平均住院时间(14±1.6)d;机械通气时间平均(134±12)h,中毒后(48～96)h意识转清。结论:氯氮平中毒继发的急性肺损伤/急性呼吸窘迫综合征主要与肺水肿、吸入性肺炎及氯氮平对肺组织的直接损伤作用有关。早期进行机械通气联合血液灌流和合理抗胆碱药物的,是治疗重度氯氮平重度并发急性肺损伤/急性呼吸窘迫综合征(ALI/ARDS)的有效方法。     

纤维支气管镜在肝移植术后急性肺损伤治疗中的应用

目的 回顾性探讨床旁纤维支气管镜(纤支镜)在肝移植术后急性肺损伤(ALI)治疗中的临床应用价值.方法 将58例肝移植术后各种原因导致的ALI患者按是否采用纤支镜干预治疗分为纤支镜治疗组(36例)和常规治疗组(22例),通过比较两组重症加强治疗病房(ICU)停留时间、机械通气时间、ALI病死率、急性呼吸窘迫综合征(ARDS)进展率及其病死率,以及纤支镜使用前后的动脉血气分析变化等,评价纤支镜治疗肝移植术后ALI的临床疗效.结果 与常规治疗组比较,纤支镜治疗组的ICU停留时间[(11±4)d比(16±4)d]、机械通气时间[(9±5)d比(14±5)d]均明显缩短(P均＜0.01),ALI病死率(11.1%比36.4%)及ARDS进展率(27.8%比54.5%)明显降低(P＜0.05和P＜0.01),而ARDS病死率无显著变化[40.0%(4/10)比66.7%(8/12),P＞0.053;纤支镜治疗后动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、动脉血氧饱和度(SaO2)及氧合指数(PaO2/FiO2)均明显好转,与治疗前比较差异均有统计学意义(P均＜0.01).结论 纤支镜是肝移植术后ALl安全、有效的治疗方法,值得推广.     

高频振荡通气治疗常规机械通气无效的新生儿ARDS

【目的】评价高频振荡通气（high～frequency oscillatory ventilation,HFOV）治疗新生儿急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）的疗效。【方法】对本院2009年1月至2010年2月30例患ARDS新生儿经常规机械通气（conventional mechanical ventilation,CMV）无效后改HFOV治疗,观察HFOV治疗前后肺功能变化及病情转归。【结果】26例（86．67％）治愈,无好转放弃治疗4例。治愈患儿中HFOV治疗2h后,动脉氧分压（PaO2）由HFOV治疗前的（45．54±9．31）mmHg上升为（78．36±12．81）mmHg（P〈0．05）,吸氧体积分数（FiO2）由HFOV治疗前（0．60±0．14）降低为（0．49±0．15）（P〈0．05）,PaO2／FiO2由（100．32±41．54）增加到（174．32±68．14）（P〈0．05）;12h后,动脉二氧化碳分压（PaCO2）由（49．08±12．45）mmHg下降到（40．38±10．81）mmHg（P〈0．05）。【结论】HFOV用于新生儿ARDS疗效好,能较快改善肺氧合功能,减少并发症。     

Pulmonary coagulopathy as a new target in therapeutic studies of acute lung injury or pneumonia--a review

OBJECTIVES: To review the involvement of coagulation and fibrinolysis in the pathogenesis of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), pulmonary infection, and ventilator-induced lung injury (VILI). DATA SOURCE: Published articles on experimental and clinical studies of coagulation and fibrinolysis in ALI/ARDS, pneumonia, and mechanical ventilation. CONCLUSIONS: Alveolar fibrin deposition is an important feature of ALI/ARDS and pulmonary infection. The mechanisms that contribute to disturbed alveolar fibrin turnover are localized tissue factor-mediated thrombin generation and depression of bronchoalveolar urokinase plasminogen activator-mediated fibrinolysis, caused by the increase of plasminogen activator inhibitors. These effects on pulmonary coagulation and fibrinolysis are regulated by various proinflammatory cytokines and are similar to those found in the intravascular spaces during severe systemic inflammation. Some studies also suggest that pulmonary coagulopathy is a feature of VILI. Recent studies have demonstrated the beneficial effect of anticoagulant therapy in sepsis. Theoretical considerations suggest that this anticoagulant therapy will benefit patients with primary lung pathology including VILI, but clinical studies are needed to examine this hypothesis before such therapy is to be advocated as a standard of care in critically ill patients.     

机械通气在肾移植术后间质性肺炎合并急性呼吸窘迫综合征抢救中的价值探讨

目的 :探讨机械通气在抢救肾移植术后间质性肺炎合并急性呼吸窘迫综合征 (ARDS)中的价值。方法 :收集 16例综合 ICU(GICU)内肾移植术后因间质性肺炎合并 ARDS患者的临床资料 ,分析与比较机械通气后缺氧改善情况等 ,了解和判断机械通气治疗的价值及影响抢救成功率的主要环节。结果 :16例患者中 ,15例应用了机械通气与不同水平的呼气末正压〔 PEEP,4～ 15 cm H2 O(1cm H2 O=0 .0 98k Pa)〕治疗 ,1例未用机械通气治疗 ;机械通气治疗〔1～ 87d,平均 (15 .4± 2 1.1) d〕与生存时间〔1～ 194 5 d,平均 (15 4 .4± 4 97.1) d〕不等 ;仅 1例痊愈 (6 .7% ) ,14例死亡 (93.3% )。死亡原因分析提示 ,在应用机械通气治疗的患者中 ,病程短(≤ 3d)的患者 (3例 ) ,导致死亡的直接因素为非呼吸因素 (循环和中枢神经 ) ;未应用机械通气治疗的患者(1例 )导致死亡的直接原因为缺氧。分析 1例抢救成功病例的主要经验在于及时应用机械通气并纠正了缺氧 ,为原发病的治疗赢得了时间。结论 :机械通气抢救肾移植术后间质性肺炎合并 ARDS的主要价值在于纠正缺氧 ,病原学诊断与治疗方面的困难可能是抢救成功率低的主要原因。     

连续性血液净化治疗对急性呼吸窘迫综合征患者降钙素原水平的影响

目的：观察连续性血液净化（CBP）在治疗合并急性呼吸窘迫综合征（ARDS）的严重肺部感染时降钙素原（PCT）的变化规律,探讨PCT与ARDS病情严重度的关系。方法：对16例合并ARDS的严重肺部感染病人,在机械通气等常规治疗的同时行CBP,于0,4,12,24,48h及停止CBP后12h分别检测患者血清PCT和动脉血气分析,并采用APACHEⅡ评分对患者整体病情进行评价。结果：16例患者中12例成活。血清PCT浓度在CBP治疗过程中各时点均低于CBP前,其中24h降至最低。结论：PCT对CBP过程中ARDS严重性及疗效的评估具临床价值。     

出血坏死性胰腺炎合并成人呼吸窘迫综合征的治疗

成人呼吸窘迫综合征（ARDS）是急性出血坏死性胰腺炎（ANP）的常见并发症，其发生率高。本文报道了18例急性出血坏死性胰腺炎病人并发ARDS，其临床表现为进行性呼吸困难，面罩吸氧后缺氧无改善。在治疗过程中，有些患者出现腹腔感染，有的病例并进而发展成ARDS．遂添治疗难度。目前ARDS尚无特效治疗方法，除对原发病采取有效治疗的同时，应积极地建立人工气道和机械通气。腹腔感染患者机械通气时间明显延长。尽可能早地进行静脉高营养在提高疗效上也是很重要的环节。     

Pulmonary lactate release in patients with acute lung injury is not attributable to lung tissue hypoxia

OBJECTIVE: To determine whether pulmonary lactate production in patients with acute lung injury is attributable to lung tissue hypoxia. DESIGN: Prospective, controlled, clinical study. SETTING: A multidisciplinary university intensive care unit in a general hospital. PATIENTS: Seventy consecutive critically ill patients requiring mechanical ventilation and invasive hemodynamic monitoring. Of these patients, 18 had no acute lung injury (no ALI); 33 had acute lung injury (ALI) (Lung Injury Score [LIS] < or =2.5); and 19 had acute respiratory distress syndrome (ARDS) (LIS >2.5). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After hemodynamic measurements, lactate and pyruvate concentrations were assessed in simultaneously drawn arterial (a) and mixed venous (v) blood samples. Pulmonary lactate release was calculated as the product of transpulmonary a-v lactate difference (L[a-v]) times the cardiac index. Two indices of anaerobic metabolism of the lung, i.e., the transpulmonary a-v difference of lactate pyruvate ratio (L/P[a-v]) and excess lactate formation across the lungs (XL), were calculated. L(a-v) and pulmonary lactate release were higher in patients with ARDS than in the other groups (p<.001), and they were also higher in patients with ALI compared with patients with no ALI (p<.001). In patients with ALI and ARDS (n = 52), pulmonary lactate release correlated significantly with LIS (r2 = .14, p<.01) and venous admixture (r2 = .13, p<.01). When all patients were lumped together (n = 70), pulmonary lactate release directly correlated with LIS (r2 = .30, p<.001), venous admixture (r2 = .26, p<.001), and P(A-a)O2 (r2 = .14, p<.01). Neither L/P(a-v) nor XL was significantly different among the three groups. CONCLUSION: The lungs of patients with ALI produce lactate that is proportional to the severity of lung injury. This lactate production does not seem to be attributable to lung tissue hypoxia.     

有创与无创序贯通气疗法在COPD急性加重患者中的应用

【目的】探讨有创-无创序贯疗法在慢性阻塞性肺疾病急性加重（Acute exacerbation of chronic obstructive pulmonary disease,AECOPD）患者中的疗效。【方法】将40例AECOPD患者随机分为两组,每组20例。治疗组给予有创-无创序贯机械通气,对照组给予有创机械通气,均给予常规疗法、营养支持及必要时给予支纤镜下灌洗等综合处理措施,观察两组患者病情变化,并对呼吸机相关肺炎（ventilators—associated pneumonia,VAP）、死亡数、气管切开发生率、气压伤发生率、机械通气时间、住院天数等进行对比研究。【结果】治疗组及对照组患者发生VAP的例数分别为2和8例（P〈0．05）;气管切开例数分别为0和8例（P〈0．01）;气压伤并发症例数分别为0和4例（P〈0．01）;总机械通气时间为（8．1±7．3）d和（15．2±8．3）d（P〈0．05）;住院时间为（11±5）d和（16±9）d（P〈0．05）,死亡例数分别为0和5例。【结论】有创-无创序贯疗法结合支纤镜、营养支持及常规疗法等综合处理措施提高了AECOPD患者的疗效,特别是有创-无创序贯通气疗法可有效地改善治疗效果,提高生存率,降低VAP发生率,减少气管切开需求,减少气压伤发生率,减少机械通气时间,并降低医疗费用。     

Acute respiratory distress syndrome: Underrecognition by clinicians

Background

Previous reports suggest that acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is underdiagnosed in both adult and pediatric clinical practice. Underrecognition of this condition may be a barrier to instituting a low tidal volume ventilation strategy. This study aimed to determine the accuracy of clinical diagnoses of ARDS in daily practice using the American European Consensus Conference (AECC) criteria as a criterion standard and to investigate whether clinical recognition of ARDS altered ventilator management.

Methods

This retrospective study included intensive care unit (ICU) patients who died and underwent postmortem examination. Two independent reviewers assigned each patient to those with ALI/ARDS or no ALI. For those who met AECC criteria for ARDS, all patient records were reviewed for the presence of a documented diagnosis of the condition. The accuracy of the clinicians in diagnosing ALI/ARDS was determined, and ventilator settings between the clinically “diagnosed” and “non-diagnosed” groups were compared. The diagnostic accuracy in predetermined subgroups (those with diffuse alveolar damage, with ≥ 3 affected chest x-ray quadrants, with diagnosis ≥ 3 days, with pulmonary vs extrapulmonary cause) was also examined.

Results

Of 98 consecutive ICU patients who died and underwent autopsy, 51 met the inclusion criteria. Sixteen of 51 patients (31.3%) who had ALI/ARDS according to the AECC criteria had this recorded in their clinical notes. Those with histologic evidence of ALI/ARDS (diffuse alveolar damage) and with a more severe chest x-ray pattern or who satisfied the criteria for a number of consecutive days were no more likely to have a clinical diagnosis of ALI/ARDS recorded. However, those with a pulmonary cause of ALI/ARDS were more likely to have a diagnosis recorded. Tidal volumes, positive end-expiratory pressure, and mean airway pressure were higher in those with a clinical diagnosis of ARDS.

Conclusions

Acute respiratory distress syndrome is underrecognized by clinicians in ICU, and recognition does not result in lower tidal volume ventilation. Significant barriers remain to the recognition of ALI/ARDS and application of an evidence-based ventilator strategy.     

输尿管镜技术治疗输尿管结石致孤立肾急性肾功能衰竭

目的探讨输尿管结石致孤立肾急性肾功能衰竭的治疗方法。方法采用输尿管镜直视下气压弹道碎石或将结石推回肾盂等方法治疗输尿管结石梗阻致孤立肾肾功能衰竭16例。结果16例均临床治愈,疗效满意。结论应用输尿管镜技术治疗输尿管结石致孤立肾急性肾功能衰竭,具有疗效可靠、安全、损伤小的优点,有条件者可作为首选方法。