卡托普利联合经鼻持续呼吸道正压给氧治疗左向右分流型先天性心脏病并肺炎心力衰竭的疗效

目的探讨卡托普利联合经鼻持续呼吸道正压(CPAP)给氧治疗左向右分流型先天性心脏病(先心病)并肺炎心力衰竭(心衰)的疗效。方法将在本院儿科住院治疗的左向右分流型先心病并肺炎心衰患儿108例,随机分为对照组、观察组、CPAP组3组,3组基础治疗相同,对照组采用(面罩或鼻导管)普通给氧,CPAP组采用经鼻CPAP,观察组在CPAP组基础上加用卡托普利治疗。结果观察组与CPAP组肺部啰音消失时间比较差异有统计学意义(P<0.01),气促呼吸困难消失、心率正常、肝脏回缩时间比较差异亦均有统计学意义(Pa<0.05);观察组与对照组气促呼吸困难消失、心率正常、肝脏回缩、肺部啰音消失时间比较差异均有统计学意义(Pa<0.01);CPAP组与对照组气促呼吸困难消失、心率正常、肝脏回缩、肺部啰音消失时间比较差异均有统计学意义(Pa<0.05)。观察组血浆氨基末端脑利钠肽前体水平降低均明显优于CPAP组和对照组(Pa<0.01),CPAP组和对照组比较其血浆氨基末端脑利钠肽前体水平降低无明显差异性。结论卡托普利联合经鼻CPAP治疗左向右分流型先心病并肺炎心衰时可产生有益的血流动力学效应,减少左向右分流量,快速缓解心衰症状,延缓心室重塑,降低患儿病死率,改善预后。     

Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome

Thirty-four spontaneously breathing newborns with respiratory distress syndrome (RDS) requiring nasal continuous positive airway pressure (CPAP) and an arterial-to-alveolar oxygen tension ratio (a/A PO₂) of 0.15-0.22 were randomized to treatment with nebulized surfactant (Curosurf^®) or to serve as controls. All children were first supported by nasal CPAP according to normal clinical routines. Surfactant was administered using a modified Aiolos^® nebulizer, and a total of 480 mg was aerosolized in each case. The control group received no nebulized material, but had the same CPAP support. Acid-base status and a/A PO₂ were determined at regular intervals before, during and after surfactant administration. Both groups included in the study were similar with regard to gestational age, birthweight, steroids given before birth, sex and Apgar scores as well as a/A PO₂ when entering the study. There were no significant differences between the groups in a/A PO₂ 1-12 h after randomization, number of infants needing mechanical ventilation, time on ventilator or CPAP. Two children in the treated group developed bronchopulmonary dysplasia. No side effects of the surfactant therapy were noted. No beneficial effects of aerosolized surfactant were demonstrated in our trial, contrary to data from animal experiments. This finding probably reflects differences in administration techniques. Our findings do not justify large clinical trials with the same protocol. Further work is needed to optimize delivery of aerosolized surfactant to the neonatal lung in clinical practice.     

Clinical and laboratorial repercussions of the nasal CPAP in preterm newborns

OBJECTIVE: Evaluate the efficacy and problems associated with nasal CPAP use. METHODS: 96 preterm newborns needing nasal CPAP either as initial ventilatory support or as weaning from the ventilator were studied prospectively. RESULTS: Nasal CPAP was used in children weighing 480g to 2,450g and corrected gestational age of 24 to 39 weeks. It was indicated in cases of apnea (12.5%), hyaline membrane disease (32.3%), pneumonia (4.2%), transient tachypnea (22%), and weaning from the ventilator (29%). The last indication was more frequent in children with lower weight (p<0.01). The median time in nasal CPAP was 60.3h. After CPAP installation, there was a significant improvement in the respiratory distress that was not shown in the blood gases analysis. The percentage of children with nasal hyperemia, nasal bleeding, abdominal distention and children that could be fed was directly proportional to how long they had been in nasal CPAP. Children weighting 相似文献   

Use of nasal continuous positive airway pressure during neonatal transfers

OBJECTIVE: To review all cases in which nasal continuous positive airway pressure (CPAP) was used as a means of respiratory support during land based ambulance transfers by a regional neonatal transport service. DESIGN: Retrospective study based on review of transport records. RESULTS: A total of 1175 transfer requests were received over the 21 month period. The infant in 163 of these cases was receiving nasal CPAP. Ninety two referrals were accepted by the doctor/nurse practitioner led team. Of these, 84 were transported while receiving nasal CPAP. Intervention during transport was required in three of these cases. Fifty five referrals were accepted by the nurse led team. Of these, 16 were transported while receiving nasal CPAP. Intervention was required in two cases. CONCLUSION: There is a small but significant demand for transferring infants who are receiving nasal CPAP. Nasal CPAP appears to be a safe method of respiratory support for a carefully selected group of infants during land based ambulance transfers.     

Early nasal continuous positive airway pressure in a cohort of the smallest infants in Denmark: neurodevelopmental outcome at five years of age

AIM: To evaluate neurodevelopmental outcome at age 5 y of age in a cohort of preterm children treated mainly with nasal continuous positive airway pressure (CPAP) in the neonatal period. METHODS: A national prospective observational study was conducted in Denmark which included all 269 surviving children with a birthweight below 1000 g or a gestational age below 28 wk born in Denmark in between 1994 and 1995. A total of 164 children (61%) had been treated with nasal CPAP only in the neonatal period. A reference group (n = 76) of term children was studied in parallel. RESULTS: Of the 269 surviving children, 252 (94%) were examined. Twenty-four children (10%) had cerebral palsy, and three children were blind. No case of hearing impairment was detected. Nineteen percent of the index children had an IQ score <-- 2 SD and 42% had an IQ score <-- 1 SD of the mean score of the reference group. CONCLUSIONS: The intellectual development of children in this cohort treated with early nasal CPAP did not suggest a higher proportion of adverse effects on the brain compared to the published follow-up studies of preterm children treated with mechanical ventilation. In our population-based cohort, however, the survival rate for infants below 25 wk of gestation was relatively low and this may indicate a limit for the use of early nasal CPAP.     

Effects of nasal continuous positive airway pressure on apnoea index and sleep in infants

Objectives: We examined the effectiveness of nasal continuous positive airway pressure (CPAP) for treatment of sleep apnoea in infants.
Methodology: We studied five infants who all had significant central and mixed apnoea and severe sleep fragmentation. Polysomnographic recordings were performed on 2 consecutive nights in these infants. One night was used as a control study and during the second night nasal CPAP was applied throughout the night
Results: Nasal CPAP significantly reduced apnoea in each infant, with the apnoea index (apnoeas/h) decreasing from 65.6± 14.6 during the control study to 10.5± 14.6 during CPAP in non-rapid eye movement (non-REM) sleep, and from 106± 13.9 during the control study to 26.6± 13.9 during CPAP in REM sleep. Nasal CPAP also improved the sleep fragmentation markedly; REM sleep increased from 14.2± 1.2% of sleep during the control study to 27.1 ± 1.2% of sleep during CPAP.
Conclusions: We conclude that nasal CPAP is an effective treatment for infantile apnoea. Sleep apnoea in these infants is associated with profound sleep fragmentation, which is reversed by nasal CPAP.     

Effect on lung function of continuous positive airway pressure administered either by infant flow driver or a single nasal prong

The aim of this study was to assess if continuous positive airways pressure (CPAP) delivered by an infant flow driver (IFD) was a more effective method of improving lung function than delivering CPAP by a single nasal prong. A total of 36 infants (median gestational age 29 weeks, range 25–35 weeks) were studied, 12 who received CPAP via an IFD, 12 who received CPAP via a single nasal prong and 12 without CPAP. CPAP was administered post extubation if apnoeas and bradycardias or a respiratory acidosis developed or electively if the infant was of birth weight <1.0 kg. Lung function was assessed by the supplementary oxygen requirement and measurement of compliance of the respiratory system using an occlusion technique. Assessments were made immediately prior to and after 24 h of CPAP administration and at similar postnatal ages in the non-CPAP group. The infants who did not require CPAP had better lung function (non significant) than the other two groups before they received CPAP. After 24 h, lung function had improved in both CPAP groups to the level of the non CPAP infants. The supplementary oxygen requirements of all three groups decreased over the 24 h period, but this only reached significance in the single nasal prong group (P < 0.05). Four infants supported by the IFD, but none with a single nasal prong, became hyperoxic. Conclusion Continuous positive airways pressure administration via the infant flow driver appears to offer no short-term advantage over a single nasal prong system when used after extubation in preterm infants. Received: 29 June 1999 and in revised form: 23 September / Accepted: 15 October 1999     

Randomised controlled trial of nasal continuous positive airways pressure (CPAP) in bronchiolitis.

AIMS: To compare continuous positive airways pressure (CPAP) with standard treatment (ST) in the management of bronchiolitis. METHODS: Children <1 year of age with bronchiolitis and capillary PCO2 >6 kPa were recruited and randomised to CPAP or ST and then crossed over to the alternative treatment after 12 h. ST was intravenous fluids and supplemental oxygen by nasal prongs or face mask. The change in PCO2 was compared between the groups after 12 and 24 h. Secondary outcomes were change in capillary pH, respiratory rate, pulse rate and the need for invasive ventilatory support. RESULTS: 29 of 31 children completed the study. PCO2 after 12 h fell by 0.92 kPa in children treated with CPAP compared with a rise of 0.04 kPa in those on ST (p<0.015). If CPAP was used first, there was a significantly better reduction in PCO2 than if it was used second. There were no differences in secondary outcome measures. CPAP was well tolerated with no complications identified. CONCLUSIONS: This study suggests that CPAP compared with ST improves ventilation in children with bronchiolitis and hypercapnoea.     

Nebulization of drugs in a nasal CPAP system

Aerosolized drugs have been used in infants for the treatment of respiratory distress syndrome and bronchopulmonary dysplasia (beta-agonists, steroids and surfactant) and bronchiolitis due to respiratory syncytial virus (epinephrine and ribavirin). Controlled clinical trials have, however, produced conflicting results, probably due in part to problems with the transportation of the aerosol from the nebulizer to the bronchioli. We have modified a nasal continuous positive airway pressure (CPAP) system permitting an aerosol to flow through a canal to the nasal prongs and into the airways of the infant. It has been used successfully for the administration of epinephrine, salbutamol, budesonide, acetylcysteine, natural surfactant and ribavirin to sick infants. The modified nasal CPAP system is a simple, safe, cost-efficient and baby-friendly system for respiratory support and drug treatment, which can be used in future trials of aerosolized drugs.     

A home respiratory support programme for children by parents and layperson carers

Aim:   To describe a respiratory support programme for children at home by parents and layperson carers.
Methods:   Analysis of records of children with long-term mechanical respiratory support at home.
Results:   From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks–19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning.
Conclusion:   Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.     

Developmental outcomes at the age of two years for very premature babies managed with nasal prong continuous positive airway pressure

AIMS: To describe the developmental progress of very premature babies at the age of 2 years, who were managed in an era where nasal prong continuous positive airway pressure (CPAP) was the preferred method for the management of initial respiratory disease. METHODS: Two groups of very premature babies of <32 weeks gestation were compared, the first being managed with an intubation and mandatory ventilation approach, and the second being managed with a CPAP approach. The groups are compared with regard to the presence of brain injury, retinopathy and requiring discharge home on oxygen and then at 2 years, for language impairment, non-ambulatory cerebral palsy and significant developmental delay. The study is designed as an audit of data collected prospectively and longitudinally for babies born from 1998 to 2002. RESULTS: A significant number of babies were successfully managed on CPAP in the second era and significantly fewer received post-natal steroids. The number being discharged home on oxygen, brain injury and retinopathy were similar in the two groups. Developmental outcome assessed at 2 years of age was the same in both eras. CONCLUSIONS: A CPAP approach to the management of initial respiratory disease in premature babies of less than 32 weeks gestation at birth is associated with no measurable developmental advantage or disadvantage at 2 years of age.     

Hyaline membrane disease. Comparison of continuous negative pressure and nasal positive airway pressure in its treatment.

The effectiveness of continuous negative pressure (CNP) and nasal continuous positive airway pressure (CPAP) in the treatment of hyaline membrane disease and the incidence of complications were compared in 36 preterm infants randomly treated with CNP or nasal CPAP. Both methods of treatment were effective in increasing PaO2 and allowing a decrease in inspired O2 concentration. The time required with mechanical assistance and with an O2 concentration of more than 40% was equal in both groups. In the CNP group, four infants required mechanical ventilation because of clinical deterioration whereas in the nasal CPAP group, seven needed this type of therapy. Three infants in each group had extraalveolar air, and two patients in each group died. The results suggest that both methods of applying continuous distending airway pressure are effective. Nasal CPAP has the advantages of easier application and better access to the infant.     

The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea

Aim: To review 66 children with obstructive sleep apnoea (OSA) for whom a trial of nasal continuous positive airway pressure (nCPAP) was proposed. Methods: Baseline sleep studies were performed to assess OSA severity; a trial of nCPAP was performed where moderate to severe OSA, not relieved by adenotonsillectomy, was found. The nCPAP trial was considered either technically successful (ST), if the child accepted the mask for sufficient time to determine nCPAP efficacy, or a technical failure (FT) if otherwise. Patients with an initial FT were offered a period of home acclimatisation to familiarise them with wearing the mask during sleep. ST patients in whom nCPAP was effective were established on long term therapy. Results: Nasal CPAP trials were successful (ST) in 49/66 (74%) patients. Nasal CPAP efficacy could not be determined in the remaining 17 FT patients (26%), generally because of their poor nCPAP tolerance. These patients were subsequently considered for other treatment. A total of 42/49 (86%) ST patients were established on long term nCPAP therapy, 2/49 (4%) derived no benefit from nCPAP, while 5/49 (10%) refused long term nCPAP therapy. Of patients on long term nCPAP, the most frequently reported side effects were skin irritation and nasal dryness; however, these were not serious enough to require any patients to discontinue therapy. A period of home acclimatisation was found to be effective in increasing nCPAP acceptance, with 26% of FT children being subsequently successfully reassessed for nCPAP. Conclusion: The use of nCPAP was feasible in a significant proportion of a paediatric OSA population. Failure was usually because of the child''s intolerance of the nCPAP equipment. Nasal CPAP was an effective treatment in the majority of patients where it could be assessed, and was adopted as a long term therapy in most cases. We have successfully used nCPAP to treat OSA across a wide range of ages. Motivated parents and skilled support staff have proved essential for the success of nCPAP in a paediatric setting.     

The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea.

AIM: To review 66 children with obstructive sleep apnoea (OSA) for whom a trial of nasal continuous positive airway pressure (nCPAP) was proposed. METHODS: Baseline sleep studies were performed to assess OSA severity; a trial of nCPAP was performed where moderate to severe OSA, not relieved by adenotonsillectomy, was found. The nCPAP trial was considered either technically successful (ST), if the child accepted the mask for sufficient time to determine nCPAP efficacy, or a technical failure (FT) if otherwise. Patients with an initial FT were offered a period of home acclimatisation to familiarise them with wearing the mask during sleep. ST patients in whom nCPAP was effective were established on long term therapy. RESULTS: Nasal CPAP trials were successful (ST) in 49/66 (74%) patients. Nasal CPAP efficacy could not be determined in the remaining 17 FT patients (26%), generally because of their poor nCPAP tolerance. These patients were subsequently considered for other treatment. A total of 42/49 (86%) ST patients were established on long term nCPAP therapy, 2/49 (4%) derived no benefit from nCPAP, while 5/49 (10%) refused long term nCPAP therapy. Of patients on long term nCPAP, the most frequently reported side effects were skin irritation and nasal dryness; however, these were not serious enough to require any patients to discontinue therapy. A period of home acclimatisation was found to be effective in increasing nCPAP acceptance, with 26% of FT children being subsequently successfully reassessed for nCPAP. CONCLUSION: The use of nCPAP was feasible in a significant proportion of a paediatric OSA population. Failure was usually because of the child's intolerance of the nCPAP equipment. Nasal CPAP was an effective treatment in the majority of patients where it could be assessed, and was adopted as a long term therapy in most cases. We have successfully used nCPAP to treat OSA across a wide range of ages. Motivated parents and skilled support staff have proved essential for the success of nCPAP in a paediatric setting.     

The A-B-C of high-flow nasal oxygen therapy use in a sick child

Heated humidified high flow nasal cannula therapy (HFNC) is a relatively new method of oxygen delivery that came into vogue only a decade ago. The additional physiological benefits it provides make HFNC more than just a fancy oxygen delivery device. Theoretically, Continuous Positive Airway Pressure (CPAP) continues to be the gold standard therapy for moderate to severe respiratory disease. Practically, there are limitations to its use especially in older children outside of an intensive care setting. Initially, thought of as a step-down or step-up from or towards CPAP i.e. halfway between CPAP and nasal oxygen, HFNC has now overtaken CPAP as the respiratory support mechanism of choice. Paediatricians go straight from failure of HFNC to intubation without a trial of CPAP, or extubate children straight onto HFNC. Today, more than a decade later, high quality evidence (FIRST-ABC and Tramontane Trials) is finally available to guide its use. The article summarises the evidence base behind the clinical safety, efficacy, cost-effectiveness and practical use of HFNC in managing sick children on high dependency and intensive care units. We outline what HFNC therapy is, the respiratory physiology underlying its use, currently available devices, practicalities of how to select the flow rate and its role in current paediatric practice with clinical examples.     

Analysis of the circumstances at the end of life in children with cancer: A single institution''s experience in Japan

BACKGROUND: With the aim of improving the quality of life of children with cancer, this study presents an analysis of one hospital's experience with terminal care. METHODS: Between 1994 and 2000, 28 children died after treatment for cancer at Hamamatsu University Hospital. The circumstances of their deaths were analyzed through medical records and interviews with 8 sets of bereaved parents. We compared results of this analysis with our previous data collected from 1978 to 1993. RESULTS: Of the 28 children, 11 had leukemia/lymphoma (LL group) and 17 had solid tumors (ST group). Six children (21.4%), all of whom were in the LL group, died of treatment-related complications. Twenty children (71.4%) died during terminal care: three (27.3%) were in the LL group and 17 (100%) in the ST group. Eleven children (39.3%) received terminal care at home and eight (28.6%) of these died at home. The number of children who received terminal care and died at home had increased in comparison with the previous period. Among problems with terminal care identified by parents were the lack of opportunity for the child to continue with education and an inadequate support system after the child's death. CONCLUSIONS: Some advances in the quality of life of the children were recognized. However, these advances were extended to a greater percentage of children in the ST group than in the LL group. The psychosocial problems faced by children and their families are now changing for the better.     

Nasal peak inspiratory flow through Turbuhaler® in children with symptomatic rhinitis and in healthy children

Topical treatment of allergic or vasomotor rhinitis is possible by means of pressurized metered dose inhalers, aqueous spray, or dry powder inhalers. In children, little is known about nasal drug delivery by dry powder inhalation. The airflow through the device is critical for the drug release and a sufficient nasal inspiratory flow is needed for intranasal drug delivery from a dry powder inhaler. In order to investigate from what age children with allergic or vasomotor rhinitis can reliably use such a device, device-dependent nasal peak inspiratory flow (DnPIF) was measured. The maximal DnPIF was measured in children aged 4–13 years making use of a dry powder inhaler (Turbuhaler^®) connected to a spirometer (Vitalograph^®). In the clinically relevant context, instructions from the doctor and one week's use of a Turbuhaler at home were found to be sufficient to obtain a good inhalation technique and were shown to improve DnPIF at least as effectively as visual feedback training at the clinic. Children with rhinitis, as well as healthy children from the age of 6 years, were able to generate a DnPIF sufficient to obtain a reliable nasal delivery of a dry powder drug dose. DnPIF values correlated with age. Consequently, a recommendation to use a nasal Turbuhaler from the age of 6 for topical drug delivery in the treatment of allergic or vasomotor rhinitis seems reasonable.     

Home and hospital treatment of acute seizures in children with nasal midazolam.

Rectal diazepam is widely used in the treatment of acute seizures in children but has some disadvantages. Nasal/sublingual midazolam administration has been recently investigated for this purpose but never at home or in a general paediatric hospital. The aim of this open study was to determine the efficacy, the tolerance and the applicability of nasal midazolam during acute seizures in children both in hospital and at home. We included known epileptic children for treatment at home and all children with acute seizures in the hospital. In all, 26 children were enrolled, 11 at home and 17 in the hospital (including two treated in both locations); only one had simple febrile seizure. They had a total of 125 seizures; 122 seizures (98%) stopped within 10 minutes (average 3.6 minutes). Two patients in the hospital did not respond and in three, seizures recurred within 3 hours. None had serious adverse effects. Parents had no difficulties administering the drug at home. Most of those who were using rectal diazepam found that nasal midazolam was easier to use and that postictal recovery was faster. Among 15 children who received the drug under electroencephalogram monitoring (six without clinical seizures), the paroxysmal activity disappeared in ten and decreased in three. Nasal midazolam is efficient in the treatment of acute seizures. It appears to be safe and most useful outside the hospital in severe epilepsies, particularly in older children because it is easy for parents to use. These data should be confirmed in a larger sample of children. Its usefulness in febrile convulsions also remains to be evaluated.     

经鼻持续气道正压给氧多中心临床试验研究

目的 评价经鼻持续气道正压(CPAP)给氧的效果.方法 2003年1月至2007年12月首都儿科研究所(牵头)和北京市9家郊区县医院对107例因肺部疾患导致低氧血症新生儿和婴幼儿进行多中心临床试验,通过脉搏血氧仪并结合临床观察对国产的CPAP氧疗仪和普通给氧方法 (面罩、头罩)在改善血氧饱和度的效果方面进行评价.结果 CPAP治疗组46例,普通给氧组61例.应用CPAP后新生儿组在给氧后0.5 h及2 h血氧饱和度为(88.6±7.9)%及(94.4±5.0)%,普通给氧组为(82.4±5.7)%及(90.3±4.5)%,两组间差异有显著性(P<0.05).婴幼儿组在CPAP给氧后1 h血氧饱和度为(95.7±2.6)%,普通给氧组为(87.3±15.8)%,两组间差异有显著性(P<0.05).给氧后紫绀和呼吸困难程度的改善,CPAP组优于普通给氧组.结论 经鼻CPAP氧疗仪是适用于基层、安全、有效、效果优于普通给氧方法 的给氧工具.     

Starting insulin therapy in children with newly diagnosed diabetes

Eight years ago, a decision was made to eliminate unnecessary hospitalization of children with newly diagnosed diabetes mellitus. This decision required changes in the basic approach to starting insulin therapy and education of the parents. Since then, 52 children aged 11 months to 16 years have been treated. Forty-four of these children were sent home after one to four hours of instruction. Five children received intravenous therapy for two to five hours and then went home. The remaining three children were admitted to the hospital for 18 to 40 hours. Subsequent establishment, at home, of diabetes control was accomplished without incident. The first injection of subcutaneous insulin was generally a combination of regular and slowly absorbed insulin. This approach has been well received by patients, parents, and referring physicians.