Adult respiratory distress syndrome in pediatric patients. II. Management

Adult respiratory distress syndrome, a clinical syndrome of respiratory failure that follows many kinds of insults, often in patients with no previous pulmonary disease, occurs in pediatric patients. This group of disorders has a typical clinical, pathologic, and pathophysiologic course, the hallmark of which is injury to the alveolar-capillary membrane with increased permeability of the pulmonary vasculature and pulmonary edema. Resolution may occur at any stage, but most patients die and many develop chronic lung disease requiring respiratory support for weeks or months. Multiple organ system failure, secondary infection, and irreversible respiratory dysfunction are responsible for the poor outcome. The underlying mechanisms that relate injury to the development of pulmonary disease are unclear. In some cases there may be direct injury to the lung, but in others, such as septic shock, there are mediators that link the initial insult to the subsequent lung injury. The leukocyte may have a central role in this process, although this is uncertain. Therapeutic measures needed to support the patient, especially increased inspired oxygen, are additional factors in the progression of lung disease. Current therapy, as summarized in Table II, is primarily supportive. Efforts to treat ARDS after it is clinically apparent have been disappointing. The pathogenic mechanisms that lead to ARDS are probably well advanced by the time the syndrome is diagnosed on the basis of the usual clinical signs. Therefore an emphasis on understanding the mechanisms of lung injury so that specific markers can be used to predict which patients will develop ARDS, allowing intervention in the early stages of the process, may prove rewarding.     

儿童恶性肿瘤并发急性呼吸窘迫综合征的危险因素和预后分析

随着强化疗方案的应用,小儿恶性肿瘤生存率得到很大改善,但化疗相关并发症发病率有所上升,急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）是常见而且较严重的并发症之一。回顾性分析本院重症监护室（PICU）1999年来收治的小儿恶性肿瘤并发ARDS病例,分析诱发ARDS的危险因素和预后影响因素。     

儿童急性呼吸窘迫综合征肺复张策略的研究进展

近年来肺复张策略因可打开肺泡,减少肺泡萎陷所致的肺损伤,改善肺顺应性,提高动脉氧分压与氧合指数,减少肺内分流而成为急性呼吸窘迫综合征机械通气治疗手段之一.本文就肺复张在儿童急性呼吸窘迫综合征的应用做一综述.     

Infection in pediatric acute respiratory distress syndrome

Pediatric acute respiratory distress syndrome (ARDS) is a severe lung injury caused by pneumonia, sepsis, and trauma. ARDS results from inflammation and pulmonary capillary leak causing major changes in lung architecture and function. It has a low incidence, but its severity and duration cause major morbidity, mortality, and use of resources. Any organism can cause ARDS. Susceptible populations develop the syndrome more often and have worse outcomes. Aggressive diagnosis and intensive treatment are essential to good outcomes in ARDS caused by infection. The prognosis for survival is good, but morbidity after the syndrome is a major burden.     

Management of respiratory distress syndrome

Respiratory distress syndrome is the most common pathology of preterm infants managed in neonatal intensive care units worldwide. Advances in neonatal intensive care, prenatal interventions, especially corticosteroid therapy, and postnatal respiratory support have considerably increased the survival of extremely premature infants. Despite these advances, epithelial lung injury and inflammation secondary to surfactant deficiency and as a consequence of mechanical ventilation ultimately leading to bronchopulmonary dysplasia has not significantly reduced. Animal studies have confirmed that the pathological cascade of inflammation is initiated within the first few breaths of life, more so in a surfactant-deficient lung. Hence early management is aimed at minimizing lung injury, starting in the delivery suite. Although a number of different modalities of ventilation are available for ongoing support, the principle is to administer controlled ventilation, avoiding overinflation, and to give just enough end expiratory pressure to prevent collapse of surfactant-deficient alveoli. Non-invasive ventilation is an invaluable tool both in the treatment of mild-to-moderate RDS and the prevention of post-extubation respiratory failure. Supportive treatment contributes equally to the outcome.     

小儿急性呼吸窘迫综合征的非机械通气治疗

小儿急性呼吸窘迫综合征一直是儿科重症监护病房最为重要的疾病之一.本文介绍了急性呼吸窘迫综合征的柏林定义,较为全面地综述了小儿急性呼吸窘迫综合征的非机械通气治疗,包括注意避免各种易患因素、加强营养支持、注意坚持保守补液、探制输血指征及防止输血相关性肺损伤;对肺表面活性物质治疗、吸入一氧化氮及糖皮质激素的应用方面近年的进展作了简要介绍;提出在重症ARDS中应坚持俯卧位通气等.     

不同呼气末正压对脓毒性休克合并急性呼吸窘迫综合征婴幼儿预后的影响

目的 评价不同呼气末正压(positive end-expiratory pressure,PEEP)对脓毒性休克合并急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)婴幼儿预后的影响.方法 将广西壮族自治区妇幼保健院PICU收治的60例脓毒性休克合并ARDS婴幼儿分为3组,每组20例,分别应用低、中、高三种水平PEEP(3、6、9 cmH2O,l cmH2O=0.098 kPa)进行呼吸机辅助通气,均采用压力控制机械通气模式,小潮气量(6 ～8 ml/kg)通气策略,同时根据美国危重病儿科高级生命支持协会2009年颁布的脓毒性休克指南指导液体复苏.监测3组患儿上机后6、24、48 h氧合指数(OI)、呼吸系统动态顺应性(Cdyn)、心脏指数(CI)的变化并统计每例患儿的液体入/出量,比较3组患儿机械通气时间、PICU住院时间及28 d病死率.结果 机械通气后6h开始,中、高PEEP组OI、Cdyn均明显好转,与低PEEP组比较差异均有统计学意义(P均＜0.01);中、低PEEP组CI明显高于高PEEP组,液体入量少于高PEEP组,差异均有统计学意义(P均＜0.01),3组液体出量比较差异无统计学意义(P＞0.05);中PEEP组呼吸机辅助通气时间[(5.40±0.61)d]、PICU住院时间[(7.00±0.61)d]均短于高、低PEEP两组[(6.23±0.90)d、(7.51±1.09)d;(8.23-±0.90)d、(9.14±1.21)d](P均＜0.01);3组患儿病死率比较差异无统计学意义(P＞0.05).结论 中PEEP能显著改善脓毒性休克合并ARDS患儿的肺功能,缩短机械通气时间,对血流动力学无严重不良影响.     

Management of neonatal respiratory distress syndrome

Significant advances have been made in the management of respiratory distress syndrome over the last number of years. Prenatal corticosteroids for lung maturation and postnatal surfactant replacement therapy have reduced the incidence, severity, and mortality associated with RDS. In this review we will examine the role of a more gentle approach to newborn stabilization and early respiratory care with the aim of improving survival whilst preventing lung injury.     

儿童急性呼吸窘迫综合征的药物管理

该文回顾了2015版儿童急性肺损伤共识会议发布的儿童急性呼吸窘迫综合征（ARDS）新共识和近年来发表的ARDS药物治疗的相关文献,总结了儿童ARDS的药物管理要点,为儿童ARDS的治疗提供依据。     

Acute respiratory distress syndrome in pediatric intensive care unit

Objective  

To report causes, clinical feature and outcome of children with Acute Respiratory Distress Syndrome (ARDS).     

儿科ICU中急性呼吸窘迫综合征的临床回顾性分析

目的总结我院儿科重症监护室中(PICU)收治的急性呼吸窘迫综合征(ARDS)患儿的临床流行病学特点,以期提高ARDS的诊治水平。方法回顾性总结2002年6月～2004年2月我院PICU的14例确诊为ARDS患儿的特点。结果ARDS的发病率为2.3%。诱发ARDS的因素有体外循环、肺炎、脓毒症、休克等,其中以体外循环为最多见(占发病人数的42.9%)。确诊时急性肺损伤指数和PaO2FiO2分别为(3.2±0.6)和(86.5±23.8)。机械通气时最高吸气峰压和呼气终末正压分别是(33.8±8.4)cmH2O、(8.3±4.8)cmH2O。ARDS平均住院时间为18.1d,占PICU危重病人总住院时间的21.2%。因多器官功能衰竭、呼吸衰竭死亡6例(病死率42.9%),占PICU死亡总数的21.5%。结论积极去除高危因素预防ARDS、探讨ARDS更有效的治疗方法、降低病死率仍是我们今后工作的重点。     

Evaluation of clinical criteria for the acute respiratory distress syndrome in pediatric patients.

OBJECTIVE: The primary goal of this study was to evaluate the validity of the North American-European Consensus Committee (NAECC) definition for acute respiratory distress syndrome (ARDS) in pediatric patients. A secondary aim was to evaluate the threshold value for the PaO2/FiO2 ratio, used to determine which pediatric patients have ARDS. DESIGN: Retrospective cohort study. SETTING: Pediatric intensive care unit. PATIENTS: Pediatric intensive care unit patients who required mechanical ventilation, died, and underwent autopsy between January 1, 1996, and December 31, 2002 (n = 34). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical and chest radiograph information was collected retrospectively through chart review using a standardized data collection tool. Data included the criteria specified in the NAECC definition of ARDS and demographic information. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of clinical diagnosis of ARDS compared with a pathologic diagnosis. The threshold value of PaO2/FiO2 was identified by plotting receiver operating characteristics curves and comparing the areas under the curves. The NAECC definition yielded a sensitivity of 80.7% (95% confidence interval 60-92%), specificity of 71.4% (95% confidence interval 30-95), positive predictive value of 91.3% (95% confidence interval 70-98), negative predictive value of 50.0% (95% confidence interval 20-78), and likelihood ratio of 2.82. A PaO2/FiO2 <150 had a slightly higher (but not significantly different) specificity for ARDS than a value >200 (71% vs. 86%, p = .15) without changing sensitivity. CONCLUSIONS: Our study suggests the need for further research with larger number of children to identify an optimal Pao2/Fio2 threshold for identifying ARDS in this population.     

Management of septic shock in the pediatric emergency department in 2004

This discussion outlines the current management strategies for infants and young children with septic shock. Septic shock is diagnosed in the clinical context of suspected infection and persistent signs of decreased perfusion. While antimicrobial therapy is directed against the common age-associated pathogens, “goal-directed” hemodynamic support is the critical focus of resuscitation of the child with septic shock. Aggressive fluid therapy and the use of inotropic drugs to attain and maintain normal cardiac index constitute the current recommendations of goal-directed therapy. Administration of up to and more than 60 ml/kg of crystalloid may be necessary during the first 30 to 60 minutes of resuscitation. In the absence of randomized controlled trials in infants and children with septic shock, dopamine is the consensus first-line drug for fluid refractory shock. Hydrocortisone therapy is reserved for use in children with catecholamine resistance and suspected or proven adrenal insufficiency.     

Emergency care in pediatric septic shock

Septic shock causes more deaths in children than cancer. However, studies have shown that mortality can be significantly reduced by adhering to the American College of Critical Care Medicine/Pediatric Advanced Life Support guidelines. This article reviews the definitions, pathophysiology, and emergency management of children with septic shock, including the controversial role of steroids.     

儿童急性呼吸窘迫综合征的诊治进展

儿童急性呼吸窘迫综合征（ARDS）是儿科重症监护室重症患者死亡的重要原因。尽管随着肺保护性通气策略的实施,儿童ARDS的预后有所改善,但中重度ARDS救治成功率仍低。鉴于与成人相比,儿童ARDS的流行病学、治疗和预后有差异,2015年国际儿科急性肺损伤共识会议第一次赋予儿童ARDS定义。提高对儿童ARDS的早期识别,规范临床管理,仍是儿科重症医学的重要挑战。该文对儿童ARDS的定义、流行病学特点和管理方案进行综述。     

感染性休克患儿病死率和死亡危险因素分析

目的 探讨感染性休克患儿病死率及其死亡危险因素.方法 采用回顾性研究方法,研究对象为72例感染性休克患儿,其中好转存活36例,死亡36例;利用SPSS 15.0的Logistic回归分析两组临床资料的死亡危险因素.结果 感染性休克患儿的病死率高达50.0%;死亡组的收缩压、舒张压、平均动脉压、血糖、pH、血清胆固醇、血清白蛋白和人院24 h尿量与存活组比较,差异均有统计学意义.Logistic间归分析显示,模型检验x2=26.781,P=0.000,有统计学意义.入院24 h尿量、舒张压、平均动脉压及白蛋白是危险因素(OR值、95%可信区间分别为5.197,1.359～19.878;1.102,1.020～1.191;1.125,1.025～1.234;1.120.0.996～1.259).随着功能障碍器官数目的 增加,病死率逐渐升高.结论 24 h尿量、舒张压、平均动脉压和血清白蛋白,可作为感染性休克患儿预后不良和疾病严重性的预测指标.     

小儿急性呼吸窘迫综合征诊疗技术规范--南京医科大学附属南京儿童医院急诊医学科/重症医学科诊疗技术规范

本文介绍一家三级儿童医院重症医学科的小儿急性呼吸窘迫综合征的技术诊疗规范,包括其病因判断、诊断标准、诊断时注意事项、诊断流程图、辅助检查及治疗等。在治疗中强调了病因治疗、保守补液、肺保护性通气策略、俯卧位通气及镇痛镇静肌松等。     

小儿脓毒性休克的诊断与治疗

小儿脓毒性休克（感染性休克）仍是危重患儿的重要死亡原因，近年来由于对脓毒症及休克的研究不断深入，认识的不断提高，以及循证医学证据的不断出现，关于脓毒性休克的定义、诊断及治疗都有了一些明显的变化，本文就这些变化作一简要介绍。