成人呼吸窘迫综合征并发肺气压伤4例

成人呼吸窘迫综合征并发肺气压伤４例上海市第一人民医院呼吸科（２０００８０）戴依利，周新，汪均陶机械通气，尤其是应用呼气末正压（ＰＥＥＰ）通气方式已广泛应用于成人呼吸窘迫综合征（ＡＲＤＳ）的治疗。ＰＥＥＰ治疗ＡＲＤＳ的效果业已证实。但在机械通气过程中，...     

多平面经食管超声心动图测量房间隔缺损面积的研究

为了探讨新型多平面经食管超声心动图（ＭＴＥＥ）测量房间隔缺损（ＡＳＤ）面积的可行性和可靠性，在２３例ＡＳＤ患者中进行了ＭＴＥＥ检查。利用心电图门控于心动周期的Ｐ波顶点、Ｐ－Ｒ段、Ｒ波顶点、Ｊ点、Ｔ波起点、Ｔ波顶点、Ｔ波终点等７个时相，以ＭＴＥＥ技术每隔１０°扫查角度测量ＡＳＤ直径，由此绘出心动周期每一时相的ＡＳＤ图形，并计算其面积，然后与手术测量的ＡＳＤ面积进行比较。结果显示：（１）ＡＳＤ面积在心动周期中呈动态改变；（２）ＭＴＥＥ于Ｐ波顶点测量的ＡＳＤ面积与手术测值相关最佳（ｒ＝０．９２），余心动周期时相ＭＴＥＥ与手术测值亦相关良好（ｒ＝０．８２～０．８８），表明ＭＴＥＥ为ＡＳＤ面积的测量提供了可靠的新方法。     

慢性低氧性肺动脉高压的无创诊断

通过Ｓｗａｎ－Ｇａｎｚ导管，测定了３０例ＣＯＰＤ并肺心病患者的肺动脉压等血流动力学参数，同步行核素心功能、超声心动图、血气分析、肺功能等检查。结果发现肺动脉平均压（ｍＰＡＰ）与右室射血分数（ＲＶＥＦ）、残气／肺总量（ＲＶ／ＴＬＣ）、肺动脉直径（ＰＣＤ）、动脉血氧饱和度（ＳａＯ２）等均有显著相关性（Ｐ均＜０．０５）。通过逐步回归分析得到最优多元回归方程：Ｙ（ｍＰＡＰ）＝３．９０２－０．１０６ＲＶＥＦ＋０．０３６ＲＶ／ＴＬＣ＋０．２００ＰＡＤ－０．０５０ＳａＯ２。该多元回归方程可试用于临床低氧性肺动脉高压的无创诊断。     

系列电药理研究筛选有效抗折返性室上性心动过速药物的临床意义

对６７例折返性室上性心动过速（ＲＳＶＴ）施行以单一抗心律失常药物（ＡＡＤ）为基础、异丙肾上腺素（Ｉｓｏ）和美托洛尔（Ｍｅｔ）为辅助的系列电药理研究（ＳＥＰＳ）（简称ＡＩＭ－ＳＥＰＳ）。结果表明，Ｉｓｏ能使普罗帕酮和莫雷西嗪的抗ＲＳＶＴ总有效率分别降低６６．７％～８０．０％和２０．０％，该效应能被Ｍｅｔ所抵消。随访资料提示，对于选择预防ＲＳＶＴ临床复发有效的长期口服ＡＡＤ，ＡＩＭ－ＳＥＰＳ明显优于单一ＡＡＤ的电药理研究。     

容许性高碳酸血症对急性肺损伤动物心肺功能影响的观察

观察不同水平的容许性高碳酸血症（ＰＨＣ）对油酸型急性肺损伤（ＡＬＩ）模型的心肺功能影响。方法复制猪ＡＬＩ模型，四腔热稀释漂浮导管监测血液动力学及不同潮气量致不同程度的ＰＨＣ。结果ＡＬＩ导致明显的心肺功能恶化。呼气末正压可改善部分病理生理指标，但吸气末平台压（Ｐｅｅ）明显升高。潮气量（ＶＴ）降至７．７±０．３ｍｌ／ｋｇ、动脉血二氧化碳分压（ＰａＣＯ２）升至９．４４±１．２７ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）时，心输出量明显改善而其它心肺功能无明显改变。ＶＴ降至６．１±０．６ｍｌ／ｋｇ、Ｐａ－ＣＯ２为１２．１±１．０５ｋＰａ时，虽气道峰压下降，但Ｐｅｅ未见降低且其它心肺指标恶化。结论合适的低潮气量致一定程度的ＰＨＣ是较为安全的通气方式。     

STUDIES AND APPLICATION OF PYRCTHROID TREATED BEDNETS FOR CONTROL OF MALARIA VECTORS INP．R．CHINA

ＳＴＵＤＩＥＳＡＮＤＡＰＰＬＩＣＡＴＩＯＮＯＦＰＹＲＣＴＨＲＯＩＤＴＲＥＡＴＥＤＢＥＤＮＥＴＳＦＯＲＣＯＮＴＲＯＬＯＦＭＡＬＡＲＩＡＶＥＣＴＯＲＳＩＮＰ．Ｒ．ＣＨＩＮＡＰａｎＢｏ，ＬｉＺｕ－ｚｉ，ＨｕａｎｇＱｉ－ＬｉｎＩｎｓｔｉｔｕｔｅｏｆＰａｒａｓ...     

肝损伤小鼠肝组织氧化／抗氧化平衡的变化及其与TXA2／PGI2？…

目的：探讨氧自由基（ＯＦＲ）及ＴＸＡ２－ＰＧＩ２在实验性肝损伤中的作用。方法：检测肝损伤小鼠肝组织过氧化脂质（ＬＰＯ）、超氧化物歧化酶（ＳＯＤ）含量以及血浆ＴＸＡ和ＰＧＩ２浓度。结果：与对照组比较肝损伤小鼠ＬＰＯ明显升高、ＳＯＤ明显降低，当归可逆转ＬＰＯ和ＳＯＤ的变化；肝损伤小鼠血浆ＴＸＢ２高于对照组，其浓度与肝细胞ＬＰＯ含量呈正相关（ｒ＝０．９５，Ｐ〈０．０１）。结论：ＯＦＲ与ＴＸＡ２／ＰＧＩ２     

双腔右心室的诊断及其外科治疗：附46例报告

我院自１９９０年１月至１９９２年６月经手术确诊双腔右心室（ＤＣＲＶ）４６例。术前诊断主要依靠二维超声心动力图（２－ＤＥ）、心导管及心室造影检查。２－ＤＥ能直接看到右心室异常肌束将右心室分为高压腔和低压腔。本组２－ＤＥ测得两腔之间的压力阶差ΔＰ为６．５±３．１ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）与右心导管测得的结果６．７±４．３ｋＰａ呈高度相关，ｒ＝０．９８。术前充分估价２－ＤＥ及心导管资料，术中仔细辨认ＤＣＲＶ解剖以免漏诊和误诊。手术经右心室切口切除异常肌束，修复合并的室间隔缺损及其它畸形，术后效果满意。     

骨髓增生异常综合征患者T细胞受体基因重排的检测价值

目的 为了解骨髓增生异常综合征（ＭＤＳ）患者Ｔ细胞受体（ＴＣＲ）基因重排情况。方法 应用聚合酶链反应检测３６例ＭＤＳ患者ＴＣＲＶγＩ－Ｊγ基因重排。结果 ８例（２２．２％）ＭＤＳ患者检测出克隆性ＴＣＲＶγＩ－Ｊγ基因重排;难治性贫血伴有原始细胞增多（ＲＡＥＢ）,慢性粒－单细胞白血病（ＣＭＭＬ）和转化中的ＲＡＥＢ（ＲＡＥＢ－Ｔ）组ＴＣＲＶγＩ－Ｊγ基因重排阳性ＭＤＳ转化为急性白血病时间显著短于重排阴     

阻塞性睡眠呼吸暂停综合征致急性呼吸衰竭的临床分析

目的阐明阻塞性睡眠呼吸暂停综合征（ＯＳＡＳ）导致的急性呼吸衰竭的临床特点，以提高在重症抢救中，对ＯＳＡＳ作为基础疾病早期识别及治疗。方法对９例ＯＳＡＳ致急性呼吸衰竭患者的临床和实验室检查资料进行分析。结果８例女性和１例男性均表现肥胖，男性体块指数（ＢＭＩ）４４．９７ｋｇ／ｍ２，女性平均ＢＭＩ４５．２５ｋｇ／ｍ２。平均年龄６８岁（６１～７４岁）。全部患者表现有呼吸性酸中毒（平均ｐＨ７．１７３２），平均ＰａＣＯ２１２．５６ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ），平均ＰａＯ２５．２０ｋＰａ。４例有肺功能检查者显示ＦＥＶ１％＞７０％，经治疗稳定后ＰａＣＯ２６．２３ｋＰａ。结论ＯＳＡＳ引致急性呼吸衰竭出现较快，表现多样，但肺功能损害程度较轻，如处理及时，预后较好     

严重急性呼吸综合征所致呼吸衰竭及无创通气治疗

目的　回顾性总结严重急性呼吸综合征 (SARS)并发呼吸衰竭患者的血气特点 ,探讨应用无创正压通气 (NPPV)治疗的策略。方法　 2 0 0 3年 4月 2 2日～ 5月 1日 ,12 0例临床符合SARS诊断标准的患者入住北京地坛医院 (SARS专科医院 )的 4个病区 ,30例患者 (占 2 5 % )在病程中出现呼吸衰竭 ,达到急性肺损伤 (ALI)和 (或 )急性呼吸窘迫综合征 (ARDS)的诊断标准。 2 8例应用双水平气道正压通气 (BiPAP)。主要观察指标 :(1)住院期间的血气分析、脉搏容积血氧饱和度 (SpO2 )及呼吸频率 ,特别是上机前、上机后 1h及撤机后的结果 ;(2 )放射学检查或临床提示住院后新出现的气胸、纵隔气肿、心包积气及皮下气肿 ;(3)应用无创通气的天数 ;(4 )需气管插管行有创通气的患者数 ;(5 )患者的病死率 ;(6 )一线医务人员因护理治疗无创通气SARS患者而感染SARS的情况。结果统计 30例患者在整个病程中的动脉血二氧化碳分压 (PaCO2 )变化情况 ,16例 (5 3% )患者出现CO2 潴留 ,PaCO2为 4 5～ 5 6mmHg ,平均 (4 8± 4 )mmHg。NPPV治疗后动脉血氧分压 (PaO2 )、SpO2 、氧合指数及呼吸频率均显著改善 (P均 <0 0 1) ,但pH及PaCO2 的变化并不明显。 18例患者成功撤机 ,应用NPPV的时间为5～ 30d ,平均 (10± 6 )d。除 1例不能耐受BiPAP     

改良的保护性肺通气策略对婴幼儿体外循环术后急性呼吸窘迫综合征的疗效

目的:探讨改良“保护性肺通气策略”的可行性,并评价其对婴幼儿体外循环术后急性呼吸窘迫综合征(ARDS)的治疗效果。方法:对17例先天性心脏病术后合并ARDS的婴幼儿采用新的通气模式:(1)低潮气量(6～8ml/kg);(2)高PEEP(6～12cmH_2O);(3)限制气道峰压(<30～35cmH_2O);(4)高呼吸频率(25～40次/分钟);(5)适当允许高碳酸血症(PaCO_2≤60mmHg)。同时注重液体限制、体位疗法等辅助措施,并在部分危重患儿及时应用外源性肺表面活性物质和(或)一氧化氮。结果:术后平均应用呼吸机时间12.73天。与以往同类病例的治疗结果相比,本组患儿无死亡,并发症发生率降低,无明显后遗症,近远期随访均满意。结论:在改良的保护性肺机械通气的基础上,辅以液体限制、外源性肺表面活性物质、一氧化氮等综合治疗手段,可以明显提高体外循环术后ARDS的治疗效果。     

Management of acidosis during lung-protective ventilation in acute respiratory distress syndrome

In ARDS, when acidosis complicates LPV, the goal of alkali therapy is to maintain arterial pH at a safe level (> or = 7.20). A pure respiratory acidosis generally does not require alkali therapy. If the Pplat is greater than 30 cm H2O, and the respiratory rate equals the upper limit (35-40 breaths/minute), then V(E) is slowly titrated down by approximately 1 L/hour, so that PaCO2 increases by 10 mm Hg/hour or less. Alkali therapy is indicated for either a metabolic acidosis or a mixed acidosis. The choice of buffer is based on the type of acidosis, cardiorespiratory status, and lung mechanics. Slow infusions of NaHCO3 can be used to treat non-anion gap metabolic acidosis and some forms of increased anion gap acidosis. Using NaHCO3 to treat type A (hypoxia-related) lactic acidosis can be hazardous, particularly under conditions of hypoxemia, inadequate circulation, and limited alveolar ventilation. Under these circumstances, THAM is the preferable buffer because it does not increase PaCO2 and is excreted by the kidneys. When renal failure is present, CRRT is indicated to manage acidosis. When ARDS is complicated by traumatic or hemorrhagic shock, overresuscitation with Cl(-)-rich solutions should be avoided to prevent metabolic acidosis.     

外源性肺泡表面活性物质联合肺泡复张手法对急性呼吸窘迫综合征的疗效

目的 观察肺泡表面活性物质(PS)、肺泡复张手法(RM)及两者联合治疗ARDS的疗效.方法 健康新西兰长耳白兔28只,反复温盐水肺泡灌洗建立ARDS动物模型,行容积控制通气,通气稳定后按随机数字表法分为对照组、PS组、RM组及PS+RM组,每组7只,分别气管内注入安慰剂、外源性PS、实施RM或PS联合RM治疗,观察动脉血气及呼吸力学指标的变化.处理后4 h处死动物,行病理组织学检查评价肺损伤程度.结果 (1)对照组、PS组、RM组和PS+RM组的PaO2分别为(74 ±15)、(234±42)、(231±17)和(253±52)mm Hg(1 mm Hg=0.133 kPa),PS、RM和PS+RIM3组均高于对照组(F=84.201,P<0.01),PS、PS+RM组氧合改善稳定,RM组PaO2随观测时间延长呈下降趋势;(2)4组的PaCO2分别为(56±11)、(46±10)、(51±8)和(46±10)mm Hg,对照组明显高于PS、PS+RM组(F=4.234,P<0.05).RM组PaCO2随时间延长呈增高趋势;(3)4组动物气道峰压分别为(33±2)、(23±1)、(24±2)和(22±1)cm H2O(1 cm H2O=0.098 kPa),静态肺顺应性(Cst)分别为(1.1±0.3)、(1.7±0.3)、(1.5±0.1)、(1.9±0.4)ml/cm H2O,PS、RM、PS+RM 3组气道峰压、Cst均较对照组显著改善(F值分别为74.911、15.863,均P<0.01).RM组Cst改善较PS+RM组差(q=2.58,P<0.05);(4)PS、RM、PS+RM 3组动物肺损伤评分分别为3.9 ±0.8、6.1±0.7和4.2±0.6,均低于对照组的13.5±0.7(F=369.6,P<0.01),RM组高于PS及PS+RM组(q值分别为6.35、5.70,均P<0.01).结论 ARDS早期补充外源性PS或实施RM均能有效改善氧合及肺脏顺应性,但RM后易出现肺泡再萎陷及呼吸机相关性肺损伤;PS联合RM治疗能防止肺泡再萎陷,并可减轻呼吸机相关性肺损伤.     

小潮气量通气对创伤性ARDS的疗效分析

目的：探讨小潮气量通气对创伤性ARDS的疗效。方法：回顾性分析48例创伤性ARDS患者的病历资料,分为两组,大潮气量组23例,VT10～12ml／kg理想体重,PEEP5～10cmH2O,平台压35-50cmH2O;小潮气量组25例,VT5～8ml／kg理想体重,PEEP10～15cmH20,平台压≤35cmH2O。观察两组通气治疗前、后3dPaO2／FiO2、PaCO2、pH值及气压伤的发生情况和ICU住院期间病死率。结果：通气治疗后两组PaO2／FiO2均较通气治疗前明显升高（P〈0．05,P〈0．01）,但在第3天,小潮气量组PaO2／FiO2明显低于大潮气量组（P〈0．01）;小潮气量组出现明显高碳酸血症,但在机体可耐受范围。大潮气量组出现3例气压伤,小潮气量组无气压伤发生。小潮气量组病死率16％（4／25）低于大潮气量组26．08％（6／23）（P〉0．05）。结论：小潮气量通气可改善创伤性ARDS患者氧合状态和预后,减少呼吸机相关性肺损伤的发生。     

Volumetric capnography in patients with acute lung injury: effects of positive end-expiratory pressure.

The aim of the study was to analyse the effects of positive end-expiratory pressure (PEEP) on volumetric capnography and respiratory system mechanics in mechanically ventilated patients. Eight normal subjects (control group), nine patients with moderate acute lung injury (ALI group) and eight patients with acute respiratory distress syndrome (ARDS group) were studied. Respiratory system mechanics, alveolar ejection volume as a fraction of tidal volume (VAE/VT), phase III slopes of expired CO2 beyond VAE and Bohr's dead space (VD/VT(Bohr)) at different levels of PEEP were measured. No differences in respiratory system resistances were found between the ALI and ARDS groups. VD/VT(Bohr) and expired CO2 slope beyond VAE were higher in ALI patients (0.52+/-0.01 and 13.9+/-0.7 mmHg x L(-1), respectively) compared with control patients (0.46+/-0.01 and 7.7+/-0.4 mmHg x L(-1), p<0.01, respectively) and in ARDS patients (0.61+/-0.02 and 24.9+/-1.6 mmHg x L(-1), p<0.01, respectively) compared with ALI patients. VAE/VT differed similarly (0.6+/-0.01 in control group, 0.43+/-0.01 in ALI group and 0.31+/-0.01 in ARDS group, p<0.01). PEEP had no effect on VAE/VT, expired CO2 slope beyond VAE and VD/VT(Bohr) in any group. A significant correlation (p<0.01) was found between VAE/VT and expired CO2 slope beyond VAE and lung injury score at zero PEEP. Indices of volumetric capnography are affected by the severity of the lung injury, but are unmodified by the application of positive end-expiratory pressure.     

压力—容量曲线对急性肺损伤家兔实行个体化保护性通气？…

OBJECTIVE: To explore the lung-protective effect of ventilation with tidal volume and PEEP determined on pressure-volume curve in oleic acid rabbit models of acute lung injury. METHODS: 24 New Zealand rabbits were randomly divided into 4 groups (V1P1, V1P2, V2P1, V2P2). After inducing lung injury, the P-V curves were measured and drawn. The low and upper inflection point pressure (Pinf and Pdef respectively) were manually determined. Two levels of tidal volume (V1 = 15 ml/kg, V2 reduced for Pplat < Pdef) and two levels of PEEP (P1 = Pinf, P2 = Pinf - 3 cm H2O) were selected. The peak airway pressure (PIP), plateau pressure (Pplat), mean pressure (PAW), static compliance (Cst), heart rate, arterial blood pressure and blood-gas analysis were measured. The lung tissues were pathologically analyzed with light microscope. RESULTS: The oxygenation was not significantly different among 4 groups. The reduced VT significantly raised PaCO2 and lowered pH. Larger VT reduced arterial blood pressure. VT and PEEP synergetically raised airway pressure. Larger PEEP improved Cst, which was counteracted by larger VT. Reduced VT significantly lessened alveolar barotrauma. Larger PEEP lightened alveolar hyaline membrane formation and hemorrhage. CONCLUSION: The ventilation with VT and PEEP determined on P-V curve has significant protective effect on the acutely injured lung.     

Dead space ventilation in critically ill children with lung injury

STUDY OBJECTIVE: In children with acute lung injury, there is an increase in minute ventilation (E) and inefficient gas exchange due to a high level of physiologic dead space ventilation (VD/VT). Mechanical ventilation with positive end-expiratory pressure, when used in critically ill patients to correct hypoxemia, may contribute to increased VD/VT. The purpose of this study was to measure metabolic parameters and VD/VT in critically ill children. DESIGN: A cross-sectional study. SETTING: Pediatric ICU of a university hospital. PATIENTS: A total of 45 mechanically intubated children (mean age, 5.5 years). INTERVENTIONS: Indirect calorimetry was used to measure metabolic parameters. VD/VT parameters were calculated using the modified Bohr-Enghoff equation. ARDS was defined based on criteria by The American-European Consensus Conference. Measurements and results: The group mean (+/- SD) ventilatory equivalent for oxygen (VeqO(2)) and ventilatory equivalent for carbon dioxide (VeqCO(2)) were 2.9 +/- 1 and 3.3 +/- 1 L per 100 mL, respectively. The group mean VD/VT was 0.48 +/- 0.2. When compared to non-ARDS patients (33 patients), the patients with ARDS (12 patients) had a significantly higher VeqO(2) (3.3 +/- 1 vs 2.8 +/- 1 L per 100 mL, respectively; p < 0.05), a significantly higher VeqCO(2) (3.7 +/- 1 L/100 vs 3.1 +/- 1 L per 100 mL, respectively; p < 0.05), and a significantly higher VD/VT (0.62 +/- 0.14 vs 0.43 +/- 0.15, respectively; p < 0.0005). CONCLUSIONS: Critically ill children with ARDS have increased VD/VT. Increased VD/VT was the main cause of the excess of E demand in these patients. Increased metabolic demands, as shown by the VeqO(2), VeqCO(2), and ventilatory support, are the major determinants of E requirements in children with ARDS.     

Permissive hypercapnia impairs pulmonary gas exchange in the acute respiratory distress syndrome

Current recommendations for mechanical ventilation in the acute respiratory distress syndrome (ARDS) include the use of small tidal volumes (VT), even at the cost of respiratory acidosis. We evaluated the effects of this permissive hypercapnia on pulmonary gas exchange with the multiple inert gas elimination technique (MIGET) in eight patients with ARDS. After making baseline measurements, we induced permissive hypercapnia by reducing VT from 10 +/- 2 ml/kg to 6 +/- 1 ml/kg (mean +/- SEM) at constant positive end-expiratory pressure. After restoration of initial VT, we infused dobutamine to increase cardiac output (Q) by the same amount as with hypercapnia. Permissive hypercapnia increased Q by an average of 1.4 L. min(-)(1). m(2), decreased arterial oxygen tension from 109 +/- 10 mm Hg to 92 +/- 11 mm Hg (p < 0.05), markedly increased true shunt (Q S/Q T), from 32 +/- 6% to 48 +/- 5% (p < 0.0001), and had no effect on the dispersion of VA/Q.VA/Q. On reinstatement of baseline V T with maintenance of a high Q, Q S/Q T remained increased, to 38 +/- 6% (p < 0.05), and Pa(O(2 ))remained decreased, to 93 +/- 4 mm Hg (p < 0. 05). These results agreed with effects of changes in VT and Q predicted by the mathematical lung model of the MIGET. We conclude that permissive hypercapnia increases pulmonary shunt, and that deterioration in gas exchange is explained by the combined effects of increased Q and decreased alveolar ventilation.     

In vitro performance characteristics of high-frequency oscillatory ventilators

This study aimed to examine the performance characteristics of four high-frequency oscillatory-type ventilators, using an in vitro model of the intubated neonatal respiratory system. Each ventilator was examined across its operative range of settings and at varying model lung compliance (C) and resistance. The oscillatory pressure waveform was measured at the airway opening (Pao). Tidal volume (VT) and flow were determined from pressure changes within the model lung (DeltaPA). The spectral content of the Pao waveform differed between ventilators. The maximum ventilator VT ranged from 3.7 to 11.1 ml at 15 Hz and a mean airway pressure (Paw) of 12 cm H(2)O to oscillate a model lung (C = 0.4 ml/cm H(2)O) through a 3.0-mm internal diameter (i.d.) endotracheal tube (ETT). A small drop in C was associated with a decrease in VT and marked increase in DeltaPA from 0.1 to 0.8 ml/cm H(2)O. The influence of C on VT and DeltaPA and the pressure cost of ventilation (DeltaPA/f.VT(2)) was dependent on the oscillatory frequency, ETT inner diameter, and the specific ventilator used. Substantive differences exist between oscillatory ventilators that need to be considered in their clinical application. The rapid establishment of optimal lung volume and oscillatory frequency is important in minimizing barotrauma during high-frequency oscillatory ventilation.