板层小体计数预测新生儿呼吸窘迫综合征临床观察

目的通过肺成熟度预测对可能发生新生儿呼吸窘迫综合征的早产儿进行积极预防,同时避免部分早产儿不必要的气管插管及PS使用。方法对136例正常新生儿及早产儿进行板层小体计数,尝试找出反应肺成熟度的不成熟判定界值和成熟判定界值,并统计其对肺成熟度的阳性预测值、阴性预测值、敏感性、特异性,以避免部分早产儿不必要的气管插管及PS的使用。结果成熟判定界值≥98000/uL时其阴性预测值100%;阳性预测值17.4%;敏感性100%;特异性36.7%;不成熟判定界值≤33000/uL时阴性预测值98%;阳性预测值36.8%;敏感性87.5%;特异性81.7%。     

正常中晚期妊娠羊水板层小体增长特征及其判断胎肺成熟的意义

目的探讨羊水板层小体数量在正常中、晚期妊娠的增长规律及其对判断胎肺成熟度的意义。方法采用自动血细胞计数仪血小板通道测量310份正常单胎妊娠16～42周的无污染羊水板层小体数目。结果羊水板层小体数目在32孕周前处于低值状态,其于16、24、31孕周时中位数分别为0、5×109/L、7×109/L;满32孕周时中位数达27×109/L,后增长速度开始逐渐加快;满37孕周时中位数为147×109/L。羊水板层小体数目与孕周呈正指数曲线相关,随孕周的增加呈指数增长,相关系数（r）为0.9386,确定系数（R2）为0.881。羊水板层小体数目对孕周的指数方程为Y（LBC）＋1=0.0273e0.2201X（孕周）（P〈0.0001）。利用指数模型预测36、37、38孕周的羊水板层小体数值分别为74×109/L、92×109/L、115×109/L。结论正常中晚期妊娠羊水板层小体数量随孕周进展呈指数增长,可利用板层小体数目对孕周的指数模型对胎肺成熟度做判断。     

新生儿羊水泡沫试验与板层小体计数结果的相关性探讨

目的胎肺发育不成熟,可致新生儿发生呼吸窘迫综合征（NRDS）,肺表面活性物质（PS）替代疗法已成为NRDS的常规治疗,但也可能导致部分患儿接受不必要的气管插管和PS使用,通过肺成熟度测定预测早产儿发生NRDS的可能性,可极早预防或减少不必要的气管插管及PS的使用。本研究进行两种肺成熟度测定方法之间的相关性探讨,为临床选择提供依据。方法羊水泡沫试验和板层小体计数。结果羊水泡沫法与板层小体计数有正相关关系。     

150例早产儿出生时羊水板层小体计数和泡沫试验的阴性预测值、阳性预测值、敏感性及特异性之间的比较

目的羊水板层小体计数和羊水泡沫试验预测早产儿发生呼吸窘迫综合征（RDS）两种方法的比较。方法对150例早产儿出生时全部采羊水进行板层小体计数和泡沫试验的检测,计算出每种方法的阴性预测值、阳性预测值、敏感性和特异性,并进行比较。结果板层小体计数和泡沫试验能很好的反映同一指标;但板层小体计数的上述各项指标均优于羊水泡沫试验,胎龄34w以内的早产儿尤为明显。结论早产儿尤其是胎龄34w以内的早产儿预测其是否发生RDS,羊水板层小体计数方法优于羊水泡沫试验。     

肺表面活性物质联合CPAP治疗NRDS的疗效

目的 观察肺表面活性物质（PS）联合持续气道正压通气（CPAP）治疗新生儿呼吸窘迫综合征（NRDS）的疗效。方法 选择2016年6月~2019年5月我院收治的62例NRDS患儿,按随机数字表法分为对照组和观察组,各31例。对照组接受CPAP治疗,观察组在对照组基础上联合PS治疗。比较两组临床疗效、pH、动脉二氧化碳分压（PaCO2）、动脉血氧分压（PaO2）、氧合指数（OI）、住院时间及并发症发生情况。结果 观察组总有效率为93.55%,高于对照组的74.19%,差异有统计学意义（P＜0.05）;观察组pH、PaO2、OI均高于对照组,PaCO2低于对照组,差异均有统计学意义（P＜0.05）;观察组支气管肺发育不良发生率低于对照组,差异有统计学意义（P＜0.05）;两组肺不张、气胸及腹胀发生率比较,差异无统计学意义（P＞0.05）;观察组住院时间短于对照组,差异有统计学意义（P＜0.05）。结论 NRDS患儿接受PS联合CPAP治疗有利于改善动脉血气指标,提升呼吸功能,缩短住院时间,降低相关并发症发生率。     

妊娠高血压综合征尿蛋白和孕龄对新生儿出生体重影响的研究

目的几乎没有研究报道妊娠高血压综合征(妊高征)患者尿蛋白、孕龄对新生儿出生体重影响的关系,本研究欲探讨各种变化因素对妊高征患者新生儿出生体重影响的量化关系.方法 1997年1月～2004年6月期间,在我院住院分娩患中、重度妊高征产妇136例,对新生儿出生体重与各种因素进行单变量和多变量回归分析.结果单变量回归分析尿蛋白、孕龄分别与新生儿出生体重有高度显著性关系(P＜0.001);尿蛋白和孕龄一起进入多元回归分析,校正影响因素,尿蛋白和孕龄仍然是影响新生儿出生体重显著性因素(P＜0.001),并且每增加一个等级尿蛋白,新生儿出生体重降低241.92g (95%CI:144.77～339.07);孕龄每增加一天,新生儿出生体重增加20.1g(95%CI:13.70～26.50).结论妊高征患者尿蛋白丢失将严重影响新生儿出生体重,孕龄的延长有增加新生儿出生体重.     

基于Logistic回归模型的足月新生儿呼吸窘迫综合征相关因素分析

目的 分析发生新生儿呼吸窘迫综合征（NRDS）的影响因素。方法 收集2014年1月~2018年12月我院85例呼吸窘迫综合征足月新生患儿设为实验组,104例同期未被诊断为呼吸窘迫综合征足月新生儿设为对照组,比较两组性别,胎龄,出生体重,分娩方式,产妇年龄,怀孕次数,流产史和妊娠并发症等临床资料。将单因素分析有统计学差异的项目进入多因素Logistic回归,分析RDS的影响因素。结果 两组性别、胎龄、分娩方式、产妇多胎、妊娠期糖尿病、胎儿宫内窘迫和新生儿窒息比较,差异有统计学意义（P＜0.05）。两组新生儿体重、产妇年龄、流产史、产妇妊高症、胎膜早破、羊水过少和胎粪污染比较,差异无统计学意义（P＞0.05）。Logistic回归分析显示,新生儿男性、剖宫产、多胎和妊娠期糖尿病为NRDS的危险因素。结论 足月儿NRDS的危险因素为男性,剖宫产、多胎和产妇妊娠期糖尿病。早期识别NRDS相关危险因素对病情控制有积极意义。     

CPAP联合肺表面活性物质治疗对新生儿呼吸窘迫综合征的疗效

目的 研究持续气道正压通气(CPAP)联合肺表面活性物质(PS)治疗新生儿呼吸窘迫综合征(NRDS)疗效及对患儿血气指标和血清磷酸肌酸激酶同工酶(CK-MB)、脑钠肽(BNP)、方法选择本院2017年8月至2020年10月诊治的105例NRDS患儿,通过随机数表法进行分组,其中对照组(52例)给予CPAP治疗,研究组(53例)给予CPAP联合PS治疗.比较两组患儿治疗前后血气指标、肺表面活性蛋白A(SPA)、甲状腺激素、脑炎症因子和血清CK-MB、BNP、Cys C水平,并统计其并发症.结果 治疗前两组患儿血气指标、SPA、甲状腺激素以及炎症因子水平比较差异无统计学意义(P>0.05),治疗后研究组患儿氧合指数(OI)、氧气分压(PaO2)、游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、白细胞介素-4(IL-4)水平高于对照组,二氧化碳分压(PaCO2)、SPA、γ-干扰素(INF-γ)水平低于对照组(P<0.05),促甲状腺素(TSH)水平两组比较差异无统计学意义(P>0.05);治疗前两组患儿血清CK-MB、BNP、Cys C水平比较差异无统计学意义(P>0.05),治疗后研究组患儿上述指标水平明显降低且低于对照组(P<0.05);两组患儿并发症发生率比较差异无统计学意义(P>0.05).结论 CPAP联合PS应用于NRDS可调节甲状腺激素水平以及血清CK-MB、BNP、Cys C水平,减轻炎症反应,改善血气指标.     

基于肺表面活性物质的临床价值对新生儿呼吸窘迫症的治疗新探讨

目的探讨肺表面活性物质（PS）珂立苏（Calsurf）治疗新生儿呼吸窘迫症的临床疗效。方法将42例生后确诊为新生儿呼吸窘迫症（NRDS）患儿分为2组,其中对照组21例给予机械通气治疗,治疗组21例在机械通气治疗基础上使用珂立苏治疗。比较2组治疗前后的临床表现、血气分析结果及胸片的变化。结果治疗组在应用珂立苏后皮肤迅速转红,用药6 h后PaO2、a/APO2、PaO2/FiO2均明显提高,PaCO2下降,pH上升,用药24h、3d,PaO2和a/APO2仍在较高水平,与对照组比较,差异均有显著意义（P〈0.05或P〈0.01）。胸部X线显示治疗组肺野透亮度改善与对照组比较,差异有显著意义（P〈0.05）。2组治疗后,治疗组存活19例（90.4%）,对照组存活12例（57.1%）,2组存活率相比,差异有显著性意义（P〈0.05）。结论肺表面活性物质能快速、有效地改善NRDS患儿肺通气、换气功能。     

Relationship between Ultrasonic Marker of Fetal Lung Maturity and Lamellar Body Count

Background

The aim of this study was prediction the fetal lung maturity by ultrasonic markers and comparison by lamellar body count and fetal outcome.

Alveolar recruitment maneuvers in acute lung injury/acute respiratory distress syndrome

Mechanical ventilation can worsen lung damage in acute lung injury and acute respiratory distress syndrome. The use of low tidal volumes is one of the strategies that has been shown to reduce lung injury and improve outcomes in this situation. However, low tidal volumes may lead to alveolar derecruitment and worsening of hypoxia. Recruitment maneuvers along with positive end-expiratory pressure may help to prevent derecruitment. Although recruitment maneuvers have been shown to improve oxygenation, improved clinical outcomes have not been demonstrated. The optimal recruitment strategy and the type of patients who might benefit are also unclear. This review summarizes the impact of recruitment maneuvers on lung mechanics and physiology, techniques of application, and the clinical situations in which they may be useful.     

肺表面活性物质蛋白B基因多态性与新生儿呼吸窘迫综合征易感性的研究

目的探讨肺泡表面活性物质蛋白B（SPB）基因多态性与新生儿呼吸窘迫综合征易感性的关系。方法收集华中科技大学同济医学院附属同济医院的新生儿呼吸窘迫综合征（NRDS）诊断病例为病例组,并按1∶2比例收集胎龄和出生体重相匹配的无明显感染症状早产儿为对照组。应用聚合酶链反应-限制性片段长度多态（PCR-RFLP）分析技术及基因测序技术检测SPB-18A/C及SPB1580C/T多态性,观察两组间基因型频率和等位基因频率的差异。并复习文献比较本研究汉族与其他种族人群等位基因频率的差异。结果 2008至2010年NRDS组91例,对照组182名进入分析。①SPB-18A/C基因在NRDS组AA,AC,CC基因型频率分别为11.0%、40.7%和48.4%,对照组分别为6.6%、31.3%和62.1%;两组基因型频率差异无统计学意义（P〉0.05）;NRDS组A等位基因频率显著高于对照组（31.3%vs22.3%）。②SPB1580C/T基因在NRDS组TT、TC和CC基因型频率分别为5.5%、63.7%和45.1%,对照组分别为30.8%、6.6%和48.4%;两组基因型频率差异无统计学意义（P〉0.05）;NRDS组C等位基因频率显著高于对照组（79.1%vs70.9%）。③本研究汉族人、美国人、巴西人和丹麦人SPB1580等位基因C频率分别为79%、35%、41%和46%,差异有统计学意义（P〈0.05）,与日本人群等位基因C频率（72%）差异无统计学意义（P〉0.05）;本研究汉族人、巴西人、美国人和丹麦人SPB-18等位基因A频率分别为31%、58%、57%和61%,差异有统计学意义（P〈0.05）。结论本研究汉族人群SPB-18A/C及SPB1580C/T基因多态性是NRDS的危险因素。不同种族人群SPB1580C/T和SPB-18A/C基因多态性分布存在明显差异。     

Acute respiratory distress syndrome: Pulmonary and extrapulmonary not so similar

Acute respiratory distress syndrome (ARDS) is characterized by acute onset respiratory failure with bilateral pulmonary infiltrates and hypoxemia. Current evidence suggests different respiratory mechanics in pulmonary ARDS (ARDSp) and extrapulmonary ARDS (ARDSexp) with disproportionate decrease in lung compliance in the former and chest wall compliance in the latter. Herein, we report two patients of ARDS, one each with ARDSp and ARDSexp that were managed using real-time esophageal pressure monitoring using the AVEA ventilator to tailor the ventilatory strategy.     

早期应用泡式鼻持续气道正压通气8cmH2O和5cmH2O联合肺表面活性物质防治新生儿呼吸窘迫综合征的临床研究

目的探讨早期应用泡式鼻持续气道正压通气（B—NCPAP）8cmH2O（1cmH2O=0．098kPa）与肺表面活性物质（PS）＋B—NCPAP 5cmH2O防治NRDS的疗效差异。方法B—NCPAP8组选取2007年4月30日至2008年8月30日在中山大学附属第三医院分娩且生后30min内收入新生儿病房的早产儿,胎龄27～37周、羊水泡沫实验（-）～（＋）,生后30min内应用B—NCPAP 8cmH2O,分为B—NCPAP8预防（治疗前未出现呼吸窘迫）和B—NCPAP8治疗亚组（治疗前出现呼吸窘迫,胸部X线检查提示存在不同程度NRDS改变）。Ps＋B—NCPAP5组选取为胎龄27—37周、羊水泡沫实验（一）～（＋）的早产儿,生后6h内气管内注入Ps并给予B—NCPAP5cmH20,分为PS＋B—NCPAP5预防及PS＋B-NCPAP5治疗亚组。结果研究期间,B—NCPAP8预防和治疗亚组分别纳入48和25例;PS＋B—NCPAP5预防和治疗亚组分别纳入36和22例。B—NCPAP8预防亚组41／48例（85．4％）未出现呼吸窘迫;7例在应用B—NCPAP4～6h后出现呼吸窘迫,其中5例为轻度NRDS,继续治疗8h后症状逐渐改善,2例为重度NRDS,在生后8～10h行气管插管注入PS并改用机械通气后存活;应用成功率为95．8％（46／48例）。PS＋B—NCPAP5预防亚组32／36例（88．9％）未出现呼吸窘迫;4例在应用BNCPAP4～6h后出现呼吸窘迫,其中3例为轻度NRDS,继续治疗后症状逐渐改善,应用成功率为97．2％（35／36例）;1／36例（2．8％）为中度NRDS,改用机械通气后死亡。B—NCPAP8治疗亚组24／25例（96．0％）治疗2h后血气分析指标改善,1例改用机械通气。PS＋B—NCPAP5治疗亚组18／22例（81．8％）治疗8h后临床症状及血气指标均改善,1／22例（4．5％）死亡。B—NCPAP8与PS＋B—NCPAP5预防及治疗亚组在防治NRDS的疗效上差异无统计学意义,但B—NCPAP8预防及治疗亚组的肺部感染发生率、住院时间及住院费用较低（P均〈0．05）。结论早期应用B．NCPAP 8cmH2O与PS＋B—NCPAP 5cmH2O预防及治疗NRDS的疗效相近,但前者能减少肺部并发症发生,缩短住院时间,减少住院费用。     

Elevated concentrations of leukotriene D4 in pulmonary edema fluid of patients with the adult respiratory distress syndrome

The possible contribution of metabolites of arachidonic acid to the increased permeability of the alveolar-capillary barrier in the adult respiratory distress syndrome was examined by quantifying the pulmonary edema fluid concentrations of lipoxygenase and cyclooxygenase products. The concentration of leukotriene D₄ in pulmonary edema fluid of 10 patients with the adult respiratory distress syndrome (18.5±6.8 pmol/ml; mean±SD), assessed by specific radioimmunoassay after isolation of the mediator, was significantly higher (P<0.001) than that of five patients with cardiogenic pulmonary edema (4.4±1.1 pmol/ml). The concentrations of leukotrienes B₄ and C₄, prostaglandin E₂, and thromboxane B₂ in edema fluid were not significantly different in the adult respiratory distress syndrome patients than in the other subjects with pulmonary edema. The edema fluid concentration of leukotriene D₄ correlated with the ratio of edema fluid to plasma concentrations of albumin (r=0.64). Leukotriene D₄ thus may contribute to the permeability defect which allows an accumulation of proteinrich alveolar fluid in the adult respiratory distress syndrome.This work was supported in part by Grants HL31809, HL25816, HL19155, and AI19784 from the National Institutes of Health.     

Incidence and outcome of acute lung injury and acute respiratory distress syndrome in the surgical intensive care unit

Introduction:

To determine the incidence and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in a cohort of patients with risk factors admitted to the Surgical Intensive Care Unit (SICU).

Materials and Methods:

A prospective observational inception cohort study with no intervention was conducted over 12 months. All patients with at least one known risk factor for ALI/ARDS admitted to the SICU were included in the study. The APACHE II severity of disease classification system scoring was performed within 1 h of admission. The ventilatory parameters and chest radiographs were recorded every 24 h. The P/F ratio, PEEP and Lung Injury Score were calculated each day until the day of discharge from the Intensive Care Unit or for the first 7 days of admission, whichever was shorter.

Results:

The incidence of ARDS among those who were mechanically ventilated was 11.4%. Sepsis was the most common (34.6%) etiology. Among those with risk factors, the incidence of ARDS was 30% and that of ALI was 32.7%. The mortality in those with ARDS was 41.8%. Those who develop ARDS had higher APACHE II scores, lower pH and higher PaCO₂ at admission compared with those who developed ALI or no lung injury.

Conclusion:

The incidence and mortality of ARDS was similar to other studies. Identifying those with risk factors for ARDS or mortality will enable appropriate interventional measures.     

Isolation and phenotypic characteristics of microparticles in acute respiratory distress syndrome

Objective: To investigate the alterations of microparticles in acute respiratory distress syndrome (ARDS) in rats. Methods: 18 Wistar male rats were randomly divided into three groups: no intervention, sham (saline control) group and ARDS group (LPS induced). Blood was collected from abdominal aorta and microparticles were extracted through multiple rounds of centrifugation. Particles were analyzed by flow cytometry and transmission electron microscope. Results: The circulating concentration of total microparticles of rats with ARDS induced by lipopolysaccharide (LPS) did not change compared with other two groups. However, ARDS rats expressed higher concentration of leukocyte- and endothelium- derived microparticles in the three groups. Conclusion: Our results indicate that leukocyte and endothelial cell-derived particles may play an important role in ARDS. Thus it is important not only to monitor total microparticle levels but also the phenotypes, which may contribute to the prevention and early treatment of ARDS.     

A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome

Aim:There is sparse data on the role of noninvasive ventilation (NIV) in acute respiratory distress syndrome (ARDS) from India. Herein, we report our experience with the use of NIV in mild to moderate ARDS.Results:A total of 41 subjects (27 women, mean age: 30.9 years) were included in the study. Tropical infections followed by abdominal sepsis were the most common causes of ARDS. The use of NIV was successful in 18 (44%) subjects, while 23 subjects required intubation. The median time to intubation was 3 h. Overall, 19 (46.3%) deaths were encountered, all in those requiring invasive ventilation. The mean duration of ventilation was significantly higher in the intubated patients (7.1 vs. 2.6 days, P = 0.004). Univariate analysis revealed a lack of improvement in PaO₂/FiO₂ at 1 h and high baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) as predictors of NIV failure.Conclusions:Use of NIV in mild to moderate ARDS helped in avoiding intubation in about 44% of the subjects. A baseline APACHE II score of >17 and a PaO₂/FiO₂ ratio <150 at 1 h predicts NIV failure.