胎粪吸人性肺炎应用常频与高频通气的研究

目的 评估常频通气和高频通气治疗胎粪吸入性肺炎(MAS)所致呼吸衰竭的临床与实验对比疗效。方法 实验方面：健康白兔，气管注入胎粪混悬液(3～5ml/kg)，呼吸衰竭模型出现后随机分组：①继续常频通气(CMV)3h后转为高频通气(HFV)3h(CMV—HFV组)；②转为HFV 3h后再转为CMV 3h(IDV—CMV组)。20例MAS患儿入院后即用CMV治疗，当所用吸入氧浓度（FiO2)＞0．82h左右，经皮氧饱和度(TcPO2)仍＜90％，改为HFV治疗；当FiO2＞0.82h左右，TcPO2能维持在90％以上，继续用CMV治疗。10例继续应用CMV治疗，10例改用HFV治疗。结果 动物出现呼吸衰竭模型时(0h)的氧合指数(OI)二组无差异，CMV—IDV组在治疗后3h OI无明显变化，至6h OI有上升3HFV—CMV组治疗后3h OI较0h时有下降，两组动物治疗后3h的OI的组间比较有差异。20例患儿中，CMV组治愈7例，死亡2例，放弃1例；HFV组治愈7例，放弃2例，死亡1例。HFV组患儿治疗后1h OI较0h有下降，至治疗后6h，OI与0h比较差异显著；CMV组治疗后1h OI有明显下降，但至治疗后6h下降幅度不明显。二组患儿的呼吸机应用时间和用氧时间均无差异。结论 MAS用HFV治疗后的氧合作用较CMV改善明显和吸入氧浓度下降迅速。     

高频通气治疗新生儿重症呼吸衰竭

目的　评价高频通气 (HFV)治疗新生儿重症呼吸衰竭的疗效。方法　 37例新生儿重症呼吸衰竭患儿 ,因在常频通气 (CMV)治疗过程中出现FiO2 ≥ 0 8,平均气道压≥ 10cmH2 O ,持续 2h以上氧饱和度≤ 90 %或胸片示肺气漏或持续高碳酸血症而启用HFV。记录HFV开始时及治疗后 6、12、2 4h的FiO2 、a A、OI、MAP、PIP、振幅参数。结果　HFV治疗成功组 2 2例 ,HFV治疗失败组 15例。成功组HFV治疗 12h后 ,FiO2 下降 (P <0 0 5 ) ;a A有上升 (P <0 0 5 ) ;OI有显著下降 (P <0 0 1)。失败组HFV治疗 12h后FiO2 无明显变化 ;a A在治疗后 12h无好转 ,2 4h有上升 (P <0 0 5 ) ;OI在HFV治疗后 6h无好转 ,12h后逐渐下降 ,但无统计学意义。结论　应用CMV疗效不佳的新生儿重症呼吸衰竭改用HFV是呼吸序贯治疗的一种有效方法。     

胎粪吸入综合征临床治疗的评价

目的 对胎粪吸人综合征(MAS)患儿应用高频通气(HFV)、肺表面活性物质(PS)及常频通气(CMV)治疗的疗效进行评价.方法 20例诊断为MAS的患儿,按治疗方法分为CMV、HFV和PS三组.通过动态观察生命体征、血气变化和计算氧合指数(OI)及吸入氧浓度(FIO2)的变化柬评价疗效.结果 三组患儿用呼吸机时间差异无统计学意义.治疗后6 h的OI比较,CMV组与PS组差异有统计学意义(13.03±3.7和8.82±2.8,t=2.22,P=0.05);PS组与HFV组比较差异有统计学意义(8.82±2.8和13.29±3.3,t=2.59,P＜0.05).三组患儿不同时段的OI组内比较,差异有统计学意义(P＜0.05).结论 MAS患儿应用PS、HFV和CMV治疗效果比较,用PS治疗后氧合改善明显;三组患儿应用呼吸机时间及治疗结果相同.     

高频通气治疗重症新生儿急性呼吸窘迫综合征

探讨高频通气(HFV)治疗重症新生儿急性呼吸窘迫综合征的疗效,对30例ARDS患儿的平均胎龄(38±3)周,出生体重为(3.3±0.7)kg,PaO2/FiO2≤75 mmHg,需要机械通气治疗者,其中10例患儿在吸氧浓度FiO2≥0.8,动脉血氧饱和度在4 h内＜0.9者改为HFV治疗.结果显示10例患儿用HFV治疗后2 h内动脉血氧饱和度均≥0.9.动脉肺泡氧分压比(a/A)较用常频通气(CMV)组显著改善,氧合指数(OI)较用CMV组明显下降,至8 h后效果更加明显.因此,对重症ARDS用CMV治疗效果差者可尝试改用HFV治疗.     

高频通气治疗重症新生儿急性肺损伤的临床观察

目的探讨高频通气（HFV）治疗重症新生儿急性肺损伤（ALI）的疗效。方法对30例ALI患儿需要机械通气治疗者进行常频通气（CMV）治疗，其中10例患儿在吸氧浓度FiO2≥0．8、动脉血氧饱和度在4h内〈0．9者改为HFV治疗，比较HFV组与CMV组在疗效、上机时间、并发症等方向的差异。结果10例患儿用HFV治疗后2h内动脉血氧饱和度均≥0．9。动脉肺泡氧分压比（a／A）较用CMV组显著改善，氧合指数（OI）较用CMV组明品下降，至8h后效果更加明显。发生BPD、PDA、IVH、气胸等并发症更少，上机时间更短。结论对重症ALI用CMV治疗效果差者可尝试改用HFV治疗。     

高频振荡通气与一氧化氮治疗新生儿重症呼吸衰竭疗效分析

目的 探讨高频震荡通气(HFOV)联合吸入一氧化氮(iNO)治疗新生儿重症呼吸衰竭的临床疗效.方法 共97例急性低氧血症呼吸衰竭新生儿,入选标准为氧合指数(OI)>20,在机械通气(常频或高频)下,患儿随机被给予iNO或无iNO,比较常频机械通气(CMV)、CMV+iNO、HFOV、HFOV+iNO组间疗效.结果 治疗12h,HFOV+iNO组中PaO2/FiO2变化最大,氧合指数下降最快.治疗24h,HFOV、HFOV+iNO组PaO2/FiO2均有明显变化,两组分别与CMV、CMV+iNO组比较,差异均有统计学意义(P<0.05);CMV+iNO、HFOV、HFOV+iNO组OI均明显下降,其中以HFOV+iNO组下降最显著,与各组比较差异均有统计学意义(P<0.01).结论 HFOV联合iNO治疗新生儿重症呼吸衰竭疗效最佳,二者有协同作用.     

高频震荡通气联合一氧化氮治疗重症胎粪吸入综合征

目的 探讨高频震荡通气(high frequency oscillatory ventilation,HFOV)联合吸入一氧化氮(inhaled nitric oxide,iNO)治疗重症新生儿胎粪吸入综合征(meconium aspiration syndrome,MAS)的临床疗效.方法 2008年10月至2011年5月期间入住我科的60例重症MAS患儿,出生后均需机械通气治疗,上机前氧合指数(oxygenation index,OI)均＞30.根据通气模式的不同,将60例患儿随机分为HFOV组、常频通气(conventional mechanical ventilation,CMV)组和HFOV+ iNO组,每组各20例,并比较3组的疗效,包括OI值、肺气漏及肺动脉高压的发生率.结果 机械通气治疗24h后,HFOV组及HFOV+ iNO组患儿较CMV组OI值明显降低(19.0±4.5 vs 11.0±5.3 vs 25.0±7.1,P＜0.05),并且HFOV+ iNO组在治疗4h后OI即出现明显下降(36.0±7.4至24.0±5.2).CMV组患儿肺气漏发生率为25％(5/20),HFOV组及HFOV+ iNO组均无肺气漏发生;HFOV组肺动脉高压发生率为30％(6/20),CMV组肺动脉高压发生率为40％(8/20),HFOV+ iNO组无一例发生肺动脉高压.结论 HFOV联合iNO是治疗重症MAS首选机械通气策略,两者合用疗效最佳.     

高频通气治疗重症新生儿急性呼吸窘迫综合征

探讨高频通气(HFV)治疗重症新生儿急性呼吸窘迫综合征的疗效,对30例ARDS患儿的平均胎龄(38±3)周,出生体重为(3.3±0.7)kg,PBO2/FiO2≤75mmHg,需要机械通气治疗者,其中10例患儿在吸氧浓度FiO2≥0.8,动脉血氧饱和度在4 h内<0.9者改为HFv治疗。结果显示:10例患儿用HFV治疗后2 h内动脉血氧饱和度均≥0.9。动脉肺泡氧分压比(a/A)较用常频通气(CMV)组显著改善,氧合指数(01)较用CMV组明显下降,至8 h后效果更加明显。因此,对重症ARDS用CMV治疗效果差者可尝试改用HFV治疗。     

高频振荡通气在新生儿胎粪吸入综合征中的应用

目的 探讨常频机械通气(CMV)与高频机械通气(HFOV)在治疗重症胎粪吸入综合征(MAS)的临床疗效.方法 将2007年1月 - 2009年12月收入NICU进行机械通气的64例重症MAS患儿,随机分为CMV组(32例)和HFOV组(32例),对比两种通气方法的治疗效果.结果 两组患儿上机前(0 h)的pH值、PaO2、PaCO2、PaO2/FiO2、OI值差异均无统计学意义(P ＞ 0.05),上机后在2、12、24、48 h时间点上,除上机后48 h的pH值两组相比差异无统计学意义(P ＞ 0.05)外,其余各时间点差异均有统计学意义(P均＜ 0.05);两组患儿的平均上机时间比较差异有高度统计学意义(t ＝ 3.30,P ＜ 0.01);两组患儿上机后的并发症比较差异有统计学意义(χ2 ＝ 4.01,P ＜ 0.05);两组患儿的治愈率比较差异有统计学意义(χ2 ＝ 4.73,P ＜ 0.05).结论 重症MAS的治疗可首选HFOV,HFOV治疗重症MAS安全、有效.     

部分液体通气治疗新生儿胎粪吸入综合征疗效观察

目的 探讨部分液体通气(PLV)在治疗新生儿严重呼吸衰竭中的疗效及可行性。方法 新生儿胎粪吸入综合征(MAS)并发严重呼吸衰竭和持续性肺动脉高压(PPHN)时肺氧合不良,在使用Babylog8000呼吸机进行常频机械通气无效的情况下,将加温后的全氟化碳(PFC)缓慢注入患儿肺内,通过球囊加压,使其在肺内均匀弥散后继续进行常频通气。㈦时监测患儿的PaO2、PaCO2、氧合指数(OI)和相关生命体征,定时进行气道分泌物的细菌学检查。结果 使用PLV治疗后,患儿的氧合情况明显改善,OI明显下降,6h后OI比PVL前下降41．18％,无明显二氧化碳潴留。使用PLV后77h撤机,撤机后7d复查：动脉导管关闭、肺动脉压力降至正常,肺部X线显示病变吸收,无呼吸机相关性肺炎发生,脑缺氧缺血性病变好转,健康出院。结论 PLV在新生儿严重呼吸衰竭时可以使用,需要继续评价其在临床医疗中的效果和规范。     

Effects of inhaled nitric oxide and high-frequency ventilation in rabbits with meconium aspiration

Aim: To evaluate effects of inhaled nitric oxide (iNO) in experimental meconium aspiration treated with high-frequency (HFV) or conventional mechanical ventilation (CMV). Ventilated adult rabbits had meconium instilled intratracheally resulting in respiratory failure as evidenced by more than 50% reduction of dynamic lung compliance (Cdyn) and increase in mean oxygenation index (OI) from 1 to 16. The animals were then allocated to 2 groups treated without (control) or with iNO at 20 ppm (NO). In each group the animals were initially ventilated with CMV or HFV mode for 3 h and then in a crossover fashion with HFV or CMV for another 3 h (CMV-->HFV, HFV-->CMV), respectively. In the first 3 h of treatment, the animals subjected to HFV-CMV in the control, and those with both HFV-CMV and CMV-HFV in the NO group had significantly reduced OI. In the subsequent 3 h, the animals in the control group with CMV-HFV did not improve in OI and those with HFV-CMV had deteriorated. In the NO group with both CMV-HFV and HFV-CMV moderate improvement of OI was observed. Platelet aggregation capability and counts were significantly decreased and bleeding time prolonged in animals receiving iNO treatment. These results suggest that both HFV alone and a combined treatment of iNO with either CMV or HFV are more effective in improving blood oxygenation than that of CMV in this animal model. The influence of iNO on platelet aggregation should be considered.     

高频通气治疗重症新生儿呼吸窘迫综合征

目的　探讨高频通气(HFV)治疗重症呼吸窘迫综合征(RDS)的疗效。方法　20例重症RDS患儿的胎龄(33±4)周,出生体重(2.1±0.8)kg,X线胸片示≥Ⅱ级,需机械通气(CMV)治疗。当所需吸入氧浓度(FiO     

Trends in use and outcome of newborn infants treated with high frequency ventilation in Australia and New Zealand, 1996-2003

AIM: To examine the use of high frequency ventilation (HFV) to treat newborn infants in Australia and New Zealand and the associated complications and outcomes. METHODS: Data for all infants receiving HFV were collected from the 28 neonatal intensive care units contributing to the Australian and New Zealand Neonatal Network database between 1996 and 2003, inclusive. For comparison, the same data were gathered on all infants who received conventional mechanical ventilation (CMV) and nasal continuous positive airway pressure. RESULTS: HFV was used to treat 3270 infants (10.1% of all ventilated infants) between 1996 and 2003; uptake doubled during this period from 5.9% to 12.6% of ventilated infants per year. HFV was most frequently applied in the context of extreme prematurity (29.9% of ventilated infants <26 weeks gestation). HFV is being increasingly used to treat complex diseases such as meconium aspiration syndrome and congenital diaphragmatic hernia (12.2% and 10.6% in 1996 to 25.2% and 48.4% in 2003, respectively, chi2 -test for trend, P<0.001). Infants receiving HFV spent longer on respiratory support than infants treated with CMV (median 21 days compared with 7 days, Mann-Whitney test P<0.001) and required a higher initial FiO2 (median 0.8 compared to 0.5, Mann-Whitney test, P<0.001). The use of HFV was associated with a higher mortality than CMV and nasal continuous positive airway pressure (39.7%, 10.1% and 0.4%, chi2 -test, P<0.001). The incidence of death and intraventricular haemorrhage decreased over time in the HFV group (chi2 -test for trend, P<0.001 and P=0.02 respectively). CONCLUSION: HFV is an established mode of neonatal ventilation in Australia and New Zealand. HFV is being applied to infants at the greatest risk of serious adverse outcomes, most likely as a rescue therapy.     

新生儿呼吸衰竭肺功能及血气分析监测的临床意义

目的　 探讨新生儿呼吸衰竭 (RF)肺功能及血气分析的特征和临床意义。 方法 　将 110例新生儿RF患儿分为 4组 ,即肺炎组 (P)、缺氧缺血性脑病组 (HIE)、胎粪吸入综合征组 (MAS)、肺透明膜病组 (RDS)。对这些患儿进行肺功能和血气分析检测 ,分析其特征和临床意义。 结果 　P组和HIE组为轻度RF ,RDS为中度RF ,MAS为重度RF。MAS组、RDS组 ,TV下降 ,RR升高 ,FRC增多 (RDS组FRC减少 ) ,Crs下降 ,Rrs增加 ;PaO2 下降 ,PaCO2 升高 ,PaO2 /FiO2 下降 ,P(A a)O2 、RI、Qs/Qt升高 ,以上指标均为显著变化 ,MAS组为各组之最 ,RDS组次之。 结论 　肺功能指标可解释与证实MAS和RDS的病理生理过程 ,与血气分析指标一样和RF的严重程度一致 ,肺功能与血气分析均可作为RF的评价指标及指导治疗 ,而且肺功能具有非损伤性 ,不受吸入氧浓度影响等特点     

High frequency ventilation

The 1990s have seen a dramatic resurgence of interest in high frequency ventilation (HFV). The role of HFV in the rescue of infants failing conventional mechanical ventilation (CMV) is now relatively well established. However, the wider role of HFV in the routine management of respiratory failure in the newborn is more contentious. Recent trials in small numbers of infants suggest that HFV may be associated with significantly less chronic lung disease than CMV when used under optimal conditions (i.e. with a 'high-volume' strategy, from early in the disease and continued to the point of weaning). Further, clinical trials are now required to define the role of HFV more clearly.     

高频振荡机械通气在血液肿瘤及多种疾病并发儿童急性低氧性呼吸衰竭中的应用

目的 评估儿童急性低氧性呼吸衰竭（acute hypoxemic respiratory failure,AHRF）给予高频振荡机械通气（high-frequency oscillatory ventilation,HFOV）治疗的意义.方法 回顾2011年1月至2013年9月收入我院PICU诊断为AHRF的病例,首先给予常规机械通气（CMV）,当PIP＞ 30cmH2O（1 cmH2O =0.098 kPa）或PEEP＞ 10 cmH2O、FiO2100％时具有以下情况之一：（1）SpO2 ＜90％或PaO2 ＜60 mmHg（1 mmHg =0.133 kPa）;（2）有严重呼吸性酸中毒（PaCO2＞ 80mmHg）;（3）严重气漏（纵隔气肿或气胸）,改为HFOV通气治疗.收集患儿性别、年龄、住PICU时间、CMV通气时间、HFOV通气时间等一般资料.分别于CMV通气末（H0）及HFOV后2 h（H2）、6 h（H6）、12 h（H12）、24 h（H24）、48 h（H48）记录并比较各时间点呼吸机参数（平均气道压、振幅、频率、FiO2）、氧合指数（PaO2/FiO2、OI）、动脉血气、心率、血压变化.分别比较存活组与死亡组、血液肿瘤组及非血液肿瘤组在H0、H2、H6、H12、H24、H48时间点的指标变化.结果 HFOV通气后,H2时间点PaO2较H0升高[76.9（61.9～128.0） mm-Hg vs 50.1 （49.5 ～ 68.0） mmHg],差异有统计学意义（P=0.006）.H2、H48时间点PaO2/FiO2分别较Ho、H24升高,差异有统计学意义[94.9（66.8 ～ 138.9） mmHg vs 68.0（49.5 ～ 86.8）mmHg,P=0.039;135.0（77.6 ～240.0）mmHg vs 90.7（54.6 ～ 161.7） mmHg,P=0.023）].所有患儿收缩压、舒张压、心率在各时间点没有明显变化（P＞0.05）.存活组（n=9）与死亡组（n=14）相比,PaO2/FiO2、OI在H6、H12、H24、H48差异有统计学意义（P＜0.05）.非血液肿瘤组（n=10）与血液肿瘤组（n=13）相比,OI在H2、H6差异有统计学意义[19.2（13.9～26.6） vs 33.8（19.7 ～48.3）,P=0.049;16.0（8.4～27.1） vs28.9（20.9 ～38.9）,P=0.027）],两组的平均气道压在H2、H6、H12差异有统计学意义（P＜0.05）.两组病死率差异无统计学意义（40.0％ vs 76.9％,P=0.086）.结论     

Partial liquid ventilation and nitric oxide in experimental acute lung injury

OBJECTIVE: To investigate the effects of inhaled nitric oxide (iNO) and partial liquid ventilation (PLV) on oxygenation and pulmonary haemodynamics in acute lung injury (ALI), and to assess their effects on lung function, systemic haemodynamics and lung injury. METHODS: Using saline lung lavage, ALI was induced in 18 piglets. A control group was ventilated with conventional mechanical ventilation (CMV) for 2 h. An iNO-first group received iNO for the first hour and then iNO with PLV. A PLV-first group received PLV for the first hour and then PLV with iNO. Variables were measured at baseline, 5 min postlavage, and at 1 h and 2 h postlavage. RESULTS: During the first hour, both treatment groups showed improvement in oxygenation index (OI). At 2 h, the dif-ferences in OI were statistically significant (P = 0.037), with a mean +/- SD of 23.8 +/- 20.7 in the control group, 4.4 +/- 0.9 in the PLV-first group and 6.5 +/- 3.1 in the iNO-first group. The OI was similar in both treatment groups (P = 0.178). At 2 h, the pulmonary artery pressure (PAP) was significantly different (P = 0.04) between groups, with a mean +/- SD PAP of 36.3 +/- 7.2 mmHg in the control group, 27.4 +/- 4.0 mmHg in the PLV-first group and 30.0 +/- 4.1 mmHg in the iNO-first group. The PAP was similar in both treatment groups (P = 0.319). CONCLUSION: In ALI, oxygenation and pulmonary hypertension are improved with PLV and iNO given together, regardless of the order in which they are commenced.     

Lung lavage using high-frequency jet ventilation in rabbits with meconium aspiration

AIM: To determine the efficacy of the expulsion effect of high-frequency jet ventilation (HFJV) on meconium clearance from the airways in comparison with conventional suctioning in adult rabbits with meconium aspiration. METHODS: Experiments were carried out on tracheotomized, anaesthetized and paralysed adult rabbits. A suspension of human meconium in saline (25 mg ml(-1), 4 ml kg(-1)) was instilled into the tracheal cannula. When respiratory failure developed, saline lavage (10 ml kg(-1) in 3 portions) was performed during conventional ventilation or by means of the inpulsion and expulsion regime of HFJV. Animals were further ventilated for 2 h with either conventional ventilation or HFJV. RESULTS: There was no significant difference between groups in the amount of meconium recovered by lavage. Compared to conventional ventilation, the application of HFJV enhanced the elimination of carbon dioxide, increased lung compliance and diminished right-to-left shunts after 30 min of ventilatory treatment. Oxygenation also improved during HFJV, although this was not a consistent finding during the ventilation period. CONCLUSION: HFJV improved gas exchange, lung compliance and reduced right-to-left pulmonary shunts, but saline lung lavage by HFJV was not found to be more efficient than lavage during conventional ventilation in rabbits with meconium aspiration.     

适应性支持通气与传统指令通气治疗小儿呼吸衰竭的比较研究

目的比较适应性支持通气(ASV)与传统指令通气(CMV)对呼吸衰竭患儿通气参数和人机对抗的影响。方法采用自身对照方法对复旦大学儿科医院PICU2006年3～8月20例呼吸衰竭患儿先予CMV模式机械通气,45min后改ASV模式。记录两种模式下的通气参数、血气分析和平均动脉压等指标的变化。结果ASV模式下吸气峰压、平均气道压、控制频率、浅快呼吸指数分别较CMV模式明显下降(P<0.01、P<0.05、P<0.01和P<0.05)。两种模式间的总呼吸频率、潮气量、分钟通气量、呼吸顺应性差异无显著性(P值均>0.05),动脉血氧分压、动脉血二氧化碳分压及平均动脉压差异亦无显著性(P值均>0.05)。结论ASV较常规通气模式有利于减轻气压伤、减少人机对抗、实行肺保护策略。     

不同机械通气方式联合肺表面活性物质对新生儿急性肺损伤/急性呼吸窘迫综合征疗效比较

目的 比较高频振荡通气+肺表面活性物质 （HFOV+PS）、常频机械通气+肺表面活性物质 （CMV+PS）、常频机械通气 （CMV）3种治疗方式对新生儿急性肺损伤/急性呼吸窘迫综合征 （ALI/ARDS）的临床疗效。方法 纳入ALI/ARDS新生儿136例 （ALI73例,ARDS63例）,其中HFOV+PS组45例,CMV+PS组53例,CMV组38例,前两组应用肺表面活性物质气管内滴入 （70~100mg/kg）。分别检测机械通气0h、12h、24h、48h、72h的PaO2、PaCO2、PaO2/FiO2、氧合指数 （OI）、呼吸指数 （RI）。结果 机械通气12h、24h、48h时HFOV+PS组的PaO2高于CMV+PS组和CMV组,PaCO2低于CMV+PS组和CMV组 （P < 0.05）;在机械通气12h、24h、48h、72h时HFOV+PS组PaO2/FiO2高于CMV+PS组和CMV组,OI、RI低于CMV+PS组和CMV组 （P < 0.05）;HFOV+PS组机械通气时间、用氧时间均低于CMV+PS组和CMV组 （P < 0.05）;3组气漏、颅内出血发生率及治愈率比较差异无统计学意义。结论 与单纯CMV以及CMV联合PS治疗相比,HFOV联合PS更可改善ALI/ARDS新生儿的肺功能,缩短通气时间及用氧时间,且不增加并发症的发生。