儿童急性肺损伤和呼吸窘迫综合征的非机械通气治疗

急性肺损伤(acute lung injury,ALI)/急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是各种原因导致肺毛细血管内皮细胞和肺泡上皮细胞损伤造成弥漫性肺间质及肺泡水肿导致的急性低氧性呼吸功能不全或呼吸衰竭.儿童ALI/ARDS的发生率为2.2～6/10万[1],在PICU住院患儿中ARDS的发生率为8.5～16/1000[2].国内有报道ARDS的住院病死率为44.8％[3].合适的呼吸末正压与合适的小潮气量通气治疗是目前公认的可以降低病死率的治疗方法.近年来,国内儿科及重症医学工作者通过全国儿科脓毒症的调查和2009至2010年甲型H1N1流感救治工作的开展,强化了对ALVARDS诊断和治疗的认识.除机械通气外,其他救治措施中依然有很多问题没有解决,现就ALVARDS非机械通气治疗热点问题进行讨论.     

肺表面活性物质在儿童急性呼吸窘迫综合征的应用

肺表面活性物质(pulmonary surfactant,PS)是由Ⅱ型肺泡上皮细胞合成分泌的脂质蛋白混合物,主要功能是降低肺泡气-液界面表面张力.急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)时多种原因引起PS的量和质出现变化,导致其功能异常.外源性PS替代治疗可以改善儿童ARDS肺部气体交换,但提高存活率作用不肯定.这可能与ARDS病因、PS成分、给药方法、时机、剂量及次数等不同有关.目前不推荐PS作为儿童ARDS的常规治疗方法.     

危重患儿急性肺损伤

儿童急性肺损伤(acute lung injury,ALI)或急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)是指由心源性以外的各种肺内外因素引起的急性、进行性缺氧性呼吸衰竭。ALI和ARDS为同一疾病过程的两个阶段,即ALI为早期、病情较轻阶段,ARDS为后期、病情严重阶段。ALI/     

儿童弥漫性肺泡出血综合征

弥漫性肺泡出血(diffuse alveolar hemorrhage,DAH)是肺循环小血管(主要是毛细血管,也包括动脉、静脉)损伤的结果。特发性肺含铁血黄素沉积症(idiopathic pulmonary hemosiderosis,IPH)一直以来被认为是儿童最经典的DAH,表现为两肺弥漫性浸润、贫血、肺泡内充满含铁血黄素巨噬细胞(hemosiderin-laden macrophage,HLMs),但病因未明确。最近一些表现为DAH的病例报道,例如肺泡毛细血管炎、婴儿急性特发性肺出血(acute idiopathic pulmonary     

血管内皮细胞生长因子与急性肺损伤

小儿急性肺损伤(ALI)及ALI的严重形式急性呼吸窘迫综合征的主要病理特征是弥漫性肺泡-毛细血管壁损伤.血管内皮细胞生长因子(VEGF)可以促进肺泡细胞、血管内皮细胞增殖.也可以提高血管通透性.因此,VEGF可能成为一种反映ALI病理和(或)肺损伤及修复状况的生物学指标.该文对VEGF及其受体的基本生物学特性、VEGF与ALI相关的动物及临床研究作一综述.     

β2肾上腺素受体激动剂在急性呼吸窘迫综合征中的应用

急性呼吸窘迫综合征（acute respiratory distress syndrome,ARDS）是危及生命的严重疾病,病情凶险,病死率高.近年来,保护性机械通气策略和保守液体管理技术是ARDS有效的治疗手段,尚缺乏有效的药物治疗.近年来,基础研究显示,β2肾上腺素受体激动剂具有抑制肺部炎症反应、保护肺泡-微血管屏障、刺激肺表面活性物质分泌、促进肺水肿液清除等功能及肺损伤后的防御与修复等作用.本文就β2肾上腺素受体激动剂应用于ARDS的治疗研究进行归纳总结.     

小儿肺炎并急性肺损伤

急性肺损伤(acutelunginjury ,ALI)是一个以肺部炎症和肺泡毛细血管通透性增加为特征的临床综合征。病理特点为弥散性肺泡毛细血管膜损伤,X线胸片示弥散性浸润影,临床表现为难以纠正的低氧血症。ALI是一个连续的病理过程,而急性呼吸窘迫综合征(acuterespiratorydistresssyn dro     

急性呼吸窘迫综合征相关的基础问题

从1967年Ashbaugh首次提出成人急性呼吸窘迫(acute respiratory distress in adults)概念之后,50多年间有关的探索始终没有停步,最新的定义为急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS),机械通气作为针对ARDS治疗的重要措施,相关的技术研究持续进行中,近20年来,有关肺保护性通气策略的提出与实施,给ARDS机械通气治疗带来诸多新的希望和进展。2015年国际上首次给予儿童急性呼吸窘迫综合征(pediatric acute respiratory distress syndrome,PARDS)明确的定义,鉴于PARDS作为儿科临床危重症之一,其治疗仍存在诸多难点,且缺乏大规模的临床研究作为临床应用的基石,此次邀请国内儿科重症医学领域的专家,就ARDS相关呼吸力学、肺保护性通气策略中的核心问题及无创监测的最新进展等问题进行讲解,冀望能对临床医师有所帮助,推动中国的PARDS相关临床研究和技术进步。     

急性肺损伤与急性呼吸窘迫综合征实验室监测指标的研究进展

目前,急性肺损伤(ALI)及急性呼吸窘迫综合征(ARDs)的诊断主要以临床诊断为主,较难早期诊断,且缺乏特异性的实验室诊断指标.与之有关的炎症标记物、肺泡Ⅰ型及Ⅱ型上皮细胞损伤的标志物、肺毛细血管通透性改变的相关指标等,有望成为ALI、ARDS早期诊断的实验室指标,其中最有价值及前景的可能为Clara细胞蛋白、人类肺泡Ⅰ型上皮细胞56kD蛋白及水通道蛋白5.     

足月新生儿急性呼吸窘迫综合征的病因和临床诊断

急性呼吸窘迫综合征(ARDS)是指机体在遭受各种病理刺激(创伤、休克、感染、败血症等)后发生的急性炎症反应。以弥漫性肺泡损伤和急性肺泡上皮，肺毛细血管内皮细胞损伤为主要病理变化，以渗出性肺水肿和肺顺应性下降为主要病理生理特点，以进行性呼吸困难和缺氧为主要临床表现的综合征。1994年美欧ARDS专题研讨会提出     

Papilledema and acute bilateral amaurosis accompanying acute sinusitis]

BACKGROUND: Acute sinusitis can lead to severe complications. This includes involvement of the optical nerve with visual loss and brain abscess as a life-threatening complication. PATIENTS: Empyema of the chiasma opticum region with neuritis nervi optici and bilateral acute amaurosis was observed in a 13 year old boy with sinusitis sphenoidalis and ethmoidalis. In a 11 year old girl, pronounced papilledema was found to be closely associated with sinusitis sphenoidalis. While she recovered completely on appropriate antibiotic therapy, visual loss in the boy was irreversible despite surgical intervention. CONCLUSIONS: Sinusitis should always be considered in patients with impaired vision, neuritis nervi optici or unexplained papilledema, especially if occurring in association with an upper respiratory infection. In addition to physical examination, cranial computer tomography or magnetic resonance imaging of the brain including sinuses and chiasma opticum should be applied early. If empyema is found, immediate surgical intervention is of prognostic importance.     

T-cell acute lymphoblastic leukemia relapsing as acute myelogenous leukemia

We present the unusual case of a 16-year-old girl with T-cell acute lymphoblastic leukemia (ALL) with an early thymocyte immunophenotype without myeloid markers, who after 13 months of complete hematological remission relapsed as acute myelogenous leukemia (AML) with minimal differentiation and died of her disease. Whether the AML represented a relapse with lineage switch of the original immature T-cell clone or a new secondary malignancy, could not be proven due to the absence of molecular or clonal markers. This report suggests that a subset of CD7+ T-cell leukemias without mature T-cell antigens (CD4-, CD8-) are minimally differentiated and can relapse as AML.     

Infantile acute pancreatitis after mumps vaccination simulating an acute abdomen

 We describe an extremely rare case of acute pancreatitis presenting as an acute abdomen that appeared as a complication of mumps vaccination in a young child. A laparotomy performed because of suspected perforated appendicitis proved unnecessary in retrospect. No similar case in infancy and early childhood has been reported to date. Accepted: 12 January 2000     

急性弥散性肺部疾病与急性肺损伤

近年来,急性起病,表现为呼吸困难、发绀,影像学显示肺部弥散性病变的病例逐渐增多。此类疾病有免疫机制参与,起病急,常有呛咳,呼吸急促、困难,伴中度发热,肺存在广泛细湿音和其他干湿音,胸部X线和CT显示广泛肺间质、实质或气道异常病变。这些病例的原发病诊断困难,缺乏客观的金标准,有些病因不明,教科书和文献对疾病归类也存在分歧。按其临床表现也符合急性肺损伤(acutelunginjury ,ALI)或急性呼吸窘迫综合征(acuterespiratorydistresssyndrome,ARDS)诊断标准,但未存在严重感染和ARDS发病高危因素。此类病例是否诊断为ALI/ARDS…     

Bronchoalveolar lavage cellular composition in acute asthma and acute bronchiolitis

OBJECTIVE: To compare cellular inflammation in the airways between acute bronchiolitis and asthma. STUDY DESIGN: Using a bronchoalveolar lavage with flexible bronchoscopy procedure, we investigated the cellular constituents of BAL fluid in children with acute exacerbation of asthma (n = 18) and infants with acute bronchiolitis caused by respiratory syncytial virus (n = 20). These results were compared with those of healthy control subjects (n = 14). RESULTS: Total lavage fluid recovered was similar in all groups. The total cell numbers were highest in the bronchiolitis group. The BAL cellular profile in the asthma group was characterized by a higher median (interquartile range) ratio of eosinophils (2.4% [1.6%-9.5%]; P <.01) than in the bronchiolitis group (0% [0%-0%]) or the control group (0% [0%-0%]). Neutrophil ratio was higher in the bronchiolitis group (40.0% [26.5%-50.0%]; P <.01), with no difference found between the asthma group (3.3% [2.0%-7.9%]) and the control group (2.0% [0.8%-5.5%]). CONCLUSIONS: Asthma and acute bronchiolitis are characterized by an elevated cellular percentage of eosinophils and neutrophils, respectively, in bronchoalveolar lavage fluid.