BiPAP联合INSURE技术治疗新生儿呼吸窘迫综合征失败的影响因素分析

目的 探讨双水平气道正压通气(bilevel positive airwaypressure,BiPAP)联合气管插管—肺表面活性物质(pulmonany surfactant,PS)—拔管给予鼻塞式气道正压通气(continuaus postive airway pressure,CPAP)技术(intubate-surfactant-extubate to CPAP,INSURE)治疗新生儿呼吸窘迫综合征失败的影响因素。方法 回顾性分析2015年5月至2019年5月西安高新医院出生的78例呼吸窘迫综合新生儿的资料,统计BiPAP联合INSURE治疗失败率,对比2组治疗失败和成功患儿临床资料,采用Logistic回归分析影响因素。结果 BiPAP联合INSURE治疗新生儿呼吸窘迫综合征失败率为28.21%;两组肺出血、重度窒息、宫内窘迫、宫内感染构成比及动脉血二氧化碳分压(PaCO₂)、胎龄、出生体重比较,差异有统计学意义(P＜0.05);Logistic多因素分析显示,肺出血、重度窒息、宫内窘迫、胎龄＜30周、出生体重＜1.2 kg、宫内感染、PaCO₂＞55 mmHg均是影响BiPAP联合INSURE治疗新生儿呼吸窘迫综合征失败的独立危险因素(OR=2.438、2.081、2.328、2.008、2.030、2.059、2.340)。结论 肺出血、重度窒息、宫内窘迫、胎龄＜30周、出生体重＜1.2 kg、宫内感染、PaCO₂＞55 mmHg均是影响BiPAP联合INSURE治疗新生儿呼吸窘迫综合征失败的独立危险因素,应加强防范。     

Effect of multiple INSURE procedures in extremely preterm infants

Abstract

Objectives.?Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants.

Methods.?We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO₂?>?0.30 without need of MV) or multiple (FiO₂?>?0.40 without need of MV) INSURE procedures.

Results.?Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO₂, lower a/ApO₂, and pO₂/FiO₂) than the former.

Conclusions.?Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.     

Current methods of non-invasive ventilatory support for neonates

Non-invasive ventilatory support can reduce the adverse effects associated with intubation and mechanical ventilation, such as bronchopulmonary dysplasia, sepsis, and trauma to the upper airways. In the last 4 decades, nasal continuous positive airway pressure (CPAP) has been used to wean preterm infants off mechanical ventilation and, more recently, as a primary mode of respiratory support for preterm infants with respiratory insufficiency. Moreover, new methods of respiratory support have been developed, and the devices used to provide non-invasive ventilation (NIV) have improved technically. Use of NIV is increasing, and a variety of equipment is available in different clinical settings. There is evidence that NIV improves gas exchange and reduces extubation failure after mechanical ventilation in infants. However, more research is needed to identify the most suitable devices for particular conditions; the NIV settings that should be used; and whether to employ synchronized or non-synchronized NIV. Furthermore, the optimal treatment strategy and the best time for initiation of NIV remain to be identified. This article provides an overview of the use of non-invasive ventilation (NIV) in newborn infants, and the clinical applications of NIV.     

INSURE技术防治新生儿呼吸窘迫综合征的临床研究

目的通过与传统气管插管机械通气(mechanical ventilation,MV)比较,分析气管插管-肺表面活性物质-拔管使用持续气道正压通气(INtubate-SURfactant-Extubate to CPAP,INSURE)技术防治新生儿呼吸窘迫综合征(neonatal respiratory distress syndrome,NRDS)的作用。方法回顾性分析2011年1月-2012年12月采用INSURE技术(INSURE组)或机械通气(MV组)治疗的127例NRDS患儿,比较两组患儿早期结局(二次使用PS、肺出血、气漏综合症、PPHN、PDA)、晚期结局(BPD、ROP、IVH、PVL);与感染相关并发症(败血症、NEC);预后。结果 1)两组患儿一般情况具有可比性(P0.05);2)早期结局:INSURE组二次使用PS、肺出血、气漏综合症、PPHN均低于MV组(P0.05);3)感染相关并发症:败血症发生率更低(P值均0.05);4)晚期结局:INSURE组BPD、ROP、IVH(III级以上)及PVL与MV组比较差异无统计学意义(P0.05);5)预后:两组死亡率及治愈率差异无统计学意义(P0.05)。结论 INSURE技术能更好改善NRDS患儿早期结局,减少二次PS使用,降低肺出血、气漏综合症、PPHN发生;降低败血症的发生;缩短用氧时间;未增加BPD、ROP、IVH、PVL的发生率及死亡率。     

INSURE技术在新生儿呼吸窘迫综合征中的应用

目的探讨INSURE技术在新生儿呼吸窘迫综合征(NRDS)中的应用效果。方法将70例NRDS患儿按随机数字表法分为对照组和观察组,各35例。对照组给予机械通气。观察组实施INSURE技术。比较两组并发症发生情况和临床疗效,治疗前后动脉血气分析指标。结果观察组并发症发生率低于对照组,治疗有效率显著高于对照组(P<0.01),观察组治疗后PaO2、PaO2/FiO2高于对照组,PaCO2、FiO2低于对照组(P<0.01)。结论INSURE技术能减少NRDS治疗并发症的发生,改善NRDS患儿血气分析指标、氧合和吸入氧浓度,提高临床治疗效果。     

肺复张联合INSURE技术在早产儿呼吸窘迫综合征的临床应用

目的 研究肺复张联合INSURE技术治疗早产儿呼吸窘迫综合征(RDS)的临床效果及并发症。方法 选择2015年1月至2017年05月我科住院的43例患有RDS且接受INSURE治疗的早产儿,采用随机数字表分为研究组(采用肺复张)和对照组(未采用肺复张)。比较两组患儿的治愈率、无创机械通气时间、氧疗时间、住院时间、第2剂PS、枸橼酸咖啡因应用、并发症等情况。 结果 研究组治愈率较对照组高(P <0.05),研究组氧疗时间、住院时间和上机时间均明显短于对照组(P <0.05),研究组支气管肺发育不良、视网膜病、需药物关闭的动脉导管开放等并发症的发生率和拔管失败率均明显低于对照组(P <0.05),研究组需第2剂肺表面活性物质(PS)和咖啡因应用亦明显少于于对照组(P <0.05);而两组在气胸、坏死性小肠结肠炎、III-IV级颅内出血等方面,两组差异无统计学意义(P＞0.05) 。结论 肺复张联合INSURE技术治疗早产儿RDS在提高治愈率、改善氧合的同时,可以缩短氧疗时间、上机时间、住院时间,减少支气管肺发育不良、需药物关闭的动脉导管开放等并发症的发生,值得临床推广。     

Successful elimination of extended-spectrum beta-lactamase (ESBL)-producing nosocomial bacteria at a neonatal intensive care unit

Background:Extended-spectrum beta-lactamase (ESBL)-producing Gram-negative bacteria are highly dangerous to neonates.At our Neonatal Intensive Care Unit (NICU),the presence of these bacteria became so threatening in 2011 that immediate intervention was required.Methods:This study was conducted during a nearly two-year period consisting of three phases:retrospective (9 months),educational (3 months) and prospective (9 months).Based on retrospective data analysis,a complex management plan was devised involving the introduction of the INSURE protocol,changes to the antibiotic regimen,microbiological screening at short intervals,progressive feeding,a safer bathing protocol,staff hand hygiene training and continuous monitoring of the number of newly infected and newly colonized patients.During these intervals,a total of 355 patients were monitored.Results:Both ESBL-producing Enterobacter cloaceae and Klebsiella pneumoniae were found (in both patients and environmental samples).In the prospective period a significant reduction could be seen in the average number of both colonized (26/167 patients;P=0.029) and infected (3/167 patients;P=0.033) patients compared to data from the retrospective period regarding colonized (72/188 patients) and infected (9/188 patients) patients.There was a decrease in the average number of patientdays (from 343.72 to 292.44 days per months),though this difference is not significant (P=0.058).During the prospective period,indirect hand hygiene compliance showed a significant increase (from the previous 26.02 to 33.6 hand hygiene procedures per patient per hospital day,P＜0.001).Conclusion:Colonizations and infections were rolled back successfully in a multi-step effort that required an interdisciplinary approach.     

Transitional hemodynamics in preterm infants with a respiratory management strategy directed at avoidance of mechanical ventilation

Background

Early respiratory management of very low birth weight infants has changed over recent years to a practice of early use of CPAP with early selective surfactant administration, and decreased use of mechanical ventilation. One strategy is to use the combination of surfactant and prompt extubation to nasal continuous positive airway pressure (INtubate, SURfactant, Extubate, or INSURE). The aim of this study is to describe blood flow and ductal flow in a prospective cohort during the transitional period when this respiratory management strategy is used.

Methods

Inborn infants < 29 week gestation underwent INSURE within 30 min of birth using 200 mg/kg Curosurf. Blood pressure and blood flow parameters (RVO, LVO, SVC flow, ductus arteriosus) were measured at 6, 24 and 72 h of age and information on morbidity was collected.

Results

Sixty-eight infants with a median (range) weight of 940 (450–1380) g were studied. 13 (19%) patients needed mechanical ventilation within 72 h of life (INSURE failure). Blood flows and blood pressure were within reported ranges. Eleven (16%) patients had a blood pressure < gestational age and 9 (13%) patients had low blood flow.

Conclusion

These data show a low prevalence of low blood pressure and low blood flow in the first 3 days after INSURE as compared to cohorts where mechanical ventilation was preferred during transition. We speculate that altered ventilation strategies have helped decrease the incidence of low blood flow and low blood pressure.     

The INSURE method in preterm infants of less than 30 weeks' gestation

Objectives.?Our aim was to identify the clinical characteristics which could distinguish infants who can be managed with INSURE (intubatio-surfactant-extubation) method for preventing mechanical ventilation (MV) and which could predict INSURE success or failure.

Methods.?Inborn infants with gestational age <30 weeks were Infants were categorised into three groups: (1) infants who needed MV in the delivery room; (2) infants spontaneously breathing who were treated only with NCPAP; (3) infants who were treated with INSURE method.

Results.?We studied 125 infants: 30 (24%) required MV, 75 (60%) received INSURE treatment, and 20 (16%) were treated with NCPAP. Sixty-eight (91%) infants were successfully treated with the INSURE method. Infants in the success group had less severe RDS and less occurrence of sepsis and pneumothorax, lower mortality, and shorter duration of stay in the NICU than infants in the failure group. A birth weight <750?g, pO₂/FiO₂ <218, and a/ApO₂ <0.44 at the first blood gas analysis were independent risk factor for INSURE failure.

Conclusions.?The INSURE method can be applied to the majority of extremely preterm infants and is followed by a high percentage of success.