双水平正压通气和经鼻持续气道正压通气在早产儿呼吸窘迫综合征INSURE治疗方式中应用的比较

目的 探讨新生儿呼吸窘迫综合征（NRDS）的早产儿在INSURE治疗方式中使用双水平正压通气（DuoPAP）和持续气道正压通气（NCPAP）模式,是否可降低有创呼吸支持率.方法 选取2012年3月至2013年2月在北京军区总医院附属八一儿童医院住院的胎龄为（30～34＋6/7）孕周,患有NRDS,生后6 h内至少需要无创呼吸机支持的早产儿201例为研究对象,其中129例患儿不符合纳入标准故排除,另72例患儿全部气管插管使用肺表面活性物质（PS）后,按压30 min,并查阅随机数字表,将其随机分为DuoPAP组（n=38）和NCPAP组（n=34）,若DuoPAP和NCPAP不能维持,则再次使用气管内插管、呼吸机辅助呼吸.主要观察指标为患儿生后24 h内,48 h内,72 h内的总插管有创呼吸支持率,使用无创呼吸支持后1 h,12 h,24 h,48 h,72 h的二氧化碳分压（PaCO2）,氧分压（PaO2）,氧合指数（OI）等比较.结果 DuoPAP组48 h内,72 h内的总有创呼吸支持率明显低于NCPAP组,2组比较,差异有统计学意义（χ2=4.09,4.09;P=0.04,0.04）,但2组在24 h内有创呼吸支持率比较,差异无统计学意义（χ2=0.80,P=0.37）.DuoPAP组1 h,12 h PaO2明显大于NCPAP组,2组比较,差异有统计学意义（t=2.99,2.56;P=0.00,0.01）,但24 h,48 h,72 h比较,差异无统计学意义（t=-0.40,1.39,0.96;P=0.69,0.17,0.34）.DuoPAP组PaCO2 12 h,24 h明显小于NCPAP组,2组比较,差异有统计学意义（t=-2.85,-2.84;P=0.01,0.01）,但1 h,48 h,72 h比较,差异无统计学意义（t=-1.72,-0.99,0.09;P=0.09,0.33,0.93）.DuoPAP组氧合指数（OI）在1 h,12 h高于NCPAP组,2组比较,差异有统计学意义（t=2.54,2.46;P=0.01,0.02）,24 h,48 h,72 h比较,差异无统计学意义（t=-0.43,1.04,0.85;P=0.67,0.30,0.40）.2组患儿的用氧总时间、无创呼吸机支持时间、有创呼吸机支持时间、气胸发病率、NEC发病率、IVH发病率（Ⅲ级以上）、败血症、痰培养呈阳性率、早产儿视网膜病变（ROP）、持续肺动脉高压（PPHN）发病率、全肠道喂养的时间、恢复出生体重时间、体重增长率、总住院时间比较,差异无统计学意义（P〉0.05）.结论 在对患有NRDS的早产儿使用INSURE治疗方式中,使用DuoPAP较NCPAP可明显降低插管有创呼吸支持率,不增加并发症,值得临床推广使用.

Duo Positive Airway Pressure Versus Continuous Positive Airway Pressure in Preterm Neonates With Respiratory Distress Syndrome After Surfactant Treatment

Objective To determine whether duo positive airway pressure （DuoPAP） or continuous positive airway pressure （CPAP） can effectively reduce the need of intubation and mechanical ventilation in preterm neonates with severe neonate respiratory distress syndrome （NRD$） after surfactant treatment. Methods In this single-center, randomized controlled trial, 201 preterm infants from March 2012 to February 2013 in Bayi Children＇s Hospital Affiliated to General Hospital of Beijing Military Command of People＇s Liberation Army were assessed for eligibility and 129 were excluded. At last, a total of 72 infants （gestational ages at 30-34＋6/z weeks） with NRDS were given surfactant and then randomly assigned to receive DuoPAP group （DuoPAP group, n= 38） or NCPAP （NCPAP, n= 34）. If the two noninvasive ventilation were not effective,intubation and mechanical ventilation were used. The primary outcome were the need for mechanical ventilation within the first 72 hours of life. Pacoz ,Paoz ,oxygenate index （OI） were compared between the two groups in 1 h, 12 h, 24 h, 48 h, 72 h. The study protocol was approved by the Ethical Review Board of Investigation in Bayi Children＇s Hospital Affiliated to General Hospital of Beijing Military Command of Peoplet s Liberation Army. Informed consent was obtained from all participates＇ parents. Results Rates of intubated in the first 24 hours do not have significant difference between DuoPAP group and NCPAP groups （Xz =0.80,P=0. 37）, however, more infants in the DuoPAP group remained extubated compared with those in the NCPAP groups within 48,72 hours （Zz = 4.09,4.09~P= 0. 04,0. 04）. Paoz at 1 h, 12 h in DuoPAP group were significantly higher than those of NCPAP group（t=2.99,2.56; P= 0. 00 , 0. 01） , there were no differences of Paoz at 24 h, 48 h, 72 h（t=--0.40,1.39,0.96;P=0.69, 0. 71,0. 34）. Paco2 between the two group had significant differences at 12 h, 24 h（t=- 2.85,--2.84;P= 0.01, 0.01）, but there were no differences at 1 h, 48 h, 72 h（t=--l. 72,--0.99,0.09~P=0.09, 0.33, 0.93）. There was a different of OI at lh,12 h between the two groups（t=2. 54,2. 46;P=0. 01,0. 02） ,but there were no different in 24 h,48 h,72 h（t=-0.43,1.04,0.85~P=0. 67,0.30,0. 40）. No significant differences were noted between 2 groups for total time of oxygen, total time on MV, Pneumothorax, necrotizing enterocolitic （ NEC ）, persistent pulmonary hypertension of the newborn （ PPHN ）, intraventricular hemorrhage （IVH） （grades 3 and 4）, retinopathy of prematurity, ROP, septicemia, sputum culture,time to full feeds, recovery time of the birth weight, weight increasing rate and duration of hospitalization （P~0. 05）. Conclusions DuoPAP can decrease the need for mechanical ventilation compared with NCPAP in NRDS after surfactant treatment and worth promoting.