婴儿急性肺损伤/急性呼吸窘迫综合征临床特征及肺功能的研究
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摘要
目的对婴儿急性呼吸窘迫综合征(Acute Lung Injury/Acute Respiratory Distress Syndrome,ALI/ARDS)临床特征的观察及对其肺功能进行探讨,了解影响疾病转归的因素及存活者肺部后遗症的情况。
方法14例符合ALI/ARDS诊断标准的机械通气病人作为病例组,同期重症肺炎患儿22例及健康婴儿28例作为两组对照组。入选同时记录病人临床资料包括性别,年龄,体重,身长,原发病等；实验室指标血常规分析包括白细胞(wbc),血红蛋白(Hb),血小板(PLT)等；凝血功能指标包括活化部分凝血酶时间(APTT),纤维蛋白原(FG)；细菌培养种类；血气分析,酸碱度(pH),氧分压(PaO2),二氧化碳分压(PaCO2)；机械通气病人急性期呼吸机参数,包括吸入氧浓度(FiO2),呼气末正压(PEEP),呼吸频率(SIMV),高于PEEP压力控制(PC above PEEP),吸气峰压(PIP),平均气道压(Pmean)。记录参数：每分呼气量(MVe),每分吸气量(MVi),吸气潮气量(VTi),呼气潮气量(VTe)。使用德国JEAGER公司Master Screen Paed测定疾病恢复期患儿及健康儿童潮气肺功能,指标有呼吸频率(RR)、公斤体重潮气量(TV/kg)、潮气呼气峰流量(PTEF)、达峰时间(TPEF),达峰容积比(VPEF/VE),达峰时间比(tTPEF/TE)、呼出和吸入50%潮气容积时的呼气流速和吸气流速之比(TEF50／TIF50),吸气时间(Ti),呼气时间(Te),吸呼比(Ti/Te),呼吸力学指标为功能残气量(FRC)和气道总阻力(REFF)。
结果14例ALI/ARDS病人中痊愈12例,死亡2例。(1)ALI/ARDS患儿急性期动脉血氧分压(PaO2)较恢复期低(p<0.05);ALI/ARDS患儿急性期及恢复期肺功能,与健康对照组比较存在气道阻塞功能障碍,反映小气道阻塞的指标VPEF/VE及tTPEF/TE差异具有统计学意义(p<0.05),反映大气道阻塞的指标TEF50/TIF50,差异有统计学意义(p<0.05)。肺容量指标TV/kg,FRC差异无统计学意义(p>0.05),呼吸力学指标REFF无差异。与重症肺炎组比较无统计学意义(p>0.05)。(2)在婴儿ALI/ARDS中围产期窒息,吸入性肺炎,胎粪吸入综合征是常见的原发疾病,其中剖宫产儿占比例大。(3)ALI／ARDS患儿多数合并细菌感染；其急性期白细胞总数,中性粒细胞比例,活化部分凝血酶时间,小儿危重病例评分回归分析示OR值均大于1,而PLT,Hb,PaO2／FiO2虽然OR值大于1,但其(p>0.10)。
结论(1)ALI/ARDS患儿急性期存在明显的低氧血症。ALI/ARDS患儿肺功能在疾病恢复后一个月内仍然存在阻塞型的通气功能障碍。(2)围产期窒息,吸入性肺炎,胎粪吸入综合征患儿及剖宫产患儿易发展为ALI/ARDS。(3)ALI /ARDS患儿急性期WBC总数,中性粒细胞比例,APTT,危重病例评分可作为ALI/ARDS发病的危险因素。
Objective To observe the clinical characteristics of ALI/ARDS and assessment of lung function tests in survivors of ALI/ARDS in infants at acute and recovery phase, in order to know risk factors affect ALI/ARDS infants' prognosis, and lung sequelae.
Method Fourteen patients with ALI/ARDS were studied,22 patients with severe pneumonia and 28 infants without lung disease served as two control groups. At the same time, recording the patients' clinical information, ventilator parameters, blood gas analysis and laboratory indices. At acute phase, ventilator parameters representing lung function were recorded, including fraction of inspired oxygen (FiO2), positive end-expiratory pressure(PEEP), PC(pressure control) above PEEP, peak inspiratory pressure(PIP), tidal volume(VTe), and so on. Lung function tests were measured with Master Screen Paed made by the German JEAGER company at resume phase. The following indices were record:respiratory rate(RR), tidal volume per kilogram(TV/kg), peak expiratory flow (PTEF), the ratio of time taken to reach peak expiratory flow to total expiratory time (tPTEF/tE), the ratio of volume taken to reach peak expiratory volume to total expiratory volume (vPEF/vE), inspiratory time (Ti), expiratory time (Te), the ratio Ti to Te (Ti/Te), time to peak expiratory flow (TPTEF), the ratio of Tidal exspiratory flow when 50% of TV is exspired to tidal inspiratory flow when 50% of TV is inspiratory (TEF50/TIF50), functional residual capacity (FRC), resistence effect (REFF).
Results Only two out of 14 ALI/ARDS infants were died. (1) At acute phase, ALI/ARDS infants had lower arterial oxygen tension(PaO2) than resume phase(p<0.05), the other parameters had no significantly difference(p<0.05), but remain had obstructive compared with normal infants, vPEF/vE, tPTEF/tE and TEF50/TIF50 had significant difference(p<0.01). The other parameters include TV/Kg, PTEF. Ti, Te, Ti/Te. TPTEF, FRC, REFF had no significant difference (p>0.05). (2) In this study, most infants with ALI/ARDS had bacteria infected. The risk factors include leukocyte, active partial thromboplastin time and danger grade, in all of them, OR>l.Most infants were caesarean birth, had asphyxia, inhalation history.
Conclusions Infants had caesarean birth, asphyxia, inhalation history may be susceptible populations develop ALI/ARDS. Any organism can cause ALI/ARDS. Susceptible populations develop the syndrome more often and have worse outcomes. Aggressive diagnosis and intensive treatment are essential to good outcomes in ALI/ARDS caused by infection. Leukocyte, active partial thromboplastin time and danger grade were risk factors of ALI/ARDS. Residual obstructive defect remain common after ALI/ARDS. Rehabilitation is useful to speed mobility and muscle strength.
方法14例符合ALI/ARDS诊断标准的机械通气病人作为病例组,同期重症肺炎患儿22例及健康婴儿28例作为两组对照组。入选同时记录病人临床资料包括性别,年龄,体重,身长,原发病等；实验室指标血常规分析包括白细胞(wbc),血红蛋白(Hb),血小板(PLT)等；凝血功能指标包括活化部分凝血酶时间(APTT),纤维蛋白原(FG)；细菌培养种类；血气分析,酸碱度(pH),氧分压(PaO2),二氧化碳分压(PaCO2)；机械通气病人急性期呼吸机参数,包括吸入氧浓度(FiO2),呼气末正压(PEEP),呼吸频率(SIMV),高于PEEP压力控制(PC above PEEP),吸气峰压(PIP),平均气道压(Pmean)。记录参数：每分呼气量(MVe),每分吸气量(MVi),吸气潮气量(VTi),呼气潮气量(VTe)。使用德国JEAGER公司Master Screen Paed测定疾病恢复期患儿及健康儿童潮气肺功能,指标有呼吸频率(RR)、公斤体重潮气量(TV/kg)、潮气呼气峰流量(PTEF)、达峰时间(TPEF),达峰容积比(VPEF/VE),达峰时间比(tTPEF/TE)、呼出和吸入50%潮气容积时的呼气流速和吸气流速之比(TEF50／TIF50),吸气时间(Ti),呼气时间(Te),吸呼比(Ti/Te),呼吸力学指标为功能残气量(FRC)和气道总阻力(REFF)。
结果14例ALI/ARDS病人中痊愈12例,死亡2例。(1)ALI/ARDS患儿急性期动脉血氧分压(PaO2)较恢复期低(p<0.05);ALI/ARDS患儿急性期及恢复期肺功能,与健康对照组比较存在气道阻塞功能障碍,反映小气道阻塞的指标VPEF/VE及tTPEF/TE差异具有统计学意义(p<0.05),反映大气道阻塞的指标TEF50/TIF50,差异有统计学意义(p<0.05)。肺容量指标TV/kg,FRC差异无统计学意义(p>0.05),呼吸力学指标REFF无差异。与重症肺炎组比较无统计学意义(p>0.05)。(2)在婴儿ALI/ARDS中围产期窒息,吸入性肺炎,胎粪吸入综合征是常见的原发疾病,其中剖宫产儿占比例大。(3)ALI／ARDS患儿多数合并细菌感染；其急性期白细胞总数,中性粒细胞比例,活化部分凝血酶时间,小儿危重病例评分回归分析示OR值均大于1,而PLT,Hb,PaO2／FiO2虽然OR值大于1,但其(p>0.10)。
结论(1)ALI/ARDS患儿急性期存在明显的低氧血症。ALI/ARDS患儿肺功能在疾病恢复后一个月内仍然存在阻塞型的通气功能障碍。(2)围产期窒息,吸入性肺炎,胎粪吸入综合征患儿及剖宫产患儿易发展为ALI/ARDS。(3)ALI /ARDS患儿急性期WBC总数,中性粒细胞比例,APTT,危重病例评分可作为ALI/ARDS发病的危险因素。
Objective To observe the clinical characteristics of ALI/ARDS and assessment of lung function tests in survivors of ALI/ARDS in infants at acute and recovery phase, in order to know risk factors affect ALI/ARDS infants' prognosis, and lung sequelae.
Method Fourteen patients with ALI/ARDS were studied,22 patients with severe pneumonia and 28 infants without lung disease served as two control groups. At the same time, recording the patients' clinical information, ventilator parameters, blood gas analysis and laboratory indices. At acute phase, ventilator parameters representing lung function were recorded, including fraction of inspired oxygen (FiO2), positive end-expiratory pressure(PEEP), PC(pressure control) above PEEP, peak inspiratory pressure(PIP), tidal volume(VTe), and so on. Lung function tests were measured with Master Screen Paed made by the German JEAGER company at resume phase. The following indices were record:respiratory rate(RR), tidal volume per kilogram(TV/kg), peak expiratory flow (PTEF), the ratio of time taken to reach peak expiratory flow to total expiratory time (tPTEF/tE), the ratio of volume taken to reach peak expiratory volume to total expiratory volume (vPEF/vE), inspiratory time (Ti), expiratory time (Te), the ratio Ti to Te (Ti/Te), time to peak expiratory flow (TPTEF), the ratio of Tidal exspiratory flow when 50% of TV is exspired to tidal inspiratory flow when 50% of TV is inspiratory (TEF50/TIF50), functional residual capacity (FRC), resistence effect (REFF).
Results Only two out of 14 ALI/ARDS infants were died. (1) At acute phase, ALI/ARDS infants had lower arterial oxygen tension(PaO2) than resume phase(p<0.05), the other parameters had no significantly difference(p<0.05), but remain had obstructive compared with normal infants, vPEF/vE, tPTEF/tE and TEF50/TIF50 had significant difference(p<0.01). The other parameters include TV/Kg, PTEF. Ti, Te, Ti/Te. TPTEF, FRC, REFF had no significant difference (p>0.05). (2) In this study, most infants with ALI/ARDS had bacteria infected. The risk factors include leukocyte, active partial thromboplastin time and danger grade, in all of them, OR>l.Most infants were caesarean birth, had asphyxia, inhalation history.
Conclusions Infants had caesarean birth, asphyxia, inhalation history may be susceptible populations develop ALI/ARDS. Any organism can cause ALI/ARDS. Susceptible populations develop the syndrome more often and have worse outcomes. Aggressive diagnosis and intensive treatment are essential to good outcomes in ALI/ARDS caused by infection. Leukocyte, active partial thromboplastin time and danger grade were risk factors of ALI/ARDS. Residual obstructive defect remain common after ALI/ARDS. Rehabilitation is useful to speed mobility and muscle strength.
引文
[1]Ashbaugh DG, Bigelow DB, Petty TL. Acute respiratory distress in adults. Lancet.1967; ⅱ:319-23.
[2]Winda J, Versteegt J, Twisk J, et al. Epidemiology of acute lung injury and acute respiratory distress syndrome in The Netherlands:A survey. Respiratory Medicine.2007;101:2091-8.
[3]Timmons OD, Vernon D. Mortality rates and prognostic variables in children with adult respiratory distress syndrome. J Pediatr.1991;119:896-9.
[4]Goh AYCP, Lum LCS. Incidence of acute respiratory distress syndrome:a comparison of two definitions. Arch Dis Child.1998;79:256-9.
[5]Clark RH, Slutsky AS, Gerstmann DR. Lung protective strategies of ventilation in the neonate:what are they? Pediatrics.2000;105:112-4.
[6]Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. Eur Respir J.2002;20:1017-28.
[7]Curley MAQ, Hibberd PL, Fineman LD. Effect of prone positioning on clinical outcomes in children with acute lung injury. JAMA.2005;294:229-37.
[8]Network TARDS. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine.2000;342.
[9]Fanconi S, Kraemer R, Weber J, Tschaeppeler H, Pfenninger J. Longterm sequelae in children surviving adult respiratory distress syndrome. J Pediatr. 1985;106:218-22
[10]Skamp GH. Lung function tests in neonates and infants with chronic lung disease of infancy:functional residual capacity. Pediatric Pulmonology. 2006;41:1-22.
[11]Lum S. Lung function tests in neonates and infants with chronic lung disease: forced expiratory maneuvers. Pediatric Pulmonology.2006:41:199-214.
[12]喻文亮,陆铸今,王莹,et al.小儿急性呼吸窘迫综合征前瞻性多中心临床流行病学研究.中华急诊医学杂志.2005；14：448-52.
[13]张皓,肖现民,郑珊,蔡映云,佘红英,王立波.1002例4岁以下小儿潮气呼吸流速-容量环正常值的研究.临床儿科杂志.2006；6.
[14]季伟,叶侃,汤文决,周卫芳,朱灿红,2006；32(08)：703-5.学江.学龄前健康儿童潮气呼吸肺功能测定.江苏医药.2006；32：703-5.
[15]刘珊珊,毛定安.婴幼儿肺功能检测方法及进展.医学临床研究.2007；8.
[16]J.Stocks, S.Godfrey, C.Beardsmore, E.Bar-Yishay, Castile R. Plethysmographic measurements of lung volume and airway resistance. Eur Respir J.2001;17:302-12.
[17]H.Bisgaard, Nielsen KG. Plethysmographic Measurements of Specific Airway Resistance in Young Children. Chest.2005;128:355-62.
[18]KGNielsen. Plethysmographic specific airway resistance. Paediatric Respiratory Reviews.2006;7(Supplement 1):S17-S9.
[19]Bernard GR, Artigas A, Brigham KL. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am JRespir Crit Care Med.1994;149:818-24.
[20]何志民,张程.重庆市大气中IP、TSP对儿童肺功能的影响.重庆医科大学学报.1996；21：333-6.
[21]邱海波,陈德昌,刘大为,et al.急性呼吸窘迫综合征患者病死危险因素的调查.中国危重病急救医学.1998；10：523-7.
[22]Faix R, Viscardi R, Pietro MD, Nicks J. Adult respiratory distress syndrome in full-term newborns. Padeiatrics.1989;83:971-6.
[23]黄中,陈伟卿,归良桢.新生儿急性呼吸窘迫综合征.中华儿科杂志.1989；27：79-81.
[24]常立文,李文斌.新生儿急性肺损伤／急性呼吸窘迫综合征.实用儿科临床杂志.2007：22：84-6.
[25]Yapicioglu H, Yildizdas D, Bayram I, Sertdemir Y. Yilmaz HL. The use of surfactant in children with acute respiratory distress syndrome:efficacy in terms of oxygenation, ventilation and mortality. Pulmonary Pharmacology & Therapeutics.2003;16:327-33.
[26]Timmons O. Infection in pediatric acute respiratory distress syndrome. Semin Pediatr Infect Dis.1999;17:65-71.
[27]Eisner MD, Thompson T, Hudson LD. Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung Injury and the acute respiratory distress. syndrome. Am J Respir Crit Care Med. 2001;164:231-6.
[28]Rothenhausler H-B, Ehrentraut S, Stoll C, Schelling G, Kapfhammer H-P. The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome:results of an exploratory study. General Hospital Psychiatry.2001;23:90-6.
[29]蔡柏蔷.机械通气时镇静剂、镇痛剂和肌松剂的临床应用.中国呼吸与危重监护杂志.2004;3.
[30]Ben-Abraham R, Weinbroum AA, Roizin H. Long-term assessment of pulmonary function tests in pediatric survivers of acute respiratory distress syndrome. Med Sci Monit.2002;8:CR153-7.
[31]崔红玉,张少丹,崔广奇,刘玉慧,程艳蕊.儿童急性呼吸窘迫综合征死亡危险因素的Logistic回归分析.中国现代医生.2008;46：15-7.
[2]Winda J, Versteegt J, Twisk J, et al. Epidemiology of acute lung injury and acute respiratory distress syndrome in The Netherlands:A survey. Respiratory Medicine.2007;101:2091-8.
[3]Timmons OD, Vernon D. Mortality rates and prognostic variables in children with adult respiratory distress syndrome. J Pediatr.1991;119:896-9.
[4]Goh AYCP, Lum LCS. Incidence of acute respiratory distress syndrome:a comparison of two definitions. Arch Dis Child.1998;79:256-9.
[5]Clark RH, Slutsky AS, Gerstmann DR. Lung protective strategies of ventilation in the neonate:what are they? Pediatrics.2000;105:112-4.
[6]Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome. Eur Respir J.2002;20:1017-28.
[7]Curley MAQ, Hibberd PL, Fineman LD. Effect of prone positioning on clinical outcomes in children with acute lung injury. JAMA.2005;294:229-37.
[8]Network TARDS. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine.2000;342.
[9]Fanconi S, Kraemer R, Weber J, Tschaeppeler H, Pfenninger J. Longterm sequelae in children surviving adult respiratory distress syndrome. J Pediatr. 1985;106:218-22
[10]Skamp GH. Lung function tests in neonates and infants with chronic lung disease of infancy:functional residual capacity. Pediatric Pulmonology. 2006;41:1-22.
[11]Lum S. Lung function tests in neonates and infants with chronic lung disease: forced expiratory maneuvers. Pediatric Pulmonology.2006:41:199-214.
[12]喻文亮,陆铸今,王莹,et al.小儿急性呼吸窘迫综合征前瞻性多中心临床流行病学研究.中华急诊医学杂志.2005；14：448-52.
[13]张皓,肖现民,郑珊,蔡映云,佘红英,王立波.1002例4岁以下小儿潮气呼吸流速-容量环正常值的研究.临床儿科杂志.2006；6.
[14]季伟,叶侃,汤文决,周卫芳,朱灿红,2006；32(08)：703-5.学江.学龄前健康儿童潮气呼吸肺功能测定.江苏医药.2006；32：703-5.
[15]刘珊珊,毛定安.婴幼儿肺功能检测方法及进展.医学临床研究.2007；8.
[16]J.Stocks, S.Godfrey, C.Beardsmore, E.Bar-Yishay, Castile R. Plethysmographic measurements of lung volume and airway resistance. Eur Respir J.2001;17:302-12.
[17]H.Bisgaard, Nielsen KG. Plethysmographic Measurements of Specific Airway Resistance in Young Children. Chest.2005;128:355-62.
[18]KGNielsen. Plethysmographic specific airway resistance. Paediatric Respiratory Reviews.2006;7(Supplement 1):S17-S9.
[19]Bernard GR, Artigas A, Brigham KL. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am JRespir Crit Care Med.1994;149:818-24.
[20]何志民,张程.重庆市大气中IP、TSP对儿童肺功能的影响.重庆医科大学学报.1996；21：333-6.
[21]邱海波,陈德昌,刘大为,et al.急性呼吸窘迫综合征患者病死危险因素的调查.中国危重病急救医学.1998；10：523-7.
[22]Faix R, Viscardi R, Pietro MD, Nicks J. Adult respiratory distress syndrome in full-term newborns. Padeiatrics.1989;83:971-6.
[23]黄中,陈伟卿,归良桢.新生儿急性呼吸窘迫综合征.中华儿科杂志.1989；27：79-81.
[24]常立文,李文斌.新生儿急性肺损伤／急性呼吸窘迫综合征.实用儿科临床杂志.2007：22：84-6.
[25]Yapicioglu H, Yildizdas D, Bayram I, Sertdemir Y. Yilmaz HL. The use of surfactant in children with acute respiratory distress syndrome:efficacy in terms of oxygenation, ventilation and mortality. Pulmonary Pharmacology & Therapeutics.2003;16:327-33.
[26]Timmons O. Infection in pediatric acute respiratory distress syndrome. Semin Pediatr Infect Dis.1999;17:65-71.
[27]Eisner MD, Thompson T, Hudson LD. Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung Injury and the acute respiratory distress. syndrome. Am J Respir Crit Care Med. 2001;164:231-6.
[28]Rothenhausler H-B, Ehrentraut S, Stoll C, Schelling G, Kapfhammer H-P. The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome:results of an exploratory study. General Hospital Psychiatry.2001;23:90-6.
[29]蔡柏蔷.机械通气时镇静剂、镇痛剂和肌松剂的临床应用.中国呼吸与危重监护杂志.2004;3.
[30]Ben-Abraham R, Weinbroum AA, Roizin H. Long-term assessment of pulmonary function tests in pediatric survivers of acute respiratory distress syndrome. Med Sci Monit.2002;8:CR153-7.
[31]崔红玉,张少丹,崔广奇,刘玉慧,程艳蕊.儿童急性呼吸窘迫综合征死亡危险因素的Logistic回归分析.中国现代医生.2008;46：15-7.
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