【作者】 马晓薇；

【导师】 罗永艾；

【作者基本信息】 重庆医科大学 ， 内科学， 2013， 博士

【摘要】 目的急性肺损伤（ALI）是由各种外源性因素打击，导致的急性、进行性缺氧性呼吸衰竭。ALI发病机制复杂，有效治疗手段少，死亡率高。本研究通过提前腹腔注射微量细菌脂多糖预激后，再次静脉注射细菌脂多糖诱导，建立急性肺损伤大鼠动物模型，观察急性肺损伤大鼠的病理生理改变及肺血管内皮细胞损伤的变化；分别给予牛磺酸、血管紧张素转换酶抑制剂及二药联合干预急性肺损伤大鼠，观察其治疗效果，探讨牛磺酸及血管紧张素转化酶抑制剂对大鼠急性肺损伤的保护作用及其相关机制。方法1分组：将126只SD清洁级大鼠随机分成5组：（1）正常对照组（n=6）；（2）急性肺损伤组：于静脉注射脂多糖后，分为3h、6h、9h、12h、24h五个时间点，每个时间点（n=6）；（3）牛磺酸治疗组：于静脉注射脂多糖后分为上述五个时间点，每个时间点（n=6）；（4）卡托普利治疗组：于静脉注射脂多糖后分为上述五个时间点，每个时间点（n=6）；（5）牛磺酸和卡托普利联合治疗组：于静脉注射脂多糖后分为上述五个时间点，每个时间点（n=6）。2建立急性肺损伤模型：腹腔注射脂多糖（LPS）（0.5mg/kg体重）预激12小时后，静脉注射LPS（5mg/kg体重），建立急性肺损伤动物模型，分别于静脉注射LPS后3h、6h、9h、12h、24h时间点采集标本。3正常对照组与治疗组：（1）正常对照组：生理盐水腹腔注射12小时，静脉注射生理盐水；（2）牛磺酸治疗组：LPS预激12小时后，腹腔注射牛磺酸（50mg/kg体重），静脉注射LPS；（3）卡托普利治疗组：LPS预激12小时后，腹腔注射卡托普利（1.25mg/kg体重），静脉注射LPS；（4）牛磺酸联合卡托普利治疗组：脂多糖预激12小时后，腹腔注射牛磺酸（50mg/kg体重）及卡托普利（1.25mg/kg体重），静脉注射LPS；正常对照组静脉注射生理盐水后3h、各治疗组静脉注射LPS后3h、6h、9h、12h、24h时间点采集标本。4检测指标：（1）测定肺湿干比重（W/D ratio）；（2）动脉血氧分压(PaO2)；（3）肺组织病理学观察,计算肺损伤病理学评分；（4）采用ELISA法检测血浆中的血管性血友病因子（vWF）的水平、内皮素-1（ET-1）、可溶性细胞间黏附分子-1（sICAM-1）、血栓调节蛋白（TM）、血小板活化因子(PAF)；（5）采用ELISA法检测肺泡灌洗液中的血管性血友病因子（vWF）的水平、内皮素-1（ET-1）、可溶性细胞间黏附分子-1（sICAM-1）、血栓调节蛋白（TM）、血小板活化因子(PAF)的水平。5统计学分析：所产生数据均采用SPSS11.5统计软件进行，计量资料以x±s表示；成组设计的多样本均数的比较采用单因素方差分析进行检验；组间多重比较采用SNK检验，取a=0.05，以P<0.05有统计学意义。结果1肺湿干比重(W/D ratio)：与正常组比较，W/D ratio值在肺损伤组五个时间点均明显升高（P<0.05），12h、24h时间点升高比较突出；与肺损伤组相比较，牛磺酸治疗组、卡托普利治疗组及两者联合治疗组各时间点W/D ratio值均较肺损伤组有不同程度的降低（P<0.05），但略高于正常组水平，以两者联合治疗后W/D ratio值降低明显（P<0.05）。2动脉血氧分压(PaO2)：与正常组比较，肺损伤组动脉血氧分压（PaO2）在各个时间点较正常对照组明显降低（P<0.05）；各时间点PaO2值接近，无变化趋势；与肺损伤组比较，牛磺酸治疗组、卡托普利治疗组及两者联合干预后PaO2值在各时间点均较肺损伤组有提高（P<0.05），但仍低于正常组PaO2值；以牛磺酸和卡托普利联合干预后PaO2值升高显著，尤其在12h、24h时间点升高较为突出。3病理学组织切片观察：与正常对照组比较，肺损伤组肺泡正常结构部分破坏，局灶性出血，炎症细胞浸润，肺泡间隔明显增厚，肺泡腔变窄，部分肺泡萎陷。牛磺酸组、卡托普利组及两药联合干预后能使上述病理变化改善。肺损伤病理学评分：与正常对照组比较，肺损伤组的病理学评分较正常对照组明显升高（P<0.05）；牛磺酸组、卡托普利组及两药联合干预后，所有治疗组肺损伤组织病理学评分明显低于肺损伤组（P<0.05），在9h、12h、24h时间点降低较突出；但各治疗组肺损伤病理学评分仍略高于正常组；以两药联合干预后肺损伤病理学评分降低最显著（P<0.05）。4血浆中vWF、 ET-1、sICAM-1、TM、PAF因子水平检测：与正常对照组相比，血浆中各因子水平在肺损伤组几乎所有时间点均升高，多数分别在3h、6h、9h时间点升高明显（P<0.05）；在牛磺酸组、卡托普利组及两药联合治疗组干预后血浆各因子水平在多数时间点较肺损伤组降低（P<0.05），以两者联合治疗后血浆各因子水平较肺损伤组降低较明显（P<0.05）；但所有治疗组血浆各因子水平在多数时间点依然略高于正常对照组。5肺泡灌洗液中vWF、 ET-1、sICAM-1、TM、PAF水平检测：与正常对照组相比，肺泡灌洗液中各种因子水平在肺损伤组所有时间点均较正常组升高（P<0.05），多数在3h、6h、9h时间点升高明显（P<0.05）；在牛磺酸组、卡托普利组及两药联合治疗组干预后各组多数时间点较肺损伤组降低（P<0.05），以两者联合干预降低较明显（P<0.05）；但各治疗组BALF中各因子水平多数依然略高于正常对照组。结论：1本研究通过提前腹腔注射小剂量内毒素预激，联合静脉内注射内毒素，大鼠肺湿干比重增加，动脉血氧分压降低，肺病理变化明显，肺损伤病理学评分升高，证明成功地建立了内毒素诱导型大鼠急性肺损伤的动物模型，模型稳定，此种制模方法目前较少见。2急性肺损伤时存在肺血管内皮细胞的活化和损伤，反应内皮细胞活化和损伤的血浆及肺泡灌洗液中的细胞因子水平增高明显，无相对固定的变化规律。3牛磺酸对急性肺损伤及其肺血管内皮细胞有治疗和保护作用。4血管紧张素转换酶抑制剂对急性肺损伤及其肺血管内皮细胞有治疗和保护作用。5牛磺酸及血管紧张素转换酶抑制剂联合应用对急性肺损伤及其肺血管内皮细胞有治疗和保护作用，效果优于单药干预治疗，提示可以考虑联合应用。目前国内尚未见两药联合治疗ALI的研究报道。目的：通过收集宁夏医科大学总医院ICU科ALI/ARDS患者的临床资料，对可能导致ALI/ARDS的发生、影响病情发展及预后的相关临床影响因素进行分析，以提高对ALI/ARDS的致病因素早期识别，早期预防，减少ALI/ARDS的发生率，降低死亡率，提高救治率。方法：回顾性研究2010年3月到2012年12月宁夏医科大学总医院综合ICU科收治的病人，将其中符合ALI/ARDS诊断标准的患者列为研究观察对象，这些病例被分为三组：①初次诊断为ALI组与ARDS组；②ALI好转组与ALI转化为ARDS组；③ARDS存活组与死亡组；对这三组患者分别从病因学；基本状况，年龄、性别、是否合并慢性疾病；是否合并急性器官障碍及其种类及数目；血气分析指标、APACHEII评分等多个临床因素进行统计分析。统计学分析:用统计学软件SPSS11.5进行统计学分析，数值变量采用x±s表示：计量资料两组间比较采用独立样本的t检验，计数资料采用单因素方差分析（x2检验）；多因素分析采用条件Logistic回归方法。结果：14125例病人中诊断ALI154例、ALI的构成比3.73%；诊断ARDS221例, ARDS的构成比5.36%；ALI/ARDS总构成比9.09%。ALI中18例死亡，病死率11.69%；ARDS中118例死亡，病死率53.40%；ALI/ARDS总病死率36.27%。2ALI中女性41例（26.62%），男性113例（73.38%），平均年龄为51.05±18.03岁；病因中创伤58例（37.66%），感染45例（29.22%），合并慢性病36例（24.68%），合并≥3个急性器官功能障碍39例(25.32%)； APACHEII评分均数16.47±7.79；平均住院天数为13.86±13.54天。3ARDS中女性61例(27.6%)，男性160例(72.4%)，平均年龄为53.57±16.38岁；病因中创伤93例(42.08%)，感染109例(49.32%)，合并慢性病77例(34.8%)，合并≥3个急性器官功能障碍101例(45.70%)；APACHEII评分16.77±6.80。平均住院天数为14.28±12.57天。4初始诊断ALI组与ARDS组结果示：原发致病因素中，肺部感染(P=0.003)、感染性休克(P=0.008)、其他部位感染(P=0.015)、手术术后（P<0.001）、不明原因（P=0.001）有统计学差异；多因素分析示纳入研究的各影响因素无统计学差异。5ALI好转组与ALI转化为ARDS组结果示：原发致病因素中，肺部感染(P<0.001)、脓毒症（P=0.008）、感染性休克(P=0.011)、手术术后（P<0.001）有统计学差异；多因素分析示纳入研究的各影响因素中，急性心血管系统障碍（P=0.016）、急性肝脏系统障碍（P=0.004）、急性神经系统障碍（P=0.006）、pH值大小（P=0.038）有统计学意义；其他观察指标无统计学意义。6ARDS存活组与死亡组结果示：原发致病因素中，创伤（P=0.004）、肺部感染（P=0.006）、感染性休克（P=0.013）、不明原因（P=0.040）有统计学差异；多因素分析提示纳入研究的各影响因素中年龄（P<0.001）、急性心血管系统障碍（P=0.001）、PCO2（P=0.005）有统计学意义。其它观察指标无统计学意义。结论：1本院ALI的构成比3.73%，ARDS的构成比5.36%，ALI/ARDS总构成比9.09%。ALI的病死率11.69%%，ARDS病死率53.40%，ALI/ARDS总病死率36.27%。 ALI/ARDS发病以男性、中老年人多见；致病因素以创伤、感染多见；入院APACHEII评分均高，住院天数大于10天。2其他部位感染及手术术后和一些不明确原因较易诱发ALI；肺部感染、感染性休克较易诱发ARDS。肺部感染、手术术后所致的ALI好转率相对高，预后相对较好；感染性休克和脓毒症所致的ALI预后相对较差，较易发展为ARDS。创伤所致的ARDS预后相对较好，肺部感染和感染性休克所致的ARDS预后较差。3急性心血管系统、肝脏系统、神经系统的器官以及PH值大小可能为ALI病情恶化转化为ARDS的独立危险因素。合并≥3个器官功能障碍时，对ALI/ARDS的病情的发生发展及预后都有非常不良的影响。4年龄、心血管系统功能障碍、二氧化碳分压值可能成为影响ARDS预后的独立危险因素。更多还原

【Abstract】 Objective:Acute lung injury is a critical illness syndrome consisting of acuteprogressive hypoxemic respiratory failure arising either from a variety ofdirect (pulmonary) or indirect (extrapulmonary) insults. Duing to thecomplex lung injury pathophysiology of ALI, it remains underdiagnosed andundertreated. At present，therapeutic interventions to treat ALI remainlimited. Mortality from ALI is substantial. To observe lung pathophysiologyand endothelial activation and injury in rats with ALI, we established theanimal model of ALI by intraperitoneal injection of mindose of LPS inadvance combined with intravenous injection of LPS. Therefore toinvestigate the protective effect by taurine and angiotensin convertingenzyme inhibitor on acute lung injury and its relative mechanism, we treatedrats with ALI by intraperitoneal injection of taurine, captopril，and both durgrespectively.Methods:1Subgrop:126male SD rats were randomly divided into five groups: (1) normal control group (n=6).(2) acute lung injury (LPS) group: ratswere divided into five time points at3h,6h,9h,12h,24h after intravenousinjection of LPS and there were6rats in every time point (n=6);(3) thetaurine group: rats were divided into above-mentioned five time points afterintravenous injection of LPS and there were6rats in every time point (n=6);(4) the captopril group: rats were divided into above-mentioned five timepoints after intravenous injection of LPS and there were6rats in every timepoint (n=6),(5) the taurine and the captopril group: rats were divided intoabove-mentioned five time points after intravenous injection of LPS andthere were6rats in every time point (n=6).2Estabished ALI model: Rats were pre-activated by intraperitonealinjection of LPS(0.5mg/kg) in advance. Then after pre-activating for12hours, rats were induced by intravenous injection of LPS (5mg/kg.).Specimens were collected after intravenous injection of LPS at five timepoint.3The normal control group and treatment group:(1) The normalcontrol group: Intraperitoneal injection of saline for12hours, saline wasinjected intravenously.(2) The taurine group: After LPS preactivating for12hours, taurine50mg/kg was injected intraperitoneally and LPS was injectedintravenously.(3) The captopril group:After LPS pre-activating for12hours,captopril1.25mg/kg was injected intraperitoneally and LPS was injectedintravenously.(4)The taurine and captopril group: After LPS preactivating for12hours, taurine50mg/kg and the captopril1.25mg/kg were injectedintraperitoneally and LPS was injected intravenously. Specimens werecollected at3h after intravenous injection of saline in normal group and at3h,6h,9h,12h,24h time point after intravenous injection of LPS in alltreatment group respectively.4Measurement: Measurement of lung wet-dry weight and arterialpartial pressure of oxygen (PaO2). Lung histopathology were observed andanalyzed. Von Willebrand factor (vWF), endothelin-1(ET-1), Solubleintercellular adhesion molecule-1(sICAM-1), thrombomodulin (TM),platelet-activating factor (PAF) levels were detected in plasma andbronchoalveolar lavage fluid (BALF) by ELISA.5Statistical Analysis: Data are expressed as mean±SD. Statisticalanalyses was done using SPSS11.5statistical software. Statisticaldifferences between the data were determined with one-way analysis ofvariance and mutltiple comparisons were tested withStudent-Newman-Keuls-test(SNK), and a P value,0.05was consideredsignificant.Resuls:1Lung wet-dry weight ratio: Lung W/D ratio showed a significantincreasing in lung injury group（P<0.05）, and it increased obviously at12h、24h time point. Lung W/D ratio decreased in varying degrees in taurinegroup, captopril group and taurine and captopril group, but still higher than the normal group（P<0.05）. The decreasing mostly is in the combinedtreatment group.2Arterial partial pressure of oxygen (PaO2) levels: PaO2levels in thelung injury group were significantly lower than the control group（P<0.05）,but increased in taurine group and captopril group, and increased mostsignificantly after the combined treatment intervention（P<0.05）and it wasobvious at9h、12h、24h time point.3Lung histology: Lung injury group showed marked inflammation andmild lung edema with marked thickening of alveolar septa and alveolarspace narrowing. Improved the pathological changes were observed in thetaurine group, captopril group and both combined. The score of lung injury:the score of lung injury in the acute lung injury group were significantlyhigher than the normal group and decreased in taurine group and captoprilgroup and both combined group（P<0.05）,and decreased mostsignificantly after the combined treatment intervention. It improvedobviously at9h、12h、24h time point4The plasma levels of vWF，ET-1, sICAM-1, TM and PAF：Theplasma levels of vWF，ET-1, sICAM-1, TM and PAF were increased in lunginjury group than in the control group（P<0.05）. Most of them wereimproved at3h,6h,9h time point obviously. But after the intervention, theywere lower in taurine treatment group, captopril group, and both treantmentgroup at the most of different time point than in the acute lung injury group（P<0.05）. The levels of them in the joint intervention were lowerthan the lung injury group obviously.5The BLAF levels of vWF，ET-1, sICAM-1, TM and PAF：TheBLAF levels of vWF,ET-1, sICAM-1, TM and PAF were increased in lunginjury group than in the control group at the different time point andincreased obviously at3h、6h、9h time point. After the treatment, they werelower in taurine treatment group, captopril group, and both treantment groupat the most of different time point than in acute lung injury group. Thelevels of them in the joint intervention group were lower than the lung injurygroup obviously and were still a little higer than the normal control group.Conclusion:1We successfully established the animal model of ALI byintra-peritoneal injection of mindose of LPS in advance combined withint-ravenous injection of LPS. It was porved by the increasing lung wet-dryweight ratio, the decreasing PaO2levels, the changes of Lung histology andthe increasing score of lung injury. The way of making animal model isrelatively rare at present.2There was lung endothelial cell activation and injury in ALI and itwas expressed by the increasing levels of plasma and BLAF vWF，ET-1,sICAM-1, TM and PAF which represented the lung endothelial cellactivation and injury.3Taurine had a protective effect on acute lung injury and the i-njuried pulmonary vascular endothelial cells.4Angiotensin-converting enzyme inhibitors had protective effect onacute lung injury and the injuried pulmonary vascular endothelial cells.5It prompted that two-drug combination had a more protective effecton lung injury and pulmonary vascular endothelial cells, and it was betterthan single drug-intervention group. The study showed that we can treat ALIwith joint treatment of taurine and captopril. The treatment of these twodrugs combination on ALI was not reported in domestic at present. Objective:To recognize and prevent the clinical influential factors in ALI/ARDSearly, reduce mortality and improve the cure rate, we collected the clinicaldata of patients with ALI/ARDS in ICU of Ningxia Medical UniversityGeneral Hospital and analyzed the influential factors that led to ALI/ARDS,affected disease progression and prognosis.Method:The clinical data of375patients from March2010to December2012were retrospectively analyzed. The patients were divided into three groups.①the initial diagnosis of ALI group and the initial diagnosis of ARDSgroup.②ALI improved group and ALI aggravated into ARDS group.③thesurvivor group of ARDS and the non-survivor group of ARDS. Etiology,age, gender, chronic disease, acute organ dysfunction, blood-gas analysis,APACHEII score of patients in theses three groups within24hours ofdiagnosis were analyzed. Statistical analyses was done using SPSS11.5statistical software. Data are expressed as mean±SD. All data were analyzedby univariate test, one-way analysis of variance and multiple logistic regression method.Results:1154patients(3.73%) developed initial diagnosis of ALI and221patients (5.36%) met criteria for initial diagnosis of ARDS in all4125patients.Total constituent ratio of ALI/ARDS was9.09%.18patients diedand mortality was11.69%%in ALI.118patients died and mortality was53.40%in ARDS. Total mortality was36.27%.2There were41female (26.62%) and113male (73.38%) patients inALI. The mean age was51.05±18.03. Lung injury occurred most commonlyin the setting of trauma(58/154;37.66%), infection (45/154;29.22%),complicating chronic disease (36/154;24.68%）, and complicating morethan three acute organ dysfunction（39/154;25.32%）. The mean score ofAPACHEII was16.47±7.79and the mean hospital day was13.86±13.54days.3There were61female (27.6%) and160male (73.38%) patients inARDS. The mean age was53.57±16.38. Lung injury occurred mostcommonly in the setting of trauma(93/221;42.08%), infection (109/221;49.32%), complicating chronic disease (77/221;34.8%), and complicatingmore than three acute organ dysfunction（101/221;45.70%）. The meanscore of APACHEII was16.77±6.80and the mean hospital day was14.28±12.57days.4The initial diagnosis of ALI and ARDS group: pneumonia (P<0.001), septic shock (P=0.008), infection of other parts except for lung (p=0.015),post operation （P<0.001）, unexplained （P=0.001） were statisticalsingnificance from etiology. And no factors included into this study reachedstatistical singnificance from the multivariater logistic regression.5The initial diagnosis of ALI improved group and aggravated intoARDS group: pneumonia (P<0.001), sepsis (p=0.008), septicshock(P=0.011), post operation（P<0.001, unexplained（P=0.001）reachedstatistical singnificancein etiology. Acute circulatory systemdysfunction(P=0.016), acute liver system disfunction(p=0.004), acutenervous system disfunction(p=0.006), pH value(p=0.038) are statisticalsingnificantfrom the multivariater logistic regression.6The survivor group and the non-survivor group of ARDS:trauma(p=0.004), pneumonia(p=0.006), septic shock(p=0.013),unexplained(p=0.040) are statistical singnificant in etiology. Andage(p<0.001), acute circulatory system disfunction(P=0.001), PCO2(P=0.005) are statistical singnificant from the multivariater logisticregression.Conclusion:1The constituent ratio was3.73%in initial diagnosis of ALI and5.36%in the initial diagnosis of ARDS. Total constituent ratio ofALI/ARDS was9.09%in Ningxia. The mortality was11.69%in ALI andwas53.40%in ARDS. Total mortality was36.27%in Ningxia. ALI/ARDS was developed in male and older people. Lung injury occurred mostcommonly in the setting of trauma and infection. There was a high score ofAPACHEII and hospital day was commonly more than ten days.2Infection of other parts except for lung, post operation, unexplainedreasons are tend to induce ALI. Pneumonia and septic shock are morelikely to induce ARDS.ALI induced by pneumonia and post operation has abetter improvement rate and prognosis, yet ALI induced by septic shockand sepsis has a poor prognosis, and is tend to aggravate into ARDS. ARDSinduced by traumah as a better prognosis, relatively, ARDS induced bypneumonia, septic shock has a poor prognosis.3Acute circulatory system dysfunction, acute liver system dysfunction,acute nervous system dysfunction, pH value may be the independent riskfactors for ALI aggravating into ARDS. There was a significant badinfluence upon the development and poor prognosis of ALI/ARDS whenthe patients complicated more than three acute organ dysfunction.4Age, acute circulatory system dysfunction, PaCO2may be theindependent risk factors for ARDS.更多还原