【作者】 张相梅；

【导师】 徐丁；

【作者基本信息】 兰州大学 ， 儿科学， 2010， 硕士

【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。更多还原

【Abstract】 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.更多还原