【作者】 王玲；

【导师】 徐礼鲜； 张惠；

【作者基本信息】 第四军医大学 ， 麻醉学， 2011， 博士

【摘要】 光气是一种有毒气体,是塑料、染料、农药等化工产品化学合成过程中的原料,同时也作为军用毒剂被用于战争和恐怖活动中。光气经呼吸道吸入后可引起严重的弥漫性肺水肿,逐渐加重的肺部气体交换功能障碍导致渐进性低氧血症,肺顺应性降低,严重者可发展成为成人呼吸窘迫综合征（ARDS）,甚至死亡。高原空气稀薄,降低的大气压导致氧分压低,这是高原环境影响机体各脏器功能的主要因素。高原环境下吸入光气,低压缺氧既可以造成机体一系列异常反应[1],也会加重化学毒物对机体脏器功能的损伤[2]。初入高原人员若发生光气中毒,机体将同时遭受高原缺氧和光气中毒性损伤双重打击。目前,高原低压缺氧的研究报道已较多,但是,尚未见国内外对高原地区光气中毒的研究报道,本研究突破传统呼吸道给氧方法,应用液体携氧方式,探讨高氧医用液体（简称高氧液）对低压缺氧复合光气中毒急性肺损伤的救治作用,为平时和战时高原地区窒息性毒气造成急性肺损伤的治疗提供新的方法和途径。第一部分高原低压缺氧复合光气中毒急性肺损伤及相关机制研究目的:本研究通过建立兔高原低压缺氧复合光气中毒急性肺损伤模型,研究低压缺氧复合光气中毒引起的急性肺损伤特点及其相关机理。方法:健康新西兰大白兔40只,雌雄不拘,随机分为4组（n=10）,正常对照组（C组,染毒柜内吸入空气5min,然后将动物置于低压舱内,但不降低舱内空气压力2h）;单纯高原低压缺氧组（H组,染毒柜里吸入空气5min,随即放入模拟高原3000m动物低压舱内2h）;单纯光气中毒组（P组,染毒柜内吸入光气5min,然后放入模拟高原动物低压舱内常压下2h）;低压缺氧复合光气中毒组（HP组,将动物染毒5min后放入模拟高原3000m低压舱内2h）。观察各组动物实验前（T₁）、出染毒柜后即刻（T₂）、出舱后即刻（T₃）、1h（T₄）、6h（T₅）时间点动物呼吸频率、心率、口唇紫绀等一般情况;抽取动脉血,测定动脉血气分析指标,记录动脉血PaO₂并计算氧合指数（PaO₂/FiO₂）;测定血液丙二醛（MDA）含量、红细胞超氧化物歧化酶（SOD）活性、肿瘤坏死因子2α（ TNF-2α）含量、白介素6（IL-6）含量;观察动物24h内生存时间、死亡率。结果:（1）、HP组与P组相比生存时间明显减少、死亡率明显升高（P<0.05或P<0.01）,两组与H组比较生存时间均减少,有显著性统计学意义,H组无一例死亡。（2）、与C组、H组比较,HP组与P组吸入光气后呼吸频率明显增快、PaO₂及氧合指数呈进行性下降（P<0.05或P<0.01）,两组动物在出舱后即刻、1h、6h时间点血浆MDA含量显著升高、SOD活性明显降低、TNF2α含量及IL-6含量均不同程度升高（P<0.05或P<0.01）;（3）、在出舱后即刻、1h、6h时间点低氧光气中毒组与单纯光气中毒组比较动物呼吸频率明显增快、PaO₂降低、血浆MDA含量显著升高、SOD活性明显降低（P<0.05或P<0.01）,前者在出舱后1h、6h的TNF-2α含量及IL-6含量明显高于后者（P<0.05）。结论:高原低压缺氧环境下光气中毒明显加重光气中毒肺损伤的程度,可能与机体脂质过氧化反应及炎性反应增强有关。第二部分高氧液对低压缺氧复合光气中毒急性肺损伤的保护作用及相关机理研究目的:本研究旨在探讨静脉输注高氧液对兔低压缺氧复合光气中毒急性肺损伤的防治作用及机制。方法:新西兰大白兔40只随机分为4组（n=10）。低氧光气中毒组（HP组,光气染毒3min后放入高原模拟海拔3000m低压舱内2h,复合损伤后不治疗）、平衡盐对照组(HPB组,染毒后在模拟海拔3000m低压舱内同时静脉输入平衡盐20 mL·kg^-1)、吸氧治疗组(HPO组,染毒后在低压舱内给予持续面罩吸氧,氧流量为0.3L·min^-1)、高氧液治疗组(HPH组,染毒后在模拟海拔3000m低压舱内静脉输入高氧液20mL·kg^-1)。分别在实验前（T₁）、出染毒柜后即刻（T₂）、出舱后即刻（T₃）、1h（T₄）、6h（T₅）时间点观察并记录动物呼吸频率;抽取动脉血,测定动脉血PaO2 ;测定血液MDA含量、SOD活性、TNF2α含量、IL-6含量;6h后颈动脉放血处死动物,开胸取肺,测定肺水含量（LW）、肺系数(L·B^-1);左肺行支气管肺泡灌洗（BAL）,测定支气管肺泡灌洗液（BALF）中MDA含量、谷胱甘肽过氧化物酶（GSH-Px）活性及细胞总数、蛋白含量,取部分肺组织作匀浆,检测肺组织GSH、GSSG含量,部分肺组织留作组织病理学检查。结果:吸氧治疗或高氧液治疗后,在各时间点呼吸频率明显低于HP、HPB组（P<0.05或P <0.01）;两组L·B^-1和LW均明显低于HP、HPB组（P <0.05）;吸氧治疗（HPO组）与高氧液治疗（HPH组）在出舱后即刻、1h、6h时间点血浆MDA含量降低、SOD活性升高、TNF-2α含量与IL-6含量均降低,与后两组相比较有显著性差异（P <0.05或P <0.01）,HPH组与HPO组相比,在出舱后即刻、1h时间点PaO₂明显升高、MDA含量降低、SOD活性升高,有显著性统计学差异（P <0.05）;肺组织GSSG含量降低,BALF中MDA及蛋白含量下降、GSH-Px活性升高,有显著性差异（P <0.05或P <0.01）;组织病理学检查显示:肉眼可见HP、HPB组兔肺有片状暗红区,气肿、水肿区,镜下见肺泡壁增厚,间质水肿,静脉淤血、大量液体和细胞渗出;吸氧治疗或高氧液治疗兔肺外观无明显大片暗红、水肿区,触之柔软,光镜下静脉淤血、液体渗出亦不明显。结论:（1）高原低压缺氧复合光气中毒造成的急性肺损伤程度比单纯光气中毒或低压缺氧带来的损伤更为严重,可能与低压缺氧、光气两种因素共同造成的机体脂质过氧化反应及应激性炎症反应有关;（2）静脉输注高氧液20ml·kg^-1能够明显减轻低氧复合光气中毒急性肺损伤程度,并降低复合损伤引起的体内脂质过氧化反应及炎性反应,对低压缺氧复合光气中毒造成的急性肺损伤有一定的保护作用。更多还原

【Abstract】 Phosgene belongs to blackdamp,which may cause toxic pneumonia,diffusive and transudatory pulmonary edema, ARDS and death even. The air becomes thinner in plateau. Hypobaric hypoxia is the main and beginning harmful environmental factor to inhigh altitude. Hypoxia is not only harmful to people but also aggravate toxic symptom. Acute exposure in both high altitude and phosgene will cause acute hybobaric hypoxia and acute phosgene poisoning.At present,it has been reported widely about hybobaric hypoxia but phosgene poisoning in high altitude has not been reported before . Recently, Hyperoxia solution （HOS） is used as an effective way to treat anoxia diseases. This study investigated the effects of HOS on phosgene poisoning and hypobaric hypoxia -induced acute lung injury.Part 1 Experimental studies on damage effects and investigate mechanism on acute rabbit lung injury induced by phosgene poisoning and hypobaric hypoxia AIM: To investigate the damage effects and investigate mechanism on acute rabbit lung injury induced by phosgene poisoning and hypobaric hypoxia.METHODS: 40 New Zealand white rabbits （weight 2.0～2.5kg） were randomly divided into 4 groups（n=10）:Control group（group C,with fresh and normal pressure ）; Hypobaric hypoxia group（group H,with fresh air for 5 min and exposure to a simulated altitude of 3000 m for 2 hours ）; Phosgene poisoning group（group P,exposure to phosgene for 5 min only）;Phosgene poisoning and hypobaric hypoxia group（group HP, exposure to phosgene for 5 min and a simulated altitude of 3000 m for 2 hours）. Breathing frequency was recorded and blood samples were taken at different time points（T₁,T₂,T₃,T₄,T₅） for the determination of PaO₂, plasma malordialdehyde （MDA） contents , superoxide dismutase（SOD） activity and tumor necrosis factor-α（ TNF-2α） contents, interleukin-6（IL-6） . Survival time of each rabbit and death rate was recorded in all groups .RESULTS: （1） The survival time shorten and death rate increased significantly in group HP in comparison with group H（P<0.05 or P<0.01 ）.（2） In group P and HP,breathing rate increased, PaO₂ and oxygenation index decreased significatly than in group H and C. At T₃,T₄,T₅ time point, plasma MDA contents, TNF2αand IL-6 contents increased and SOD activity decreased distinctly in group P and HP comparied with group H and C（P<0.05 or P<0.01）.（3）In group HP,breathing rate and MDA cotents increased, PaO₂ and SOD activity decreased significatly（P<0.05或P<0.01）at T₃,T₄,T₅ in comparison with group P. TNF-2αand IL-6 contents raised obviously at T₄,T₅ in group HP than group H（P<0.05）.CONCLUSION:Phosgene poisoning and hypobaric hypoxia result in more serious injury in lung than only phosgene poisoning or hypobaric hypoxia. Part 2 Experimental studies on Protective effects and investigate mechanism of hyperoxia solution infusion on acute rabbit lung injury induced by phosgene poisoning and hypobaric hypoxia.AIM: To investigate the protective effect and mechanism of HOS on rabbit with acute lung injury induced by phosgene and hypobaric hypoxia.METHODS : 40 New Zealand white rabbits （weight 2.0～2.5kg） were randomly divided into 4 groups（n=10）:Group HP : with exposure to phosgene for 3 min and a simulated altitude of 3000 m for 2 hours;Group HPB :After exposed to phosgene for 3min ,this group was exposed to a simulated altitude of 3000 m for 2 hours with an infusion of balanced salt solution(BS,20mL·kg^-1) in 1h ;Group HPO: After exposed to phosgene for 3min ,this group was exposed to a simulated altitude of 3000 m for 2 hours with continued mask oxygen inhalation (0.3 L·min^-1) in 1h; Group HPH: After exposed to phosgene for 3min ,this group was exposed to a simulated altitude of 3000 m for 2 hours with an infusion of HOS (20mL·kg^-1) in 1h . Breathing frequency was recorded and blood samples were taken at different time points（T₁,T₂,T₃,T₄,T₅） for the determination of PaO₂, plasma malordialdehyde （MDA） contents , superoxide dismutase（SOD） activity and tumor necrosis factor-α（ TNF-2α） contents, interleukin-6（IL-6） . After 6 hours, the chests were opened and lungs removed. The wet left lungs were weight for L·B^-1, then after lavaging bronchoalveolar with 0.9% salt solution for plasma MDA contents,GSH-Px activity and protein level in bronchoalveolar lavage fluid（BALF）, they were placed in an oven at 70 deg C and dried to a constant weight to measure LW. Small piece of left lung was homogenized and analyzed tissue Glutathione （GSH/GSSG） contents. The remaining parts of left lung were collected to observe pathologic changes.RESULTS: Breathing rate and LW ,L·B^-1 was significantly lower and PaO₂ was higher in HPH and HPO than in HP and HPB. At T₃,T₄,T₅ time point, plasma MDA contents, TNF2αand IL-6 contents decreased and SOD activity increased distinctly in group HPH and HPO in comparison with group HP and HPB（P<0.05 or P<0.01）. In group HPH, MDA contents decreased , PaO₂ and SOD activity increased significantly than in group HPO. MDA contents and protein levels in BALF depressed and GSH-Px activity increased distinctly in group HPH and HPO than in group HPB and HP （P<0.01 or P<0.05）. ONCLUSION:（1） More serious injury in lung induced by phosgene and hypobaric hypoxia than simple phosgene poisoning or hypobaric hypoxia.（2） Treatment with HOS shown a protective effect on rabbits with acute lung injury induced by phosgene exposure and hypobaric hypoxia.更多还原