本文選題：一氧化氮 + 高頻通氣��； 參考：《天津醫(yī)科大學(xué)》2012年碩士論文

【摘要】：目的：人們已經(jīng)嘗試用吸入一氧化氮(inhaled NO, iNO)治療多種病因引起的持續(xù)性肺動脈高壓(persistent pulmonary hypertension of newborn,PPHN)。目前國內(nèi)研究多應(yīng)用常頻機械通氣與iNO治療PPHN,國外有研究發(fā)現(xiàn)高頻振蕩通氣(high-frequencey oscillatory ventilation,HFOV)聯(lián)合iNO治療比單獨使用任一種療法能更好的改善動脈氧合,減少體外膜肺(exracorporeal membrane oxygenation,ECMO)的需求。本研究探討吸入一氧化氮(iNO)聯(lián)合高頻振蕩通氣(HFOV)治療新生兒持續(xù)性肺動脈高壓(PPHN)的有效性和安全性。 對象與方法： 一.對象 2007年8月—2011年8月在我院新生兒病房經(jīng)超聲心動圖診斷為PPHN的患兒36例,其中男20例,女16例。早產(chǎn)兒10例,足月兒24例,過期產(chǎn)兒2例。胎齡31+5～42+4周,平均(38.24±3.4)周,體重1740～4100g,平均(3073.9±832.2)g。出生時新生兒窒息16例,母親妊娠高血壓綜合征(妊高征)8例,母親糖尿病3例。原發(fā)�。禾ゼS吸入性肺炎13例；宮內(nèi)感染性肺炎10例；呼吸窘迫綜合征合并肺出血4例；先天性心病6例(包括單心室1例,完全性大血管轉(zhuǎn)位1例,肺靜脈異位引流1例,肺動脈狹窄3例)；原因不明者3例。將無器質(zhì)性心臟病所致PPHN30例歸為Ⅰ組,有先天性心臟病6例歸為Ⅱ組。對所有患兒進行HFOV和iNO聯(lián)合治療。 二.方法 1.儀器與監(jiān)測指標呼吸機應(yīng)用SLE5000(英國產(chǎn)),并使用NOSYS SLE3600—Inhaled Nitric Oxide System(英國產(chǎn))監(jiān)測NO和NO2濃度。分別在吸入NO前、吸入30min、吸入24h后動態(tài)監(jiān)測氧合指數(shù)(0I)、超聲心動肺動脈壓力(PASP)、心率、平均氣道壓(MAP)、動脈導(dǎo)管前后的經(jīng)皮血氧飽和度(TcSaO2)、測量并計算平均壓=舒張壓+1/3(收縮壓-舒張壓)；吸入N030min及24h后測定高鐵血紅蛋白(methemoglobin,MetHb)與NO2濃度。 2.應(yīng)用iNO治療標準PASP30mm Hg(1mm Hg=0.133kPa)。當(dāng)患兒對常頻機械通氣效果不佳時,采用HFOV治療2h以上：當(dāng)吸氧濃度(FiO2)80%、氧分壓(PaO2)50mm Hg、TcSaO285%或OI15,應(yīng)用iNO聯(lián)合HFOV治療 3.iNO治療方法調(diào)節(jié)iNO的濃度,開始為8～10ppm,如效果不好,每15～30min增加5ppm(最大量為20ppm)；應(yīng)用時間不超過96h。如果患兒血氧穩(wěn)定達12h,每隔15～30min調(diào)整一次NO吸入濃度,每次降低5ppm,如果能維持動脈Pa02達理想水平,對氧的需求小于50%,3～5ppm時可以停止吸入NO。 4.統(tǒng)計學(xué)方法應(yīng)用SPSS17.0軟件進行統(tǒng)計分析,數(shù)據(jù)采用均數(shù)±標準差(x±s)表示,分析采用自身對照配對t檢驗,以P0.05為差異有統(tǒng)計學(xué)意義。 結(jié)果：兩組吸入NO前后相關(guān)指標變化Ⅰ組,吸入N030min和24h后,MAP、01和PASP均下降,導(dǎo)管前TcSaO2和導(dǎo)管后TcSaO2升高,心率在吸入NO24h后下降,差異有統(tǒng)計學(xué)意義(P0.01)。Ⅱ組,吸入NO前后下列所有的檢測指標差異均無統(tǒng)計學(xué)意義(P0.05)。 1.治療結(jié)局治愈26例：其中早產(chǎn)兒6例,足月兒20例。死亡4例：1例為32+2周早產(chǎn)兒,原發(fā)病為呼吸窘迫綜合征合并肺出血；1例為宮內(nèi)感染性肺炎,33+2周,后因全身嚴重感染、感染性休克合并心功能不良死亡：1例為胎糞吸入性肺炎,42+2周,后合并張力性氣胸,心輸出量下降死亡：1例為重度肺動脈狹窄合并心力衰竭。放棄6例：其中5例先天性心臟病治療效果不佳,均放棄治療；1例因經(jīng)濟原因放棄治療。 2.不良反應(yīng)Ⅰ組患兒吸入NO30min、24h后的MetHb濃度均3%,NO2濃度均1×10-6mg/L,均在安全范圍。 結(jié)論：HFO持續(xù)應(yīng)用恒定的平均氣道壓可以更好地保持肺泡開放并降低肺血管阻力,改善通氣/血流比值,減少肺內(nèi)右向左分流。肺泡開放越多,到達血管平滑肌細胞通路上的NO越多。從而導(dǎo)致肺血流量增加,氧合改善�！�34周的早產(chǎn)兒在試用機械通氣治療效果不佳時,可以吸入低劑量NO以改善氧合指數(shù),降低吸氧濃度,減少遠期并發(fā)癥。劑量越低毒副作用越小,為了盡量避免這些毒副作用,最好使用吸入NO的最低有效劑量。肺血管痙攣型PPHN患兒盡早采用最低有效劑量iNO聯(lián)合HFOV治療。特別是≥34周早產(chǎn)PPHN患兒療效更佳。
[Abstract]:Objective: people have tried to use inhaled nitric oxide (inhaled NO, iNO) to treat the persistent pulmonary hypertension (persistent pulmonary hypertension of newborn, PPHN) caused by various causes. Entilation, HFOV) combined with iNO therapy can better improve arterial oxygenation and reduce the requirement for exracorporeal membrane oxygenation, ECMO. This study explores the effectiveness and safety of inhaled nitric oxide (iNO) combined with high frequency oscillatory ventilation (HFOV) in the treatment of persistent pulmonary hypertension (PPHN) of newborn (PPHN).
Objects and methods:
1. Objects
From August 2007 to August 2011, 36 cases of PPHN were diagnosed by echocardiography in the neonatal ward of our hospital. Among them, there were 20 males and 16 females, 10 cases of preterm infants, 24 foot children and 2 perinatal infants. The average age of fetal age was 31+5 to 42+4 weeks, the average weight was 1740 to 4100g, and the average (3073.9 + 832.2) g. was born in the newborn asphyxia, and the mother's pregnancy was high blood. 8 cases of pressure syndrome (PIH), 3 cases of mother diabetes, 13 cases of meconium aspiration pneumonia, 10 cases of intrauterine infectious pneumonia, 4 cases of pulmonary hemorrhage in respiratory distress syndrome, 6 cases of congenital heart disease (including 1 cases of single ventricle, 1 complete large vessel transposition, 1 cases of pulmonary venous drainage, 3 cases of pulmonary artery stenosis); 3 cases of unknown cause. PPHN30 cases without organic heart disease were classified as group I, and 6 patients with congenital heart disease were classified as group II. All children were treated with HFOV and iNO.
Two. Method
1. instrument and monitoring index ventilator used SLE5000 (British produced) and monitoring NO and NO2 concentration using NOSYS SLE3600 - Inhaled Nitric Oxide System (British production). After inhaling NO, inhaling 30min. After inhalation 24h, dynamic monitoring of oxygenation index, echocardiographic pulse pressure, heart rate, mean airway pressure, and before and after ductus arteriosus Percutaneous oxygen saturation (TcSaO2) was used to measure and calculate the mean pressure = diastolic pressure +1/3 (systolic pressure diastolic pressure); after inhalation of N030min and 24h, the concentration of HB (methemoglobin, MetHb) and NO2 was measured.
2. iNO treatment standard PASP30mm Hg (1mm Hg=0.133kPa). When children have poor effect on normal frequency mechanical ventilation, HFOV is used to treat 2H above: when oxygen concentration (FiO2) (FiO2) 80%, oxygen partial pressure (PaO2) 50mm Hg, TcSaO285%, or
3.iNO therapy regulates the concentration of iNO, starting from 8 to 10ppm, if the effect is not good, each 15 to 30min increases 5ppm (the maximum amount is 20ppm); the application time does not exceed 96h. if the child's blood oxygen is stable to 12h, adjust the NO inhalation concentration every 15 to 30min, each decrease 5ppm, if the ideal level of the artery Pa02 is maintained, the demand for oxygen is less than 50%, 3 The inhalation of NO. can be stopped at 5ppm
4. statistical analysis was carried out by SPSS17.0 software. The data were expressed by mean mean standard deviation (x + s), and the analysis of t test was used by self control. The difference was statistically significant with the difference of P0.05.
Results: after inhaling N030min and 24h, after inhaling N030min and 24h, after inhalation of NO, MAP, MAP, and PASP were all decreased, TcSaO2 increased before and after catheter, and the heart rate decreased after inhaling NO24h (P0.01). Group II, there was no statistically significant difference between all the following indexes before and after inhalation of NO (P0.05).
1. the outcome of the treatment was cured in 26 cases: 6 cases of premature infants, 20 cases of full moon, 4 cases of death: 1 cases of 32+2 weeks premature infants, the original incidence of respiratory distress syndrome combined with pulmonary hemorrhage, 1 cases of intrauterine infection pneumonia, 33+2 weeks, severe infection of the whole body, and death of septic shock with heart failure: 1 cases of meconium aspiration pneumonia, 42+2 weeks after. Combined with tension pneumothorax, cardiac output decreased, 1 cases were severe pulmonary stenosis and heart failure. 6 cases were given up: 5 cases of congenital heart disease were not treated well, all were given up treatment, 1 cases were given up for economic reasons.
2. adverse reactions in group I inhaled NO30min, 24h after MetHb concentration was 3%, NO2 concentration was 1 x 10-6mg/L, both in the safe range.
Conclusion: the constant mean airway pressure of HFO can better maintain the opening of the alveoli and reduce the pulmonary vascular resistance, improve the ventilation / blood flow ratio and reduce the right to left shunt in the lung. The more the alveolus opening, the more NO on the vascular smooth muscle cell pathway, which leads to the increase of the volume of pulmonary blood flow and the improvement of oxygenation. The preterm infants more than 34 weeks are in the test. When the effect of mechanical ventilation is poor, low dose NO can be inhaled to improve oxygenation index, reduce oxygen concentration and reduce long-term complications. The lower the dose, the less toxic and side effects, and to avoid these side effects, it is best to use the minimum effective dose of inhaled NO. The minimum effective dose of iNO in children with pulmonary vascular spasmodic type PPHN is used as early as possible. Combined with HFOV treatment, especially for children with premature PPHN who are more than 34 weeks old, the curative effect is better.

【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2012
【分類號】：R722.1

【參考文獻】

相關(guān)期刊論文 前1條

1 杜軍保;張鳳文;;肺動脈高壓的一氧化氮臨床治療[J];實用兒科臨床雜志;2010年18期

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本文編號：1837445