一氧化氮治疗新生儿持续肺动脉高压

发布时间：2018-05-03 06:38

本文选题：一氧化氮 + 高频通气　；参考：《天津医科大学》2012年硕士论文

【摘要】：目的：人们已经尝试用吸入一氧化氮(inhaled NO, iNO)治疗多种病因引起的持续性肺动脉高压(persistent pulmonary hypertension of newborn,PPHN)。目前国内研究多应用常频机械通气与iNO治疗PPHN,国外有研究发现高频振荡通气(high-frequencey oscillatory ventilation,HFOV)联合iNO治疗比单独使用任一种疗法能更好的改善动脉氧合,减少体外膜肺(exracorporeal membrane oxygenation,ECMO)的需求。本研究探讨吸入一氧化氮(iNO)联合高频振荡通气(HFOV)治疗新生儿持续性肺动脉高压(PPHN)的有效性和安全性。对象与方法：一.对象 2007年8月—2011年8月在我院新生儿病房经超声心动图诊断为PPHN的患儿36例,其中男20例,女16例。早产儿10例,足月儿24例,过期产儿2例。胎龄31+5～42+4周,平均(38.24±3.4)周,体重1740～4100g,平均(3073.9±832.2)g。出生时新生儿窒息16例,母亲妊娠高血压综合征(妊高征)8例,母亲糖尿病3例。原发病：胎粪吸入性肺炎13例；宫内感染性肺炎10例；呼吸窘迫综合征合并肺出血4例；先天性心病6例(包括单心室1例,完全性大血管转位1例,肺静脉异位引流1例,肺动脉狭窄3例)；原因不明者3例。将无器质性心脏病所致PPHN30例归为Ⅰ组,有先天性心脏病6例归为Ⅱ组。对所有患儿进行HFOV和iNO联合治疗。二.方法 1.仪器与监测指标呼吸机应用SLE5000(英国产),并使用NOSYS SLE3600—Inhaled Nitric Oxide System(英国产)监测NO和NO2浓度。分别在吸入NO前、吸入30min、吸入24h后动态监测氧合指数(0I)、超声心动肺动脉压力(PASP)、心率、平均气道压(MAP)、动脉导管前后的经皮血氧饱和度(TcSaO2)、测量并计算平均压=舒张压+1/3(收缩压-舒张压)；吸入N030min及24h后测定高铁血红蛋白(methemoglobin,MetHb)与NO2浓度。 2.应用iNO治疗标准PASP30mm Hg(1mm Hg=0.133kPa)。当患儿对常频机械通气效果不佳时,采用HFOV治疗2h以上：当吸氧浓度(FiO2)80%、氧分压(PaO2)50mm Hg、TcSaO285%或OI15,应用iNO联合HFOV治疗 3.iNO治疗方法调节iNO的浓度,开始为8～10ppm,如效果不好,每15～30min增加5ppm(最大量为20ppm)；应用时间不超过96h。如果患儿血氧稳定达12h,每隔15～30min调整一次NO吸入浓度,每次降低5ppm,如果能维持动脉Pa02达理想水平,对氧的需求小于50%,3～5ppm时可以停止吸入NO。 4.统计学方法应用SPSS17.0软件进行统计分析,数据采用均数±标准差(x±s)表示,分析采用自身对照配对t检验,以P0.05为差异有统计学意义。结果：两组吸入NO前后相关指标变化Ⅰ组,吸入N030min和24h后,MAP、01和PASP均下降,导管前TcSaO2和导管后TcSaO2升高,心率在吸入NO24h后下降,差异有统计学意义(P0.01)。Ⅱ组,吸入NO前后下列所有的检测指标差异均无统计学意义(P0.05)。 1.治疗结局治愈26例：其中早产儿6例,足月儿20例。死亡4例：1例为32+2周早产儿,原发病为呼吸窘迫综合征合并肺出血；1例为宫内感染性肺炎,33+2周,后因全身严重感染、感染性休克合并心功能不良死亡：1例为胎粪吸入性肺炎,42+2周,后合并张力性气胸,心输出量下降死亡：1例为重度肺动脉狭窄合并心力衰竭。放弃6例：其中5例先天性心脏病治疗效果不佳,均放弃治疗；1例因经济原因放弃治疗。 2.不良反应Ⅰ组患儿吸入NO30min、24h后的MetHb浓度均3%,NO2浓度均1×10-6mg/L,均在安全范围。结论：HFO持续应用恒定的平均气道压可以更好地保持肺泡开放并降低肺血管阻力,改善通气/血流比值,减少肺内右向左分流。肺泡开放越多,到达血管平滑肌细胞通路上的NO越多。从而导致肺血流量增加,氧合改善。≥34周的早产儿在试用机械通气治疗效果不佳时,可以吸入低剂量NO以改善氧合指数,降低吸氧浓度,减少远期并发症。剂量越低毒副作用越小,为了尽量避免这些毒副作用,最好使用吸入NO的最低有效剂量。肺血管痉挛型PPHN患儿尽早采用最低有效剂量iNO联合HFOV治疗。特别是≥34周早产PPHN患儿疗效更佳。
[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.

【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2012
【分类号】：R722.1

【参考文献】