【作者】 孙波；

【导师】 孙若鹏；

【作者基本信息】 山东大学 ， 儿科学（专业学位）， 2015， 硕士

【摘要】 研究背景和目的：新生儿呼吸窘迫综合征,是导致新生儿,尤其是早产儿早期死亡的主要疾病之一,患儿多在出生后早期阶段出现进行性呼吸困难,临床表现为呼吸急促、呼气性呻吟、吸气时三凹征、青紫等症状,严重时可出现呼吸衰竭,低血压甚至休克,所以,早期发现并诊断新生儿呼吸窘迫综合征,及时应用外源性肺泡表面活性物质和机械通气治疗,可以迅速并且有效的改善患儿的临床症状,提高患儿的抢救成功机率,降低了患儿的死亡率。CPAP属于无创性治疗方法,经典的治疗对象是新生儿RDS。而常频机械通气则有较多的合并症,如气道损伤、气管插管并发症、慢性肺损伤、气漏综合症、心血管系统并发症、感染、ROP、IVH等,本研究通过分析64例诊断为新生儿呼吸窘迫综合症的早产儿应用肺表面活性物质联合两种不同模式机械通气(CPAP;和常频机械通气)治疗新生儿呼吸窘迫综合征的临床疗效,比较两组患儿的合并症发生的多少(气胸、支气管肺发育不良、NEC、ROP)、住院总时间、住院总费用等方面的临床资料,以期得到更佳的治疗新生儿呼吸窘迫综合症治疗方式,提高患儿的治愈率,降低并发症的发生率及死亡率,提高临床疗效。研究方法：(一)研究对象：选取2012年1月1日至2014年12月31日入住枣庄市妇幼保健院新生儿重症监护病房,胎龄小于32周,诊断为NRDS的早产儿共64例。NRDS诊断标准：(1)临床：有鼻扇、呼吸急促、呻吟、吸气三凹征等呼吸困难表现；(2)胸片提示NRDS。入选标准：胎龄小于32周,诊断为NRDS,有自主呼吸。排除标准：无自主呼吸,人院时已经气管插管,合并严重窒息、感染、贫血、肺出血造成的呼吸困难,心力衰竭和先天畸形：共有64例患儿符合入选标准,其中包括40例男性患儿,24例女性患儿,其入院日龄小于30分钟。将其随机分为观察组和与对照组,每组各32例患儿,母亲分娩前使用激素44例,观察组21例,对照组23例,极低出生体重儿共50例,观察组24例,对照组26例,胎膜早破观察组27例,对照组23例,母亲患妊高症观察组8例,对照组24例。两组患儿的一般资料相比较,差异不显著(P>0.05),无统计学意义,具有可比性。研究方法1.操作步骤：患儿予清理呼吸道分泌物,入院后4h内气管插管内快速注入PS(珂立苏,北京双鹤制药公司,剂量100 mg/kg),气囊加压通气(5～10min),其中观察组应用PS后拔出气管插管应用n-CPAP (INFANT FLOW SYSTEM,美国VIASYS HEALTHCARE INC),对照组应用PS后不拔出气管插管直接连接呼吸机(SIMV模式)(NEWPONT e360),患儿目标氧饱和度为85%～93%,按需调节参数。n-CPAP的撤离标准为CPAP压力小干4-5cmH20,无呼吸暂停和心动过缓、无SaO2降低。呼吸机的撤离标准为PIP≤10-15cmH20, PEEP=2-4cmH20,频率≤10次/分,氧浓度≤0.4,动脉血气正常,转为CPAP,或撤离呼吸机。观察组若不能使患儿目标氧饱和度为85%～93%或血气正常,则转化为气管插管呼吸机辅助呼吸,维持目标氧饱和度或正常血气。2.给予2组患儿同样的常规治疗,如保暖、抗感染、维持内环境稳定、静脉营养等。研究结果：1.一般情况：2组患儿的胎龄、出生体重、性别构成比、入院日龄、入院至使用PS时间、5 min Apgar评分、孕母产前使用激素、极低出生体重儿、胎膜早破、孕母妊娠期高血压疾病、肺部x线严重程度分级差异均无统汁学意义(P值均>0.05)。2.2组患儿并发症比较：CPAP组支气管发育不良、住院总时间、住院总费用差异有统计学意义(P值均<0.05),气胸、坏死性小肠结肠炎、ROP差异无统计学意义(P值均>0.05)。研究结论：肺表面活性物质联合应用n-CPAP相对于联合应用常频机械通气治疗新生儿呼吸窘迫综合征,可降低支气管肺发育不良的发生率,缩短住院时间,减少住院费用,但不能减少气胸、坏死性小肠结肠炎、ROP的发生率。更多还原

【Abstract】 Background and objectives:Neonatal respiratory distress syndrome, and is in newborns, especially one of the main diseases of premature infants early death, children in early stage after birth more progressive dyspnea, clinical manifestations of shortness of breath and inhale, exhale moan three concave), blue wait for a symptom, serious when can appear respiratory failure, hypotension or shock, so early detection and diagnosis of neonatal respiratory distress syndrome, and timely application of exogenous alveolar surface active substance and mechanical ventilation treatment, can quickly and effectively improve the patient’s clinical symptoms, improve the patient’s rescue success probability, reduce the mortality rate of children. CPAP belongs to non-invasive treatment, the classical treatment object is neonatal RDS. While Chang Pin mechanical ventilation has more complications, such as airway, tracheal intubation complications of injury, chronic lung injury, gas leak syndrome, cardiovascular complications, such as infection, ROP, the IVH, this study analyzes 64 cases diagnosed as premature application of neonatal respiratory distress syndrome lung surface active substance joint of two different modes of mechanical ventilation (CPAP and Chang Pin mechanical ventilation) the clinical curative effect of treatment of neonatal respiratory distress syndrome, compared two groups of children with how many complications happened (pneumothorax, bronchial pulmonary hypoplasia, NEC, ROP), total time of be in hospital, the length of the clinical data of the total cost, etc, in order to get a better way of treatment of neonatal respiratory distress syndrome, improve the patient’s cure rate, reduce the incidence of complications and mortality, improve clinical curative effect.Methods:(a) the object of study:on January 1,2012 to December 31,2014 in zaozhuang maternity and child care neonatal intensive care unit, and gestational age less than 32 weeks, a total of 64 patients diagnosed with NRDS premature infants. NRDS clinical diagnostic criteria [4]:(1):fan, shortness of breath, moaning nose, breathe in three concave) such as difficulty breathing; (2) X-ray suggests NRDS. Inclusion criteria: gestational age less than 32 weeks, diagnosed with NRDS, spontaneous breathing. Exclusion criteria:no spontaneous breathing, courtyard have endotracheal intubation, and severe asphyxia, infections, anemia, pulmonary hemorrhage caused by breathing difficulties, heart failure and congenital malformations:a total of 64 cases of children with meet the inclusion criteria, including 40 cases of male patients,24 cases of children with women, the hospitalized days of age less than 30 minutes. It were randomly divided into observation group and control group, each group of 32 cases, mother before delivery using hormones 44 cases, observation group 21 cases,23 cases of control group, extremely low birth weight, a total of 50 cases, observation group of 24 cases, the control group,26 cases of premature rupture of membranes observed group of 27 cases,23 cases of control group, the mother of 8 cases of pih group, control group 24 cases. In comparison with the general data of two groups of children, no significant difference (P> 0.05), no statistical significance, comparable. Research methods 1. The operation steps:to clear the respiratory secretions, children admitted to hospital within 4 h after endotracheal intubation in rapid injection of PS (cosette made Sue, Beijing double crane pharmaceutical companies, dose of 100 mg/kg), gasbag pressurized ventilation (5-10 min), the observation group after application of PS out endotracheal intubation applied n-CPAP (INFANT FLOW SYSTEM, the United States VIASYS HEALTHCARE INC), the control group after application of PS don’t pull out endotracheal intubation directly connected breathing machine (SIMV mode) (NEWPONT e360), children with target oxygen saturation is 85%～ 93%, according to the need to adjust the parameters. N-CPAP evacuation standard for CPAP pressure is less than 4-5 cmh2o, apnoea and bradycardia, SaO2 decreased. Breathing machine out of standard for PIP 10-15 or less cmh2o, PEEP= 2-4 cmh2o, frequency 10 times/min or less, oxygen concentration of 0.4 or less, arterial blood gas, normal into CPAP, or out of breathing machine. Observation group if not make children target oxygen saturation is 85%～93% or flesh is normal, is converted to endotracheal intubation auxiliary breathing breathing machine, to keep the normal target oxygen saturation or flesh.2. Give children with the same routine therapy of two groups, such as thermal, anti-infection, maintain a stable internal environment, parenteral nutrition, etc.(b) Results:1. General situation:two groups of children with gestational age, birth weight and gender ratio and hospital days of age, hospital to use PS time,5 min Apgar score, pregnant mother antenatal corticosteroids, extremely low birth weight, premature rupture of membranes, motherhood gestational hypertension disease, and lung X-ray severity grading differences were no series juice learning significance (P> 0.05). 2.2 set of complications in children with comparison:CPAP group total bronchial dysplasia, hospitalization time, hospitalization cost difference was statistically significant (P< 0.05), pneumothorax, necrotizing enterocolitis, there was no statistically significant difference ROP (all P values> 0.05).Conclusions:Lung surface active material combined application of n-CPAP relative to the combined use of Chang Pin mechanical ventilation treatment of neonatal respiratory distress syndrome, and can reduce the incidence of bronchial pulmonary dysplasia, shorten hospitalization time, reduce hospitalization expenses, but does not reduce the incidence rate of pneumothorax, necrotizing enterocolitis, ROP.更多还原