【作者】 李莉；

【导师】 陈晓；

【作者基本信息】 南昌大学 ， 儿科学（专业学位）， 2020， 硕士

【摘要】 目的:探讨在常规治疗基础上加用吸入糖皮质激素治疗对呼吸机相关性肺炎（Ventilator-associated pneumonia,VAP）的早产儿肺氧合、病程和并发症的影响,从而评估吸入性糖皮质激素的临床应用价值。方法:本研究选取于2018年4月-2019年3月期间赣州市人民医院新生儿重症监护室住院治疗的胎龄≤32 W且诊断VAP的早产儿70例,随机分成研究组和对照组各35例,70例早产儿均以新生儿呼吸窘迫综合征（Neonatal respiratory distress syndrome,NRDS）为原发病,且因NRDS行机械通气≥48 h。记录患儿的一般资料,包括性别、胎龄、出生体重、分娩方式和产前糖皮质激素应用情况等,记录VAP治疗前及治疗后1 d、2 d、3 d、7 d患儿的动脉血气分析中血氧分压（PaO₂）、二氧化碳分压（PaCO₂）、氧合指数（OI）,并进行分析,比较两组治疗后7 d撤机率、治疗总有效率,记录总吸氧时间、住院天数、并发症等情况。采用SPSS 20.0软件进行统计学分析。计量资料呈正态分布者以均数±标准差（?x±SD）表示,组间对比采用独立样本t检验;计数资料用例数和率（%）表示,组间对比采用?²检验,P<0.05为差异有统计学意义。结果:1.治疗前两组患儿的PaO₂、PaCO₂和OI值均无统计学差异（P>0.05）。与治疗前比较,治疗后两组患儿的PaCO₂、OI值均有下降,PaO₂上升。研究组的PaO₂在治疗后1 d、2 d、3 d时均高于对照组,PaCO₂、OI值在治疗后1 d、2d、3 d时均低于对照组,上述各时间点两组间相应指标的差异均有统计学意义（P<0.05）,两组患儿的PaO₂、PaCO₂在治疗后7 d差异无统计学意义（P>0.05）,但研究组OI值在治疗后7 d时低于对照组,差异有统计学意义（P<0.05）。2.两组患儿治疗后7 d撤机率、治疗总有效率对比,研究组均高于对照组,差异均具有统计学意义（P<0.05）。3.与对照组比较,研究组总吸氧时间、住院天数均有缩短,差异均有统计学意义（P<0.05）。4.比较两组患儿住院期间的并发症情况:研究组动脉导管未闭、肺动脉高压、颅内出血与对照组比较无统计学差异（P>0.05）,但研究组支气管肺发育不良的发生率低于对照组,差异具有统计学意义（P<0.05）。结论:1.吸入糖皮质激素治疗早产儿呼吸机相关性肺炎后PaO₂、PaCO₂、OI值均明显改善,尤其是OI值的改善更具优势,提示加用吸入糖皮质激素治疗能迅速纠正低氧血症,减轻CO₂潴留,降低气道平均压力,提高肺泡顺应性,从而有效改善肺氧合和通气功能。2.吸入糖皮质激素治疗后患儿的临床症状、肺部体征、X线检查肺部阴影改善更快,治疗后7 d撤机率和治疗总有效率均有提高,且总吸氧时间、住院天数均有缩短,提示吸入糖皮质激素能缩短早产儿VAP的病程,有利于疾病恢复。3.吸入糖皮质激素并未增加早产儿住院期间并发症,动脉导管未闭、肺动脉高压、颅内出血等的发生无影响,而对早产儿支气管肺发育不良（Bronchopulmonary dysplasia,BPD）的进展有影响。吸入糖皮质激素治疗后BPD的发生率下降,提示一旦诊断早产儿VAP早期加用吸入糖皮质激素治疗能降低BPD的发生风险。更多还原

【Abstract】 Objective:On the basis of conventional treatment,this study aimed to investigate the effect of glucocorticoid inhalation on pulmonary oxygenation,diseases course and complication in premature infants with ventilator-associated pneumonia（VAP）,thereby evaluating the clinical value of glucocorticoid inhalation.Methods:In this study,seventy premature infants（gestational age<32 W）diagnosed with VAP from April 2018 to March 2019 in the neonatal intensive care unit of Ganzhou People’s Hospital were collected.These infants were randomly divided into experimental group and control group,35 cases in each group,all of them had neonatal respiratory distress syndrome（NRDS）,and received mechanical ventilation>48 h.The general information of infants was recorded,including gender,gestational age,birth weight,delivery mode,and application of prenatal glucocorticoids.The PaO₂,PaCO₂ and OI were analyzed before treatment and after treatment（1 d,2 d,3 d and 7 d）,moreover,withdrawal rate of 7 days after treatment,total oxygen intake time,hospitalization days,complications between two groups were compared,as well as total therapeutic efficiency.SPSS 20.0 software was used for statistical analysis.The measurement data were expressed as mean±standard deviation（?x±SD）,the independent-samples T test was used for data comparison between groups.The chi-square test was used for counting data.P<0.05 was considered as statistically significant.Result:1.The data of PaO₂,PaCO₂ and OI between two groups before treatments show no significant different（P>0.05）.Compared with before treatment,the data of PaCO₂and OI after treatments was decreased in two groups,while the data of PaO₂ was increased.PaO₂ in the experimental group was higher than that in the control group at1 d,2 d and 3 d after treatment,while PaCO₂,OI was lower than that in the control group at 1 d,2 d and 3 d after treatment,all the differences were statistically significant（P<0.05）.There was no statistically significant difference in PaO₂ and PaCO₂ between two groups on 7 d after treatment（P>0.05）.However,the OI data of the experimental group were lower than the control group on 7 d after treatment,with statistically significant differences（P<0.05）.2.The treatment efficiency in the two groups was compared,the withdrawal rate of 7 d after treatment and the total efficiency of the experimental group was higher than that of the control group,with statistically significant differences（P<0.05）.3.Compared with the control group,the total oxygen intake time and hospitalization days were significantly shortened,with statistically significant differences（P<0.05）.4.Complications during treatment were compared:there was no statistical difference of complications between the experimental group and the control group,including patent ductus arteriosus,persistent pulmonary hypertension of the newborn and intracranial hemorrhage（P>0.05）.However,the incidence of bronchopulmonary dysplasia in experimental group was significantly lower than that in the control group,with statistically significant differences（P<0.05）.Conclusion:1.The data of PaO₂,PaCO₂ and OI were significantly improved after glucocorticoid inhalation treating premature infants with VAP,which suggested that it can quickly treat hypoxemia,reduce carbon dioxide retention,lower mean airway pressure,increase alveolar compliance,and effectively improve pulmonary oxygenation and ventilation.2.The treatment of glucocorticoid inhalation improve the clinical symptoms,vital signs and lung images,it increased the treatment effectiveness,and improve the withdrawal rate of 7 d and the total efficiency after treatment,as well as total oxygen time,hospitalization days,suggesting glucocorticoid inhalation can shorten the disease course of premature infants with VAP,and be beneficial to the recovery.3.The treatment of glucocorticoid inhalation cannot increased the complications,such as patent ductus arteriosus,persistent pulmonary hypertension of the newborn,intracranial hemorrhage,interestingly,it had effect on BPD progress of premature infants,it significantly decreased the incidence of BPD,our results suggested that early addition of glucocorticoid inhalation can reduce BPD risk in infants with VAP.更多还原