国内部分地区新生儿重症监护病房新生儿呼吸窘迫综合征诊治现状及东西部差异调查

Regional variation in practice and outcome of neonatal respiratory distress syndrome between the Southeastern and Mid-western China

目的调查我国新生儿重症监护病房（neonatal intensive care unit，NICU）诊治呼吸窘迫综合征（respiratory distress syndrome，RDS）的现状，并比较东南沿海和中西部地区间的差异。方法国内23家拥有NICU建制的儿童医院或妇幼保健院组成研究协作组参加调查。采用前瞻性方法调查2004年3月1日至2005年2月28日期间协作医院诊断为RDS的患儿，用描述性流行病学调查方法，对全部病例进行个案资料搜集。调查表内容包括患儿的一般临床特征、产前和出生史、表面活性物质和辅助通气的使用情况、患儿预后和疾病负担等。结果23家医院连续12个月收治RDS患儿711例，占NICU收治总数的5．4％。平均胎龄（32．0±2．8）周，平均出生体重（1767±571）g，72．3％为男性，18．0％为小于胎龄儿，20．6％有胎儿窘迫史，剖宫产率为38．7％，多胎出生率为21．4％，15．5％患儿5min Apgar评分〈7分。胎龄≤34周患儿母亲中仅25．0％接受了产前糖皮质激素治疗。与东南沿海地区医院相比，中西部医院收治的RDS患儿胎龄或出生体重更大，小于胎龄儿、胎儿窘迫、剖宫产和多胎分娩率更高，而产前激素使用率更低（P均〈0．05）。711例患儿中，241例（33．9％）在产房或NICU接受了表面活性物质治疗，602例（84．7％）接受了辅助通气包括经鼻持续气道正压通气，东南沿海地区表面活性物质和辅助通气的使用率均明显高于中西部地区（P=0．000），且东南沿海地区54．9％（245／446）的患儿接受了经鼻持续气道正压通气治疗，而中西部地区仅有35．1％（93／265）。RDS患儿总病死率为31．4％（223／711）；中西部地区患儿的病死率明显高于沿海地区（x^2=13．384，P=0．000）。存活出院患儿的中位住院时间为18．0d，住院费用为人民币1．65万元；东南沿海地区的住院时间和住院费用明显高于中西部地区，差异有统计学意义（P=0．000）。结论当前我国RDS的救治技术和救治疗效均显著提高，但中西部地区与东南沿海地区相比，仍存在较大的差距。

Objective To investigate and compare the status of admission and treatment of neonatal respiratory distress syndrome （RDS） in neonatal intensive care units （NICUs） between the South-eastern and Mid-western China. Methods Twenty-three NICUs of tertiary maternity and children＇s hospitals participated in the survey. Data of infants with RDS admitted to NICU of participated hospitals from Mar. 1, 2004 to Feb. 28, 2005 were collected. Infant information including demographics, ante-and perinatal history, respiratory care, survival and clinical burden were compared. Results Seven hundred and eleven infants with RDS accounted for 5. 4% of NICU admissions enrolled in this study. The mean gestational age （GA） and birth weight （BW） were （32.0 ±2.8） weeks and （1767±571） g. Among these patients, 72.3% were male, 18.0% small for gestational age （SGA）, 20. 6% fetal distress, 38.7% delivered by cesarean section, 21.4% multiple births and 15.5% Apgar score 〈7 at 5 min. Among the infants whose GA≤34 weeks, only 25.0% received antenatal steroids. Compared to South-eastern area, infants of Mid-western area had larger GA or BW, and higher rates of SGA, fetal distress, cesarean section and multiple births, and lower rate of antenatal steroid use （P〈0.05）. Of all RDS infants, 241 （33.9%） received pulmonary surfactant therapy in delivery room or NICU, and 602 （84.7 %） required assisted ventilation including nasal continuous positive airway pressure; infants of South-eastern area had higher rates of receiving pulmonary surfactant and assisted ventilation than Mid-western area （P〈0.01）. In South-eastern area, 10 infants receive inhaled nitric oxide, but none in Mid-western area. Overall, the in-hospital mortality for RDS was 31.4% （223/711）. Of 223 died cases, 49 died after aggressive treatment and 174 after withdrawal of intensive care. Mortality in Mid-western area was significanty higher than that in South-eastern area （x^2=13. 384, P= 0. 000）. Median length and cost of hospital stay for survived infants were 18.0 days and 16 500 Yuan （CNY）. Infants in South-eastern area had longer length and higher cost of hospital stay than those in Mid-western （P 〈 0.01）. Conclusions Both of the application and effectiveness of rescue respiratory therapies make great improvement in our country in the last years, but with regional variation. Great quality improvement in neonatal intensive care should be made in our country, especially in Mid-western China.