体外膜式氧合治疗新型甲型H1N1流感所致重症急性呼吸窘迫综合征患者的临床分析

Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome caused by novel 2009 influenza A （H1N1） virus

目的 总结体外膜式氧合（ECMO）治疗新型甲型H1N1流感所致重症急性呼吸窘迫综合征（ARDS）的临床经验,探讨其应用指征.方法 收集2009年12月至2010年1月北京及天津地区5家医院5个ICU收治的18例接受ECMO治疗的危重型新型甲型H1N1流感患者的临床资料,设计统一表格,由具有ECMO操作经验的医师采集资料并填写表格,主要包括患者一般情况、ECMO前一般情况、ECMO疗效及并发症、机械通气应用情况和临床转归.以SPSS 11.5统计软件包进行数据处理.结果 共有18例新型甲型H1N1流感所致重症ARDS接受ECMO治疗,男性及女性各9例（女性均为孕产妇）,平均年龄（33±11）岁,其中8例并发有气压伤（6例为气胸）.接受ECMO前,平均应用无创正压通气ld,有创通气60h.ECMO前2～6h生理学指标：平均氧合指数为（53±14）mm Hg,呼气末正压（PEEP）为（17±5）cm H20,Murray急性肺损伤评分3.80±0.29,pH值7.38±0.10,血乳酸（3.3±2.3）mmol/L,急性生理与慢性健康Ⅱ（APACHEⅡ）评分16±8.均采用静脉-静脉ECMO（VV-ECMO）方式,ECMO前、ECMO后2h机械通气参数设置分别为：呼吸道峰压（31±7）、（25±6）cm H2O,呼吸频率（15±4）、（22±6）次/min,吸入气氧浓度0.8～1.0、0.35～0.50,PEEP（16±5）、（12±4）cm H20.与ECMO前6h相比,ECMO后2h及24h动脉血气指标（pH,PaO2及PaCO2）均显著改善（P＜0.05）.ECMO支持时间2～168 d,平均为8d.11例成功脱离ECMO（其中8例存活出院,1例仍在ICU接受治疗,2例在ICU内死亡）,7例ECMO治疗过程中死亡.结论 对于常规机械通气难于支持的新型甲型H1N1流感所致重症急性ARDS,ECMO可显著改善这类患者的氧合与通气状况,使肺充分休息,为治疗原发病争取足够时间.

Objective To summarize the clinical experiences and indications of extracorporeal membrane oxygenation（ECMO）for severe ARDS caused by novel 2009 influenza A（H1N1）virus.Methods All ECMO cases with severe ARDS associated with novel 2009 influenza A（H1 N1）virus were analyzed in 5 intensive care units（ICUs）from 5 different hospitals in Beijing and Tianjin.A physician experienced in ECMO handling collected the relevant data,including general conditions pre and postEMCO,efficacy and complication parameters,ventilator settings of mechanical ventilation and clinical outcomes.The statistical software of SPSS（version 11.5）was used for data analysis.Results 18 cases of novel H1 N1 influenza with severe ARDS received ECMO.There were 9 males and 9 females（all pregnant）.The mean age was（33 ± 11）years old.Eight were complicated with pulmonary barotraumas（6 of pneumothorax）.Prior to ECMO,the patients underwent noninvasive and invasive positive pressure ventilation for 1 day and 60 hours respectively.Physiological parameters 2-6 hours prior to ECMO use were：（53 ± 14）mm Hg of PaO2/FiO2,（17 ± 5）cm H2O of positive end expiratory pressure（PEEP）,3.80 ± 0.29 of Murray lung injury score,（7.38 ±0.10）of arterial pH,（3.3 ±2.3）mmol/L of serum lactate,16 ±8 of APACHE Ⅱ score.All patients treated venous-venous ECMO（VV-ECMO）for a mean duration of 8 days（range：2-168）.Settings of mechanical ventilation（prior to ECMO vs 2 hours postECMO）were：peak airway pressure（31 ±7）vs（25 ±6）cm H2O,respiratory rate（15 ±4）vs（22 ±6）breaths/min,FiO20.8-1.0 vs 0.35-0.50,PEEP（16 ± 5）vs（12 ± 4）cm H2O.Arterial blood gas （pH,PaO2 and PaCO2）Post-ECMO of 2 hours and 24-hour significantly improved（P 〈 0.05）.Severn patients died during ECMO,11 patients were successfully weaned from ECMO.And 8 of them survived and were discharged.One patient stayed in ICU and 2 died in ICU.Conclusions As an effective measure of respiratory supports,ECMO may provide pulmonary rest and improve gas exchanges in severe ARDS induced by novel H1N1 Influenza.