高频振荡机械通气在血液肿瘤及多种疾病并发儿童急性低氧性呼吸衰竭中的应用

High-frequency oscillatory ventilation in children with hematologic neoplasms and other causes induced acute hypoxic respiratory failure

目的 评估儿童急性低氧性呼吸衰竭（acute hypoxemic respiratory failure,AHRF）给予高频振荡机械通气（high-frequency oscillatory ventilation,HFOV）治疗的意义.方法 回顾2011年1月至2013年9月收入我院PICU诊断为AHRF的病例,首先给予常规机械通气（CMV）,当PIP＞ 30cmH2O（1 cmH2O =0.098 kPa）或PEEP＞ 10 cmH2O、FiO2100％时具有以下情况之一：（1）SpO2 ＜90％或PaO2 ＜60 mmHg（1 mmHg =0.133 kPa）;（2）有严重呼吸性酸中毒（PaCO2＞ 80mmHg）;（3）严重气漏（纵隔气肿或气胸）,改为HFOV通气治疗.收集患儿性别、年龄、住PICU时间、CMV通气时间、HFOV通气时间等一般资料.分别于CMV通气末（H0）及HFOV后2 h（H2）、6 h（H6）、12 h（H12）、24 h（H24）、48 h（H48）记录并比较各时间点呼吸机参数（平均气道压、振幅、频率、FiO2）、氧合指数（PaO2/FiO2、OI）、动脉血气、心率、血压变化.分别比较存活组与死亡组、血液肿瘤组及非血液肿瘤组在H0、H2、H6、H12、H24、H48时间点的指标变化.结果 HFOV通气后,H2时间点PaO2较H0升高[76.9（61.9～128.0） mm-Hg vs 50.1 （49.5 ～ 68.0） mmHg],差异有统计学意义（P=0.006）.H2、H48时间点PaO2/FiO2分别较Ho、H24升高,差异有统计学意义[94.9（66.8 ～ 138.9） mmHg vs 68.0（49.5 ～ 86.8）mmHg,P=0.039;135.0（77.6 ～240.0）mmHg vs 90.7（54.6 ～ 161.7） mmHg,P=0.023）].所有患儿收缩压、舒张压、心率在各时间点没有明显变化（P＞0.05）.存活组（n=9）与死亡组（n=14）相比,PaO2/FiO2、OI在H6、H12、H24、H48差异有统计学意义（P＜0.05）.非血液肿瘤组（n=10）与血液肿瘤组（n=13）相比,OI在H2、H6差异有统计学意义[19.2（13.9～26.6） vs 33.8（19.7 ～48.3）,P=0.049;16.0（8.4～27.1） vs28.9（20.9 ～38.9）,P=0.027）],两组的平均气道压在H2、H6、H12差异有统计学意义（P＜0.05）.两组病死率差异无统计学意义（40.0％ vs 76.9％,P=0.086）.结论 AHRF患儿给予CMV通气失败后改用HFOV可以改善患儿的PaO2和氧合指数,对患儿心率、血压没有明显影响.血液肿瘤伴AHRF组较非血液肿瘤伴AHRF组HFOV初始阶段需要较高的MAP改善氧合,但对病死率无影响.

Objective To evaluate the significance of high-frequency oscillatory ventilation（HFOV） used in acute hypoxic respiratory failure（AHRF） children,failing to conventional ventilation.Methods This was a retrospective study of AHRF children ventilated by HFOV from January 2011 to September,2013.All patients were initially treated by conventional mechanical ventilation （CMV）,and changed to be treated by HFOV if the patient met to one of the following criteria after the CMV parameters of PIP 〉 30 mmH2O（1cmH2O =0.098 kPa） or PEEP 〉 10 cmH2O with FiO2 100% ∶ （1） SpO2 〈 90% or PaO2 〈 60 mmHg （1 mmHg =0.133 kPa） ; （2） severe respiratory acidosis （PaCO2 〉 80 mmHg） ; （3） serious air leakage （mediastinal emphysema or pneumothorax）.The following parameters were recorded：patient＆#39;s gender,age,living PICU time,CMV ventilation time,HFOV ventilation time.We reviewed ventilation parameter settings （MAP,△P,F,FiO2）,oxygenation index（PaO2/FiO2,OI）,arterial blood gas,heart rate,blood pressure at different time points including late CMV（H0）,2 h after HFOV（H2）,6 h after HFOV（H6）,12 h after HFOV（H12）,24 h after HFOV （H24） and 48 h after HFOV （H48）,respectively.Various indexes at different time points were compared between survival group and death group,oncology group and no-oncology group.Results PaO2 at H2 compared with H0 had significant improvement[76.9（61.9 ～ 128.0） mmHg vs 50.1 （49.5 ～68.0） mmHg,P =0.006] . PaO2/FiO2 at H2,H48 had significant improvement compared with those at H0,H24 [94.9（66.8 ～ 138.9） mmHg vs 68.0（49.5 ～86.8） mmHg,P=0.039; 135.0（77.6～240.0） mmHg vs 90.7 （54.6 ～161.7） mmHg,P =0.023）].All children＆#39;s systolic pressure,diastolic blood pressure,heart rate at various time points had no difference （P 〉0.05）.Compared to death group（n =14）,PaO2/FiO2,OI at H6,H12,H24,H48 in survival group （n =9） had significant improvement（P 〈 0.05）.Compared to oncology group （n =10）,OI at H2,H6 in no-oncology group（n =10） had significant improvement [（19.2 （13.9 ～ 26.6） vs 33.8 （19.7 ～ 48.3）,P =0.049 ; 16.0（8.4 ～27.1） vs 28.9（20.9 ～38.9）,P =0.027）],and mean airway pressure between two groups at H2,H6,H12 had significant improvement（P 〈 0.05）.Mortality had no significant differcence between two groups （4/10 vs 10/13,P =0.086）.Conelusion HFOV used in children with AHRF which had failed with CMV ventilation can improve the patient＇s PaO2 and OI.Heart rate and blood pressure are stable during HFOV treatment.Oncology group patients needed higher initial MAP to improve oxygenation than no-oncology group patients when changed to HFOV treatment,but the mortality showed no difference between two groups.