重症肺炎并呼吸衰竭患儿动态无创肺动脉压力监测及其意义

Noninvasive pulmonary arterial pressure monitoring in the children with severe pneumonia and respiratory failures and its significance

目的 探讨动态无创肺动脉压力（PAP）测定在重症肺炎并呼吸衰竭中的应用价值。方法 前瞻性研究，对象为2013年6月至12月上海交通大学附属儿童医院儿童重症监护病房收治的重症肺炎并呼吸衰竭患儿69例，排除心源性疾病并肺动脉高压（PAH）患儿。采用床旁彩色多普勒超声心动图动态测定PAP、心脏指数（CI）、左心室射血分数（LVEF）、心脏舒张早期心室充盈速度最大值/舒张晚期心室充盈速度最大值（E/A）变化。根据有否PAH，分为PAP正常组和 PAH 组，评估 PAP变化对预后、机械通气情况等转归影响。有PAH 时应用米力农［0.5 μg/（kg·min）］，比较用米力农前及治疗后24 h、48 h、72 h PAP变化和心功能情况。结果 （1）69例患儿中，男40例，女29例；年龄2个月～12岁；体质量（14.3±8.9）kg。小儿危重病例评分为（70.5±9.6）分，儿童死亡危险因素评估为（13.5±5.0）分。69例患儿中，PAH 组46例，其中机械通气38例，死亡9例；PAP正常组23例，其中需机械通气8例，2组机械通气率及病死率比较差异有统计学意义（χ2=15.78，P 〈0.01；χ2=5.18，P 〈0.05）。与PAP正常组比较，PAH 组机械通气时间明显延长，差异有统计学意义（t=3.89，P 〈0.01）。46例并 PAH 患儿，使用米力农后24 h、48 h、72 h后 PAP监测分别为（49.10 ±4.69）mmHg（1 mmHg=0.133 kPa）、（42.53±4.54）mmHg、（35.63±4.78）mmHg，明显低于用药前（58.23±5.44）mmHg，差异有统计学意义（F =67.11，P 〈0.01）；用药前后CI、LVEF及E/A无明显统计学意义（P均 〉0.05）。9例PAP无明显下降，反而呈上升趋势，最后未撤离呼吸机，自动出院或死亡。结论 动态无创PAP测定，有助于重症肺炎并呼吸衰竭患儿病情评估及预后判断，米力农治疗可降低PAP。

Objective To evaluate the value of noninvasive monitoring of pulmonary arterial pressure in the children with severe pneumonia and respiratory failure. Methods A prospective study was adopted to investigate 69 patients who suffered from severe pneumonia and respiratory failure in Pediatric Intensive Care Unit in Shanghai Children＇s Hospital from June 2013 to December 2013 were involved in this study, except for heart disease. The pulmonary arterial pressure （PAP） and cardiac function were monitored by using bedside color doppler ultrasound cardiogram, such as PAP, cardiac index （CI）, left ventricle ejection fraction （LEFT）, and heart early diastolic filling velocity maxi- mum/heart late diastolic filling velocity maximum （ E/A ratio）. They were divided into 2 groups according to PAP, one group as pulmonary arterial pressure normal group, the other group as pulmonary arterial hypertension（ PAH ） group, and the impact of the PAP on the prognosis and mechanical ventilation was assessed. Milrinone[0.5 μg/（ kg · min） ] were given the patients who were combined with pulmonary hypertension, and the PAP and cardiac function before using Milrinone and 24 h,48 h and 72 h after giving medicine was observed. Results Among 69 cases,40 cases were male and 29 cases were female,age ranging from 2 months to 12 years old,and the weight range was （ 14.3 ± 8.9） kg. The pediatric critical illness score（PICS） was 70.5 ± 9.6 ,and the pediatric risk of score mortalityⅢ was 13.5 ± 5.0. Among 69 cases ,46 cases had pulmonary arterial hypertension ,38 cases of them experienced mechanical ventilation ,and 9 cases died. Among 23 cases who had no pulmonary arterial hypertension, only 8 cases experienced mechanical ventilation. There was a significant difference in the mechanical ventilation rate and mortality between two groups（χ^2 = 15.78 ,P 〈 0.01 ; χ^2=5.18, P 〈 0.05 ）. The mechanical ventilation time was longer in pulmonary arterial hypertension group （ t = 3.89, P 〈 0.01 ）. PAP was （ 58.23 ±5.44 ） mmHg （ 1 mmHg = 0.133 kPa）, （49.10 ± 4.69 ） mmHg, （ 42.53 ± 4.54 ） mmHg and（35.63 ±4.78） mmHg respectively before and after using Milrinone 24 h,48 h and 72 h in 46 cases with pulmonary arterial hypertension, and the pressure decreased significantly after using medicine （F = 67.11, P 〈 0.01 ）. There was no significant difference in CI, LVEF and E/A（ all P 〉 0.05 ）. However,9 cases of them did not show any response to Milrinone, and in the end they couldn＇t live without mechanical ventilation, they died. Conclusions Noninvasive pulmonary arterial pressure monitoring could be beneficial in judging patient＇s condition and assessing prognosis of children with severe pneumonia and respiratory failure, and milrinone could decrease PAP.