小儿急性呼吸窘迫综合征应用肺保护性通气策略的预后比较

The outcome of acute respiratory distress syndrome in children treated by lung protective ventilation strategy

目的观察29d至14岁小儿肺内外源性急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）应用小潮气量肺保护性通气策略的救治效果及临床转归的差异。方法对2003年1月至2014年12月中国医科大学附属盛京医院PICU收治的354例ARDS患儿进行回顾性分析。依照病因及通气策略分为肺内源性ARDS肺保护性通气组154例、肺内源性ARDS传统通气组96例、肺外源性ARDS肺保护性通气组72例和肺外源性ARDS传统通气组32例。肺内源性ARDS肺保护性通气组与肺外源性ARDS肺保护性通气组采用肺保护性通气策略，潮气量6—8ml／kg，应用相对较高的呼气末正压（PEEP），调节FiO2及PEEP以维持经皮血氧饱和度高于88％。肺内源性ARDS传统通气组与肺外源性ARDS传统通气组采用传统通气策略，潮气量10～12ml/kg，调节Fi02以维持经皮血氧饱和度高于88％。分别比较肺内源性ARDS肺保护性通气组与传统通气组、肺外源性ARDS肺保护性通气组与传统通气组的病死率、机械通气天数及PICU住院时间。结果肺内源性ARDS肺保护性通气组病死率35．29％，机械通气天数[12（2～44）d]及PICU住院时间[16（2～67）d]低于肺内源性ARDS传统通气组病死率45．62％，机械通气天数[16（3—26）d]及PICU住院时间[22（3—56）d]，但差异无统计学意义（P〉0．05）。肺外源性ARDS肺保护性通气组病死率22．22％、机械通气天数[9（1～19）d]及PICU住院时间[14（1～66）d]低于肺外源性ARDS传统通气组病死率46．87％、机械通气天数[16（1—21）d]及PICU住院时间[25（1～47）d]，差异有统计学意义（P〈0．05）。结论肺外源性ARDS应用肺保护性通气策略的治疗效果可能优于肺内源性ARDS，但确定结论尚需进一步进行前瞻性临床研究。

Objective To observe the effect of lung protective ventilation on children with acute respiratory distress syndrome primarily from pulmonary diseases （ARDSp）and acute respiratory distress syndrome primarily from extra-pulmonary diseases（ARDSexp）. Methods Between January 2003 and December 2014,354 chip dren with ARDS admitted in PICU of Shengjing Hospital of China Medical University were enrolled and devided into ARDSp protective-ventilation group （ n = 154）, ARDSp conventional-ventilation group （ n = 96）, ARDSexp pro- tective-ventilation group（ n = 72）and ARDSexp conventional-ventilation group （n = 32 ）. The patients in ARDSp protective-ventilation group and ARDSexp protective-ventilation group received lower tidal volume （6-8 ml/kg） and high levels of positive end-expiratory pressure （PEEP）, and optimal oxygenation was achieved by adjusting FiO2 and PEEP. The patients in ARDSp conventional-ventilation group and ARDSexp conventional-ventilation group received relatively higher tidal volume（ 10-12 ml/kg）, and optimal oxygenation was achieved by adjusting FiO： and PEEP. The mortality,ventilator days and PICU stay days were compared among the four groups. Resdts The mortality, ventilation days, and PICU stay days were lower in ARDSp protective-ventilation group than those of ARDSp conventionalventilation group [ 35. 29% vs. 45.62%, 12 （ 2 -44 ） d vs. 16 （ 3-26 ） d, 16 （ 2-67 ） d vs. 22 （3-56） d ] ,but there were no significant differences（P 〉0. 05 ）. The mortality, ventilation days ,and PICU stay days were also lower in ARDSexp protective-ventilation group than those of conventional-ventilation group E 22. 22% vs. 46. 87% ,9（ 1-19 ） d vs. 16（ 1-21 ） d, 14（1-66） d vs. 25 （ 1-47 ） d ], which showed significant differences（ P 〈0. 05 ）. Conclusion Lung protective ventilation may improve the outcome for pediatric patients with ARDSexp,however, larger trials are required before a definite conclusion can be reached.