同步间歇正压通气和同步间歇指令通气对新生儿肺透明膜病早产儿心功能的影响研究

Synchronized Intermittent Positive Pressure Ventilation versus Synchronized Intermittent Mandatory Ventilation on Cardiac Function of Premature Infants with Hyaline Membrane Disease

目的探讨在相同通气参数下,同步间歇正压通气(SIPPV)和同步间歇指令通气(SIMV)模式对新生儿肺透明膜病(HMD)早产儿心功能的影响。方法选择2013年3月—2015年3月深圳市人民医院新生儿科收治的新生儿HMD早产儿100例,采用随机数字表法分为SIPPV组50例和SIMV组50例,另外选取健康早产儿50例为对照组,SIPPV组与SIMV组早产儿均使用瑞典产Maquet SERVO-i呼吸机,采用合适的气管导管,通气参数相同;SIPPV组模式为SIPPV,SIMV组模式为SIMV。记录气道压、潮气量、呼吸频率(RR)、血压、pH值、二氧化碳分压(PCO_2)、氧分压(PO_2)。3组早产儿使用彩色多普勒超声诊断仪测定左心室泵血功能指标,包括左心室射血分数(LVEF)、左心室短轴缩短率(LVFS)、左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、每搏量(SV)、心率(HR)、心输出量(CO);同时测量心脏各瓣膜血流速度,包括主动脉瓣口血流速度(AV)、肺动脉瓣口血流速度(PV)和左房室瓣口(MV)及右房室瓣口(TV)的舒张早期峰值血流速度(E峰)与舒张晚期峰值血流速度(A峰)比值(M-E/A、T-E/A)。结果 SIMV组早产儿气道压、潮气量较SIPPV组降低(P<0.05)。SIPPV组与SIMV组早产儿血压、pH值、PCO_2、PO_2比较,差异均无统计学意义(P>0.05);SIMV组早产儿RR较SIPPV组降低(P<0.05)。3组早产儿LVEF、LVFS、LVEDV、LVESV、SV、CO、AV、M-E/A比较,差异均无统计学意义(P>0.05);3组早产儿HR、PV、T-E/A比较,差异均有统计学意义(P<0.05);其中SIPPV组早产儿HR较对照组升高,PV、T-E/A较对照组降低(P<0.05);SIMV组早产儿HR较SIPPV组降低,PV、T-E/A较对照组降低,PV、T-E/A较SIPPV组升高(P<0.05)。SIPPV组和SIMV组气道压、潮气量与PV、T-E/A均呈负相关(P<0.05)。结论早产儿应用SIPPV和SIMV模式机械通气,在设定相同通气参数下,右心室舒张功能和PV降低,SIPPV模式较SIMV影响更大。两者对左心室泵功能和舒张功能无明显影响。

Objective To compare the effect of synchronized intermittent positive pressure ventilation（ SIPPV） with that of synchronized intermittent mandatory ventilation（ SIMV） at the same level of parameters on the cardiac function in premature infants with hyaline membrane disease（ HMD）. Methods One hundred premature infants with HMD admitted in Department of Neonatology,Shenzhen People＇s Hospital from March 2013 to March 2015 were randomized into SIPPV group（ 50cases） and SIMV group（ 50 cases）. Both groups were treated with invasive mechanical ventilation,with the Maquet SERVO-i respirator produced in Sweden,appropriate tracheal catheter and the same level of parameters,but different ventilation mode,SIPPV group adopted SIPPV mode,SIMV group adopted SIMV mode. Other 50 healthy premature infants with matched sex,gestational age,mode of delivery and birth weight were selected as the control group. The mean airway pressure（ MAP）,tidal volume（ VT）,respiratory rate（ RR）,blood pressure,pH value,carbon dioxide（ PCO2）,oxygen partial pressure（ PO2）of the SIPPV and SIMV groups were recorded. In all groups,color Doppler echocardiography was used to determine the indexes for evaluating left ventricular pump blood function,including left ventricular ejection fraction（ LVEF）,left ventricular fractional shortening（ LVFS）,left ventricular end-diastolic volume（ LVEDV）, left ventricular end-systolic volume（ LVESV）,stroke volume（ SV）, heart rate（ HR）, and cardiac output（ CO）, and to measure the blood flow velocity at the valve orifices,covering peak flow rate at the aortic valve orifice（ AV）,and peak flow rate at the pulmonary valve orifice（ PV）,mitral ratio of early to late diastolic filling velocities（ M-E/A） and tricuspid ratio of early to late ventricular filling velocities（ T-E/A）. Results MAP and VT in the SIMV group were lower than those in the SIPPV group（ P〈0. 05）. Blood pressure,pH value,PCO2,PO2 between SIPPV group and SIMV group had no significant difference（ P〈0. 05）. RR in the SIMV group was lower than that in the SIPPV group（ P〈0. 05）. LVEF,LVFS,LVEDV,LVESV,SV,CO,AV,M-E/A among the three groups did not differ significantly（ P〈0. 05）. Notable differences in HR,PV,T-E/A were found among the three groups（ P〈0. 05）. Compared with the control group,the SIPPV group had higher HR but lower PV and T-E/A（ P〈0. 05）. SIMV group had lower HR but higher PV and T-E/A than the SIPPV group did（ P〈0. 05）. And it had lower PV and T-E/A than the control group did（ P〈0. 05）. MAP and VT were negatively correlated with PV and T-E/A in both the SIPPV group and SIMV group（ P〈0. 05）. Conclusion Right ventricular diastolic function and PV decreased in both the SIPPV and SIMV groups at the same level of parameters,but they decreased more in the former group; while left ventricular pump function and diastolic function in both groups had no obvious changes.