允许性高碳酸血症通气在新生儿呼吸衰竭中的应用

Application of permissive hypercapnia ventilation in neonatal respiratory failure

目的研究允许性高碳酸血症（permissive hypercapnia，PHC）在无创通气方式同步鼻塞间歇正压通气治疗新生儿呼吸衰竭的疗效。方法选择2015年1月至2017年12月我院NICU收治的47例呼吸衰竭患儿进行回顾性研究。将研究对象分为PHC组（27例，PaCO2 45-70 mmHg，1 mmHg＝0.133 kPa）和非PHC组（20例，PaCO2 35-45 mmHg）。比较无创通气治疗前及24 h的血气指标（PaO2、PaCO2、PaO2/FiO2）；无创通气24 h两组患儿呼吸机参数（PIP、PEEP、FiO2、Ti）；氧疗时间、无创通气时间、开奶时间、住院时间；颅内出血、气漏、呼吸机相关性肺损伤并发症的发生率；无创通气失败后予气管插管行有创通气的再插管率。结果无创通气治疗后24 h两组患儿的PaO2和OI（PaO2/FiO2）显著高于治疗前（P〈0.05）；治疗前后两组间比较差异均无统计学意义（P〉0.05）。非PHC组治疗后PaCO2下降（P〈0.05），但PHC组与治疗前差异无统计学意义（P〉0.05）；PHC组的呼吸机参数PIP值[（19.9±2.7） mmHg]明显低于非PHC组[（21.7±2.3） mmHg]（P〈0.05），其他呼吸机参数两组间比较差异无统计学意义（P〈0.05）。PHC组的氧疗时间、开奶时间、无创通气时间、住院时间均明显短于非PHC组[（79.5±10.8）h比（92.7±19.1）h；（34.3±8.8）h比（47.1±10.8）h；（67.4±12.3）h比（97.6±17.3）h；（11.0±4.6）d比（14.0±3.9）d]，差异有统计学意义（P〈0.05）。PHC组和非PHC组的颅内出血和气漏的发生率比较差异无统计学意义（3/27例比4/20例；3/27例比2/20例）（P〉0.05）；再插管率两组之间差异无统计学意义（2/27例比3/20例）（P〉0.05）；PHC组呼吸机相关性肺损伤的发生率明显低于非PHC组（2/27例比7/20例）（P〈0.05）。结论PHC组与非PHC组治疗改善呼吸衰竭患儿的呼吸功能效果相似，但PHC治疗缩短了患儿氧疗时间、无创通气时间及住院时间，开奶时间提前，降低了呼吸机相关性肺损伤的发生率，临床疗效更显著。

Objective To investigate the significance of permissive hypercapnia（PHC） in the treatment of neonates with respiratory failure using synchronized nasal intermittent positive pressure ventilation. Methods A retrospective study was conducted in 47 neonates with respiratory failure admitted to our NICU during January 2015 to December 2017. The subjects were divided into PHC group （ n = 27, PaCO2 45 - 70 mmHg, 1 mmHg = 0. 133 kPa） and non-permissive hypercapnia （non-PHC） group （ n = 20, PaCO2 35 - 45 mmHg）, respectively. The blood gas indicators （ PaO2, PaCO2, PaO2/FiO2 ） before and after non-invasive ventilation treatment were compared; Ventilator parameters of the two groups （ PIP, PEEP, PiO2 , Ti ） were compared. Duration of oxygen therapy, non-invasive ventilation time, starting time of feeding, length of hospi- tal stay ,the incidence of intracranial hemorrhage, air leakage, ventilation induced lung injury, and reintubation rate were compared between the two groups. Results After treatment, the blood gas indexes of PaO2 and OI at 24h in two groups were significantly higher than those before the treatment（ P 〈 0.05 ）. There was no sig- nificant difference on PaO2 and OI between two groups both before and after treatment. PaCO2 was lower in non-PHC group after treatment than that before the treatment（ P 〈0.05 ） ,but it showed no difference in PHC group （ P 〉 0. 05 ）. The PIP value of the ventilator parameters in PHC group[ （ 19. 9 ± 2. 7 ） mmHg] was sig- nificantly lower than that in the non-PHC group [ （21.7 ± 2.3 ） mmHg 3 （P 〈 0.05 ）, and there was no statisti- cally significant difference between the two groups in the other ventilator parameters （ P 〉 0. 05 ）. Duration of oxygen therapy, starting time of feeding, the time of using noninvasive ventilation, length of hospital stay in PHC group were shorter obviously than those in non-PHC group[ （79. 5 ± 10. 8） h vs. （92. 7 ± 19. 1 ） h;（34.3 ±8.8）h vs. （47. 1±10. 8）h;（67.4±12.3）h vs. （97.6 ± 17.3）h;（11.0±4. 6）d vs. （14.0 ±3.9） d] （P 〈 0. 05）. The incidences of air leakage, and intracraniai hemorrhage showed no significant difference between PHC group and non-PHC group （3/27 eases vs. 4/20 eases ;3/27 cases vs. 2/20 cases） （P 〉 0. 05 ）. There was no significant difference between the two groups in the rate of reintubation of invasive ventilation after non-invasive ventilation failure （ 2/27 cases vs. 3/20 cases, P 〉 0. 05 ）. The incidence of ventilator induced lung injury was significantly lower in PHC group than that in non-PHC group （2/27 cases vs. 7/20 cases） （ P 〈 0. 05 ）. Conclusion The effects of treating respiratory failure were similar in PHC group and non-PHC group. However,the PHC treatment could shorten the time of oxygen therapy,non-invasive ventila- tion time and hospitalization time, reduce the incidence of lung injury associated with ventilator. The clinicai efficacv of PHC was more sienificant.