基于“柏林定义”的新生儿急性呼吸窘迫综合征临床流行病学调查研究

A prospective, multi-center epidemiological study in neonates with acute respiratory distress syndrome based on the Berlin definition

目的了解江苏省新生儿重症监护病房（neonatal intensive care unit，NICU）新生儿急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）的发生率、病死率及影响因素。方法采用前瞻性、多中心临床流行病学研究方法，并应用2012年欧洲危重症协会在德国柏林主持修订的ARDS诊断新标准（柏林定义），对2015年3月至2016年2月收入江苏省9家医院NICU的新生儿ARDS病例及其影响因素进行调查。结果江苏省9家医院NICU在一年内共收治新生儿10 422例，其中8 795例符合危重病例，给予机械通气治疗1 681例。根据ARDS柏林定义，278例诊断为ARDS，其中轻度57例（20.5%），中度85例（30.6%），重度136例（48.9%）；男185例，女93例；足月儿216例，早产儿62例；出生体重2 500～4 000 g 210例，〈2 500 g 57例，〉4 000 g 11例；顺产48例，剖宫产196例，吸引产21例，产钳助产13例。原发疾病包括围产期窒息176例（63.3%），胎粪吸入综合征97例（34.9%），败血症89例（32.0%），肺炎65例（23.4%），新生儿休克38例（13.7%），弥散性血管内凝血28例（10.1%）。在NICU收治的所有患儿中，ARDS发生率为2.7%，占危重病例的3.2%，占机械通气患儿的16.5%。治愈ARDS患儿172例（61.9%），死亡79例（28.4%），自动出院27例（9.7%）。对自动出院的27例患儿进行电话随访，其中17例自动出院后转上级医院治愈，10例自动出院后24 h内死亡。本组新生儿ARDS共死亡89例，病死率32.0%。结论NICU新生儿ARDS发生率及其在危重病例和机械通气病例中的比例均较高，围产期窒息、胎粪吸入综合征、败血症、肺炎、休克和弥散性血管内凝血为主要原发疾病，采取综合治疗可提高治愈率。

ObjectiveTo study the prevalence, mortality and influencing factors of acute respiratory distress syndrome （ARDS） in newborns in Jiangsu province.MethodFrom March 2015 to February 2016, a prospective, multi-center clinical epidemiological study was conducted in neonates admitted to NICUs of 9 hospitals in Jiangsu province. The diagnosis of ARDS was established according to the new diagnostic criteria revised by the European Society for critical Care in Berlin, in 2012 （Berlin definition）.ResultA total of 10 422 neonates were studied, 8 795 critically ill and 1 681 treated with mechanical ventilation. According to the Berlin definition, 278 cases were diagnosed with ARDS, including 57 mild cases （20.5%）, 85 moderate cases （30.6%）, and 136 severe cases （48.9%）. Among the 278 neonates with ARDS, 185 were males and 93 females, 216 full-term infants and 62 preterm infants, 210 cases with birth weight 2 500~4 000 g, 57 cases〈2 500 g and 11 cases〉4 000 g; 48 cases spontaneous delivery, 196 cases cesarean section, 21 cases induced abortion, and 13 cases forceps delivery. The clinical diagnosis on discharge included 176 cases of perinatal asphyxia （63.3%）, 97 cases of meconium aspiration syndrome （34.9%）, 89 cases of sepsis （32.0%）, 65 cases of pneumonia （23.4%）, 38 cases of neonatal shock （13.7%） and 28 cases of disseminated intravascular coagulation （10.1%）. Among all infants admitted to NICU, the incidence of ARDS was 2.7%, accounting for 3.2% of the critical cases and 16.5% of the infants with mechanical ventilation. 172 cases of ARDS were cured, 79 cases died, and 27 cases left the hospital. The 27 leaving cases were followed up by phone. Among them, 17 cases were cured after transferred to higher-tier hospitals, and the other 10 died within 24 hours after discharge. A total of 89 children died in the ARDS group, and the mortality was 32.0%.ConclusionThe incidences of ARDS, critically ill cases and neonates need mechanical ventilation in NICU neonates are quite high. Perinatal asphyxia, meconium aspiration syndrome, sepsis, pneumonia, pulmonary hemorrhage and shock are the main underlying diseases. Comprehensive treatment may improve the outcome.