儿童重症监护病房重症腺病毒肺炎特点和救治方法探讨

Characteristics and treatment of severe adenovirus pneumonia in pediatric intensive care unit

目的了解PICU重症社区获得性腺病毒肺炎的临床特征、治疗现状与预后,探讨合适救治策略。方法回顾性总结2016年8月至2019年1月上海交通大学附属儿童医院PICU收治重症肺炎患儿中,腺病毒肺炎患儿的临床资料,包括症状、器官功能状态、实验室检查特点、抢救措施与结局。结果同期收治重症社区获得性肺炎患儿531例,其中腺病毒肺炎患儿32例,占6.03%。发生年龄集中于3个月~2岁(68.8%),平均年龄18(12,37)个月。高热、呼吸窘迫或喘息、精神萎靡为主要症状。急性期影像学以肺部非对称性渗出病变,部分渗出融合与间质气肿为主。肺外合并症主要为心血管障碍(63.1%)、胃肠障碍(50%)、肝功能障碍(46.9%)、凝血功能障碍(31.3%)和神经系统功能障碍(26.1%)等。呼吸支持包括高流量吸氧2例,机械通气30例,俯卧位通气12例;连续性肾脏替代治疗9例;体外膜肺氧合治疗6例。死亡5例,住院病死率15.6%。其中体外膜肺氧合治疗存活4例,出院存活率66.7%。结论腺病毒感染为PICU收治社区获得性肺炎重要病因,病死率高。俯卧位通气、连续性肾脏替代治疗和体外膜肺氧合等应用,可能改善儿童重症腺病毒肺炎抢救成功率。

Objective To summarize the clinical features, treatment status and prognosis of severe community-acquired pneumonia (CAP) caused by adenovirus in a single pediatric intensive care unit (PICU), and to explore the appropriate diagnosis and treatment strategies. Methods From August 2016 to January 2019, the clinical data of children with adenovirus pneumonia, including symptoms, organ function, laboratory features, rescue measures and results were analyzed retrospectively. Results A total of 531 cases with severe CAP were admitted in PICU, Shanghai Children′s Hospital, Shanghai Jiaotong University.Among them, 32 cases with adenovirus pneumonia accounted for 6.03%.The high incidence age was from 3 months to 2 years old (68.8%), and the average age was 18(12, 37) months.High fever, respiratory distress and mental infirmity were the main symptoms.In acute stage, the pulmonary asymmetrical exudation lesion, partial exudation fusion and interstitial emphysema were observed by chest X rays.The main complications of extrapulmonary organ were cardiovascular disorder (63.1%), gastrointestinal disorder (50%), liver dysfunction (46.9%), coagulation dysfunction (31.3%) and nervous system dysfunction (26.1%). Respiratory support included high flow nasal oxygen therapy in 2 cases, mechanical ventilation in 30 cases, prone position ventilation in 12 cases, and continuous renal replacement therapy (CRRT) in 9 cases, extracorporeal membrane oxygenation (ECMO) therapy in 6 cases.There were 5 cases of death, and the hospital mortality was 15.6%.There were 4 cases survived by ECMO, and the discharge rate was 66.7%. Conclusion Adenovirus infection remains an important cause of CAP in PICU, and the mortality is high.Prone position ventilation, CRRT and ECMO may improve the survival rate of severe adenovirus pneumonia in children.