INSURE策略治疗早产儿呼吸窘迫综合征失败的危险因素

Risk factors for the failure of the INSURE strategy in premature infants with respiratory distress syndrome

目的分析初始采用气管插管-气管内滴入肺表面活性物质-拔管后经鼻持续呼吸道正压通气(INSURE)策略治疗早产儿呼吸窘迫综合征(RDS)失败的相关危险因素.方法选取2016年8月至2018年11月厦门市妇幼保健院新生儿科收治的初始采用INSURE方案治疗的RDS 351例,胎龄<34周,依据出生72 h内患儿是否需再次气管插管应用有创呼吸机治疗,分为INSURE成功组(281例)与INSURE失败组(70例),分析2组早产儿的相关临床资料.结果INSURE治疗失败率为19.9%(70/351例).与INSURE成功组比较,INSURE失败组早产儿胎龄[31.9(30.0,32.6)周]及出生1 min Apgar评分[(8.0±1.9)分]偏低(Z=10.533、t=2.354,均P<0.05);男婴比例(74.3%)、动脉导管未闭(PDA)并发率(无PDA 12.9%,<0.25cm 26.8%,≥0.25 cm 28.3%)及孕产妇中胎盘早剥的发生率(21.4%)更高,RDS分级(1级2.5%,2级16.1%,3级30.3%,4级66.7%)更为严重(x2=41.169,P<0.05);产前糖皮质激素的使用率(未使用28.3%、部分疗程24.9%及足疗程14.4%)偏低(x2=7.315,P<0.05).Logistic回归分析显示:孕妇产前未使用糖皮质激素(OR=0.634,95%CI:0.423~0.951,P=0.027)、胎盘早剥(OR=2.203,95%CI:1.024~4.738,P=0.043)、胎儿为男性(OR=2.475,95%CI:1.259~4.867,P=0.009)、低胎龄(OR=0.835,95%CI:0.707~0.986,P=0.033)、RDS分级严重(OR=2.829,95%CI:1.886~4.245,P=0.000)及PDA(OR=1.550,95%CI:1.040~2.311,P=0.032)是INSURE治疗失败的危险因素,差异均有统计学意义(均P<0.05).结论胎盘早剥、男性、RDS分级高及PDA存在是INSURE治疗失败的危险因素,产前糖皮质激素的使用可提高INSURE治疗的成功率.

Objective To analyze the risk factors for the failure of the intubate-surfactant-extubate to continuous positive airway pressure(INSURE)strategy in preterm infants with respiratory distress syndrome(RDS).Methods Premature infants with gestation age<34 weeks and hospitalized between August 2016 and November 2018 in Department of Neonatology,Xiamen Maternal and Child Health Hospital were eligible for this descriptive study,and were classified into 2 groups:INSURE success group(281 cases),and INSURE failure group(70 cases),according to whether the infants need to be re-intubated and have invasive ventilator therapy within 72 hours after birth.The clinic information of premature infants in different groups were analyzed.Results The failure rate of INSURE strategy was 19.9%(70/35I cases).Compared with the success group,the premature infants in failure group had smaller gestational age[31.9(30.0,32.6)weeks]and lower 1 minute Apgar score(8.0±1.9)scores(Z=10.533,t=2.354,all P<0.05).The incidence of male infants(74.3%),patent ductus arteriosus(PDA)(12.9%without PDA,26.8%<0.25 cm,28.3%≥0.25 cm)and maternal placental abruption was higher(21.4%),and radiological grade(grade 1 was 2.5%,grade 2 was 16.1%,grade 3 was 30.3%,and grade 4 was 66.7%)was more severe(χ2=41.169,P<0.05).The use rate of antepartum glucocorticoid(28.3%without use,24.9%for partial treatment and 14.4%for full treatment)was lower(χ2=7.315,P<0.05).Logistic regression analysis showed that no use of antepartum glucocorticoid(OR=0.634,95%CI:0.423-0.951,P=0.027),placental abruption(OR=2.203,95%CI:1.024-4.738,P=0.043),male infants(OR=2.475,95%CI:1.259-4.867,P=0.009),low gestational age(OR=0.835,95%CI:0.707-0.986,P=0.033),severe radiological grade(OR=2.829,95%CI:1.886-4.245,P=0.000),and PDA(OR=1.550,95%CI:1.040-2.311,P=0.032)were the risk factors for INSURE failure.Conclusions Placental abruption,male infants,lower gestational age,severe RDS grading,and PDA are risk factors for the failure of the INSURE strategy in preterm infants with respiratory distress syndrome.Antepartum glucocorticoid treatment can improve success rate of INSURE treatment.