高频振荡通气联合容量保证通气治疗新生儿持续性肺动脉高压的临床疗效

Clinical efficacy of high frequency oscillatory ventilation combined with volume guarantee ventilation in the treatment of neonates with persistent pulmonary hypertension

目的探讨高频振荡通气(HFOV)+容量保证(VG)通气治疗新生儿持续性肺动脉高压(PPHN)的疗效。方法选择2016年3月至2019年9月华中科技大学同济医学院附属武汉儿童医院及华中科技大学同济医学院附属同济医院收治的93例PPHN患儿为研究对象。根据随机数字表法,将其分为3组:HFOV+VG组(n=30,采用HFOV联合VG模式进行通气治疗);HFOV组(n=31,采用HFOV模式进行通气治疗)和SIMV+VG组(n=32,采用SIMV联合VG模式进行通气治疗)。观察3组患儿不同时间点氧合指数(OI)、动脉/肺泡氧分压比值(a/APO_2)、氧疗时间、机械通气(MV)时间、NO吸入(iNO)时间、平均住院时间、并发症及神经系统随访情况。采用单因素方差分析与最小显著差异(LSD)-t法,对3组患儿胎龄、肺动脉收缩压(sPAP)、出生体重、生后5 min Apgar评分、MV时间、氧疗时间、iNO时间、住院时间、住院费用等进行统计学分析。采用重复测量资料方差分析,对3组患儿不同时间点OI和a/APO_2进行统计学分析。采用χ~2检验,对患儿性别、病因构成比和并发症发生率等进行分析。本研究得到华中科技大学同济医学院附属武汉儿童医院伦理委员会批准(审批文号:武汉妇儿中心2016045)。本研究与纳入研究患儿监护人均签署临床研究知情同意书。结果 (1)3组患儿性别、胎龄、sPAP、出生体重、生后5 min Apgar评分、OI等临床资料比较,差异均无统计学意义(P>0.05)。(2)3组患儿接受不同通气模式治疗后,不同时间点OI和a/APO_2方差分析结果显示,对于OI,不同处理措施和时间因素有交互效应(F_(处理×时间)=9.420,P<0.001),对于a/APO_2,亦有交互效应(F_(处理×时间)=21.331,P<0.001)。(3)3组患儿MV时间、氧疗时间、iNO时间、住院时间和住院费用分别总体比较,差异均有统计学意义(P<0.05)。(4)3组患儿VAP、肺气漏、肺出血、颅内出血发生率、28 d病死率及中位生存时间比较,差异均无统计学意义(P>0.05)。(5)3组患儿3、6个月龄《Gesell发育量表》 5项能区结果显示,大运动行为、精细运动行为、语言行为、适应性行为、个人社交行为发育商值比较,差异均无统计学意义(P>0.05)。结论 HFOV+VG模式可迅速改善患儿肺部氧合状况,缩短MV及iNO时间,降低平均住院日及住院费用,不影响患儿近期并发症发生率及远期神经系统发育结局。

Objective To investigate efficacy of high frequency oscillatory ventilation(HFOV)+volume guarantee(VG)ventilation in the treatment of persistent pulmonary hypertension(PPHN)in neonates.Methods From March 2016 to September 2019,a total of 93 neonates with PPHN admitted to Wuhan Children′s Hospital,Tongji Medical College of Huazhong University of Science&Technology and Tongji Hospital,Tongji Medical College of Huazhong University of Science&Technology were selected into this study.They were divided into three groups according to random number table,HFOV+VG group(n=30,treatment by HFOV combined with VG);HFOV group(n=31,treatment by single HFOV)and SIMV+VG group(n=32,treatment by SIMV combined with VG).Oxygenation index(OI),arterial/alveolar oxygen partial pressure ratio(a/APO 2),duration of oxygen therapy,duration of mechanical ventilation(MV),duration of NO inhalation(iNO),hospital stay,recent complications and neurological follow-up were observed.Gestational age,systolic pulmonary arterial pressure(sPAP),birth weight,Apgar score at 5 minutes after birth,duration of mechanical ventilation,duration of oxygen therapy,duration of iNO,hospital stay,and hospital costs among three groups were analyzed by one-way ANOVA and least significant difference(LSD)-t test for overall comparison and further comparison between each two groups.OI and a/APO 2 at different time points among three groups were statistically analyzed by ANOVA of repeated measurement data,independent-samples t test and LSD-t test.Gender,etiological constituent ratio and incidence of complications were analyzed by chi-square test.The procedures followed in this study were in accordance with the standards established by the Committee of Investigation in Human Beings of Wuhan Children′s Hospital,Tongji Medical College of Huazhong University of Science&Technology,and this study was approved by the committee(Approval No.2016045).Informed consent was obtained from each participates′guardians.Results①There were no significant differences among three groups in clinical data,such as gender,gestational age,sPAP,birth weight,Apgar score at 5 minutes after birth and OI(P>0.05).②The OI and a/APO 2 at 0,12,24 and 72 h after MV among 3 groups showed that,for OI,there was an interaction effect between different treatment measures and time factors(F treatment×time=9.420,P<0.001);for a/APO 2,there was interaction effect between different treatment measures and time factors(F treatment×time=21.331,P<0.001).③There were significant differences in the duration of mechanical ventilation,oxygen therapy,iNO,hospital stay and hospitalization costs among 3 groups(P<0.05).④There was no significant difference in the incidence of VAP,pulmonary air leak,pulmonary hemorrhage,intracranial hemorrhage,28 d mortality and survival time among 3 groups(P>0.05).⑤The results of the five performance areas of the Gesell Developmental Scale at 3 and 6 months of age in the three groups showed that there were no significant differences in the developmental quotient of macromotor behavior,fine motor behavior,language behavior,adaptive behavior,and personal social behavior(P>0.05).⑤The results of the 5 Gesell subscales of Gesell Developmental Scale at 3-and 6-month among 3 groups showed that there were no significant differences in the developmental quotient of gross motor behavior,fine motor behavior,language behavior,adaptive behavior and personal social behavior(P>0.05).Conclusions HFOV+VG mode can rapidly improve the pulmonary oxygenation,shorten MV and iNO duration,reduce average length of hospital stay and hospitalization costs,does not affect the incidence of short-term complications and long-term neurological development outcomes.