高频振荡通气与常规机械通气治疗婴幼儿重症呼吸道合胞病毒肺炎的随机对照研究

High frequency oscillatory ventilation and conventional mechanical ventilation in the treatment of infants with severe respiratory syncytial virus pneumonia:a randomized controlled trial

目的比较高频振荡通气(HFOV)与常规机械通气(CMV)对婴幼儿重症呼吸道合胞病毒(RSV)肺炎的临床疗效。方法采用前瞻性随机对照研究方法,选择2018年1月至2019年12月在首都儿科研究所附属儿童医院重症监护病房(ICU)进行有创机械通气治疗的重症RSV肺炎婴幼儿。根据研究对象入ICU顺序,利用随机数字表,将研究对象分配至HFOV组及CMV组。记录两组患儿基本资料、小儿危重评分、血气、呼吸机参数、氧合指数〔OI,OI=平均气道压(Pmean)×吸入氧浓度(FiO2)/动脉血氧分压(PaO2)×100〕、机械通气时间、ICU住院时间、并发症、预后、肌松药及血管活性药物使用情况等临床指标。结果共28例患儿纳入分析,其中接受CMV 15例,HFOV 13例。两组患儿年龄、体质量、入组前小儿危重评分和OI、合并Ⅱ型呼吸衰竭、多器官功能障碍、基础疾病及入组前实验室检查指标比较差异均无统计学意义。入组后6 h,HFOV组心率(HR)、呼吸频率(RR)、经皮血氧饱和度(SpO2)下降例数、HR下降例数、心肺复苏(CPR)例数和OI均较CMV组明显降低〔HR(次/min):130(125,138)比144(140,160),RR(次/min):35(34,38)比40(35,45),SpO2下降例数(例:1比10),HR下降例数(例:0比6),CPR例数(例:0比4),OI:6.5(4.4,8.9)比9.3(8.0,12.8)〕,使用肌松药例数(例:3比0)和7 d液体正平衡量〔mL/kg:167.1(113.8,212.6)比90.8(57.8,112.7)〕均较CMV组显著升高,差异均有统计学意义(均P<0.05)。两组患儿均未使用血液净化治疗,均未出现气胸和颅内出血等严重并发症,且28 d内无一例死亡。结论应用HFOV治疗婴幼儿重症RSV肺炎较CMV可更早改善氧合水平和临床生理指标,减少HR、SpO2下降和CPR等不良事件的发生风险,增加肌松药的使用和液体正平衡,不增加气胸和颅内出血等严重并发症的发生风险,临床应用安全。

Objective To compare the clinical efficacy of high frequency oscillatory ventilation(HFOV)and conventional mechanical ventilation(CMV)in the treatment of infants with severe respiratory syncytial virus(RSV)pneumonia.Methods A prospective randomized controlled trial was conducted.The infants with severe RSV pneumonia who received invasive mechanical ventilation admitted to intensive care unit(ICU)of Children's Hospital Affiliated to Capital Institute of Pediatrics from January 2018 to December 2019 were enrolled.According to the order of admission,each infant was assigned to HFOV group or CMV group by random number table.The basic data,pediatric critical score,blood gas analysis,ventilator parameters,oxygenation index[OI,OI=mean airway pressure(Pmean)×fraction of inspired oxygen(FiO2)/arterial partial pressure of oxygen(PaO2)×100],duration of mechanical ventilation,length of ICU stay,complications,prognosis,use of muscle relaxants and vasoactive drugs and other clinical indicators of the two groups were recorded.Results A total of 28 infants were enrolled in the analysis,including 15 infants receiving CMV and 13 infants receiving HFOV.There were no significant differences in age,body weight,pediatric critical score and OI before enrollment,typeⅡrespiratory failure,multiple organ dysfunction,basic diseases and laboratory examination indexes before enrollment between the two groups.Six hours after enrollment,compared with CMV group,heart rate(HR),respiratory rate(RR),case of transcutaneous oxygen saturation(SpO2)decrease,case of HR decrease,case of cardiopulmonary resuscitation(CPR)and OI in HFOV group were significantly decreased[HR(bpm):130(125,138)vs.144(140,160),RR(times/min):35(34,38)vs.40(35,45),SpO2 decrease(case:1 vs.10),HR decrease(case:0 vs.6),CPR(case:0 vs.4),OI:6.5(4.4,8.9)vs.9.3(8.0,12.8)],while case of use of muscle relaxants(case:3 vs.0)and volume of 7-day positive fluid balance[mL/kg:167.1(113.8,212.6)vs.90.8(57.8,112.7)]were significantly higher,the differences were statistically significant(all P<0.05).There was no use of blood purification treatment,no severe complications such as pneumothorax and intracranial hemorrhage,and no death within 28 days in the two groups.Conclusion Compared with CMV,HFOV in the treatment of infants with severe RSV pneumonia can improve the oxygenation level and clinical physiological indexes earlier,reduce the incidence of adverse events such as HR,SpO2 decrease and CPR,increase the use of muscle relaxants and the positive fluid balance,and do not increase the incidence of severe complications such as pneumothorax and intracranial hemorrhage,so its clinical application is safe.