西北10家医院5年间2次早产儿呼吸窘迫综合征诊治状况调查

Surveys on management of neonatal respiratory distress syndrome in ten hospitals in Northwest China in 2016 and 2021

目的分析西北地区10家医院5年间早产儿呼吸窘迫综合征(respiratory distress syndrome,RDS)的诊治状况的变化。方法回顾性调查西北地区新生儿协作组中部分医院(陕西省6家、甘肃省3家、新疆维吾尔自治区1家)新生儿重症监护病房2016年1月1日至12月31日和2021年1月1日至12月31日收治的入院日龄≤3 d并诊断为RDS的早产儿。比较5年间患儿的基本情况、围产期情况、治疗情况、并发症及预后等方面的变化。采用t检验、秩和检验或χ^(2)检验分析各组数据。结果(1)2016年及2021年符合纳入标准的RDS早产儿分别为322例和349例,胎龄30~33周+6的早产儿仍是主要患病人群,男性居多[分别为64.3%(207/322)和57.3%(200/349)]。2021年母亲平均生育年龄明显高于2016年[(30.6±4.8)岁与(28.6±5.4)岁,t=24.02,P<0.001],高龄产妇多于2016年[19.2%(67/349)与12.4%(40/322),χ^(2)=4.18,P<0.05]。(2)2021年与2016年相比,辅助生殖技术受孕率[11.7%(41/349)与1.9%(6/322),χ^(2)=25.12]、正规产前检查率[58.5%(204/349)与30.4%(98/322),χ^(2)=53.33]、产前糖皮质激素使用率[62.2%(217/349)与28.6%(92/322),χ^(2)=82.58]、剖宫产率[73.6%(257/349)与51.6%(166/322),χ^(2)=35.06]、选择性剖宫产率[24.1%(84/349)与6.5%(21/322),χ^(2)=39.07]和瘢痕子宫妊娠率[7.4%(26/349)与3.4%(11/322),χ^(2)=5.23]均较高(P值均<0.05);胎儿窘迫[30.1%(105/349)与20.2%(65/322),χ^(2)=8.68]、妊娠期高血压疾病[24.6%(86/349)与13.0%(42/322),χ^(2)=14.59]、胎膜早破[16.0%(56/349)与10.2%(33/322),χ^(2)=4.89]、羊水胎粪污染[12.6%(44/349)与5.6%(18/322),χ^(2)=9.83]、胎盘早剥[10.3%(36/349)与5.3%(17/322),χ^(2)=5.84]、妊娠期糖尿病[10.3%(36/349)与1.6%(5/322),χ^(2)=22.41]、绒毛膜羊膜炎[4.6%(16/349)与0.9%(3/322),χ^(2)=8.12]、甲状腺功能异常[4.3%(15/349)与0.6%(2/322),χ^(2)=7.88]和心脏病[4.3%(15/349)与0.3%(1/322),χ^(2)=9.17]的比例均较高(P值均<0.05)。(3)治疗情况:2021年肺表面活性物质(pulmonary surfactant,PS)应用率、猪PS应用剂量和牛PS的应用比例均高于2016年[73.6%(257/349)与67.1%(216/322),χ^(2)=11.62;(178.5±38.0)mg/kg与(165.2±42.8)mg/kg,t=7.85;47.9%(123/257)与19.4%(42/216),χ^(2)=41.72;P值均<0.01]。2021年与2016年气管插管-注入PS-拔管后正压通气使用率、早期(生后2 h内)应用PS及PS治疗前后的血气值差异无统计学意义。2021年与2016年相比较,抗生素应用时间[7.0 d(5.0~14.0 d)与5.0 d(1.0~8.0 d),Z=7.55]、辅助通气时间[144 h(81~264 h)与73 h(47~134 h),Z=8.20]和住院时间[24 d(14~42 d)与16 d(10~25 d),Z=6.74]明显增加(P值均<0.01),经鼻间歇正压通气[29.6%(100/338)与1.0%(3/306),χ^(2)=97.81]和常频通气的使用率[42.6%(144/338)与30.1%(92/306),χ^(2)=10.87]明显升高(P值均<0.01)。(4)2021年与2016年相比较,动脉导管未闭[15.5%(54/349)与6.2%(20/322),χ^(2)=63.40]、支气管肺发育不良[9.2%(32/349)与2.8%(9/322),χ^(2)=12.88]、持续性肺动脉高压[5.4%(19/349)与0.6%(2/322),χ^(2)=12.85]、脑室周围白质软化[4.3%(15/349)与1.2%(4/322),χ^(2)=7.52]和气胸[3.4%(12/349)与0.3%(1/322),χ^(2)=9.68]的比例升高(P值均<0.05),院内感染比例明显下降[7.4%(26/349)与19.6%(63/322),χ^(2)=21.37,P<0.001]。(5)2021年早产儿RDS治愈率高于2016年[70.8%(247/349)与56.2%(181/322),χ^(2)=15.37,P<0.001],放弃率[7.7%(27/349)与14.3%(46/322),χ^(2)=7.41]和病死率[院内:1.4%(5/349)与5.6%(18/322),χ^(2)=8.74;院外:8.3%(29/349)与13.7%(44/322),χ^(2)=4.96]低于2016年(P值均<0.05)。结论这一期间参与研究单位的早产儿RDS的临床救治技术水平提高了,但仍存在一定不足。

Objective To analyze the status of neonatal respiratory distress syndrome(RDS)management in 10 hospitals in Northwest China over the past five years and to investigate the strategies for improving the prevention and treatment of RDS.Methods This retrospective study involved premature infants with RDS who were admitted to the neonatal intensive care units(NICU)of 10 hospitals(six in Shaanxi Province,three in Gansu Province,and one in Xinjiang Uygur Autonomous Region)of the Northwest China Neonatal Collaborative Group within 3 d after birth from January 1 to December 31,2016,and from January 1 to December 31,2021.Basic information,perinatal condition,treatment approaches,complications,and prognosis of the patients were compared.T-test,rank sum,and Chi-square tests were used for statistical analysis.Result(1)This study enrolled 322 premature infants with RDS in 2016 and 349 in 2021.Premature infants at the gestational age of 30 to 33 weeks were mainly affected,and the majority were male[64.3%(207/322)and 57.3%(200/349)].The average maternal age in 2021 was older than that in 2016[(30.6±4.8)years vs(28.6±5.4)years,t=24.02,P<0.001],and the proportion of women at advanced maternal age was also higher in 2021[19.2%(67/349)vs 12.4%(40/322),χ^(2)=4.18,P<0.05].(2)The proportions of pregnancies conceived with assisted reproductive technologies[11.7%(41/349)vs 1.9%(6/322),χ^(2)=25.12],underwent routine prenatal examinations[58.5%(204/349)vs 30.4%(98/322),χ^(2)=53.33],exposed to steroids[62.2%(217/349)vs 28.6%(92/322),χ^(2)=82.58]and delivered by cesarean section or elective cesarean section[73.6%(257/349)vs 51.6%(166/322),χ^(2)=35.06;24.1%(84/349)vs 6.5%(21/322),χ^(2)=39.07],as well as the ratio of cesarean scar pregnancy[7.4%(26/349)vs 3.4%(11/322),χ^(2)=5.23]were all higher in 2021 than those in 2016(all P<0.05).Moreover,the incidence of fetal distress[30.1%(105/349)vs 20.2%(65/322),χ^(2)=8.68],gestational hypertension[24.6%(86/349)vs 13.0%(42/322),χ^(2)=14.59],premature rupture of membranes[16.0%(56/349)vs 10.2%(33/322),χ^(2)=4.89],meconium-stained amniotic fluid[12.6%(44/349)vs 5.6%(18/322),χ^(2)=9.83],placental abruption[10.3%(36/349)vs 5.3%(17/322),χ^(2)=5.84],gestational diabetes mellitus[10.3%(36/349)vs 1.6%(5/322),χ^(2)=22.41],chorioamnionitis[4.6%(16/349)vs 0.9%(3/322),χ^(2)=8.12],thyroid dysfunction[4.3%(15/349)vs 0.6%(2/322),χ^(2)=7.88]and heart disease[4.3%(15/349)vs 0.3%(1/322),χ^(2)=9.17]were higher in 2021 than in 2016(all P<0.05).(3)In 2021,the rate of pulmonary surfactant(PS)usage,the dosage of porcine PS,and the proportion of bovine PS usage were all significantly higher than those in 2016[73.6%(257/349)vs 67.1%(216/322),χ^(2)=11.62;(178.5±38.0)mg/kg vs(165.2±42.8)mg/kg,t=7.85;47.9%(123/257)vs 19.4%(42/216),χ^(2)=41.72;all P<0.01].No significant difference in the incidence of intubation-surfactant-extubation(INSURE),early PS administration(≤2 h after birth),or the arterial blood gas values before and after PS treatment was found between the cases enrolled in 2021 and 2016.The duration of antibiotic treatment[7.0 d(5.0-14.0 d)vs 5.0 d(1.0-8.0 d),Z=7.55]and assisted ventilation[144 h(81-264 h)vs 73 h(47-134 h),Z=8.20]and the median hospital stay[24 d(14-42 d)vs 16 d(10-25 d),Z=6.74]were significantly longer in 2021 than in 2016(all P<0.01).More patients required nasal intermittent positive pressure ventilation[29.6%(100/338)vs 1.0%(3/306),χ^(2)=97.81]and conventional ventilation[42.6%(144/338)vs 30.1%(92/306),χ^(2)=10.87]in 2021 as compared with those five years ago(both P<0.01).(4)In 2021,the incidence of patent ductus arteriosus[15.5%(54/349)vs 6.2%(20/322),χ^(2)=63.40],bronchopulmonary dysplasia[9.2%(32/349)vs 2.8%(9/322),χ^(2)=12.88],persistent pulmonary hypertension[5.4%(19/349)vs 0.6%(2/322),χ^(2)=12.85],periventricular leukomalacia[4.3%(15/349)vs 1.2%(4/322),χ^(2)=7.52]and pneumothorax[3.4%(12/349)vs 0.3%(1/322),χ^(2)=9.68]increased as compared with those in 2016(all P<0.05),while the incidence of nosocomial infection decreased significantly[7.4%(26/349)vs 19.6%(63/322),χ^(2)=21.37,P<0.001].(5)The cure rate of premature infants with RDS was 70.8%(247/349)in 2021,which was significantly higher than that in 2016[56.2%(181/322),χ^(2)=15.37,P<0.001].Moreover,the rate of withdrawing treatment and the total mortality rate was lower in 2021 than in 2016[7.7%(27/349)vs 14.3%(46/322),χ^(2)=7.41;in-hospital:1.4%(5/349)vs 5.6%(18/322),χ^(2)=8.74;out of hospital:8.3%(29/349)vs 13.7%(44/322),χ^(2)=4.96;all P<0.05].Conclusions The clinical management of RDS in premature infants in the involved hospitals has been improved.However,there is room for improvement in prenatal examinations.