俯卧位在肾移植术后耶氏肺孢子菌肺炎致重度ARDS中的应用

Application of prone position in severe ARDS caused by pneumocystis jirovecii pneumonia after kidney transplantation

目的探讨肾移植术后耶氏肺孢子菌肺炎(PJP)致重度急性呼吸窘迫综合征(ARDS)患者实施俯卧位治疗后对氧合的改善情况。方法回顾性分析5例肾移植术后PJP致中、重度ARDS患者的临床资料,总结其临床特征、治疗方案及预后情况。结果5例患者临床表现为发热、干咳,伴胸闷、气短,全身大汗、乏力,体温波动在38~39℃,经皮动脉血氧饱和度(SpO_(2))进行性下降,呼吸窘迫症状加重。肺部CT表现为弥漫性磨玻璃影。入住重症监护室(ICU)后,所有患者暂停免疫抑制药,均予复方磺胺甲噁唑、卡泊芬净、小剂量糖皮质激素抗耶氏肺孢子菌(PJ)治疗、氧疗及其它对症支持治疗。4例患者入住ICU时为重度ARDS,行俯卧位治疗;1例患者为中度ARDS,未行俯卧位治疗。与俯卧位治疗前比较,治疗后1 d患者动脉血氧分压(PaO_(2))和氧合指数均升高,肺泡-动脉氧分压差(A-aDO_(2))均下降(均为P<0.05);与治疗后1 d比较,治疗后4 d患者SpO_(2)、PaO_(2)和氧合指数均升高,A-aDO_(2)下降(均为P<0.05)。箱形图结果显示,俯卧位治疗后氧合指数呈整体上升趋势,A-aDO_(2)呈整体下降趋势。5例患者ICU入住时间为14(8,29)d。所有俯卧位患者均未出现皮肤压疮、脱管、管路移位等并发症。5例患者中,4例患者病情好转,1例患者因后期发生脓毒性休克、多器官衰竭而死亡。结论无论是清醒俯卧位还是插管俯卧位均可明显改善肾移植术后PJP致重度ARDS患者的氧合,并改善患者预后。早期尽快确诊及精准规范治疗是提高治愈率的关键。

Objective To investigate the improvement of oxygenation after the treatment of prone position in patients with severe acute respiratory distress syndrome(ARDS)caused by pneumocystis jirovecii pneumonia(PJP)after kidney transplantation.Methods Clinical data of 5 cases of moderate and severe ARDS caused by PJP after kidney transplantation were analyzed retrospectively,and clinical characteristics,treatment regimen and prognosis were summarized.Results Clinical manifestations of 5 patients were fever,dry cough,chest tightness,shortness ofbreath,sweating and fatigue,and body temperature fluctuated between 38℃and 39℃,percutaneous arterial oxygen saturation(SpO_(2))was gradually decreased,and respiratory distress symptoms were worsened.Pulmonary CT scan showed diffuse ground-glass shadow.After transfer to intensive care unit(ICU),immunosuppressive drugs were terminated,and all patients were given with compound sulfamethoxazole,caspofungin,low-dose glucocorticoids against pneumocystis jirovecii(PJ),oxygen therapy and other symptomatic supportive treatments.Four patients diagnosed with severe ARDS upon admission to ICU were treated in a prone position.One patient with moderate ARDS was not kept in a prone position.At 1 d after treatment in a prone position,partial pressure of arterial oxygen(PaO_(2))and oxygenation index were increased,whereas alveolar-arterial oxygen difference(A-aDO_(2))was decreased compared with before treatment(allP<0.05).Compared with 1 d after treatment,SpO_(2),PaO_(2) and oxygenation index were all increased,while A-aDO_(2) was decreased at 4 d after treatment(all P<0.05).Box diagram showed that oxygenation index showed an overall upward trend after prone-position treatment,whereas A-aDO_(2) showed an overall downward trend.The length of ICU stay of 5 patients was 14(8,29)d.All patients in a prone position did not develop complications,such as skin pressure sore,tube detachment and tube displacement,etc.Among 5 patients,4 patients were mitigated,and 1 patient died of septic shock and multiple organ failure.Conclusions For both conscious and intubated patients,a prone position may significantly improve oxygenation and prognosis of patients with severe ARDS caused by PJP after kidney transplantation.Early diagnosis and accurate and standardized treatment play a pivotal role in enhancing cure rate.