雾化吸入联合气管镜检查在先天性心脏病术后ARDS患儿中的应用研究

doi:10.3760/cma.j.issn.1007-1245.2023.18.028

摘要/Abstract

摘要：

目的　探讨雾化吸入联合气管镜检查在先天性心脏病（CHD）术后急性呼吸窘迫综合征（ARDS）患儿中的应用价值。方法　选取2022年8月至2023年1月阜外华中心血管病医院收治的CHD术后ARDS患儿60例，采用随机对照研究，并按照随机抽签法将其分为两组，各30例。其中对照组男19例、女11例，年龄（9.36±1.40）个月，体质量（7.66±1.14）kg；观察组男17例、女13例，年龄（9.24±1.38）个月，体质量（7.58±1.13）kg。入组患儿均在体外循环（CPB）下行心内直视手术，且术后合并ARDS，两组患儿均施以CHD术后ARDS患者的常规护理，观察组在此基础上给予雾化吸入联合气管镜检查。比较两组干预2 h、3 d后呼吸功能监测指标［平台压（Pplat）、气道峰压（Ppeak）、肺动态顺应（Cdyn）］水平，评估两组术后恢复情况和不良反应发生率。统计学方法采用χ²检验、t检验。结果　干预2 h、3 d后，观察组动脉血氧分压（PaO₂）、动脉血氧饱和度（SaO₂）、氧合指数（PaO₂/FiO₂）、肺动态顺应（Cdyn）水平均高于对照组［（58.42±8.76）mmHg（1 mmHg=0.133 kPa）比（53.69±8.05）mmHg、（79.71±11.95）mmHg比（69.36±10.40）mmHg、（87.61±13.14）%比（80.44±12.06）%、（95.39±14.45）%比（88.26±13.23）%、（198.92±29.83）比（184.17±26.65）、（215.06±32.25）比（189.74±28.46）、（4.84±0.72）比（4.26±0.63）、（6.47±0.97）比（4.85±0.72）］，差异均有统计学意义（t=2.177、3.578、2.201、2.285、2.019、3.224、3.320、7.345，均P<0.05）；干预2 h、3 d后，观察组动脉血二氧化碳分压（PaCO₂）、气道峰压（Ppeak）、平台压（Pplat）水平均低于对照组［（37.65±5.64）mmHg比（41.71±6.25）mmHg、（32.33±4.84）mmHg比（36.45±5.46）mmHg、（23.43±3.51）cmH₂O（1 cmH₂O=0.098 kPa）比（25.75±3.86）cmH₂O、（21.76±3.26）cmH₂O比（23.85±3.57）cmH₂O、（13.98±2.09）cmH₂O比（15.56±2.33）cmH₂O、（11.76±1.76）cmH₂O比（13.92±2.08）cmH₂O］，差异均有统计学意义（t=2.641、3.092、2.435、2.367、2.764、4.342，均P<0.05）；观察组机械通气、住ICU时间均短于对照组［（121.48±18.22）h比（144.35±21.65）h、（192.66±28.89）h比（264.24±39.63）h］，差异均有统计学意义（t=4.426、7.994，均P<0.05）；观察组不良反应发生率低于对照组［3.33%（1/30）比20.00%（6/30）］，差异有统计学意义（χ²=4.043，P<0.05）。结论　将雾化吸入联合气管镜检查应用于CHD术后合并ARDS患儿，临床效果显著，有利于改善患儿的动脉血气指标和呼吸功能水平，促进患儿术后恢复，降低不良反应的发生风险。

关键词:

先天性心脏病, 急性呼吸窘迫综合征, 雾化吸入, 气管镜检查

Abstract:

Objective　To investigate the application value of nebulizing inhalation combined with tracheoscopy in children with ARDS after congenital heart disease (CHD) surgery. Methods　Sixty children with ARDS after CHD surgery who were admitted to Fuwai Central China Cardiovascular Hospital from August 2022 to March 2023 were selected for the randomized controlled trial. The patients were divided into a control group and an observation group by lottery, with 30 cases in each group. In the control group, there were 19 males and 11 females who were (9.36±1.40) months old; their body weight was (7.66±1.14) kg. In the observation group, there were 17 males and 13 females who were (9.24±1.38) months old; their body weight was (7.58±1.13) kg. All the enrolled children underwent open-heart surgery under extracorporeal circulation and were complicated with ARDS after the surgery. Both groups received routine nursing care for ARDS patients after CHD surgery; in addition, the observation group received atomization inhalation and tracheoscopy. The levels of respiratory function indicators [platform pressure (Pplat), air way peak pressure (Ppeak), and dynamic lung compliance (Cdyn)] 2 h and 3 d after the intervention were compared between the two groups. The postoperative recovery and the incidence of adverse reactions were evaluated in both groups. χ² and t were applied. Results　Two hours and 3 days after the intervention, the PaO₂, SaO₂, PaO₂/FiO₂, and Cdyn in the observation group were higher than those in the control group [(58.42±8.76) mmHg (1 mmHg=0.133 kPa) vs. (53.69±8.05) mmHg, (79.71±11.95) mmHg vs. (69.36±10.40) mmHg, (87.61±13.14)% vs. (80.44±12.06)%, (95.39±14.45)% vs. (88.26±13.23)%, (198.92±29.83) vs. (184.17±26.65), (215.06±32.25) vs. (189.74±28.46), (4.84±0.72) vs. (4.26±0.63), and (6.47±0.97) vs. (4.85±0.72)], with statistical differences (t=2.177, 3.578, 2.201, 2.285, 2.019, 3.224, 3.320, and 7.345; P<0.05). Two hours and 3 days after the intervention, the PaCO₂, Ppeak, and Pplat in the observation group were lower than those in the control group [(37.65±5.64)mmHg vs. (41.71±6.25) mmHg, (32.33±4.84) mmHg vs. (36.45±5.46) mmHg, (23.43±3.51) cmH₂O (1 cmH₂O=0.098 kPa) vs. (25.75±3.86) cmH₂O, (21.76±3.26) cmH₂O vs. (23.85±3.57) cmH₂O, (13.98±2.09)cmH₂O vs. (15.56±2.33) cmH₂O, and (11.76±1.76) cmH₂O vs. (13.92±2.08) cmH₂O], with statistical differences (t=2.641, 3.092, 2.435, 2.367, 2.764, and 4.342; all P<0.05). The duration of mechanical ventilation and ICU stay in the observation group were shorter than those in the control group [(121.48±18.22) h vs. (144.35±21.65) h and (192.66±28.89) h vs. (264.24±39.63) h], with statistical differences (t=4.426 and 7.994; both P<0.05). The incidence of adverse reactions in the observation group was significantly lower than that in the control group [3.33% (1/30) vs. 20.00% (6/30)],with a statistical difference (χ²=4.043,P<0.05). Conclusion　Atomization inhalation combined with tracheoscopy has significant clinical effects for children with ARDS after CHD surgery, and is conducive to improving the levels of arterial blood gas indicators and respiratory function, promoting their postoperative recovery, and effectively reducing the risk of adverse reactions.

Key words:

先天性心脏病, 急性呼吸窘迫综合征, 雾化吸入, 气管镜检查

庞秋贺胡朋鹤朱春荷张媛媛.

雾化吸入联合气管镜检查在先天性心脏病术后ARDS患儿中的应用研究 [J]. 国际医药卫生导报, 2023, 29(18): 2636-2641.

Pang Qiuhe, Hu Penghe, Zhu Chunhe, Zhang Yuanyuan.

Application of atomized inhalation combined with tracheoscopy in children with ARDS after congenital heart disease surgery [J]. International Medicine and Health Guidance News, 2023, 29(18): 2636-2641.

参考文献

[1] 梁志朋.沐舒坦、布地奈德雾化吸入+无创呼吸机治疗COPD致肺源性心脏病伴Ⅱ型呼吸衰竭患者的疗效分析[J].北方药学,2021,18(12):44-46.DOI:10.3969/j.issn.1672- 8351. 2021.12.015.
[2] 赵俊霞,彭岚刚,苏洁,等. 乙酰半胱氨酸联合布地奈德雾化吸入用于先天性心脏病患儿体外循环术后的疗效观察[J]. 中国医院用药评价与分析,2021,21(3):311-314,318.DOI:10.14009/j.issn.1672-2124.2021.03.013.
[3] 唐敏,李娜. 急性呼吸窘迫综合征发病机制及相关生物标志物的研究进展[J]. 中国现代医学杂志,2022,32(5):1-6.DOI:10.3969/j.issn.1005-8982.2022.05.001.
[4] 宋超,李涛,王妍,等. 纤维支气管镜肺泡灌洗联合乙酰半胱氨酸局部注入治疗重症肺炎的效果及安全性[J]. 临床误诊误治,2021,34(6):80-85.DOI:10.3969/j.issn.1002-3429. 2021.06.017.
[5] 葛均波,徐永健.内科学[M].8版.北京:人民卫生出版社,2013:28-31.
[6] 中华医学会重症医学分会. 急性肺损伤/急性呼吸窘迫综合征诊断和治疗指南(2006)[J]. 中华急诊医学杂志,2007,16(4):343-349.DOI:10.3760/j.issn:1671-0282.2007. 04.002.
[7] 中华医学会呼吸病学分会介入呼吸病学学组,中国医师协会内镜医师分会. 支气管镜操作围手术期雾化治疗专家共识[J]. 中华结核和呼吸杂志,2021,44(12):1045-1053.DOI:10.3760/cma.j.cn112147-20210712-00491.
[8] 吴为,黄海燕,李菠,等. 成人呼吸机雾化吸入疗法护理实践标准研究[J]. 循证护理,2021,7(15):2101-2104.DOI:10.12102/j.issn.2095-8668.2021.15.022.
[9] 刘妍,朱光发. 心脏术后急性呼吸窘迫综合征危险因素的研究进展[J]. 临床肺科杂志,2017,22(10):1893-1896.DOI:10.3969/j.issn.1009-6663.2017.010.039.
[10] Kim-Campbell N, Gretchen C, Ritov VB, et al. Bioactive oxylipins in infants and children with congenital heart disease undergoing pediatric cardiopulmonary bypass[J]. Pediatr Crit Care Med,2020,21(1):33-41.DOI:10.1097/PCC.0000000000002036.
[11] 冯敏,周秀琴. 高压氧联合硝普钠雾化吸入对先天性心脏病合并月动脉高压患者疗效及预后分析[J]. 生物医学工程与临床,2021,25(5):596-600.DOI:10.13339/j.cnki.sglc. 20210820.016.
[12] 蒋小芝,张辉,齐静文. 乙酰半胱氨酸雾化吸入联合乌司他丁用于ARDS机械通气患者的价值研究[J]. 临床医学工程,2022,29(10):1381-1382.DOI:10.3969/j.issn.1674- 4659.2022.10.1381.
[13] Marinari E, Rizza A, Iacobelli R, et al. Ventricular-arterial coupling in children and infants with congenital heart disease after cardiopulmonary bypass surgery: observational study[J].Pediatr Crit Care Med,2019,20(8):753-758.DOI:10.1097/PCC.0000000000001982.
[14] 方伯梁,钱素云,桂晋刚. 穿心莲内酯磺化物雾化吸入治疗儿童中重度急性呼吸窘迫综合征疗效探讨[J]. 中国小儿急救医学,2022,29(7):503-509.DOI:10.3760/cma.j.issn.1673-4912.2022.07.005.
[15] 董文吉. 重症急性呼吸窘迫综合征患者在俯卧位下行呼吸机雾化吸入治疗的护理措施及效果[J]. 医疗装备,2020,33(18):169-170.DOI:10.3969/j.issn.1002-2376. 2020.18.102.
[16] 胡一明,徐旭燕,张艺. 纤支镜肺泡灌洗痰热清联合乌司他丁对心脏术后急性呼吸窘迫综合征患者肺循环功能、心功能的影响[J]. 现代中西医结合杂志,2020,29(1):34-38.DOI:10.3969/j.issn.1008-8849.2020.01.008.
[17] Rogliani P, Matera MG, Page C, et al. Efficacy and safety profile of mucolytic/antioxidant agents in chronic obstructive pulmonary disease: a comparative analysis across erdosteine, carbocysteine, and N-acetylcysteine[J]. Respir Res,2019,20(1):104.DOI:10.1186/s12931-019-1078-y.
[18] 张雨曦,徐敖,杨芳芳. 乙酰半胱氨酸溶液、布地奈德雾化在急性呼吸窘迫综合征机械通气患者治疗中的临床疗效[J]. 实用医院临床杂志,2022,19(2):133-136.DOI:10.3969/j.issn.1672-6170.2022.02.037.
[19] 张荣媛,王旭,李守军,等. 肺表面活性物质治疗低龄危重先天性心脏病患儿术后急性呼吸窘迫综合征的疗效[J].中华实用儿科临床杂志,2019,34(6):421-424.DOI:10. 3760／cma. j. issn. 2095-428Ⅹ. 2019. 06. 006.
[20] 李雪琳,梅立峰. 低分子肝素雾化吸入治疗急性重症胰腺炎合并ALI/ARDS患者的疗效观察[J]. 海南医学,2021,32(24):3239-3241.DOI:10.3969/j.issn.1003-6350. 2021.24.031.
[21] 崔红艳. 小儿重症及复杂先天性心脏病术后急性呼吸窘迫综合征的临床危险因素[J]. 吉林医学,2019,40(11):2619-2620.DOI:10.3969/j.issn.1004-0412.2019.11.086.
[22] 高亚,陈信,张阵,等. 经鼻持续气道正压通气与振动网格雾化吸入肺表面活性物质联合治疗新生儿呼吸窘迫综合征的疗效和安全性[J]. 中华危重病急救医学,2022,34(1):80-84.DOI:10.3760/cma.j.cn121430-20210602-00815.
[23] 袁雪燕,邱海波,刘玲. 急性呼吸窘迫综合征患者气体交换功能的评估及临床意义[J]. 中华医学杂志,2022,102(36):2834-2838.DOI:10.3760/cma.j.cn112137-20220121- 00164.
[24] 刘颖,段顺艳,杜岚岚,等. 雾化肺表面活性物质联合无创辅助通气治疗新生儿呼吸窘迫综合征[J]. 广州医药,2022,53(2):1-6.DOI:10.3969/j.issn.1000-8535.2022.02.001.
[25] 郭明,陈宏吉,李功科,等. 乌司他丁联合无创机械通气治疗重症急性胰腺炎并急性呼吸窘迫综合征患者的临床疗效及其对血清炎性因子水平的影响[J]. 实用心脑肺血管病杂志,2019,27(9):65-69.DOI:10.3969/j.issn.1008-5971. 2019.09.014.
[26] 陈群娣,阳梅,张天英. 鼻塞式同步间歇正压通气(NIPPV)联合布地奈德雾化治疗新生儿急性呼吸窘迫综合征疾病的临床应用研究[J]. 北方药学,2020,17(4):10-11.DOI:10.3969/j.issn.1672-8351.2020.04.006.