探讨围生期肺内源性急性呼吸窘迫综合征(ARDSp)及肺外源性急性呼吸窘迫综合征(ARDSexp)患儿呼吸力学指标、肺动脉压力(PAP)变化及意义。

选择2015年5月至2017年8月，于东南大学医学院附属盐城医院新生儿科收治的78例围生期急性呼吸窘迫综合征(ARDS)患儿为研究对象。按照病因，将其中41例ARDSp患儿，纳入ARDSp组；37例ARDSexp患儿，纳入ARDSexp组。选择同期、同日龄及同一家医院产科40例健康新生儿，纳入对照组。根据氧合指数(OI)，将78例ARDS新生儿的ARDS严重程度判定为轻、中、重度。采用成组t检验、方差分析及χ²检验，对如下计量资料或计数资料进行统计学比较。①对ARDSp组及ARDSexp组患儿临床资料、OI及呼吸力学指标进行比较；对不同严重程度ARDS患儿的PAP值，进行组间及组内比较；②对2组ARDS患儿呼吸支持后0、24、48、72、96 h及拔管前，以及对照组新生儿相应小时龄时的PAP值进行组间比较。采用Pearson相关性分析，对78例ARDS患儿的OI与PAP进行相关性分析。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》。

①ARDSexp组围生期新生儿胎龄、出生体重、肺表面活性物质(PS)使用率、新生儿持续肺动脉高压(PPHN)发生率及死亡率[(37.5±1.7)周、(2 548±465) g、13.5%、2.7%、2.7%]，均低于ARDSp组[(38.9±1.7)周、(3 188±513) g、78.0%、24.4%、19.5%]，而持续气道正压通气(CPAP)成功率(13.5%)，则高于ARDSp组(0)，并且差异均有统计学意义(t＝3.632，P<0.001；t＝5.750，P<0.001；χ²＝32.491，P<0.001；χ²＝7.552，P＝0.006；χ²＝5.384，P＝0.020；χ²＝5.920，P＝0.015)。②本研究73例ARDS患儿采用有创机械通气24 h时，ARDSexp组患儿OI、平均气道压(MAP)及气道阻力(Raw)[(14.8±4.3), (10.4±2.9) cmH₂O, (83.9±18.3) cmH₂O/(L·s)](1 cmH₂O＝0.098 kPa)，均低于ARDSp组[(18.8±3.2), (15.5±2.4) cmH₂O, (115.8±30.7) cmH₂O/(L·s)]，而呼吸系统顺应性(Crs)[(0.39±0.09) mL/(cmH₂O·kg)]，则高于ARDSp组[(0.26±0.05) mL/(cmH₂O·kg)]，并且差异均有统计学意义(t＝4.561、8.754、5.537、7.713,均为P<0.001)。③呼吸支持24 h时：ARDSexp组中度或重度ARDS患儿的PAP[(54.7±5.9) mmHg, (64.2±4.9) mmHg](1 mmHg＝0.133 kPa)，均分别低于ARDSp组[(62.5±5.4) mmHg, (68.0±6.5) mmHg]，并且差异均有统计学意义(t＝3.258、2.148，均为P<0.05)。ARDSp组内，重度ARDS患儿PAP高于中度ARDS患儿，并且差异有统计学意义(t＝2.424，P＝0.021)；ARDSexp组内，重度ARDS患儿PAP分别高于轻度[(37.8±6.5) mmHg]、中度ARDS患儿，中度ARDS患儿PAP高于轻度ARDS患儿，并且差异均有统计学意义(t＝14.060、4.891、5.629，均为P<0.001)。④Pearson相关性分析结果显示，本研究78例ARDS患儿的OI与PAP呈线性正相关关系(r＝0.720, P<0.001)。⑤ARDSp组及ARDSexp组患儿呼吸支持后0、24、48、72、96 h及拔管前PAP，均分别高于相应小时龄时对照组新生儿，并且差异均有统计学意义(t＝16.920、21.600、27.200、24.440、21.670、18.690，t＝11.380、24.680、37.800、15.670、14.460、18.060；均为P<0.001)。ARDSexp组患儿呼吸支持后0、48、72、96 h的PAP，均低于ARDSp组，呼吸支持后24 h的PAP高于ARDSp组，并且差异均有统计学意义(t＝5.136、4.829、8.197、6.691、7.483，均为P<0.001)。

围生期ARDS新生儿PAP均有不同程度增高，其增高程度与疾病严重程度相关。ARDSp与ARDSexp患儿存在呼吸力学指标与PAP差异，PAP可以作为判断患儿呼吸窘迫严重程度及预后的指标。

To explore the changes and significance of respiratory mechanics parameters and pulmonary arterial pressure (PAP) of prenatal stage neonates with pulmonary acute respiratory distress syndrome (ARDSp) or extrapulmonary acute respiratory distress syndrome (ARDSexp).

From May 2015 to August 2017, a total of 78 prenatal stage neonates with acute respiratory distress syndrome (ARDS) who were admitted to department of Neonatology of the Affiliated Yancheng Hospital of Southeast University Medical College, were chosen as research subjects. According to different causes of ARDS, 41 neonates with ARDSp were including into ARDSp group and 37 neonates with ARDSexp were including into ARDSexp group. And from department of Obstetrics in same hospital during the same period, a total of 40 healthy neonates with same age were included into control group. The severity of 78 ARDS neonates were determined as mild, moderate and severe according to oxygenation index (OI). The independent-samples t test, variance analysis and chi-square test were used to compare the following measurement data or numeration data. ①Comparasion of clinical data, OI and respiratory mechanics parameters between ARDSp group and ARDSexp group; PAP values of different severity degrees of ARDS neonates in each group or between two groups. ②PAP values of ARDSp and ARDSexp groups at 0, 24, 48, 72, 96 h after breath support, and pre-extubation time points, also PAP values of control group at corresponding hourly ages. Pearson correlation analysis was used to analyze the correlation between OI and PAP of 78 neonates with ARDS. This study met the requirements of World Medical Association Declaration of Helsinki revised in 2013.

①Perinatal stage neonates′gestational age, birth weight, usage rate of pulmonary surfactant (PS), incidence rate of persistent pulmonary hypertension of newborn (PPHN) and mortality rate of ARDSexp group [(37.5±1.7) gestational weeks, (2 548±465) g, 13.5%, 2.7%, 2.7%] were all lower than those of ADRSp group [(38.9±1.7) gestational weeks, (3 188±513) g, 78.0%, 24.4%, 19.5%], while the success rate of continuous positive airway pressure (CPAP) of ARDSexp group (13.5%) was higher than that of ARDSp group (0), and all the differences were statistically significant (t=3.632, P<0.001; t=5.750, P<0.001; χ²=32.491, P<0.001; χ²=7.552, P=0.006; χ²=5.384, P=0.020; χ²=5.920, P=0.015). ②A total of 73 ARDS neonates accepted invasive mechanical ventilation in this study, and at time point of 24 h, the OI, mean airway pressure (MAP) and airway resistance (Raw) of ARDSexp group [(14.8±4.3), (10.4±2.9) cmH₂O, (83.9±18.3) cmH₂O/(L·s)] (1 cmH₂O=0.098 kPa) were all lower than those of ARDSp group [(18.8±3.2), (15.5±2.4) cmH₂O, (115.8±30.7) cmH₂O/(L·s)], while compliance of the respiratory system (Crs) of ARDSexp group [(0.39±0.09) mL/(cmH₂O·kg)] was higher than that of ARDSp group [(0.26±0.05) mL/(cmH₂O·kg)], and all the differences were statistically significant (t=4.561, 8.754, 5.537, 7.713; all P<0.001). ③After 24 h of respiratory support, PAP values of moderate or severe ARDS neonates in ARDSexp group [(54.7±5.9) mmHg, (64.2±4.9) mmHg] (1 mmHg=0.133 kPa) were lower than those in ARDSp group [(62.5±5.4) mmHg, (68.0±6.5) mmHg], respectively, and the differences were statistically significant (t=3.258, 2.148; all P<0.05). In ARDSp group, PAP values of severe ARDS neonates was higher than that of moderate ARDS neonates, and the difference was statistically significant (t=2.424, P=0.021). In ARDSexp group, PAP values of severe ARDS neonates were higher than that of mild [(37.8±6.5) mmHg] and moderate ARDS neonates, respectively, while PAP values of moderate ARDS neonates was higher than that of mild ARDS neonates, and all the differences were statistically significant (t=14.060, 4.891, 5.629; all P<0.001). ④Pearson correlation analysis showed that there was a positive linear correlation between OI and PAP in 78 ARDS neonates (r=0.720, P<0.001). ⑤PAP values of neonates in ARDSp and ARDSexp group after respiratory support of 0, 24, 48, 72, 96 h and pre-extubation were higher than those of neonates at the corresponding hourly age after birth in control group, respectively, and the differences were statistically significant (t=16.920, 21.600, 27.200, 24.440, 21.670, 18.690; t=11.380, 24.680, 37.800, 15.670, 14.460, 18.060; all P<0.001). PAP values of neonates in ARDSexp group after 0, 48, 72, 96 h of respiratory support were lower than those in ARDSp group, but higher than that in ARDSp group after 24 h of respiratory support, and all the differences were statistically significant (t=5.136, 4.829, 8.197, 6.691, 7.483, all P<0.001).

The PAP of perinatal stage neonates with ARDS increased in varying degrees, and its increased degree was related to the severity of ARDS. The respiratory mechanics paramaters and PAP of ADRSp neonates were different from ADRSexp neonates, PAP can be used as a judgement indicator of the severity and prognosis of ARDS.