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中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (03) : 300 -306. doi: 10.3877/cma.j.issn.1673-5250.2019.03.010

所属专题： 文献；

论著

高呼气末正压通气治疗高原肺水肿重症患儿的临床疗效观察
夏成1, 刘勤1, 王顺琴1, 李德渊2,†()   
  1. 1. 四川省甘孜藏族自治州人民医院儿科，康定　626000
    2. 四川大学华西第二医院儿科，成都　610041
  • 收稿日期:2019-03-06 修回日期:2019-05-13 出版日期:2019-06-01
  • 通信作者: 李德渊

Clinical effect of high positive end expiratory pressure ventilation in treatment of children with severe high altitude pulmonary edema

Cheng Xia1, Qin Liu1, Shunqin Wang1, Deyuan Li2,†()   

  1. 1. Department of Pediatrics, Ganzi Tibetan Autonomous Prefecture People′s Hospital, Kangding 626000, Sichuan Province, China
    2. Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
  • Received:2019-03-06 Revised:2019-05-13 Published:2019-06-01
  • Corresponding author: Deyuan Li
  • About author:
    Corresponding author: Li Deyuan, Email:
  • Supported by:
    National Natural Science Foundation of China for Youth(81000261); Key Research and Development Project of Science and Technology Department of Sichuan Province(2017SZ0055); Scientific Research Project of Health and Family Planning Commission of Sichuan Province(16PJ240)
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引用本文：

夏成, 刘勤, 王顺琴, 李德渊. 高呼气末正压通气治疗高原肺水肿重症患儿的临床疗效观察[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(03): 300-306.

Cheng Xia, Qin Liu, Shunqin Wang, Deyuan Li. Clinical effect of high positive end expiratory pressure ventilation in treatment of children with severe high altitude pulmonary edema[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(03): 300-306.

目的

探讨高呼气末正压(PEEP)通气治疗高原肺水肿(HAPE)重症患儿的临床疗效。

方法

选择2010年1月至2017年6月，于四川省甘孜藏族自治州人民医院儿童重症监护病房收治的42例接受同步间歇指令性通气(SIMV)联合PEEP通气治疗的HAPE重症患儿为研究对象。按照其入院顺序，将其随机分为低PEEP通气组(n＝21)与高PEEP通气组(n＝21)，2组患儿接受有创机械通气治疗时，呼吸机初始PEEP分别设置为<5 cmH2O(1 cmH2O＝0.098 1 kPa)、5～7 cmH2O。2组患儿治疗前、后的心率，呼吸频率(RR)，血氧饱和度(SpO2)，动脉血气分析指标，机械通气治疗时间，患儿住院时间及急性病生理与长期健康评价(APACHE)Ⅱ评分比较，采用成组t检验，上述指标组内比较，采用配对t检验。本研究遵循的程序符合四川省甘孜藏族自治州人民医院人体试验委员会制定的标准，经过该伦理委员会批准(批准文号：2010-K-12)，并且与所有患儿监护人签署临床研究知情同意书。

结果

① 2组患儿年龄、治疗前APACHE Ⅱ评分、HAPE发病时间等一般临床资料比较，差异均无统计学意义(P>0.05)。② 42例患儿接受SIMV联合PEEP通气治疗后，40例患儿存活，2例放弃治疗。③机械通气治疗2 h后，高PEEP通气组患儿的心率、RR，均显著低于低PEEP通气组，而SpO2显著高于低PEEP通气组，差异均有统计学意义(t＝4.062、P<0.001，t＝4.392、P<0.001，t＝－3.219、P＝0.006)。低PEEP通气组患儿治疗2 h后，心率、RR均显著低于治疗前，并且差异均有统计学意义(t＝24.646、20.125，P<0.001)。高PEEP通气组患儿治疗2 h后，心率、RR均显著低于治疗前，SpO2则显著高于治疗前，并且差异亦均有统计学意义(t＝31.159、19.913、－8.022，P<0.001)。④机械通气治疗24 h后，低PEEP通气组、高PEEP通气组患儿的氧合指数[动脉血氧分压(PaO2)/吸入氧气分数(FiO2)]、血清pH值及动脉血二氧化碳分压(PaCO2)，均较组内治疗前明显改善，并且差异均有统计学意义(低PEEP通气组：t＝－17.374、－7.607、12.338，P<0.001；高PEEP通气组：t＝－13.645、－12.262、17.949，P<0.001)。机械通气治疗24 h后，高PEEP通气组患儿PaO2/FiO2显著高于低PEEP通气组，PaCO2则显著低于低PEEP通气组，2组比较，差异均有统计学意义(t＝2.820、P＝0.013，t＝3.230、P＝0.006)。⑤高PEEP通气组患儿机械通气治疗时间、住院时间及治疗后APACHEⅡ评分分别为(36.7±2.8) h、(14.0±0.4) d、(16.9±7.9)分，均显著低于低PEEP通气组的(40.2±4.0) h、(18.4±0.5) d、(18.6±2.2)分，2组比较，差异均有统计学意义(t＝2.316、P＝0.035，t＝5.985、P<0.001，t＝2.499、P＝0.025)。

结论

采用SIMV联合PEEP通气模式治疗HAPE重症患儿效果良好，采取高PEEP通气(呼吸机初始PEEP为5～7 cmH2O)模式，对该病患儿相对更为安全，可更好地提高HAPE重症患儿治疗疗效。

关键词: 肺水肿, 高原病, 间歇正压呼吸, 通气机，机械, 正压呼吸, 血气分析, 重症高原肺水肿, 儿童
Objective

To investigate the clinical effect of high end-expiratory positive pressure (PEEP) ventilation in treatment of children with severe plateau pulmonary edema (HAPE).

Methods

From January 2010 to June 2017, a total of 42 children with severe HAPE who received synchronized intermittent mandatory ventilation (SIMV) combined with PEEP ventilation in the Pediatric Intensive Care Unit, Ganzi Tibetan Autonomous Prefecture People′s Hospital were selected as research subjects. According to the order of admission, these 42 children were randomly divided into low PEEP ventilation group (n=21) and high PEEP ventilation group (n=21). The initial PEEP of ventilator in low PEEP ventilation group and high PEEP ventilation group was set as <5 cmH2O (1 cmH2O=0.098 1 kPa) and 5-7 cmH2O, respectively. The heart rate and respiratory rate (RR), blood oxygen saturation (SpO2), arterial blood gas analysis index, length of mechanical ventilation treatment, length of hospital stay and acute physiology and chronic health evaluation (APACHE) Ⅱ score before and after treatment in two groups were compared by independent-samples t test, and pairwise t test was used to compare within each group. The guardians of all severe HAPE children signed the informed consent for clinical research. The procedures followed in this study were consistent with the standards of Ethic Committee of Human Beings in Ganzi Tibetan Autonomous Prefecture People′s Hospital, and this study was approved by this committee (Approval No. 2010-K-12).

Results

①There were no statistically significant differences between two groups in the general clinical data, such as age, APACHE Ⅱ score before treatment, and onset time of serve HAPE (P>0.05). ②After receiving treatment of SIMV combined with PEEP ventilation, 40 cases survived and 2 cases gave up treatment among these 42 cases of children with severe HAPE. ③After 2 h of mechanical ventilation treatment, the heart rate and RR of children in high PEEP ventilation group were significantly lower than those in low PEEP ventilation group, while the SpO2 was significantly higher than that in low PEEP ventilation group, and all the differences were statistically significant (t=4.062, P<0.001; t=4.392, P<0.001; t=-3.219, P=0.006). In low PEEP ventilation group, the heart rate and RR after 2 h of treatment were significantly lower than those before treatment, and the differences were statistically significant (t=24.646, 20.125; P<0.001). After 2 h of treatment, the heart rate and RR of high PEEP ventilation group were significantly lower than those before treatment, while SpO2 was significantly higher than that before treatment, and all the differences were statistically significant (t=31.159, 19.913, -8.022; P<0.001). ④After mechanical ventilation treatment for 24 h, the oxygenation index partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2), serum pH value and partial pressure of carbon dioxide (PaCO2) of the children in low PEEP ventilation group and high PEEP ventilation group were significantly improved compared with those within group before treatment, and all the differences were statistically significant (low PEEP ventilation group: t=-17.374, -7.607, 12.338, P<0.001; high PEEP ventilation group: t=-13.645, -12.262, 17.949, P<0.001). After mechanical ventilation treatment for 24 h, PaO2/FiO2 in high PEEP ventilation group was significantly higher than that in low PEEP ventilation group, while PaCO2 was significantly lower than that in low PEEP ventilation group, and the differences between two groups were statistically significant (t=2.820, P=0.013; t=3.230, P=0.006). ⑤The length of mechanical ventilation treatment, length of hospital stay and APACHE Ⅱ score after treatment in children of high PEEP ventilation group were (36.7±2.8) h, (14.0±0.4) d, (16.9±7.9) points, respectively, which all were significantly lower than (40.2±4.0) h, (18.4 ±0.5) d, (18.6±2.2) points, respectively in low PEEP ventilation group, and all the differences were statistically significant (t=2.316, P=0.035; t=5.985, P<0.001; t=2.499, P=0.025).

Conclusions

The effect of invasive mechanical ventilation method of SIMV combined with PEEP ventilation in treatment of children with severe HAPE is a good. High PEEP ventilation (with initial PEEP of ventilator set as 5-7 cmH2O) is relatively safe and can better improve the clinical efficacy of children with severe HAPE.

Key words: Pulmonary edema, Altitude sickness, Intermittent positive-pressure breathing, Ventilators, mechanical, Positive-pressure respiration, Blood gas analysis, Severe high altitude pulmonary edema, Child
表1 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿一般临床资料比较
组别 例数 年龄(岁，±s) 治疗前APACHEⅡ评分(分，±s) HAPE发病时间[d，M(P25～P75)]
低PEEP通气组 21 5.0±0.7 21.2±1.8 3.0(1.2～5.0)
高PEEP通气组 21 5.3±0.7 20.8±1.7 2.0(1.0～3.8)
检验值 ? t＝－1.261 t＝0.678 Z＝－0.941
P值 ? 0.222 0.508 0.347
表2 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后心率、RR、SpO2比较(±s)
组别 例数 心率(次/min) RR(次/min) SpO2(%)
治疗前 治疗2 h后 治疗前 治疗2 h后 治疗前 治疗2 h后
低PEEP通气组 21 124.0±5.1 95.1±3.6 31.2±1.9 22.2±1.4 93.5±1.9 94.3±3.4
高PEEP通气组 21 126.6±4.9 89.3±2.6 30.9±1.8 20.5±1.1 92.3±1.2 97.7±2.4
t值 ? －1.214 4.062 0.374 4.392 2.643 －3.219
P值 ? 0.244 <0.001 0.713 <0.001 0.018 0.006
表3 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗前、后动脉血气分析指标比较(±s)
组别 例数 PaO2/FiO2(mmHg) 血清pH值 PaCO2(mmHg)
治疗前 治疗24 h后 治疗前 治疗24 h后 治疗前 治疗24 h后
低PEEP通气组 21 102.6±6.7 129.6±1.9 7.25±0.06 7.37±0.01 54.4±4.9 39.6±1.1
高PEEP通气组 21 99.0±6.5 133.9±5.9 7.27±0.03 7.38±0.01 54.4±3.9 37.6±1.8
t值 ? 1.961 －2.820 －1.252 －1.954 0.000 3.230
P值 ? 0.069 0.013 0.230 0.070 1.000 0.006
表4 低PEEP通气组与高PEEP通气组高原肺水肿重症患儿机械通气治疗时间、住院时间及治疗后APACHEⅡ评分比较(±s)
组别 例数 机械通气治疗时间(h) 住院时间(d) 治疗后APACHEⅡ评分(分)
低PEEP通气组 21 40.2±4.0 18.4±0.5 18.6±2.2
高PEEP通气组 21 36.7±2.8 14.0±0.4 16.9±7.9
t值 ? 2.316 5.985 2.499
P值 ? 0.035 <0.001 0.025
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