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中华妇幼临床医学杂志(电子版)

中华妇幼临床医学杂志(电子版) ›› 2024, Vol. 20 ›› Issue (01) : 9 -17. doi: 10.3877/cma.j.issn.1673-5250.2024.01.002

先天性膈疝专辑

新生儿先天性膈疝术后呼吸支持相关危险因素分析
梁靓1, 谭征1,†(), 黄婷1, 高跃1, 章坚1, 夏杰1   
  1. 1. 浙江大学医学院附属儿童医院胸外科·国家儿童健康与疾病临床医学研究中心，杭州　310052
  • 收稿日期:2023-10-13 修回日期:2024-01-09 出版日期:2024-02-01
  • 通信作者: 谭征

Risk factors of postoperative respiratory support in newborns with congenital diaphragmatic hernia

Liang Liang1, Zheng Tan1,†(), Ting Huang1, Yue Gao1, Jian Zhang1, Jie Xia1   

  1. 1. Department of Thoracic Surgery, Children′s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou 310052, Zhejiang Provence, China
  • Received:2023-10-13 Revised:2024-01-09 Published:2024-02-01
  • Corresponding author: Zheng Tan
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引用本文：

梁靓, 谭征, 黄婷, 高跃, 章坚, 夏杰. 新生儿先天性膈疝术后呼吸支持相关危险因素分析[J]. 中华妇幼临床医学杂志(电子版), 2024, 20(01): 9-17.

Liang Liang, Zheng Tan, Ting Huang, Yue Gao, Jian Zhang, Jie Xia. Risk factors of postoperative respiratory support in newborns with congenital diaphragmatic hernia[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2024, 20(01): 9-17.

目的

探讨先天性膈疝(CDH)新生儿手术后呼吸支持情况，以及影响术后呼吸支持时间的相关危险因素。

方法

选择2015年1月至2023年6月浙江大学医学院附属儿童医院胸外科收治的接受手术治疗，并早期存活的96例CDH新生儿为研究对象。采取回顾性分析方法，对96例CDH新生儿临床资料，如出生体重、性别、出生胎龄，生后1及5 min Apgar评分，是否合并心脏畸形、肺动脉高压，以及术前呼吸支持情况、膈肌缺损等级、疝孔位置、有无疝囊、手术径路、术后机械通气治疗时间及术后无创吸氧治疗时间，采用Mann-Whitney U检验或Kruskal-Wallis H秩和检验进行单因素分析。结合既往研究结果与临床经验及单因素分析有统计学意义指标，进一步采用多因素非条件logistic回归，分析影响CDH患儿术后有创机械通气治疗时间及无创吸氧治疗时间延长的独立影响因素。本研究遵循的程序经本院伦理委员会批准(审批文号：2022-IRB-277)，所有CDH新生儿监护人对本诊断过程知情同意，并签署临床研究知情同意书。

结果

本研究结果如下。①这96例CDH新生儿中，男性患儿为49例，女性为47例；低出生体重儿为11例，出生体重为(2.18±0.26)kg；早产儿为8例，足月儿为88例；生后1、5 min Apgar评分为低等级者分别为5例和7例；合并肺动脉高压为47例；术前采取高频振荡通气(HFOV)或体外膜肺氧合(ECMO)治疗者为9例；膈肌缺损等级为A、B、C、D级者分别为29、38、27、2例；CDH位于左侧为78例，右侧为18例；有疝囊为45例；经胸手术为88例，经腹手术为8例。②术后有创机械通气治疗中位时间为45.0 h (23.0 h，89.8 h)，术后无创吸氧治疗中位时间为7.0 d (3.0 d，9.8 d)。③多因素非条件logistic回归分析结果显示，术前合并肺动脉高压、膈肌缺损等级高(C级＋D级)，是导致CDH新生儿术后有创机械通气治疗时间延长的独立危险因素(OR＝3.516、4.253，95%CI：1.329～9.308、1.085～16.674，P＝0.011、0.038)，而有疝囊是其独立保护因素(OR＝0.209，95%CI：0.062～0.701，P＝0.011)；合并肺动脉高压、膈肌缺损等级高是导致CDH新生儿术后无创吸氧治疗时间延长的独立危险因素(OR＝3.138、3.607，95%CI：1.187～8.294、1.011～12.876，P＝0.021、0.048)。

结论

合并肺动脉高压、膈肌缺损等级高、无疝囊与CDH新生儿术后呼吸支持时间延长有关。

关键词: 疝，横膈，先天性, 胸壁震荡通气, 体外膜氧合作用, 呼吸支持, 外科手术治疗, 婴儿，新生
Objective

To explore the postoperative respiratory support of neonatal congenital diaphragmatic hernia (CDH) and the risk factors affecting the time of postoperative respiratory support.

Methods

A total of 96 newborns with CDH who received surgical treatment in the Department of Thoracic Surgery of Children′s Hospital, Zhejiang University School of Medicine from January 2015 to June 2023 were collected. Clinical data of 96 CDH newborns such as birth weight, gender, gestational age, 1 and 5 min Apgar score, cardiac malformation, pulmonary hypertension, preoperative respiratory support, diaphragma defect grade, hernia location, hernia sac, surgical approach, postoperative ventilation time and postoperative non-invasive oxygen inhalation time were analyzed by Mann-Whitney U test or Kruskal-Wallis H rank sum test. Combined with the previous research results, clinical experience, and indexes with statistical difference in univariate analysis, multivariate unconditioned logistic regression was used to analyze the independent influencing factors of postoperative ventilation time and non-invasive oxygen inhalation time. The procedure in this study was approved by the Ethics Committee of our hospital (Approval No. 2022-IRB-277). Informed consents were obtained from all guardians of all participants.

Results

The results of this study were as follows. ①Among the 96 children with CDH, there were 49 males and 47 females; 11 low birth weight infants, their birth weight was ( 2.18±0.26) kg; 8 premature infants and 88 full-term infants. The abnormal Apgar scores at 1 and 5 min after birth were 5 cases and 7 cases respectively. There were 47 children with pulmonary hypertension and 9 children with high frequency oscillation ventilation (HFOV) or extracorporeal membrane oxygenation (ECMO) before operation. With diaphragma defect grades A, B, C and D were 29, 38, 27 and 2 cases, respectively. 78 cases of CDH were on the left side and 18 cases were on the right side, and 45 cases had hernia sac. There were 88 cases of transthoracic operation and 8 cases of transabdominal operation. ②The time of postoperative ventilation was 45.0 h (23.0 h, 89.8 h), and the time of postoperative non-invasive oxygen inhalation was 7.0 d (3.0 d, 9.8 d). ③Multivariate unconditioned logistic regression analysis showed that preoperative pulmonary hypertension, and high grade of diaphragma defect were the independent risk factors for prolonged time of postoperative ventilation (OR=3.516, 4.253; 95%CI: 1.329-9.308, 1.085-16.674; P=0.011, 0.038), and with hernia sac was its independent protective factor (OR=0.209, 95%CI: 0.062-0.701, P=0.011). Preoperative pulmonary hypertension, and high grade of diaphragma defect also were the independent risk factors for prolonged time of non-invasive oxygen inhalation (OR=3.138, 3.607; 95%CI: 1.187-8.294, 1.011-12.876; P=0.021, 0.048).

Conclusions

Preoperative pulmonary hypertension, high grade hernia defect and absence of hernia sac may be related to the prolongation of postoperative respiratory support time of newborns with CDH.

Key words: Hernias, diaphragmatic, congenital, Chest wall oscillation, Extracorporeal membrane oxygenation, Respiratory support, Treatment of surgical procedures, Infant, newborn
表1 CDH新生儿术后有创机械通气及无创吸氧治疗时间影响因素的单因素分析结果
影响因素 例数 术后有创机械通气治疗 术后无创吸氧治疗
时间[h，M(Q1，Q3)] Z值 P值 时间[d，M(Q1，Q3)] Z值 P值
性别     0.48 0.629   0.75 0.453
男 49 48.0(25.5，75.5)     7.0(3.0，10.0)    
女 47 45.0(22.0，95.0)     6.0(3.0，9.0)    
是否为早产儿     1.33 0.185   0.73 0.465
是 8 31.0(19.0，56.6)     8.0(2.5，29.3)    
否 88 48.0(24.0，91.5)     6.5(3.0，9.8)    
生后1 min Apgar评分等级a     1.88 0.061   2.17 0.003
高 90 41.3(22.4，86.8)     6.0(3.0，9.0)    
低 5 124.0(44.3，227.0)     10.0(8.0，26.5)    
生后5 min Apgar评分等级a     1.72 0.086   3.29 0.001
高 88 41.3(22.6，83.3)     6.0(3.0，9.0)    
低 7 124.0(43.5，216.0)     13.0(10.0，28.0)    
是否为低出生体重儿     1.38 0.167   0.79 0.429
是 11 39.0(18.0，50.0)     8.0(4.0，27.0)    
否 85 48.0(24.0，91.5)     6.0(3.0，9.5)    
是否合并肺动脉高压     3.76 <0.001   2.64 0.008
是 47 67.0(38.0，120.0)     8.0(4.0，13.0)    
否 49 26.0(20.0，55.0)     5.0(2.0，8.0)    
术前是否采取HFOV或ECMO治疗     3.50 <0.001   2.11 0.035
是 9 143.0(120.0，335.0)     9.0(7.0，19.5)    
否 87 40.5(22.5，72.0)     6.0(3.0，9.0)    
膈肌缺损等级     2.55 0.011   3.15 0.002
低(A级＋B级) 67 40.0(21.5，72.0)     5.0(2.0，9.0)    
高(C级＋D级) 29 61.0(38.0，153.5)     8.0(6.0，16.5)    
手术方式     2.86 0.004   1.37 0.169
开放 9 164.0(90.3，249.0)     10.0(2.0，26.0)    
腔镜 87 42.0(22.5，75.0)     6.0(3.0，9.0)    
手术径路     2.49 0.013   0.88 0.380
经胸 88 42.7(22.6，75.0)     6.5(3.0，9.0)    
经腹 8 153.5(63，8，269.5)     9.5(1.5，22.3)    
CDH位置     0.23 0.818   1.57 0.116
左侧 78 44.3(22.9，89.3)     6.0(2.8，9.3)    
右侧 18 47.5(22.4，117.0)     8.0(5.8，10.8)    
有无疝囊     2.21 0.027   0.50 0.632
有 45 38.0(20.8，69.5)     7.0(3.5，10.0)    
无 51 60.0(24.0，120.0)     6.0(3.0，9.0)    
术中是否应用补片修补     1.21 0.226   1.35 0.109
是 10 55.0(35.8，148.3)     7.5(6.0，21.3)    
否 86 44.3(22.4，86.8)     6.0(3.0，9.0)    
表2 导致CDH新生儿术后有创机械通气治疗时间延长的多因素非条件logistic回归分析结果
影响因素 B SE Wald值 P值 OR值 OR值95%CI
生后1 min Apgar评分 0.157 0.219 0.515 0.473 1.170 0.762～1.798
生后5 min Apgar评分 －0.196 0.262 0.558 0.455 0.822 0.492～1.374
合并肺动脉高压 1.257 0.497 6.411 0.011 3.516 1.329～9.308
术前采取HFVO或ECMO治疗 1.383 1.183 1.367 0.242 3.988 0.392～40.532
膈肌缺损等级高(C级＋D级) 1.448 0.679 4.311 0.038 4.253 1.085～16.674
腔镜手术 －1.006 1.016 0.979 0.322 0.366 0.050～2.680
有疝囊 －1.567 0.618 6.430 0.011 0.209 0.062～0.701
常数项 0.852 2.078 0.168 0.682 2.344 —
表3 导致CDH新生儿术后无创吸氧治疗时间延长的多因素非条件logistic回归分析结果
影响因素 B SE Wald值 P值 OR值 OR值95%CI
生后1 min Apgar评分 －0.158 0.234 0.458 0.499 0.854 0.540～1.350
生后5 min Apgar评分 －0.309 0.279 1.222 0.269 0.734 0.425～1.270
合并肺动脉高压 1.144 0.496 5.320 0.021 3.138 1.187～8.294
术前采取HFVO或ECMO治疗 1.472 1.202 1.500 0.221 4.357 0.413～45.932
膈肌缺损等级高(C级＋D级) 1.283 0.649 3.905 0.048 3.607 1.011～12.876
腔镜手术 －0.136 1.055 0.017 0.897 0.873 0.110～6.897
有疝囊 －0.367 0.572 0.411 0.521 0.693 0.226～2.126
常数项 3.354 2.399 1.954 0.162 28.616 —
[1]
Politis MD, Bermejo-Sánchez E, Canfield MA, et al. Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study[J]. Ann Epidemiol, 2021, 56(1): 61.e3-69.e3. DOI: 10.1016/j.annepidem.2020.11.007.
[2]
Toussaint-Duyster LCC, van der Cammen-van Zijp MHM, Spoel M, et al. Lung function in school-aged congenital diaphragmatic hernia patients; a longitudinal evaluation[J]. Pediatr Pulmonol, 2019, 54(8): 1257-1266. DOI: 10.1002/ppul.24375.
[3]
Panitch HB, Weiner DJ, Feng R, et al. Lung function over the first 3 years of life in children with congenital diaphragmatic hernia[J]. Pediatr Pulmonol, 2015, 50(9): 896-907. DOI: 10.1002/ppul.23082.
[4]
Wigen RB, Duan W, Moraes TJ, et al. Predictors of long-term pulmonary morbidity in children with congenital diaphragmatic hernia[J]. Eur J Pediatr Surg, 2019, 29(1): 120-124. DOI: 10.1055/s-0038-1676586.
[5]
Tracy S, Chen C. Multidisciplinary long-term follow-up of congenital diaphragmatic hernia: a growing trend[J]. Semin Fetal Neonatal Med, 2014, 19(6): 385-391. DOI: 10.1016/j.siny.2014.09.001.
[6]
Yamoto M, Nagata K, Terui K, et al. Long-term outcomes of congenital diaphragmatic hernia: report of a multicenter study in Japan[J]. Children (Basel), 2022, 9(6): 856. DOI: 10.3390/children9060856.
[7]
Berman L, Jackson J, Miller K, et al. Expert surgical consensus for prenatal counseling using the Delphi method[J]. J Pediatr Surg, 2018, 53(8): 1592-1599. DOI: 10.1016/j.jpedsurg.2017.11.056.
[8]
Chotzoglou E, Hedrick HL, Herkert LM, et al. Therapy at 30 days of life predicts lung function at 6 to 12 months in infants with congenital diaphragmatic hernia[J]. Pediatr Pulmonol, 2020, 55(6): 1456-1467. DOI: 10.1002/ppul.24736.
[9]
Wright T, Filbrun A, Bryner B, et al. Predictors of early lung function in patients with congenital diaphragmatic hernia[J]. J Pediatr Surg, 2014, 49(6): 882-885. DOI: 10.1016/j.jpedsurg.2014.01.016.
[10]
Cauley RP, Potanos K, Fullington N, et al. Pulmonary support on day of life 30 is a strong predictor of increased 1 and 5-year morbidity in survivors of congenital diaphragmatic hernia[J]. J Pediatr Surg, 2015, 50(5): 849-855. DOI: 10.1016/j.jpedsurg.2014.12.007.
[11]
Lally KP, Lasky RE, Lally PA, et al. Standardized reporting for congenital diaphragmatic hernia--an international consensus[J]. J Pediatr Surg, 2013, 48(12): 2408-2415. DOI: 10.1016/j.jpedsurg.2013.08.014.
[12]
张奕，马立霜，曹玲，等. 先天性膈疝患儿手术后近期肺功能观察及相关因素分析[J]. 临床小儿外科杂志，2022, 21(3): 236-241. DOI: 10.3760/cma.j.cn101785-202107030-007.
[13]
Cauley RP, Stoffan A, Potanos K, et al. Pulmonary support on day 30 as a predictor of morbidity and mortality in congenital diaphragmatic hernia[J]. J Pediatr Surg, 2013, 48(6): 1183-1189. DOI: 10.1016/j.jpedsurg.2013.03.012.
[14]
Semama C, Vu S, Kyheng M, et al. High-frequency oscillatory ventilation versus conventional ventilation in the respiratory management of term neonates with a congenital diaphragmatic hernia: a retrospective cohort study[J]. Eur J Pediatr, 2022, 181(11): 3899-3906. DOI: 10.1007/s00431-022-04590-w.
[15]
Porta NFM, Naing K, Keene S, et al. Variability for age at successful extubation in infants with congenital diaphragmatic hernia (CDH)[J]. J Pediatr, 2022, 253: 129.e1-134.e1. DOI: 10.1016/j.jpeds.2022.09.031.
[16]
Fuyuki M, Usui N, Taguchi T, et al. Prognosis of conventional vs. high-frequency ventilation for congenital diaphragmatic hernia: a retrospective cohort study[J]. J Perinatol, 2021, 41(4): 814-823. DOI: 10.1038/s41372-020-00833-6.
[17]
Snoek KG, Capolupo I, van Rosmalen J, et al. Conventional mechanical ventilation versus high-frequency oscillatory ventilation for congenital diaphragmatic hernia: a randomized clinical trial (The VICI-trial)[J]. Ann Surg, 2016, 263(5): 867-874. DOI: 10.1097/SLA.0000000000001533.
[18]
Derraugh G, Levesque M, Schantz D, et al. High-frequency vs. conventional ventilation at the time of CDH repair is not associated with higher mortality and oxygen dependency: a retrospective cohort study[J]. Pediatr Surg Int, 2020, 36(11): 1275-1280. DOI: 10.1007/s00383-020-04740-x.
[19]
Yang Y, Gowda SH, Hagan JL, et al. Blood transfusion is associated with increased mortality for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation support[J]. Vox Sang, 2022, 117(12): 1391-1397. DOI: 10.1111/vox.13363.
[20]
Zamora IJ, Cass DL, Lee TC, et al. The presence of a hernia sac in congenital diaphragmatic hernia is associated with better fetal lung growth and outcomes[J]. J Pediatr Surg, 2013, 48(6): 1165-1171. DOI: 10.1016/j.jpedsurg.2013.03.010.
[21]
Levesque M, Derraugh G, Schantz D, et al. The presence of a hernia sac in isolated congenital diaphragmatic hernia is associated with less disease severity: a retrospective cohort study[J]. J Pediatr Surg, 2019, 54(5): 899-902. DOI: 10.1016/j.jpedsurg.2019.01.016.
[22]
王伟鹏，潘伟华，陈杰，等. 疝囊对先天性膈疝患儿临床结局的影响[J]. 中华小儿外科杂志，2019, 40(3): 212-215. DOI: 10.3760/cma.j.issn.0253-3006.2019.03.005.
[23]
侯龙龙，林土连，何秋明，等. 先天性膈疝疝囊的产前识别及其对预后的影响[J]. 临床小儿外科杂志，2022, 21(9): 827-832. DOI: 10.3760/cma.j.cn101785-202206003-006.
[24]
Qin J, Ren Y, Ma D. A comparative study of thoracoscopic and open surgery of congenital diaphragmatic hernia in neonates[J]. J Cardiothorac Surg, 2019, 14(1): 118. DOI: 10.1186/s13019-019-0938-3.
[25]
吴雨昊，况虹宇，吕铁伟，等. 先天性膈疝微创手术及开放手术治疗效果的Meta分析[J]. 临床小儿外科杂志，2017, 16(1): 18-25, 76. DOI: 10.3969/j.issn.1671-6353.2017.01.006.
[26]
Okawada M, Ohfuji S, Yamoto M, et al. Thoracoscopic repair of congenital diaphragmatic hernia in neonates: findings of a multicenter study in Japan[J]. Surg Today, 2021, 51(10): 1694-1702. DOI: 10.1007/s00595-021-02278-6.
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