CAJ | 학술논문

目的：探讨先天性膈疝( congenital diaphragmatic hernia,CDH)新生儿围手术期呼吸支持的方式及治疗结果。方法回顾性分析我院NICU收治的13例CDH患儿的临床资料,其中产前确诊患儿生后立即给予气管插管,转入NICU后给予呼吸机支持,术前采用高频振荡通气( high-frequency oscillatory ventilation,HFOV)模式,合并肺动脉高压的患儿给予HFOV联合一氧化氮吸入治疗至生命体征稳定后,转入儿外科给予根治性的膈疝修补术治疗,术后依然入NICU给予HFOV模式进行呼吸机支持,参照患儿术前呼吸机参数适当调节后设置术后通气参数,当吸入氧浓度≤40%,平均气道压≤10 cmH2O(1 cmH2O=0．098 kPa),血气分析结果在正常范围内,导管前经皮氧饱和度维持在85%~95%,改为常频机械通气锻炼患儿自主呼吸,模式为同步间歇指令通气+压力支持模式,当患儿自主呼吸平稳有力, X线胸片提示肺透亮度均匀,膈肌位于第8、9肋后,吸入氧浓度≤30%,平均气道压≤8 cmH2 O,经皮氧饱和度、血气在正常范围内时,撤离呼吸机。结果经过上述呼吸支持治疗,13例CDH患儿除放弃的2例外,其余11例在围手术期顺利渡过呼吸关,患儿围手术期早期使用HFOV治疗,待呼吸及血流动力学稳定后进行延期手术治疗,提高了膈疝患儿的生存率并降低支气管肺发育不良的发生率,取得了良好的临床治疗效果。结论通过对新生儿期CDH患儿进行围手术期的呼吸支持,为患儿能够成功进行外科手术及术后恢复治疗提供了生命支持保障,通过多学科协作治疗本病提高了患儿的治愈率及生存质量。
목적：탐토선천성격산( congenital diaphragmatic hernia,CDH)신생인위수술기호흡지지적방식급치료결과。방법회고성분석아원NICU수치적13례CDH환인적림상자료,기중산전학진환인생후립즉급여기관삽관,전입NICU후급여호흡궤지지,술전채용고빈진탕통기( high-frequency oscillatory ventilation,HFOV)모식,합병폐동맥고압적환인급여HFOV연합일양화담흡입치료지생명체정은정후,전입인외과급여근치성적격산수보술치료,술후의연입NICU급여HFOV모식진행호흡궤지지,삼조환인술전호흡궤삼수괄당조절후설치술후통기삼수,당흡입양농도≤40%,평균기도압≤10 cmH2O(1 cmH2O=0．098 kPa),혈기분석결과재정상범위내,도관전경피양포화도유지재85%~95%,개위상빈궤계통기단련환인자주호흡,모식위동보간헐지령통기+압력지지모식,당환인자주호흡평은유력, X선흉편제시폐투량도균균,격기위우제8、9륵후,흡입양농도≤30%,평균기도압≤8 cmH2 O,경피양포화도、혈기재정상범위내시,철리호흡궤。결과경과상술호흡지지치료,13례CDH환인제방기적2예외,기여11례재위수술기순리도과호흡관,환인위수술기조기사용HFOV치료,대호흡급혈류동역학은정후진행연기수술치료,제고료격산환인적생존솔병강저지기관폐발육불량적발생솔,취득료량호적림상치료효과。결론통과대신생인기CDH환인진행위수술기적호흡지지,위환인능구성공진행외과수술급술후회복치료제공료생명지지보장,통과다학과협작치료본병제고료환인적치유솔급생존질량。
Objective To explore the ventilation strategies and treatment outcomes in the neonates with congenital diaphragmatic hernia(CDH) during perioperative period. Methods We conducted a retro-spective study of 13 infants with CDH in our NICU. Infants with prenatal diagnosis of CDH should be intuba-ted immediately after delivery,then they were transferred to NICU and gave ventilator support. During pre-operation period,high-frequency oscillatory ventilation(HFOV) mode was used as initial therapy. Neonates with CDH-associated pulmonary hypertension received inhaled nitric oxide( iNO) therapy. The surgical repair of CDH was usually delayed until physiologic stabilization and improvement of pulmonary hypertension. After surgical repair,we still used HFOV mode. According to the pre-operation parameter,the parameters of postop-erative ventilation were regulated. The ventilator mode was changed to conventional ventilation( synchronized intermittent mandatory ventilation+pressure support ventilation) when FiO2≤40%,mean airway pressure≤10 cmH2O(1 cmH2O=0. 098 kPa),blood gas analysis resulted within normal range,the target preductal satu-ration range was 85% to 95%. When the babies′ spontaneous respiration maintained stronger,FiO2≤30%, mean airway pressure≤8 cmH2 O, SaO2 , blood gas analysis resulted within normal range, thoracic X-ray showed the lung border on the contralateral side between the 8th and the 9th rib,then we weaned ventilator support. Results This gentle ventilation strategies were routinely used in our center,and made a good thera-peutic effect in infants with CDH. Eleven of 13 CDH cases smoothly passed the ventilator support,no one de-veloped into bronchopulmonary dysplasia. Conclusion Infants with CDH should be intubated immediately after birth and give ventilator support in perioperative period. This gentle ventilation strategy to avoid baro-trauma until vital organs functions are stabilized. In order to improve the survival rate of infants with CDH, multidisciplinary collaboration become very important.