| Meconium aspiration syndrome(MAS)is the result of a series of reactions caused by meconium aspiration respiratory mechanical obstruction and chemical inflammation,which is the most common aspiration pneumonia before or during production.Nowadays,with the opening of two-child policy,the main population tends to younger,which has gradually become an important part of Chinese population,how to improve the survival rate and quality of this group,is particularly important.The occurrence of meconium aspiration syndrome may be related with family and social / economic status,the medical resources and maternal age at first pregnancy and other factors.The pathogenesis of neonatal meconium aspiration syndrome,as the name suggests,the specific mechanism is related with meconium suction and discharge process,because of,meconium formation and excretion and gestational age growth have certain correlation,therefore,MAS is more common in full-term infants,but the mechanism of intrauterine meconium discharge is not very clear.In general,even if not by meconium stained amniotic fluid,with obvious respiratory distress,normal intrauterine breathing will not cause meconium aspiration,or limited to the inhalation of upper airway or trachea,but if fetal distress in obvious intrauterine under the condition of the meconium into small airway or alveolar,after breathing after the start of the meconium into the distal airway,thus,meconium aspiration syndrome and fetal distress is a certain degree of correlation.In recent years,there is a growing number of scholars on the administration of PS,drug selection,select bronchoscopic lavage or not according to the actual conditions,or with ambroxol lavage compared to evaluate the necessity and effectiveness of endotracheal lavage with PS and the effects on the prognosis.The previous studies showed that pulmonary surfactant(PS)inactivation plays an important role in the pathogenesis of MAS.The domestic and foreign multi center randomized controlled trials,tracheal administration of pulmonary surfactant with MAS can effectively improve oxygenation and ventilation function,reduce complications(PPHN,ARDS,lung leakage,pneumonia,ventilator-associated pneumonia etc)incidence rate,reduce mortality.Since 1978 the first application of fiberoptic bronchoscope in pediatric clinical practice,diagnosis and treatment of fiberoptic bronchoscopy in the pediatric respiratory disease effects have been widely recognized.In recent years,due to the continuous improvement of the size and structure,the clinical bronchoscopy doctors continuously improve the level of bronchoscopy for diagnosis and treatment of respiratory diseases of various gestational age,birth weight play a very important role.In our country,because of national conditions,medical conditions,bronchoscopy more costly,bronchoscopy is not yet widely used in pediatric clinical neonatal.As a special group of patients,newborn babies need more professional,more precise diagnosis and high-end,we hope this research on neonatal meconium the clinical diagnosis and treatment of inhalation syndrome has a guiding role.Objective The purpose of this study was to investigate the curative effect and prognosis of the early line of bronchoalveolar lavage in treatment of neonatal meconium aspiration syndrome(MAS),and the dilution PS lavage group,NS lavage group and non BAL group contrast each other,understand the treatment,whether there is difference in complications and prognosis or not,we can study the pathogenesis of lung injury meconium aspiration in further,which can provide timely and effective treatment and improve the prognosis for the new treatment of neonatal meconium aspiration,has clinical significance better.Methods This study has selected the June 2014-2016 year in June in our hospital neonatal intensive care unit(NICU)of mature newborns were diagnosed with a total of 48 MAS cases,through the inclusion and exclusion criteria collected during the study period in accordance with the conditions of the 36 patients,6 patients were excluded from the records of incomplete information and drop out hospital treatment of children,the final 30 cases completed the study,taken randomly divided into diluted PS lavage group,NS lavage group,control group,10 cases in each group.The family members were required to sign the informed consent.(1)The diluted PS lavage group: in 12 hours after the birth treated with pulmonary surfactant diluted(3~5ml/kg.)underwent bronchoalveolar lavage lavage,the second step was intratracheal instillation of PS 100mg/kg,which had been taken 4 hours after the first step,and then provided respiratory support;(2)the saline lavage group(NS): after birth within 12 hours of saline(3~5ml/kg)bronchoalveolar lavage lavage,the second step was the same as in the first group,and then provided respiratory support;(3)the control group was given conventional respiratory tract cleaning and symptomatic treatment,after tracheal intubation,we drip into the alveolar surface active material 100mg/kg,given appropriate respiratory support treatment.During the treatment,in accordance with the consider the need for the condition of mechanical ventilation,PS can be repeatedly given when necessary,and all received general treatment in routine monitoring.Endotracheal suction was prohibited within 4~6 hours after PS intratracheal administration.Observation index: compare the three groups of patients,treatment before and after 2,4,8,12,24,48,72 h,ranscutaneous blood gas,oxygenation index(OI),P/F value,time of mechanical ventilation,lung ultrasound,hospitalization time,complications(PPHN,ARDS,lung leakage,pneumonia,ventilator-associated pneumonia etc)incidence rate,cure rate,mortality rate.Respiratory support and oxygen therapy : The ventilator support and removal of the ventilator indications of three groups of patients were the same;invasive ventilation on indication:(1)Pa O2 < 60 mm Hg and Fi O2 > 60%;(2)the blood gas analysis: PH < 7.2,PCO2 > 60 mm Hg,BE >-8mmol/L.Extubation indications:(1)spontaneous breathing can be tolerated,attracted the breath and airway cough reflex more than 24h;(2)the blood gas analysis: PH > 7.25,PCO2 < 60 mm Hg,BE <-8mmol/L;(3)PIP = 10~15cm H2 O,positive end expiratory pressure(PEEP)4cm H2 O,the frequency is less than or equal to 10 minute duration 24~48h;(4)the average airway pressure is less than 8cm H2 O,respiratory rate less than 30 BPM,inhaled oxygen concentration(Fi O2)< 40%,Sp O2 > 0.93,last more than 24 hours.Noninvasive ventilation indications(NIPPV)indication:(1)Fi O2 > 40% cannot be maintained with Pa O2 > 60 mm Hg;(2)the blood gas analysis: PCO2 > 60 mm Hg;(3)after extubation,three concave syndrome or(and)respiratory distress appeared again.The removal of NIPPV indications:(1)positive end expiratory pressure(PEEP)4cm H2 O maintained 24~48h;(2)Fi O2<30%,respiratory frequency< 60 times / min,Sp O2 in 0.91~0.95 maintained above 24h;(3)non apnea,bradycardia,no decrease of Sa O2,the work of breathing did not increase;(4)the patients were tolerated when nursing is temporarily out of NIPPV.Meet the above conditions at the same time,blood gas analysis meet the following requirements: PH > 7.25,PCO2 < 60 mm Hg,BE <-8mmol/L.The patients who had been removed of NIPPV were given high flow nasal catheter oxygen until oxygen is stopped.When need to repeatedly give indications of pulmonary surfactant:(1)OI(oxygen index)values had no improvement or < 200;(2)Fi O2 > 50%;(3)the main parameters of the ventilator PIP and PEEP had difficuly with down-regulation;(4)combined with ARDS;(5)combined with PPHN.Data analysis: the data were processed by SPSS 19 statistical software.Measurement data in x— ±s said,compared with the two groups were t test,compared with group before and after treatment by paired t test;level data were compared with rank sum test;count data were compared with X2 test,P < 0.05 the difference was statistically significant.Results The final 30 cases of MAS were included in this study,10 cases in each group.Each group of babies with gender,gestational age,birth weight,age at the time of admission,were not statistically significant differences in Apgar scores(P < 0.05).Each group of before treatment,after treatment of 2,4,8,12,24,48,72 h,the oxygenation index(OI)and P/F: PS group compared with NS group,at 4-12 hours after irrigation period,OI and P/F had significant difference(P > 0.05),during the hour 12-72 h there were no significant difference(P < 0.05 P/F).Compared with the control group,OI and P/F of PS lavage group and NS lavage group at each observation time showed significant difference(P > 0.05).Comparison of respiratory support and PS usage: Compared with the control group,the PS lavage group and NS lavage group had less extubation time,NIPPV time,high flow oxygen using time,lower rate of high frequency to support,the differences were statistically significant(P < 0.05).The amount and the number of times of the PS lavage group and NS lavage group were less than the control group,the difference was statistically significant(P < 0.05).Between PS lavage group and NS lavage group,indexes above showed no significant difference(P > 0.05).Comparison of complications: Compared with the control group,the PS lavage group and NS lavage group had lower rate of lung leakage,pneumonia,VAP,and PPHN,ARDS,the differences were statistically significant(P < 0.05).The rate of death and give up of PS lavage group and NS lavage group reduced significantly,there are statistically significant difference(P < 0.05).Between PS lavage group and NS lavage group,indexes above showed no significant difference(P > 0.05).Conclusion The early efficacy of fiberoptic bronchoscopy bronchoalveolar lavage lavage group was obviously better than that of not;there was no significant difference between the curative effect of early to dilute PS lavage and NS lavage;curative effect of intratracheal instillation of PS for the treatment of MAS.In short,early to bronchoalveolar lavage in treatment of neonatal MAS can obviously improve blood oxygenation and ventilation function,promote disease recovery,reduce the incidence of complications and mortality.This research also had disadvantages,for example,a small sample,a short span of time,no hospital follow-up outcomes,mechanical ventilation was not a unified design and so on,so we need further improvement and perfection. |
PDF Full Text Request