肺表面活性物质吸入NO治疗ALIARDS.ppt

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1、1.ARDS临床流行病调查临床流行病调查2.肺表面活性物质肺表面活性物质/吸入吸入NO治疗治疗ALI/ARDS Clinical epidemiology of ALI/ARDS Incidence of respiratory failure,mechanical ventilation,and ALI/ARDS in ICU Standard diagnosis and care management Clinical trial,control and intervention Follow up outcomes Assess cost-effectiveness Medical re

2、sources,network上海市医院急性呼吸窘迫综合征上海市医院急性呼吸窘迫综合征临床发病情况调查临床发病情况调查A 12-Month Survey of ARDS in Adult ICUsShanghai ARDS Study GroupIntensive Care Med 2004;30(12):2197-2203 Morbidity 15 PICUs,5320 admissions/2001-2002(12 mon)108 ARDS(2%of admission)(Europe 6-7%)15 years old 24 h of admission,2.5(n)33Intensiv

3、e Care Med 2004;30(12):2197-2203MortalityDeath:74(68.5%)in-hospital 76(70.4%)at 3 months after onsetDeath rate(病死率病死率)ICU total death548/5320(10.3%)ARDS/ICU total death 74/548(13.5%)ARDS:non-ARDS6.4:1(RR)Intensive Care Med 2004;30(12):2197-2203 Predisposing factors of ARDSDeath Pulmonary origin41(39

4、%)32-Pneumonia37(34.3%)29 Non-pulmonary67(61%)42-Sepsis33(30.6%)MODS44/74(60%)Respiratory failure17/74(23%)Septic shock 9/74(12%)Intensive Care Med 2004;30(12):2197-2203 Pediatric ARDSA 12-month survey of incidence,management and outcome of ARDS in 25 pediatric ICU in ChinaChinese Pediatric ARDS Stu

5、dy GroupATS 2005 San Diego Intl Conference北京儿童医院北京儿童医院首都儿研所儿童医院首都儿研所儿童医院北京大学第一医院北京大学第一医院哈尔滨儿童医院哈尔滨儿童医院中国医科大学第二医院中国医科大学第二医院河北医科大学第二医院河北医科大学第二医院天津儿童医院天津儿童医院山西省儿童医院山西省儿童医院郑州儿童医院郑州儿童医院重庆医科大学儿童医院重庆医科大学儿童医院广州儿童医院广州儿童医院湖南省儿童医院湖南省儿童医院长春市儿童医院长春市儿童医院深圳儿童医院深圳儿童医院成都市儿童医院成都市儿童医院泉州儿童医院泉州儿童医院江西省儿童医院江西省儿童医院浙江大学儿童医院

6、浙江大学儿童医院温州育英儿童医院温州育英儿童医院南京儿童医院南京儿童医院苏州儿童医院苏州儿童医院上海儿童医学中心上海儿童医学中心上海新华医院上海新华医院上海儿童医院上海儿童医院复旦大学儿科医院复旦大学儿科医院小儿小儿ARDSARDS协作组协作组PICU alladmissionsCriticalALI/ARDSSurvivaldeathPIM+GuidePIM+Guide1994 AECC1994 AECCTreatment基本流程基本流程25 Pediatric ICU25 Pediatric ICU 2004.01-12 2004.01-12PICU total 11453Critical

7、 6839RF呼吸衰竭呼吸衰竭1862MV 1883ALIALI303303ARDSARDS 97 97ResultsIncidence/PICU admission ARDS 患病率患病率 1.42%ALI 患病率患病率4.4%Death rateARDS病死率病死率62.9%(61)Total PICU 6.8%RRARDS:non-ARDS 8.3:1Cost:ARDS/non-ARDS 4.5:1Predisposing factors of pediatric ARDS Pneumonia40 Sepsis14 Immunocompromised15 Intoxication 8 P

8、ost-operation 4 Trauma 4 Asphyxia 3 Others11Measurement to reduce mortality Early diagnosis and management Ventilation:low tidal volume Specific therapy:alveolar atelectasis:PEEP,surfactantintrapulmonary shunting:inhaled NOfluid balance:restricted infusionalveolar leakage:selected coloidrenal:CRRTex

9、acerbated:ECMO 临床意义临床意义 ARDSARDS是是ICUICU最具代表性的、高死亡风险的危重症最具代表性的、高死亡风险的危重症 (综合征综合征)之一之一患病率占患病率占ICUICU收治收治1.5-2.0%,1.5-2.0%,病死率病死率60%60%临床流行病研究对于形成正确的诊断和治疗有助临床流行病研究对于形成正确的诊断和治疗有助于开展临床干预治疗于开展临床干预治疗(对照和基础治疗对照和基础治疗)中国人口高度集中的城市医院成为研究中国人口高度集中的城市医院成为研究ARDSARDS发生发生发展和转归的重要场所发展和转归的重要场所 人群流行病资料依靠正确的临床诊断人群流行病资料依

10、靠正确的临床诊断 加强区域、国际合作研究加强区域、国际合作研究Surfactant treatment for ARDS 60s Adult RDS and neonatal RDS 80 Surfactant replacement therapy 30 RCT 90 Surfactant and ARDS/NO and ARDS 2000-:RCT Surfactant/NOEarly case study of surfactant replacement for ARDS(Spragg R,Chest 1994;105:195-204)6 ARDS,2 days,3 survived

11、Curosurf 80 mg/ml,4 g/50 ml,50 mg/kg(Walmrath AJRCCM 1996;154:57-62)10 ARDS,5 survived Alveofact 300 mg/kg,multiple dose PaO2/FiO2 200 mmHg,Qs/Qt 20%Multicenter randomized controlled trialAnzueto A NEJM 1996,Exosurf aerosol(no SP)Gregory TJ AJRCCM 1997 SurvantaLuchetti M PCCM 2002 Curosurf(Pediatric

12、)Walmrath D ERJ 2002 AlveolfactSpragg R AJRCCM 2003 Venticute(SP-C)Spragg R NEJM 2004 VenticuteWillson DF JAMA 2005 CalfactantEffect of Recombinant Surfactant Protein CBased Surfactant on the ARDSSpragg RG et al NEJM 2004;351:884-892 448 adult patients with ARDS standard therapy alone (control)stand

13、ard therapy+surfactant(test)exogenous surfactant did not improve survival.exogenous surfactant improve gas exchange during 24-hour treatment period.Effect of Calfactant in Pediatric ALIWillson DF et al JAMA.2005;293:470-6 153 children(age 1 week to 21 years)with respiratory failure from ALI Air plac

14、ebo(control)Intratracheal Calfactant 100 mg/kg(test)Calfactant group:oxygenation index(20 to 13.9)o mortality (15/77)Placebo group:oxygenation index(20.5 to 15.1)o o o o mortality (27/75)Calfactant improved oxygenation and decreased mortalitySurfactant Treatment of Neonates With Respiratory Failure

15、and GBS Infection Herting E et al.Pediatrics 2000;106:957-964 118 neonates with GBS infection and respiratory failure treated with Curosurf(test);236 noninfected premature neonates RDS(control).Surfactant improves gas exchange;Response to surfactant in GBS group is slower than in control group.A-B,F

16、iO2,PaO2/FiO2,after surfactant treatment.*P.01*P.001versus before surfactant.Treatment of Severe Meconium Aspiration Syndrome with Porcine Surfactant:A Multicenter,Randomized,Controlled Trial Chinese Collaborative Study Group for Neonatal Respiratory DiseasesActa Paediatrica 2005Questions Why surfactant does not work well in ALI/ARDS as neonatal RDS?Adverse effects of excessive fluid loading Ventilation Metabolism of surfactant in injured lungsAlveolar and tissue pool sizes in human lungs Alveol