早產(chǎn)兒呼吸窘迫綜合征歐洲共識中英對照

早產(chǎn)兒呼吸窘迫綜合征歐洲共識中英對照第1頁/共24頁PrenatalCare產(chǎn)前治療MothersathighriskofpretermbirthshouldbetransferredtoperinatalcentreswithexperienceinmanagementofRDS(C).有早產(chǎn)高危因素的母親應被轉運至對處理新生兒呼吸窘迫綜合癥有豐富經(jīng)驗的醫(yī)療中心。Cliniciansshouldofferasinglecourseofantenatalsteroidstoallwomenatriskofpretermdeliveryfromabout23weeksupto35completedweeks’gestation(A).對于孕23周至35周有早產(chǎn)高危因素的母親，醫(yī)生均應使用一療程產(chǎn)前激素。Antibioticsshouldbegiventomotherswithpretermpre-labourruptureofthemembranesasthisreducestheriskofpretermdelivery(A).對于有早產(chǎn)高危因素合并胎膜早破的孕婦，抗生素的使用可減少早產(chǎn)的發(fā)生。第2頁/共24頁Cliniciansshouldconsidershort-termuseoftocolyticdrugstoallowcompletionofacourseofantenatalsteroidsand/orinuterotransfertoaperinatalcentre(A).醫(yī)生應考慮短期使用抗分娩藥物，使產(chǎn)前激素療程可完成/能及時轉運至醫(yī)療中心。AsecondcourseofantenatalsteroidsshouldbeconsiderediftheriskfromRDSisfelttooutweightheuncertaintyaboutpossiblelong-termadverseeffects(D).Oneexamplewherebenefitmightoutweightheriskismultiplepregnancy(C).若考慮發(fā)生新生兒呼吸窘迫綜合征的危險大于使用激素產(chǎn)生長期副作用的不確定性，應考慮使用第二療程的產(chǎn)前激素。其中一個利大于弊的例子是多胎妊娠。第3頁/共24頁DeliveryRoomStabilisationIfpossible,delayclampingoftheumbilicalcordforatleast30-45swiththebabyheldbelowthemothertopromoteplacento-fetaltransfusion(A).如果可能，延遲鉗夾臍帶30-45秒，且使嬰兒位置低于母親，有利于母-嬰輸血。Oxygenforresuscitationshouldbecontrolledbyusinganair-oxygenblender.Thelowestconcentrationofoxygenpossibleshouldbeusedduringstabilisation,providedthereisanadequateheartrateresponse.Aconcentrationof30%oxygenisappropriatetostartstabilisationandadjustmentsupordownshouldbeguidedbyapplyingpulseoximetryfrombirthtogiveinformationonheartrate(B).Normalsaturationsduringtransitionimmediatelyafterbirthinverypreterminfantsmaybebetween40and60%,reachingbetween50and80%at5minofageandshouldbe>85%by10minofage.Exposuretohyperoxiashouldbeavoidedduringstabilisation(B).復蘇時氧氣濃度需用空氣-氧氣混合器控制。需要使用最低的氧濃度達到使嬰兒穩(wěn)定的目的（合適的心率）。30%的氧濃度作為復蘇起始的氧濃度較適宜，然后根據(jù)脈搏-氧飽和度儀提供心率的信息作出調整。對于極早產(chǎn)兒，生后立即的氧飽和度大約為40-60%，5分鐘時上升至50-80%，10分鐘時應>85%。應避免復蘇時高氧的暴露。第4頁/共24頁InspontaneouslybreathingbabiesstartstabilisationwithCPAPofatleast5-6cmH2Oviamaskornasalprongs(B).Ifbreathingisinsufficient,considertheuseofasustainedinflationbreathtorecruitthelungratherthanintermittentpositivepressurebreaths(B).對于自主呼吸好的嬰兒,面罩/鼻塞持續(xù)正壓通氣時最少使用5-6cm水柱的呼氣末正壓。若自主呼吸不足，持續(xù)通氣優(yōu)于間歇正壓通氣。VentilationwithaT-piecedeviceispreferabletoaself-in-flating,orflow-flatingbaginordertogenerateappropriatepositiveend-expiratorypressure(PEEP)(C).使用T管優(yōu)于球囊因為它可以維持一個合適的呼氣末正壓。第5頁/共24頁Ifpositivepressureventilationisneededforstabilisation,aimtoavoidexcessivetidalvolumesbyincorporatingresuscitationdeviceswhichmeasureoflimitthePIPwhilstatthesametimemaintainingPEEPduringexpiration(D).如果需要正壓通氣維持病情的穩(wěn)定，目標是通過限制吸氣峰壓和維持呼氣末正壓來避免過度通氣。Intubationshouldbereservedforbabieswhohavenotrespondedtopositivepressureventilationorthoserequiringsurfactanttherapy(D).當無創(chuàng)正壓通氣無效或需要使用肺表面活性物質治療時，需考慮氣管插管。第6頁/共24頁Ifthebabyisintubated,correctpositioningoftheendotrachealtubeshouldbeverifiedbycolorimetricCO2detection(D).當氣管插管時，需根據(jù)二氧化碳分壓調整氣管插管深度。Plasticbagsorocclusivewrappingunderradiantwarmersshouldbeusedduringstabilisationinthedeliverysuiteforbabies<28weeks’gestationtoreducetheriskofhypothermia(A).胎齡小于28周的早產(chǎn)兒復蘇過程中在輻射搶救臺上需使用塑料薄膜包裹以減少低體溫的發(fā)生。第7頁/共24頁SurfactantTherapy肺表面活性藥物BabieswithorathighriskofRDSshouldbegivenanaturalsurfactantpreparation(A).患新生兒呼吸窘迫綜合癥或有該病高危因素的嬰兒需備好天然的肺表面活性藥物。Prophylaxis(within15minofbirth)shouldbegiventoalmostallbabiesof<26weeks’gestation.ProphylaxisshouldalsobegiventoallpretermbabieswithRDSwhorequireintubationforstablisation(A).胎齡<26周的早產(chǎn)兒幾乎都需要預防性使用肺表面活性藥物（生后15min內(nèi)）。所有患有新生兒呼吸窘迫綜合癥且需要插管的早產(chǎn)兒均需要預防性使用肺表面活性物質。第8頁/共24頁EarlyrescuesurfactantshouldbeadministeredtopreviouslyuntreatedbabiesifthereevidenceofRDS(A).IndividualunitsneedtodevelopprotocolsforwhentointerveneasRDSprogressesdependingongestationalageandpriortreatmentwithantenatalsteroids(D).Poractantalfainaninitialdoesof200mg/kgisbetterthan100mg/kgofporactantalfaorberactantfortreatmentofmoderatetosevereRDS(B).當有新生兒呼吸窘迫綜合癥的證據(jù)且未使用肺表面活性物質的早產(chǎn)兒，應盡早應用治療性的肺表面活性物質。不同機構需根據(jù)胎齡及產(chǎn)前激素的使用來制定新生兒呼吸窘迫綜合癥的干預策略。對于中至重度的新生兒呼吸窘迫綜合癥，首劑200毫克/公斤的豬肺表面活性物質/貝拉康坦優(yōu)于100毫克/公斤。第9頁/共24頁Considerimmidiate(orearly)extubationtonon-invasiverespiratorysupport(CPAPornasalintermittentpositivepressureventilation(NIPPV))followingsurfactantadministrationprovidedthebabyisotherwisestable(B).當嬰兒病情穩(wěn)定時，建議使用肺表面活性物質后立即或盡早拔除氣管插管，改為無創(chuàng)呼吸支持（持續(xù)正壓通氣或鼻塞間歇正壓通氣）。Asecond,andsometimesathirddoseofsurfactantshouldbeadministeredifthereisongoingevidenceofRDSsuchasapersistentoxygenrequirementandneedforMV(A).當新生兒呼吸窘迫綜合癥繼續(xù)進展（表現(xiàn)為持續(xù)需氧或需要機械通氣），需考慮第二劑甚至第三劑肺表面活性物質的使用。第10頁/共24頁OxygenSupplementationbeyondStabilisationInbabiesreceivingoxygen,saturationshouldbemaintainedbetween85and93%(D).早產(chǎn)兒的氧飽和度需維持在85-93%之間。AftergivingsurfactantavoidahyperoxicpeakbyrapidreductioninFiO2(C).使用肺表面活性物質后注意避免急速下調供氧濃度。AvoidfluctuationsinSaO2inthepostnatalperiod(D).避免生后氧飽和度的波動。第11頁/共24頁RoleofCPAPinManagementofRDSCPAPshouldbestartedfrombirthinallbabiesatriskofRDS,suchasthose<30weeks’gestationwhodonotneedMV,untiltheirclinicalstatuscanbeassessed(D).所有有新生兒呼吸窘迫綜合癥高危因素的早產(chǎn)兒應首選持續(xù)正壓通氣，例如胎齡小于30周無需呼吸機輔助呼吸者，直至臨床表現(xiàn)穩(wěn)定后。Shortbinasalprongsshouldbeusedratherthanasingleprongastheyreducetheneedforintubationandapressureofatleast5cmH2Oshouldbeapplied(A).雙鼻塞優(yōu)于單鼻塞（呼氣末正壓至少需達到5厘米水柱），因為它能減少插管的需要。TheuseofCPAPwithearlyrescuesurfactantshouldbeconsideredinbabieswithRDSinordertoreducetheneedforMV(A).患新生兒呼吸窘迫綜合癥的患兒早期應用肺表后直接應用持續(xù)正壓通氣可減少呼吸機的使用。第12頁/共24頁MechanicalVentilationStrategies

呼吸機策略MVshouldbeusedtosupportbabieswithrespiratoryfailureasthisimprovessurvival(A).呼吸衰竭時需使用呼吸機輔助呼吸，增加生存率。AvoidhypocapniaasthisisassociatedwithincreasedrisksofBPDandperiventricularleucomalacia(B).避免低碳酸血癥，因為它與慢性肺疾病及腦室周圍白質軟化相關。SettingsofMVshouldbeadjustedfrequentlywiththeaimofmaintainingoptimumlungvolume(C).呼吸機的參數(shù)需不斷的調整，目標是維持理想的肺容量。DurationofMVshouldbeminimisedtoreduceitsinjuriouseffectonlung(B).盡量減少呼吸機通氣的時間，減輕肺損傷。第13頁/共24頁AvoidingorReducingDurationofMechanicalVentilation

避免或縮短使用呼吸機CaffeineshouldbeusedinbabieswithapnoeaandtofacilitateweaningfromMV(A).Caffeineshouldbeconsideredforallbabiesathighriskofneedingventilation,suchasthose<1,250gbirthweight,whoaremanagedonCPAPorNIPPV(B).有呼吸暫?；驕蕚涑窓C的患兒，應使用咖啡因?？Х纫驊褂糜谒杏猩蠙C高危因素的患兒，例如出生體重小于1250克，正在使用持續(xù)正壓通氣或鼻塞間歇正壓通氣者。CPAPorNIPPVshouldbeusedpreferentiallytoavoidorreducethedurationofMVthroughanendotrachealtube(B).為了避免或縮短氣管插管呼吸機輔助通氣的時間，應優(yōu)先選用持續(xù)正壓通氣或鼻塞間歇正壓通氣。第14頁/共24頁WhenweaningfromMVitisreasonabletotolerateamoderatedegreeofhypercapnia,providedthepHremainsabove7.22(D).當撤機后，容許允許性高碳酸血癥的存在（血氣PH需維持在7.22以上）。SynchronisedandtargetedtidalvolumemodesofconventionalventilationwithanaggressiveweaningapproachshouldbeusedtoshortendurationofMV(B).應該使用同步及容量保證的常頻呼吸機模式加上一個積極的撤機方法來縮短使用呼吸機的時間。第15頁/共24頁ProphylacticTreatmentforSepsis

敗血癥的預防性治療AntibioticsshouldbestartedinbabieswithRDSuntilsepsishasbeenruledout.Acommonregimenincludespenicillin/ampicillinincombinationwithanaminoglycoside,however,individualunitsshoulddeveloplocalprotocolsforantibioticusebasedontheprofileofbacterialpathogenscausingearlyonsetsepsis(D).患新生兒呼吸窘迫綜合癥的患兒需預防性使用抗生素直至除外敗血癥。常見的藥物是青霉素或氨芐西林聯(lián)合氨基糖苷類，然而，各機構需根據(jù)導致早發(fā)敗血癥的各自的細菌病原譜選擇抗生素。第16頁/共24頁Unitsshoulddevelopprotocolsforantifungalprophylaxisinverypretermbabiesbasedonthelocalincidenceandriskfactors(D).不同的機構需要根據(jù)當?shù)氐恼婢腥景l(fā)生率及危險因素建立極早產(chǎn)兒預防性使用抗真菌藥物的規(guī)則。第17頁/共24頁SupportiveCare

支持治療Bodytemperatureshouldbemaintainedat36.5-37.5oCatalltimes(C).體溫需一直維持在36.5-37.5oC。Mostbabiesshouldbestartedonintravenousfluidsof70-80ml/kg/daywhilebeingkeptinahumidifiedincubator(D).生后第一天給予70-80ml/公斤/天的靜脈液體（處于保濕暖箱中）。Fluidandelectrolytetherapyshouldbetailoredindividuallyinpreterminfants,allowinga2.5-4%dailyweightloss(15%total)overthefirst5days(D).早產(chǎn)兒液體及電解質的供給需個體化，允許生后頭五天每天2.5-4%的體重下降（總共15%）。第18頁/共24頁Sodiumintakeshouldberestrictedoverthefirstfewdaysoflifeandinitiatedaftertheonsetofdiuresiswithcarefulmonitoringoffluidbalanceandelectrolytelevels(B).生后頭幾天需限制鈉鹽的供給，當尿量增多后在密切監(jiān)測出入量及電解質水平后可開始給予。Fullparenteralnutritioncanbeinitiatedonday1(A).Thismayincludestartingproteinat3.5g/kg/dayandlipidat3g/kg/dayin10%dextrosesolution.全量胃腸外營養(yǎng)可于生后第一天開始。這包括蛋白質3.5g/kg/day及脂肪3g/kg/day，加入10%的糖水中。Minimalenteralfeedingshouldbestartedfromthefirstday(B).EarlyaggressivefeedingisincreasinglypopularbutlevelAevidenceofitsbenefitislacking.少量腸內(nèi)喂養(yǎng)應在生后第一天開始。早期快速增加喂養(yǎng)越來越流行，但缺乏A類證據(jù)的支持。第19頁/共24頁Treatmentofarterialhypotensionisrecommendedwhenitisconfirmedbyevidenceofpoortissueperfusion(C).組織灌注不良導致的低血壓是需要治療的。Volumeexpansionwith10-20ml/kg0.9%salineshouldbeusedasfirst-linetreatmentofhypotensionifmyocardialdysfunctionhasbeenexcluded(D).已排除心功能不全引起的低血壓，首選使用生理鹽水10-20ml/kg擴容。Dopamine(2-20μg/kg/min)shouldbeusedifvolumeexpansionfailstosatisfactorilyimprovebloodpressure(B).多巴胺(2-20μg/kg/min)在擴容后未能改善血壓使用。第20頁/共24頁Dobutamine(5-20μg/kg/min),asafirstline,andepinephrine(0.01-1.0μg/kg/min)asasecondline,shouldbeusediflowsystemicbloodflowandmyocardialdysfunctionneedtobetreated(D).當有效血容量不足和心功能不全時，使用多巴酚丁胺(5-20μg/kg/min)（一線）,腎上腺素(0.01-1.0μg/kg/min)（二線）治療。Hydrocortisone(1mg/kg8hourly)shouldbeusedincasedofrefractoryhypotensionwhereconventionaltherapyhasfailed(B).難治性低血壓可使用氫化可的松(1mg/kg每八小時一次)治療。Echoc