DeBruin W, Notterman D A, Magid M, Godwin T, Johnston S
Department of Pediatrics, New York Hospital-Cornell Medical Center, New York 10021.
Crit Care Med. 1992 Sep;20(9):1223-34. doi: 10.1097/00003246-199209000-00008.
To examine the clinical and pathologic features of acute hypoxemic respiratory failure in children.
Retrospective review of medical records and pathologic material during a 44-month period.
Multidisciplinary pediatric ICU.
With the assistance of a computerized database, the medical records of 2,254 pediatric ICU admissions were evaluated to identify children with respiratory failure. Children with acute hypoxemic respiratory failure who met the following definition were selected for inclusion: a) PaO2 less than 75 torr (less than 10.0 kPa) with an FIO2 of greater than 0.5; b) diffuse bilateral infiltrates on chest radiograph; and c) exclusion of cardiogenic pulmonary edema clinically or by pulmonary artery catheterization. Patients were excluded if they did not receive tracheal intubation and assisted ventilation. The medical records were reviewed for demographic, clinical, and physiologic information. Pathologic findings from autopsy or lung biopsy were also reviewed. Patients were placed in one of six groups based on their underlying disorder. In addition, the presence of neutropenia, septic shock, or a history of bone marrow transplantation was noted as a coexisting condition.
A total of 100 acute hypoxemic respiratory failure patients were identified (4.4% of all 2,254 pediatric ICU admissions; 50 male, 50 female). Mean age was 6.0 +/- 5.4 (SD) yrs (range 1 month to 18 yrs). The overall mortality rate was 72%. The mortality rate was not affected by the underlying disorder, but it was higher in the presence of septic shock (80% vs. 58%; odds ratio 2.8), neutropenia (88% vs. 64%; odds ratio 4.0), and bone marrow transplantation (95% vs. 66%; odds ratio 10.4). When multivariate regression analysis was performed using all coexisting conditions, human immunodeficiency virus status, and patient gender, only a history of bone marrow transplantation and gender appeared to affect outcome. Oxygenation ratio (PaO2/FIO2), alveolar-arterial oxygen tension difference, duration of exposure to high levels of oxygen, and airway pressure measurements indicated more severe derangement of pulmonary function in those patients who died. Cardiac function was similar in survivors and nonsurvivors. Respiratory failure occurred in 32 children with severe neutropenia (mean absolute neutrophil count 55 +/- 101 cells/mm3), including 16 children with an absolute neutrophil count of 0. Pulmonary tissue from 37 children was studied. Diffuse alveolar damage was observed in 24%; morphologic evidence of infectious pneumonitis was encountered in an additional 41%.
Children with acute hypoxemic respiratory failure represent a heterogeneous subset of patients. In our group of patients, infectious pneumonitis was more commonly encountered than diffuse alveolar damage. The mortality rate of children with acute hypoxemic respiratory failure has not improved since 1980.
研究儿童急性低氧性呼吸衰竭的临床和病理特征。
对44个月期间的病历和病理资料进行回顾性分析。
多学科儿科重症监护病房。
借助计算机数据库，对2254例儿科重症监护病房收治患儿的病历进行评估，以确定呼吸衰竭患儿。入选符合以下定义的急性低氧性呼吸衰竭患儿：a）在吸入氧分数（FIO2）大于0.5时，动脉血氧分压（PaO2）低于75托（低于10.0千帕）；b）胸部X线片显示双侧弥漫性浸润；c）临床或通过肺动脉导管检查排除心源性肺水肿。未接受气管插管和辅助通气的患者被排除。查阅病历以获取人口统计学、临床和生理学信息。还回顾了尸检或肺活检的病理结果。根据潜在疾病将患者分为六组之一。此外，记录是否存在中性粒细胞减少、感染性休克或骨髓移植史作为并存情况。
共确定100例急性低氧性呼吸衰竭患者（占2254例儿科重症监护病房收治患儿的4.4%；男50例，女50例）。平均年龄为6.0±5.4（标准差）岁（范围1个月至18岁）。总死亡率为72%。死亡率不受潜在疾病影响，但在存在感染性休克（80%对58%；优势比2.8）、中性粒细胞减少（88%对64%；优势比4.0）和骨髓移植（95%对66%；优势比10.4）时更高。当使用所有并存情况、人类免疫缺陷病毒状态和患者性别进行多因素回归分析时，只有骨髓移植史和性别似乎影响预后。氧合比（PaO2/FIO2）、肺泡-动脉氧分压差、高氧暴露时间和气道压力测量表明，死亡患者的肺功能紊乱更严重。幸存者和非幸存者的心脏功能相似。32例严重中性粒细胞减少患儿（平均绝对中性粒细胞计数55±101个/立方毫米）发生呼吸衰竭，其中16例绝对中性粒细胞计数为0。对37例患儿的肺组织进行了研究。观察到24%存在弥漫性肺泡损伤；另外41%有感染性肺炎的形态学证据。
急性低氧性呼吸衰竭患儿是一组异质性患者。在我们的患者组中，感染性肺炎比弥漫性肺泡损伤更常见。自1980年以来，急性低氧性呼吸衰竭患儿的死亡率没有改善。
