Jobe A
Adv Pediatr. 1983;30:93-130.
In this review I have emphasized the complicated events that occur during the course of RDS. RDS is initiated by an inadequate pool size of functional surfactant within a structurally and functionally immature lung. Obstetric and delivery room management apparently can significantly influence surfactant function and, therefore, the incidence of RDS, possibly by affecting the permeability properties of the pulmonary vascular endothelium and alveolar epithelium. The course and severity of RDS will be further influenced by neonatal care and other occurrences such as the presence or absence of a PDA. Many details of the biochemical and physiologic events that result in RDS have not been defined, so we are currently unable to quantitatively understand how all the various factors interact during the course of RDS to give the characteristic clinical course of the disease. Variations in the magnitude and timing of these interactions will likely explain the variable manifestations of respiratory failure in the tiny infant. Within the context of the pathophysiology of RDS, surfactant replacement therapy and HFV represent two new and very different approaches to treatment. Initial clinical trials of surfactant replacement therapy in infants with RDS are encouraging, and experience with animal models indicates that such an approach will work. Replacement therapy also makes sense if one considers what is known about surfactant metabolism during RDS. However, no standard, tested, and safe preparation of surfactant is available. If past experience is any guide, it may not be easy to develop an acceptable product for general use. HFV offers an opportunity to ventilate infants with relatively high mean airway pressures but without the use of high peak airway pressures. Early clinical trials suggest the technique will benefit some infants, however no ventilators for HFV are available for clinical use. In light of the low mortality from respiratory failure in RDS and a morbidity from RDS resulting mostly from the other diseases of prematurity, these new therapeutic approaches need to be thoroughly tested and understood before general clinical use.
在这篇综述中，我着重强调了呼吸窘迫综合征（RDS）病程中发生的复杂事件。RDS始于结构和功能均未成熟的肺内功能性表面活性物质储备量不足。产科和产房管理显然会显著影响表面活性物质的功能，进而影响RDS的发生率，这可能是通过影响肺血管内皮和肺泡上皮的通透性来实现的。RDS的病程和严重程度还会受到新生儿护理及其他情况的进一步影响，比如动脉导管未闭的有无。导致RDS的生化和生理事件的许多细节尚未明确，所以目前我们无法定量地了解在RDS病程中所有这些不同因素是如何相互作用从而呈现出该疾病典型的临床病程的。这些相互作用在程度和时间上的差异可能解释了极低体重儿呼吸衰竭的不同表现。在RDS的病理生理学背景下，表面活性物质替代疗法和高频通气（HFV）代表了两种全新且截然不同的治疗方法。对患有RDS的婴儿进行表面活性物质替代疗法的初步临床试验结果令人鼓舞，动物模型实验表明这种方法是可行的。如果考虑到RDS期间表面活性物质代谢的已知情况，替代疗法也是合理的。然而，目前尚无标准的、经过测试且安全的表面活性物质制剂。如果以过去的经验为参考，开发出一种可普遍使用的合格产品可能并非易事。HFV提供了一个机会，可让婴儿在相对较高的平均气道压力下通气，而无需使用高的气道峰压。早期临床试验表明该技术会使一些婴儿受益，然而目前尚无用于临床的HFV呼吸机。鉴于RDS中呼吸衰竭导致的死亡率较低，且RDS的发病率大多源于其他早产相关疾病，在普遍临床应用之前，这些新的治疗方法需要进行全面测试并深入了解。
