Hoffman G M, Ross G A, Day S E, Rice T B, Nelin L D
Department of Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, USA.
Crit Care Med. 1997 Feb;25(2):352-9. doi: 10.1097/00003246-199702000-00026.
To determine if the use of inhaled nitric oxide therapy reduces the need for extracorporeal membrane oxygenation (ECMO) in persistent pulmonary hypertension of the newborn.
A matched cohort study with retrospective data extraction.
Pediatric and neonatal intensive care units at a medical school-affiliated children's hospital serving as a regional referral center for respiratory failure.
Records of all neonates transferred for rescue therapy for persistent pulmonary hypertension during the study period were analyzed, with inclusion in the study based on defined gas exchange parameters, and with exclusion from the study based on the presence of congenital heart disease, diaphragmatic hernia, or lethal chromosomal abnormality. Assignment to cohorts was based on availability of inhaled nitric oxide therapy: group 1 patients were admitted when inhaled nitric oxide was unavailable; group 2 patients were admitted when inhaled nitric oxide was available.
Standard criteria (alveolar-arterial oxygen tension gradient of > 600 torr [> 80 kPa], or oxygenation index of > 40) were used to trigger initial evaluation for ECMO when these criteria were met for 2 hrs, and ECMO was initiated if these criteria continued to be met for 12 hrs, or if cardiovascular instability occurred. Ventilator management in all patients was directed to improve arterial oxygenation, such that ECMO criteria were no longer met. Patients in group 2 only were treated with inhaled nitric oxide after meeting ECMO evaluation criteria, and they continued to receive inhaled nitric oxide if a quantifiable improvement in gas exchange occurred.
Fifty patients qualified for inclusion in the analysis (29 patients in group 1, and 21 patients in group 2). In group 1, 21 (72%) patients met ECMO criteria, and 16 (76%) patients required ECMO therapy. In group 2, 16 (76%) patients met ECMO criteria, 15 patients received inhaled nitric oxide therapy, and only four (25%) patients required ECMO therapy (p = .003 compared with group 1). Treatment with inhaled nitric oxide resulted in an initial increase in PaO2, without adverse effects, in all of the treated patients. The reduction in ECMO utilization in group 2 was achieved with a higher rate of complication-free survival (survival without oxygen, requirement at 28 days, p = .018; survival without intracranial hemorrhage, p = .048), and a lower hospital cost per survivor (p = .021), compared with group 1 patients.
In neonates with persistent pulmonary hypertension, therapy with inhaled nitric oxide reliably and safely improves oxygenation, thereby resulting in a decreased need for ECMO therapy, improved patient outcome, and lower hospital costs.
确定吸入一氧化氮疗法是否能减少新生儿持续性肺动脉高压患者对体外膜肺氧合（ECMO）的需求。
一项采用回顾性数据提取的配对队列研究。
一所医学院附属医院的儿科和新生儿重症监护病房，该医院是呼吸衰竭的区域转诊中心。
分析了研究期间因持续性肺动脉高压接受抢救治疗而转诊的所有新生儿的记录，根据确定的气体交换参数纳入研究，排除患有先天性心脏病、膈疝或致死性染色体异常的患者。根据吸入一氧化氮疗法的可获得性将患者分配到队列中：第1组患者在无法获得吸入一氧化氮时入院；第2组患者在可获得吸入一氧化氮时入院。
当满足标准（肺泡 - 动脉氧分压差>600托[>80千帕]或氧合指数>40）达2小时时，使用标准标准触发对ECMO的初始评估，如果这些标准持续满足12小时或出现心血管不稳定，则启动ECMO。所有患者的呼吸机管理旨在改善动脉氧合，以使不再满足ECMO标准。仅第2组患者在达到ECMO评估标准后接受吸入一氧化氮治疗，如果气体交换有可量化的改善，则继续接受吸入一氧化氮治疗。
50例患者符合纳入分析的条件（第1组29例，第2组21例）。第1组中，21例（72%）患者符合ECMO标准，16例（76%）患者需要ECMO治疗。第2组中，16例（76%）患者符合ECMO标准，15例患者接受吸入一氧化氮治疗，仅4例（25%）患者需要ECMO治疗（与第1组相比，p = 0.003）。吸入一氧化氮治疗使所有接受治疗的患者的PaO2最初升高，且无不良反应。与第1组患者相比，第2组ECMO使用率降低，无并发症生存率更高（无需吸氧生存，28天时的需求，p = 0.018；无颅内出血生存，p = 0.048），且每位存活患者的住院费用更低（p = 0.021）。
在新生儿持续性肺动脉高压患者中，吸入一氧化氮疗法能可靠且安全地改善氧合，从而减少对ECMO治疗的需求，改善患者预后并降低住院费用。
