成人甲型H1N1流感伴呼吸衰竭18例分析  

Eighteen cases of 2009 influenza A H1N1 associated with respiratory failure in adults

作　　者：孙甲君[1] 李琛[5] 吴大玮[5] 李晨华[1] 秦卫华[1] 李亚林[1] 刘清岳[1] 李金秀[1] 邹玉刚[1] 黄冬青[2] 解建军[3] 李恩杰[4] 

机构地区：[1]山东省聊城市第二人民医院ICU,临清252601 [2]山东省聊城市第二人民医院CT室,临清252601 [3]山东省聊城市第二人民医院病理科,临清252601 [4]山东省聊城市第二人民医院细菌室,临清252601 [5]山东大学附属齐鲁医院ICU

出　　处：《中国危重病急救医学》2010年第3期156-160,共5页Chinese Critical Care Medicine

摘　　要：目的探讨甲型H1N1流感并呼吸衰竭成年患者的临床特点、治疗及预后。方法采用前瞻性观察方法，记录并分析2009年11月22日至2010年1月16日收住本院重症监护病房（ICU）甲型H1N1流感并呼吸衰竭成年患者的临床资料。结果确诊9例，疑似9例；男8例，女10例（其中孕产妇7例）；年龄20～61岁，平均37．1岁，20-40岁12例；有基础疾病者8例；肥胖患者3例；17例表现为病毒性肺炎并急性呼吸窘迫综合征（ARDS），1例表现为哮喘急性发作；发病至人院时间1～5d，平均4．1d；发病至服用首剂奥司他韦时间2～12d，平均5．5d；发病至开始机械通气时间4～12d，平均6．8d；3例发生多器官功能障碍综合征（MODS）。12例接受了糖皮质激素治疗，10例需要血管加压药物；所有患者接受了机械通气治疗，1例接受了体外膜肺氧合（ECM0）治疗。共死亡7例患者，28d病死率为33．3％（6／18），1例住院34d死亡；死亡组急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分显著高于存活组[（29．2±7．3）分比（18．6士6．4）分，P=0．02]。死亡组患者均于机械通气7d内接受高条件机械通气[气道峰压≥35cmH2O（1cmH2O=0．098kPa）、呼气末正压≥18cmH2O]情况下，氧合指数〈60mmHg（1mmHg=0．133kPa），持续时间14～59h，平均24h；存活组仅1例于15d起达此呼吸条件，少于死亡组（9．1％比100．0％，P〈0．01）。死亡组应用血管加压药物及急性肾损伤和气压伤发生率均明显高于存活组（100．0％比36．4％，42．9％比27．3％，28．6％比9．1％，均P〈0．05）。结论甲型H1N1流感成年危重患者主要表现为呼吸衰竭，机械通气7d内高通气条件仍不能维持满意的氧合、持续需要血管加压药物、发生急性肾损伤及气压伤者提示预后不良。Objective To investigate the clinical feature, treatment and outcome of respiratory failure in patients with 2009 influenza A H1N1 infection in critically ill adults. Methods A prospective observational study of 18 patients with respiratory failure suffering from 2009 influenza A H1N1 infection admitted between November 22, 2009 and January 16, 2010. Their clinical data were analyzed. Results Respiratory failure occurred in 18 patients with confirmed （n= 9） or probable （n= 9） 2009 influenza A H1N1. Among the 18 patients 8 patients were male, 10 patients were female （7 were pregnant or postpartum）. Eight patients had pre-existing medical conditions. Twelve patients were between 20 and 40 years of age, the mean age was 37.1 years. Three were obese with body mass index over 30 kg/m2. The 28-day mortality was 33.3% （6/18） with 1 additional late death. The median duration from the onset of the illness to hospital admission was 4.1 days （1 5 days） and from the onset to first dose of oseltamivir was 5.5 days （2 - 12 days）, from onset to mechanical ventilation initiation was 6.8 days （4 - 12 days）. Seventeen patients had primary viral pneumonia and 1 patient had an asthma exacerbation and 3 patients experienced multiple organ dysfunction syndrome （MODS）. Twelve patients received corticosteroids, 10 patients required vasopressors. All patients were mechanically ventilated, 1 patient underwent extracorporeal membrane oxygenation （ECMO）. Patients who died had higher acute physiology and chronic health evaluation Ⅰ score compared to survivors （29.2±7.3 vs. 18.6±6.4, P〈 0.02）. All deceased patients received high-level ventilation settings Cpeak inspiratory pressure ≥35 cm H2O （1 cm H20 ： 0. 098 kPa） and positive end-expiratory pressure≥18 cm H2O] within the first 7 days of ventilation, and the hypoxemia [oxygenation index≤60 mm Hg （1 mm Hg=0. 133 kPa）] lasted 24 hours. In contrast only 1 among survivors did （9.1% vs. 100.0%, P 〈 0.01）. Compared with survivors

关 键 词：甲型H1N1流感 呼吸衰竭 急性呼吸窘迫综合征 治疗 预后 

分 类 号：R563.8[医药卫生—呼吸系统] R511.7[医药卫生—内科学]