俯卧位在肾移植术后耶氏肺孢子菌肺炎致重度ARDS中的应用  

Application of prone position in severe ARDS caused by pneumocystis jirovecii pneumonia after kidney transplantation

作　　者：田莉 方晓楠 张玲[1] 李克 Tian Li;Fang Xiaonan;Zhang Ling;Li Ke(Department of Emergency Medicine,People’s Hospital of Ningxia Hui Autonomous Region,Yinchuan 750002,China;不详)

机构地区：[1]宁夏回族自治区人民医院急诊医学科,银川750002 [2]厦门大学附属翔安医院重症医学科

出　　处：《器官移植》2023年第6期847-854,共8页Organ Transplantation

基　　金：宁夏回族自治区科技惠民项目(2023CMG03008);李克科研启动经费(包干项目)(PM201809170012)。

摘　　要：目的探讨肾移植术后耶氏肺孢子菌肺炎(PJP)致重度急性呼吸窘迫综合征(ARDS)患者实施俯卧位治疗后对氧合的改善情况。方法回顾性分析5例肾移植术后PJP致中、重度ARDS患者的临床资料,总结其临床特征、治疗方案及预后情况。结果5例患者临床表现为发热、干咳,伴胸闷、气短,全身大汗、乏力,体温波动在38~39℃,经皮动脉血氧饱和度(SpO_(2))进行性下降,呼吸窘迫症状加重。肺部CT表现为弥漫性磨玻璃影。入住重症监护室(ICU)后,所有患者暂停免疫抑制药,均予复方磺胺甲噁唑、卡泊芬净、小剂量糖皮质激素抗耶氏肺孢子菌(PJ)治疗、氧疗及其它对症支持治疗。4例患者入住ICU时为重度ARDS,行俯卧位治疗;1例患者为中度ARDS,未行俯卧位治疗。与俯卧位治疗前比较,治疗后1 d患者动脉血氧分压(PaO_(2))和氧合指数均升高,肺泡-动脉氧分压差(A-aDO_(2))均下降(均为P<0.05);与治疗后1 d比较,治疗后4 d患者SpO_(2)、PaO_(2)和氧合指数均升高,A-aDO_(2)下降(均为P<0.05)。箱形图结果显示,俯卧位治疗后氧合指数呈整体上升趋势,A-aDO_(2)呈整体下降趋势。5例患者ICU入住时间为14(8,29)d。所有俯卧位患者均未出现皮肤压疮、脱管、管路移位等并发症。5例患者中,4例患者病情好转,1例患者因后期发生脓毒性休克、多器官衰竭而死亡。结论无论是清醒俯卧位还是插管俯卧位均可明显改善肾移植术后PJP致重度ARDS患者的氧合,并改善患者预后。早期尽快确诊及精准规范治疗是提高治愈率的关键。Objective To investigate the improvement of oxygenation after the treatment of prone position in patients with severe acute respiratory distress syndrome(ARDS)caused by pneumocystis jirovecii pneumonia(PJP)after kidney transplantation.Methods Clinical data of 5 cases of moderate and severe ARDS caused by PJP after kidney transplantation were analyzed retrospectively,and clinical characteristics,treatment regimen and prognosis were summarized.Results Clinical manifestations of 5 patients were fever,dry cough,chest tightness,shortness ofbreath,sweating and fatigue,and body temperature fluctuated between 38℃and 39℃,percutaneous arterial oxygen saturation(SpO_(2))was gradually decreased,and respiratory distress symptoms were worsened.Pulmonary CT scan showed diffuse ground-glass shadow.After transfer to intensive care unit(ICU),immunosuppressive drugs were terminated,and all patients were given with compound sulfamethoxazole,caspofungin,low-dose glucocorticoids against pneumocystis jirovecii(PJ),oxygen therapy and other symptomatic supportive treatments.Four patients diagnosed with severe ARDS upon admission to ICU were treated in a prone position.One patient with moderate ARDS was not kept in a prone position.At 1 d after treatment in a prone position,partial pressure of arterial oxygen(PaO_(2))and oxygenation index were increased,whereas alveolar-arterial oxygen difference(A-aDO_(2))was decreased compared with before treatment(allP<0.05).Compared with 1 d after treatment,SpO_(2),PaO_(2) and oxygenation index were all increased,while A-aDO_(2) was decreased at 4 d after treatment(all P<0.05).Box diagram showed that oxygenation index showed an overall upward trend after prone-position treatment,whereas A-aDO_(2) showed an overall downward trend.The length of ICU stay of 5 patients was 14(8,29)d.All patients in a prone position did not develop complications,such as skin pressure sore,tube detachment and tube displacement,etc.Among 5 patients,4 patients were mitigated,and 1 patient died of septic shock and multiple

关 键 词：俯卧位 耶氏肺孢子菌肺炎(PJP) 急性呼吸窘迫综合征(ARDS) 肾移植 氧合指数 肺泡-动脉氧分压差(A-aDO_(2)) 动脉血氧分压(PaO_(2)) 复方磺胺甲噁唑 卡泊芬净 

分 类 号：R617[医药卫生—外科学] R563.1[医药卫生—临床医学]