早產(chǎn)兒呼吸窘迫綜合征歐洲共識中英對照課件

1、European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm infants-2010 UpdatePrenatal Care產(chǎn)前治療Mothers at high risk of preterm birth should be transferred to perinatal centres with experience in management of RDS(C).有早產(chǎn)高危因素的母親應(yīng)被轉(zhuǎn)運(yùn)至對處理新生兒呼吸窘迫綜合癥有豐富經(jīng)驗(yàn)的醫(yī)療中心。Cli

2、nicians should offer a single course of antenatal steroids to all women at risk of preterm delivery from about 23weeks up to 35 completed weeks gestation (A).對于孕23周至35周有早產(chǎn)高危因素的母親，醫(yī)生均應(yīng)使用一療程產(chǎn)前激素。Antibiotics should be given to mothers with preterm pre-labour rupture of the membranes as this reduces the

3、 risk of preterm delivery (A).對于有早產(chǎn)高危因素合并胎膜早破的孕婦，抗生素的使用可減少早產(chǎn)的發(fā)生。Clinicians should consider short-term use of tocolytic drugs to allow completion of a course of antenatal steroids and/or in utero transfer to a perinatal centre (A).醫(yī)生應(yīng)考慮短期使用抗分娩藥物，使產(chǎn)前激素療程可完成/能及時(shí)轉(zhuǎn)運(yùn)至醫(yī)療中心。A second course of antenatal ster

4、oids should be considered if the risk from RDS is felt to outweigh the uncertainty about possible long-term adverse effects (D). One example where benefit might outweigh the risk is multiple pregnancy (C).若考慮發(fā)生新生兒呼吸窘迫綜合征的危險(xiǎn)大于使用激素產(chǎn)生長期副作用的不確定性，應(yīng)考慮使用第二療程的產(chǎn)前激素。其中一個(gè)利大于弊的例子是多胎妊娠。Delivery Room Stabilisatio

5、nIf possible, delay clamping of the umbilical cord for at least 30-45 s with the baby held below the mother to promote placento-fetal transfusion (A).如果可能，延遲鉗夾臍帶30-45秒，且使嬰兒位置低于母親，有利于母-嬰輸血。Oxygen for resuscitation should be controlled by using an air-oxygen blender. The lowest concentration of oxygen

6、 possible should be used during stabilisation, provided there is an adequate heart rate response. A concentration of 30% oxygen is appropriate to start stabilisation and adjustments up or down should be guided by applying pulse oximetry from birth to give information on heart rate (B). Normal satura

7、tions during transition immediately after birth in very preterm infants may be between 40 and 60%, reaching between 50 and 80% at 5 min of age and should be 85% by 10 min of age. Exposure to hyperoxia should be avoided during stabilisation (B).復(fù)蘇時(shí)氧氣濃度需用空氣-氧氣混合器控制。需要使用最低的氧濃度達(dá)到使嬰兒穩(wěn)定的目的（合適的心率）。30%的氧濃度作

8、為復(fù)蘇起始的氧濃度較適宜，然后根據(jù)脈搏-氧飽和度儀提供心率的信息作出調(diào)整。對于極早產(chǎn)兒，生后立即的氧飽和度大約為40-60%，5分鐘時(shí)上升至50-80%，10分鐘時(shí)應(yīng)85%。應(yīng)避免復(fù)蘇時(shí)高氧的暴露。In spontaneously breathing babies start stabilisation with CPAP of at least 5-6 cm H2O via mask or nasal prongs (B). If breathing is insufficient, consider the use of a sustained inflation breath to re

9、cruit the lung rather than intermittent positive pressure breaths (B).對于自主呼吸好的嬰兒,面罩/鼻塞持續(xù)正壓通氣時(shí)最少使用5-6cm水柱的呼氣末正壓。若自主呼吸不足，持續(xù)通氣優(yōu)于間歇正壓通氣。Ventilation with a T-piece device is preferable to a self-in-flating, or flow-flating bag in order to generate appropriate positive end-expiratory pressure (PEEP) (C).使

10、用T管優(yōu)于球囊因?yàn)樗梢跃S持一個(gè)合適的呼氣末正壓。If positive pressure ventilation is needed for stabilisation, aim to avoid excessive tidal volumes by incorporating resuscitation devices which measure of limit the PIP whilst at the same time maintaining PEEP during expiration (D).如果需要正壓通氣維持病情的穩(wěn)定，目標(biāo)是通過限制吸氣峰壓和維持呼氣末正壓來避免過度通氣。

11、Intubation should be reserved for babies who have not responded to positive pressure ventilation or those requiring surfactant therapy (D).當(dāng)無創(chuàng)正壓通氣無效或需要使用肺表面活性物質(zhì)治療時(shí)，需考慮氣管插管。If the baby is intubated, correct positioning of the endotracheal tube should be verified by colorimetric CO2 detection (D).當(dāng)氣管插

12、管時(shí)，需根據(jù)二氧化碳分壓調(diào)整氣管插管深度。Plastic bags or occlusive wrapping under radiant warmers should be used during stabilisation in the delivery suite for babies 28 weeks gestation to reduce the risk of hypothermia (A).胎齡小于28周的早產(chǎn)兒復(fù)蘇過程中在輻射搶救臺上需使用塑料薄膜包裹以減少低體溫的發(fā)生。Surfactant Therapy肺表面活性藥物Babies with or at high risk o

13、f RDS should be given a natural surfactant preparation (A).患新生兒呼吸窘迫綜合癥或有該病高危因素的嬰兒需備好天然的肺表面活性藥物。Prophylaxis (within 15 min of birth) should be given to almost all babies of 26 weeks gestation. Prophylaxis should also be given to all preterm babies with RDS who require intubation for stablisation (A).

14、胎齡26周的早產(chǎn)兒幾乎都需要預(yù)防性使用肺表面活性藥物（生后15min內(nèi)）。所有患有新生兒呼吸窘迫綜合癥且需要插管的早產(chǎn)兒均需要預(yù)防性使用肺表面活性物質(zhì)。Early rescue surfactant should be administered to previously untreated babies if there evidence of RDS (A). Individual units need to develop protocols for when to intervene as RDS progresses depending on gestational age and

15、prior treatment with antenatal steroids (D). Poractant alfa in an initial does of 200 mg/kg is better than 100 mg/kg of poractant alfa or beractant for treatment of moderate to severe RDS (B).當(dāng)有新生兒呼吸窘迫綜合癥的證據(jù)且未使用肺表面活性物質(zhì)的早產(chǎn)兒，應(yīng)盡早應(yīng)用治療性的肺表面活性物質(zhì)。不同機(jī)構(gòu)需根據(jù)胎齡及產(chǎn)前激素的使用來制定新生兒呼吸窘迫綜合癥的干預(yù)策略。對于中至重度的新生兒呼吸窘迫綜合癥，首劑200毫

16、克/公斤的豬肺表面活性物質(zhì)/貝拉康坦優(yōu)于100毫克/公斤。Consider immidiate ( or early) extubation to non-invasive respiratory support (CPAP or nasal intermittent positive pressure ventilation (NIPPV) following surfactant administration provided the baby is otherwise stable (B).當(dāng)嬰兒病情穩(wěn)定時(shí)，建議使用肺表面活性物質(zhì)后立即或盡早拔除氣管插管，改為無創(chuàng)呼吸支持（持續(xù)正壓通氣或

17、鼻塞間歇正壓通氣）。A second, and sometimes a third dose of surfactant should be administered if there is ongoing evidence of RDS such as a persistent oxygen requirement and need for MV (A).當(dāng)新生兒呼吸窘迫綜合癥繼續(xù)進(jìn)展（表現(xiàn)為持續(xù)需氧或需要機(jī)械通氣），需考慮第二劑甚至第三劑肺表面活性物質(zhì)的使用。Oxygen Supplementation beyond StabilisationIn babies receiving oxy

18、gen, saturation should be maintained between 85 and 93% (D).早產(chǎn)兒的氧飽和度需維持在85-93%之間。After giving surfactant avoid a hyperoxic peak by rapid reduction in FiO2 (C).使用肺表面活性物質(zhì)后注意避免急速下調(diào)供氧濃度。Avoid fluctuations in SaO2 in the postnatal period (D).避免生后氧飽和度的波動(dòng)。Role of CPAP in Management of RDSCPAP should be sta

19、rted from birth in all babies at risk of RDS, such as those 30 weeks gestation who do not need MV, until their clinical status can be assessed (D).所有有新生兒呼吸窘迫綜合癥高危因素的早產(chǎn)兒應(yīng)首選持續(xù)正壓通氣，例如胎齡小于30周無需呼吸機(jī)輔助呼吸者，直至臨床表現(xiàn)穩(wěn)定后。Short binasal prongs should be used rather than a single prong as they reduce the need for i

20、ntubation and a pressure of at least 5 cm H2O should be applied (A).雙鼻塞優(yōu)于單鼻塞（呼氣末正壓至少需達(dá)到5厘米水柱），因?yàn)樗軠p少插管的需要。The use of CPAP with early rescue surfactant should be considered in babies with RDS in order to reduce the need for MV (A).患新生兒呼吸窘迫綜合癥的患兒早期應(yīng)用肺表后直接應(yīng)用持續(xù)正壓通氣可減少呼吸機(jī)的使用。Mechanical Ventilation Strate

21、gies呼吸機(jī)策略MV should be used to support babies with respiratory failure as this improves survival (A).呼吸衰竭時(shí)需使用呼吸機(jī)輔助呼吸，增加生存率。Avoid hypocapnia as this is associated with increased risks of BPD and periventricular leucomalacia (B).避免低碳酸血癥，因?yàn)樗c慢性肺疾病及腦室周圍白質(zhì)軟化相關(guān)。Settings of MV should be adjusted frequently

22、with the aim of maintaining optimum lung volume (C).呼吸機(jī)的參數(shù)需不斷的調(diào)整，目標(biāo)是維持理想的肺容量。Duration of MV should be minimised to reduce its injurious effect on lung (B).盡量減少呼吸機(jī)通氣的時(shí)間，減輕肺損傷。Avoiding or Reducing Duration of Mechanical Ventilation避免或縮短使用呼吸機(jī)Caffeine should be used in babies with apnoea and to facilita

23、te weaning from MV (A). Caffeine should be considered for all babies at high risk of needing ventilation, such as those 1,250 g birth weight, who are managed on CPAP or NIPPV (B).有呼吸暫停或準(zhǔn)備撤機(jī)的患兒，應(yīng)使用咖啡因?？Х纫驊?yīng)使用于所有有上機(jī)高危因素的患兒，例如出生體重小于1250克，正在使用持續(xù)正壓通氣或鼻塞間歇正壓通氣者。CPAP or NIPPV should be used preferentially t

24、o avoid or reduce the duration of MV through an endotracheal tube (B).為了避免或縮短氣管插管呼吸機(jī)輔助通氣的時(shí)間，應(yīng)優(yōu)先選用持續(xù)正壓通氣或鼻塞間歇正壓通氣。When weaning from MV it is reasonable to tolerate a moderate degree of hypercapnia, provided the pH remains above 7.22 (D).當(dāng)撤機(jī)后，容許允許性高碳酸血癥的存在（血?dú)釶H需維持在7.22以上）。Synchronised and targeted tid

25、al volume modes of conventional ventilation with an aggressive weaning approach should be used to shorten duration of MV (B).應(yīng)該使用同步及容量保證的常頻呼吸機(jī)模式加上一個(gè)積極的撤機(jī)方法來縮短使用呼吸機(jī)的時(shí)間。Prophylactic Treatment for Sepsis敗血癥的預(yù)防性治療Antibiotics should be started in babies with RDS until sepsis has been ruled out. A common

26、regimen includes penicillin/ampicillin in combination with an aminoglycoside, however, individual units should develop local protocols for antibiotic use based on the profile of bacterial pathogens causing early onset sepsis (D).患新生兒呼吸窘迫綜合癥的患兒需預(yù)防性使用抗生素直至除外敗血癥。常見的藥物是青霉素或氨芐西林聯(lián)合氨基糖苷類 ，然而，各機(jī)構(gòu)需根據(jù)導(dǎo)致早發(fā)敗血癥的

27、各自的細(xì)菌病原譜選擇抗生素。Units should develop protocols for antifungal prophylaxis in very preterm babies based on the local incidence and risk factors (D).不同的機(jī)構(gòu)需要根據(jù)當(dāng)?shù)氐恼婢腥景l(fā)生率及危險(xiǎn)因素建立極早產(chǎn)兒預(yù)防性使用抗真菌藥物的規(guī)則。Supportive Care 支持治療Body temperature should be maintained at 36.5-37.5 oC at all times (C).體溫需一直維持在36.5-37.5 oC

28、 。Most babies should be started on intravenous fluids of 70-80 ml/kg/day while being kept in a humidified incubator (D).生后第一天給予70-80ml/公斤/天的靜脈液體（處于保濕暖箱中）。Fluid and electrolyte therapy should be tailored individually in preterm infants, allowing a 2.5-4% daily weight loss (15% total) over the first 5

29、 days (D).早產(chǎn)兒液體及電解質(zhì)的供給需個(gè)體化，允許生后頭五天每天2.5-4%的體重下降（總共15%）。Sodium intake should be restricted over the first few days of life and initiated after the onset of diuresis with careful monitoring of fluid balance and electrolyte levels (B).生后頭幾天需限制鈉鹽的供給，當(dāng)尿量增多后在密切監(jiān)測出入量及電解質(zhì)水平后可開始給予。Full parenteral nutrition c

30、an be initiated on day 1 (A). This may include starting protein at 3.5 g/kg/day and lipid at 3 g/kg/day in 10% dextrose solution.全量胃腸外營養(yǎng)可于生后第一天開始。這包括蛋白質(zhì)3.5 g/kg/day 及脂肪3 g/kg/day ，加入10%的糖水中。Minimal enteral feeding should be started from the first day (B). Early aggressive feeding is increasingly pop

31、ular but level A evidence of its benefit is lacking.少量腸內(nèi)喂養(yǎng)應(yīng)在生后第一天開始。早期快速增加喂養(yǎng)越來越流行，但缺乏A類證據(jù)的支持。Treatment of arterial hypotension is recommended when it is confirmed by evidence of poor tissue perfusion (C).組織灌注不良導(dǎo)致的低血壓是需要治療的。Volume expansion with 10-20 ml/kg 0.9% saline should be used as first-line tr

32、eatment of hypotension if myocardial dysfunction has been excluded (D).已排除心功能不全引起的低血壓，首選使用生理鹽水10-20 ml/kg 擴(kuò)容。Dopamine (2-20 g/kg/min) should be used if volume expansion fails to satisfactorily improve blood pressure (B).多巴胺(2-20 g/kg/min) 在擴(kuò)容后未能改善血壓使用。Dobutamine (5-20 g/kg/min), as a first line, and

33、 epinephrine (0.01-1.0 g/kg/min) as a second line, should be used if low systemic blood flow and myocardial dysfunction need to be treated (D).當(dāng)有效血容量不足和心功能不全時(shí)，使用多巴酚丁胺(5-20 g/kg/min)（一線）, 腎上腺素(0.01-1.0 g/kg/min) （二線）治療。Hydrocortisone (1 mg/kg 8 hourly) should be used in cased of refractory hypotension where conventional therapy has failed (B).難