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1、ARDS临床流行病调查 2. 肺表面活性物质/吸入NO治疗ALI/ARDS 孙波 复旦大学儿科医院,Clinical Epidemiology of ARDS in China Surfactant and iNO in Treatment of ARDS Bo Sun, MD, PhD Childrens Hospital of Fudan University 2005-03-19 Beijing,Clinical epidemiology of ALI/ARDS,Incidence of respiratory failure, mechanical ventilation, and A
2、LI/ARDS in ICU Standard diagnosis and care management Clinical trial, control and intervention Follow up outcomes Assess cost-effectiveness Medical resources, network,上海市医院急性呼吸窘迫综合征临床发病情况调查,A 12-Month Survey of ARDS in Adult ICUs Shanghai ARDS Study Group Intensive Care Med 2004; 30 (12): 2197-2203,
3、Morbidity,15 PICUs, 5320 admissions / 2001-2002 (12 mon) 108 ARDS (2% of admission) (Europe 6-7%) 15 years old 24 h of admission, 2.5 (n) 33 Intensive Care Med 2004; 30 (12): 2197-2203,Mortality,Death: 74 (68.5%) in-hospital 76 (70.4%) at 3 months after onset Death rate (病死率) ICU total death 548/532
4、0 (10.3%) ARDS/ICU total death 74/548 (13.5%) ARDS : non-ARDS 6.4 : 1 (RR) Intensive Care Med 2004; 30 (12): 2197-2203,Predisposing factors of ARDS,Death Pulmonary origin 41 (39%) 32 - Pneumonia 37 (34.3%) 29 Non-pulmonary 67 (61%) 42 - Sepsis 33 (30.6%) MODS 44/74 (60%) Respiratory failure 17/74 (2
5、3%) Septic shock 9/74 (12%) Intensive Care Med 2004; 30 (12): 2197-2203,Pediatric ARDS,A 12-month survey of incidence, management and outcome of ARDS in 25 pediatric ICU in China Chinese Pediatric ARDS Study Group ATS 2005 San Diego Intl Conference,北京儿童医院 首都儿研所儿童医院 北京大学第一医院 哈尔滨儿童医院 中国医科大学第二医院 河北医科大学
6、第二医院 天津儿童医院 山西省儿童医院 郑州儿童医院 重庆医科大学儿童医院 广州儿童医院 湖南省儿童医院 长春市儿童医院,深圳儿童医院 成都市儿童医院 泉州儿童医院 江西省儿童医院 浙江大学儿童医院 温州育英儿童医院 南京儿童医院 苏州儿童医院 上海儿童医学中心 上海新华医院 上海儿童医院 复旦大学儿科医院,小儿ARDS协作组,PICU all admissions,Critical,ALI/ARDS,Survival death,PIM+Guide,1994 AECC,Treatment,基本流程,25 Pediatric ICU 2004.01-12,PICU total 11453,Cr
7、itical 6839,RF呼吸衰竭1862,MV 1883,ALI 303,ARDS 97,Results,Incidence/PICU admission ARDS 患病率 1.42 % ALI 患病率 4.4 % Death rate ARDS 病死率 62.9 % (61) Total PICU 6.8 % RR ARDS : non-ARDS 8.3 : 1 Cost: ARDS/ non-ARDS 4.5 : 1,Predisposing factors of pediatric ARDS,Pneumonia 40 Sepsis 14 Immunocompromised 15 In
8、toxication 8 Post-operation 4 Trauma 4 Asphyxia 3 Others 11,Measurement to reduce mortality,Early diagnosis and management Ventilation: low tidal volume Specific therapy: alveolar atelectasis: PEEP, surfactant intrapulmonary shunting: inhaled NO fluid balance: restricted infusion alveolar leakage: s
9、elected coloid renal: CRRT exacerbated: ECMO,临床意义,ARDS是ICU最具代表性的、高死亡风险的危重症 (综合征)之一 患病率占ICU收治1.5-2.0%, 病死率60% 临床流行病研究对于形成正确的诊断和治疗有助于开展临床干预治疗(对照和基础治疗) 中国人口高度集中的城市医院成为研究ARDS发生发展和转归的重要场所 人群流行病资料依靠正确的临床诊断 加强区域、国际合作研究,Surfactant treatment for ARDS,60s Adult RDS and neonatal RDS 80 Surfactant replacement t
10、herapy 30 RCT 90 Surfactant and ARDS /NO and ARDS 2000-: RCT Surfactant /NO,Early case study of surfactant replacement for ARDS,(Spragg R, Chest 1994; 105: 195-204) 6 ARDS, 2 days, 3 survived Curosurf 80 mg/ml, 4 g/50 ml, 50 mg/kg (Walmrath AJRCCM 1996; 154: 57-62) 10 ARDS, 5 survived Alveofact 300
11、mg/kg, multiple dose PaO2/FiO2 200 mmHg, Qs/Qt 20%,Multicenter randomized controlled trial,Anzueto A NEJM 1996, Exosurf aerosol (no SP) Gregory TJ AJRCCM 1997 Survanta Luchetti M PCCM 2002 Curosurf (Pediatric) Walmrath D ERJ 2002 Alveolfact Spragg R AJRCCM 2003 Venticute (SP-C) Spragg R NEJM 2004 Ve
12、nticute Willson DF JAMA 2005 Calfactant,Effect of Recombinant Surfactant Protein CBased Surfactant on the ARDS Spragg RG et al NEJM 2004; 351:884-892,448 adult patients with ARDS standard therapy alone (control) standard therapy + surfactant (test) exogenous surfactant did not improve survival. exog
13、enous surfactant improve gas exchange during 24-hour treatment period.,Effect of Calfactant in Pediatric ALI Willson DF et al JAMA. 2005; 293:470-6,153 children (age 1 week to 21 years) with respiratory failure from ALI Air placebo (control) Intratracheal Calfactant 100 mg/kg (test) Calfactant group
14、 : oxygenation index (20 to 13.9) o mortality (15/77) Placebo group: oxygenation index (20.5 to 15.1) o o o o mortality (27/75) Calfactant improved oxygenation and decreased mortality,Surfactant Treatment of Neonates With Respiratory Failure and GBS Infection Herting E et al. Pediatrics 2000; 106: 9
15、57-964,118 neonates with GBS infection and respiratory failure treated with Curosurf(test); 236 noninfected premature neonates RDS (control). Surfactant improves gas exchange; Response to surfactant in GBS group is slower than in control group.,A-B, FiO2, PaO2/ FiO2, after surfactant treatment. *P.0
16、1 *P.001 versus before surfactant.,Treatment of Severe Meconium Aspiration Syndrome with Porcine Surfactant: A Multicenter, Randomized, Controlled Trial Chinese Collaborative Study Group for Neonatal Respiratory Diseases Acta Paediatrica 2005,Questions,Why surfactant does not work well in ALI/ARDS as neonata
