摘要
目的：探讨经鼻高流量氧疗（HFNC）治疗中东呼吸综合征（MERS）患者的应用价值。方法2015年5月28日广东省惠州市中心人民医院重症医学科收治中国首例输入性MERS并急性呼吸窘迫综合征（ARDS）患者，通过观察应用HFNC的临床疗效，分析各项临床参数的变化及意义。结果患者男性，43岁，因背部酸痛7 d、发热2 d入院。患者入院后住负压隔离监护病房，持续监测生命体征和脉搏血氧饱和度（SpO2）等。入院后给予口服利巴韦林共12 d；入院第1天曾应用α-干扰素1次；但抗病毒治疗2周后病毒相关检测仍为阳性。入院第4天予头孢曲松钠治疗，3 d后改为美罗培南治疗，2周后停用；入院第4天开始应用免疫球蛋白1周，入院第8天开始应用胸腺肽α1共2周。根据既往史，继续使用甲巯咪唑治疗甲状腺功能亢进（甲亢）；同时给予其他对症支持治疗等。入院后即予鼻导管氧疗（6 L/min），但患者病情逐渐加重，频繁咳嗽，伴有明显气促，X线胸片示肺部渗出逐渐增加。SpO2仅可维持在0.91左右，氧合指数（PaO2/FiO2）降至144 mmHg（1 mmHg＝0.133 kPa）。遂于鼻导管氧疗2 d后改用HFNC，参数设定为：温度34℃，流量20 L/min，吸入氧浓度（FiO2）0.50，每10 min上调流量5 L/min，重复操作直至目标值60 L/min；根据SpO2、PaO2/FiO2等调整FiO2，入院第5天FiO2调整至0.80。经积极应用HFNC后，入院第7天患者气促症状好转，PaO2/FiO2上升，逐渐调低FiO2至0.58；随后流量缓慢下调至30 L/min。PaO2/FiO2持续改善，继续降低HFNC参数，于入院第20天停用HFNC，改为鼻导管低流量氧疗（2～3 L/min）。入院第23天停用氧疗，SpO2维持在0.98～1.00，床旁活动量逐渐增加。6月26日患者治愈出院。患者应用HFNC的耐受性好、依从性高；治疗期间未发生院内传播。结论 HFNC可明显改善MERS患者的呼吸功能并纠正伴发的ARDS，或能减少院内传播。
ObjectiveTo investigate the value of high flow nasal cannula （HFNC） in treating a patient with Middle East respiratory syndrome （MERS）.Methods The effect of HFNC applied in the first imported MERS patient with complication of acute respiratory distress syndrome （ARDS） to China was observed. The patient was admitted to Department of Critical Care Medicine of Huizhou Municipal Central Hospital on May 28th, 2015, and the changes in various clinical parameters and their significance were analyzed.Results A 43-year old male was admitted to negative pressure isolation intensive care unit with the complaint of back ache for 7 days and fever for 2 days. Vital signs and saturation of pulse oximetry （SpO2） were monitored continuously. After admission, ribavirin was given orally for 12 days andα-interferon was administered once on the first day. However, after 2-week anti-virus therapy, the virus test was positive. Ceftriaxone was given on the 4th day, and it was changed to meropenem on the 3rd day for 2 weeks. Immune globulin was given on the 4th day and continued for 1 week. Thymosin-α1 was given on the 8th day and continued for 2 weeks. According to his past history, methimazole had been given continuously for hyperthyroidism and other symptomatic treatment. Oxygen inhalation （6 L/min） was given immediately after admission, but the condition of patient worsened with the following symptoms： frequent cough and obvious shortness of breath. Moreover pleural effusion gradually increased as shown by X-ray. SpO2 was maintained only at about 0.91.＆amp;nbsp;Oxygenation index （PaO2/FiO2） decreased to 144 mmHg （1 mmHg = 0.133 kPa）. So oxygen inhalation via nasal cannula was changed to HFNC after 2 days. The parameters were set as follows： temperature 34℃, flow rate 20 L/min, fraction of inspired oxygen （FiO2） 0.50. The flow was raised 5 L/min every 10 minutes, and was continued till the target value reached 60 L/min. FiO2 was modified according to SpO2 and PaO2/FiO2. FiO2 was set to 0.80 on the 5th day of admission. Shortness of breath of the patient was improved on the 7th day of admission after the application of HFNC. FiO2 was then decreased to 0.58 as PaO2/FiO2 rose. Then the flow was gradually decreased to 30 L/min. HFNC was reduced with continuous improvement in PaO2/FiO2. HFNC was changed to low flow oxygen inhalation nasal cannula （2-3 L/min） on the 20th day. Oxygen treatment was stopped on the 23rd day, and SpO2 was maintained at 0.98-1.00. Activities on bed were gradually increased. The patient was cured and discharged from hospital on June 26th. The patient showed good tolerance and high compliance during the treatment with HFNC. No nosocomial spread occurred during the treatment.ConclusionsHFNC could improve respiratory function of the patient with MERS obviously, and complication ARDS was prevented. HFNC might reduce nosocomial spread.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2015年第10期841-844,共4页
Chinese Critical Care Medicine
基金
广东省临床重点专科建设项目（2011-144）
关键词
中东呼吸综合征
急性呼吸窘迫综合征
经鼻高流量氧疗
Middle East respiratory syndrome
Acute respiratory distress syndrome
High-flow nasal cannula
