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

田莉; 方晓楠; 张玲; 李克

doi:10.3969/j.issn.1674-7445.2023115

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

doi: 10.3969/j.issn.1674-7445.2023115

田莉^1,,
方晓楠²,
张玲¹,
李克^2, ,

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

基金项目: 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）

详细信息

作者简介:

通讯作者:
李克（ORCID：0009-0009-0729-7947），博士，主任医师，研究方向为器官移植受者围手术期管理，Email：like-icu@163.com

中图分类号: R617， R563.1
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出版历程
- 收稿日期: 2023-06-18
- 录用日期: 2023-09-11
- 刊出日期: 2023-11-09

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

Tian Li^1
,,
Fang Xiaonan²,
Zhang Ling¹,
Li Ke^{2
, ,}

1.
Department of Emergency Medicine, People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan 750002, China

More Information

Corresponding author: Li Ke, Email: like-icu@163.com

摘要

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（SpO₂）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（PaO₂）和氧合指数均升高，肺泡-动脉氧分压差（A-aDO₂）均下降（均为P<0.05）；与治疗后1 d比较，治疗后4 d患者SpO₂、PaO₂和氧合指数均升高，A-aDO₂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-aDO₂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。
- 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-aDO₂） /
- 动脉血氧分压（PaO₂） /
- 复方磺胺甲噁唑 /
- 卡泊芬净
Abstract: 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(SpO₂) 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 (PaO₂) and oxygenation index were increased, whereas alveolar-arterial oxygen difference (A-aDO₂) was decreased compared with before treatment (allP<0.05). Compared with 1 d after treatment, SpO₂, PaO₂ and oxygenation index were all increased, while A-aDO₂ 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-aDO₂ 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 organ failure. Conclusions For both conscious and intubated patients, a prone position may significantly improve oxygenation and prognosis of patients with severe ARDS caused by PJP after kidney transplantation. Early diagnosis and accurate and standardized treatment play a pivotal role in enhancing cure rate.
- Prone position /
- Pneumocystis jirovecii pneumonia (PJP) /
- Acute respiratory distress syndrome (ARDS) /
- Kidney transplantation /
- Oxygenation index /
- Alveolar-arterial oxygen difference (A-aDO₂) /
- Partial pressure of arterial oxygen (PaO₂) /
- Compound sulfamethoxazole /
- Caspofungin

HTML全文

图 1 例2俯卧位治疗前后肺部CT检查结果对比

注：A图为例2患者俯卧位治疗前的胸部CT结果：两侧肺门周围对称性斑片状磨玻璃影，由肺门向外周的肺野发展并融合，并伴有不同程度的网状影或小叶间隔增厚，支气管血管束周围间质增厚等；B图为例2患者俯卧位治疗后的胸部CT结果：双肺对称性斑片状磨玻璃影、网状影以及部分实变影吸收、消散。

Figure 1. Comparison of chest CT examination result before and after prone position treatment in case 2

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图 2 俯卧位治疗前后氧合指数和A-aDO₂箱形图

注：A图为4例患者俯卧位治疗前后氧合指数的箱形图；B图为4例患者俯卧位治疗前后A-aDO₂的箱形图。

Figure 2. Box chart of oxygenation index and A-aDO₂ before and after prone position treatment

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表 1 5例PJP患者的临床资料

Table 1. Clinical data of 5 patients with PJP

例序	性别	年龄（岁）	术后时间（月）	PJ预防时间（月）	APACHE Ⅱ评分（分）	ARDS 分级	mNGS结果			机械通气时间^①（d）	俯卧位时间^②（d）	ICU入住时间（d）	预后
例序	性别	年龄（岁）	术后时间（月）	PJ预防时间（月）	APACHE Ⅱ评分（分）	ARDS 分级	细菌	病毒	真菌	机械通气时间^①（d）	俯卧位时间^②（d）	ICU入住时间（d）	预后
1	男	51	8	0	19	重度	阴性	巨细胞病毒、乙型肝炎病毒	马尔尼菲青霉菌、PJ	0+21	0+10	42	死亡
2	女	53	4	0	24	重度	鲍曼不动杆菌、嗜麦芽窄食嗜单胞菌	阴性	PJ、白假丝酵母、高里假丝酵母	0+13	0+7	14	治愈
3	男	29	36	6	22	重度	铜绿假单胞菌	巨细胞病毒	PJ、白假丝酵母	2+13	2+7	16	治愈
4	女	32	8	6	7	重度	阴性	阴性	PJ	4+0	4+0	6	治愈
5	男	54	9	0	18	中度	阴性	阴性	PJ、白假丝酵母	0+10	0	10	治愈
注：①为无创（包括高流量）+有创通气时间。　　　　②为清醒俯卧位+插管俯卧位时间。

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表 2 4例患者俯卧位治疗前后氧合相关指标变化比较（$\bar {\boldsymbol{x}} $±s）

Table 2. Comparison of oxygenation related indexes before and after prone position treatment in 4 patients

时间	n	SpO₂（%）	PaO₂（mmHg）	A-aDO₂（mmHg）	氧合指数（mmHg）
治疗前	4	96.05±1.19	82±12	533±39	96±17
治疗后1 d	4	96.87±0.82	85±11^a	422±58^a	112±13^a
治疗后4 d	4	97.62±0.08^a	123±9^{a, b}	266±65^{a, b}	177±13^{a, b}
注：与治疗前比较，^aP< 0.05；与治疗后1 d比较，^bP< 0.05。

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参考文献(35)

[1]	EPLING BP, MANION M, SIRAJUDDIN A, et al. Long-term outcomes of patients with HIV and pneumocystis jirovecii pneumonia in the antiretroviral therapy era[J]. Open Forum Infect Dis, 2023, 10(8): ofad408. DOI: 10.1093/ofid/ofad408.
[2]	TASAKA S. Recent advances in the diagnosis and management of pneumocystis pneumonia[J]. Tuberc Respir Dis (Seoul), 2020, 83(2): 132-140. DOI: 10.4046/trd.2020.0015.
[3]	刘兆润, 董丽, 吴国刚. 俯卧位通气在中重度急性呼吸窘迫综合征的临床应用进展[J]. 中国呼吸与危重监护杂志, 2016, 15(5): 517-519. DOI: 10.7507/1671-6205.2016119. LIU ZR, DONG L, WU GG. Clinical application of prone position in moderate to severe acute respiratory distress syndrome[J]. Chin J Respir Critical Care, 2016, 15(5): 517-519. DOI: 10.7507/1671-6205.2016119.
[4]	NADEEM R, CHIRAYATH-WILSON N, D'SOUZA JP, et al. Pressure injury incidence and impact on patients treated with prone positioning for COVID-19 ARDS[J]. J Wound Care, 2023, 32(8): 500-506. DOI: 10.12968/jowc.2023.32.8.500.
[5]	OLIVEIRA FV, COLTRO PS, NUNES AA, et al. Comparative cohort analysis of pressure ulcer/injury in intensive care unit patients before and during the COVID-19 pandemic[J]. J Plast Reconstr Aesthet Surg, 2023, 85: 98-103. DOI: 10.1016/j.bjps.2023.06.072.
[6]	CHOI JS, LEE SH, LEEM AY, et al. Pneumocystis jirovecii pneumonia (PCP) PCR-negative conversion predicts prognosis of HIV-negative patients with PCP and acute respiratory failure[J]. PLoS One, 2018, 13(10): e0206231. DOI: 10.1371/journal.pone.0206231.
[7]	GUERIN C, GAILLARD S, LEMASSON S, et al. Effects of systematic prone positioning in hypoxemic acute respiratory failure: a randomized controlled trial[J]. JAMA, 2004, 292(19): 2379-2387. DOI: 10.1001/jama.292.19.2379.
[8]	冼盈, 段智勤, 李衡, 等. 肾移植术后感染病原菌特点及死亡风险[J]. 中国感染控制杂志, 2023, 22(5): 539-546. DOI: 10.12138/j.issn.1671-9638.20233265. XIAN Y, DUAN ZQ, LI H, et al. Characteristics of infection pathogens and risk of death after kidney transplantation[J]. Chin J Infect Control, 2023, 22(5): 539-546. DOI: 10.12138/j.issn.1671-9638.20233265.
[9]	IRIART X, BOUAR ML, KAMAR N, et al. Pneumocystis pneumonia in solid-organ transplant recipients[J]. J Fungi (Basel), 2015, 1(3): 293-331. DOI: 10.3390/jof1030293.
[10]	GORDON SM, LAROSA SP, KALMADI S, et al. Should prophylaxis for pneumocystis carinii pneumonia in solid organ transplant recipients ever be discontinued?[J]. Clin Infect Dis, 1999, 28(2): 240-246. DOI: 10.1086/515126.
[11]	张华伟, 王耀丽, 张鹏, 等. 俯卧位通气改善重度急性呼吸窘迫综合征氧合的临床分析[J/CD]. 中华肺部疾病杂志(电子版), 2018, 11(1): 78-81. DOI: 10.3877/cma.j.issn.1674-6902.2018.01.016. ZHANG HW, WANG YL, ZHANG P, et al. Clinical analysis of prone position improving oxygenation in severe acute respiratory distress syndrome[J/CD]. Chin J Pulm Dis, 2018, 11(1): 78-81. DOI: 10.3877/cma.j.issn.1674-6902.2018.01.016.
[12]	PETRONE P, BRATHWAITE CEM, JOSEPH DK. Prone ventilation as treatment of acute respiratory distress syndrome related to COVID-19[J]. Eur J Trauma Emerg Surg, 2021, 47(4): 1017-1022. DOI: 10.1007/s00068-020-01542-7.
[13]	GRASSELLI G, CALFEE CS, CAMPOROTA L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies[J]. Intensive Care Med, 2023, 49(7): 727-759. DOI: 10.1007/s00134-023-07050-7.
[14]	HU SL, HE HL, PAN C, et al. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials[J]. Crit Care, 2014, 18(3): R109. DOI: 10.1186/cc13896.
[15]	MALDONADO-BELTRÁN I, RÍOS-AYALA MA, OSUNA-PADILLA IA, et al. Changes in pulmonary mechanics from supine to prone position measured through esophageal manometry in critically ill patients with COVID-19 severe acute respiratory distress syndrome[J]. Med Intensiva (Engl Ed), 2023,DOI: 10.1016/j.medine.2023.07.013[Epub ahead of print
[16]	INAGAWA T, OHSHIMO S, SHIME N. Controversial efficacy of early timing of prone positioning for severe acute respiratory distress syndrome during venovenous extracorporeal membrane oxygenation[J]. Crit Care Med, 2023, 51(7): e148-e149. DOI: 10.1097/CCM.0000000000005899.
[17]	ERGÜN B, YAKAR MN, KÜÇÜK M, et al. Combined effects of prone positioning and airway pressure release ventilation on oxygenation in patients with COVID-19 ARDS[J]. Turk J Anaesthesiol Reanim, 2023, 51(3): 188-198. DOI: 10.4274/TJAR.2022.22783.
[18]	COPPO A, BELLANI G, WINTERTON D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study[J]. Lancet Respir Med, 2020, 8(8): 765-774. DOI: 10.1016/S2213-2600(20)30268-X.
[19]	ALHAZZANI W, PARHAR KKS, WEATHERALD J, et al. Effect of awake prone positioning on endotracheal intubation in patients with COVID-19 and acute respiratory failure: a randomized clinical trial[J]. JAMA, 2022, 327(21): 2104-2113. DOI: 10.1001/jama.2022.7993.
[20]	EHRMANN S, LI J, IBARRA-ESTRADA M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomised, controlled, multinational, open-label meta-trial[J]. Lancet Respir Med, 2021, 9(12): 1387-1395. DOI: 10.1016/S2213-2600(21)00356-8.
[21]	GUÉRIN C, REIGNIER J, RICHARD JC, et al. Prone positioning in severe acute respiratory distress syndrome[J]. N Engl J Med, 2013, 368(23): 2159-2168. DOI: 10.1056/NEJMoa1214103.
[22]	刘志, 高剑波, 张斯佳, 等. 肾移植受者肺孢子菌肺炎高分辨率CT诊断[J]. 实用放射学杂志, 2021, 37(9): 1437-1440. DOI: 10.3969/j.issn.1002-1671.2021.09.009. LIU Z, GAO JB, ZHANG SJ, et al. High-resolution CT diagnosis of pneumocystis pneumonia in kidney transplant recipients[J]. J Pract Radiol, 2021, 37(9): 1437-1440. DOI: 10.3969/j.issn.1002-1671.2021.09.009.
[23]	CHEN J, HE T, LI X, et al. Metagenomic next-generation sequencing in diagnosis of a case of pneumocystis jirovecii pneumonia in a kidney transplant recipient and literature review[J]. Infect Drug Resist, 2020, 13: 2829-2836. DOI: 10.2147/IDR.S257587.
[24]	徐春晖, 伊慧明, 陈书连, 等. 宏基因组二代测序技术在血液病合并肺孢子菌肺炎患者诊治中的应用价值[J]. 中国感染与化疗杂志, 2023, 23(2): 195-200. DOI: 10.16718/j.1009-7708.2023.02.010. XU CH, YI HM, CHEN SL, et al. Utility of metagenomic next generation sequencing for managing pneumocystis jirovecii pneumonia in patients with hematological disease[J]. Chin J Infect Chemother, 2023, 23(2): 195-200. DOI: 10.16718/j.1009-7708.2023.02.010.
[25]	DELBOVE A, ALAMI H, TISSOT A, et al. Pneumocystis pneumonia after lung transplantation: a retrospective multicenter study[J]. Respir Med, 2020, 169: 106019. DOI: 10.1016/j.rmed.2020.106019.
[26]	LEE WS, HSUEH PR, HSIEH TC, et al. Caspofungin salvage therapy in pneumocystis jirovecii pneumonia[J]. J Microbiol Immunol Infect, 2017, 50(4): 547-548. DOI: 10.1016/j.jmii.2016.03.008.
[27]	FISHMAN JA, GANS H, AST Infectious Diseases Community of Practice. Pneumocystis jiroveci in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice[J]. Clin Transplant, 2019, 33(9): e13587. DOI: 10.1111/ctr.13587.
[28]	沈轶, 潘雁, 尹成胜, 等. 二代测序诊断肺移植后耶氏肺孢子菌肺炎二例并文献复习[J]. 中国呼吸与危重监护杂志, 2021, 20(7): 479-486. DOI: 10.7507/1671-6205.202104007. SHEN Y, PAN Y, YIN CS, et al. Pneumocystis jirovecii pneumonia diagnosed by next-genetation sequencing after lung transplantation: case report and literature review[J]. Chin J Respir Crit Care Med, 2021, 20(7): 479-486. DOI: 10.7507/1671-6205.202104007.
[29]	王红宇, 张思森, 焦宪法, 等. ECMO在肾移植术后耶氏肺孢子菌肺炎致重度ARDS中的应用[J]. 中华器官移植杂志, 2021, 42(9): 524-528. DOI: 10.3760/cma.j.cn421203-20201214-00426. WANG HY, ZHANG SS, JIAO XF, et al. Application of ECMO in treating severe ARDS caused by pneumocystis yersoni pneumonia after kidney transplantation[J]. Chin J Organ Transplant, 2021, 42(9): 524-528. DOI: 10.3760/cma.j.cn421203-20201214-00426.
[30]	GIANI M, MARTUCCI G, MADOTTO F, et al. Prone positioning during venovenous extracorporeal membrane oxygenation in acute respiratory distress syndrome. a multicenter cohort study and propensity-matched analysis[J]. Ann Am Thorac Soc, 2021, 18(3): 495-501. DOI: 10.1513/AnnalsATS.202006-625OC.
[31]	PAPAZIAN L, SCHMIDT M, HAJAGE D, et al. Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis[J]. Intensive Care Med, 2022, 48(3): 270-280. DOI: 10.1007/s00134-021-06604-x.
[32]	刘家振, 姜小敢. 静脉-静脉体外膜肺氧合联合俯卧位通气治疗重度急性呼吸窘迫综合征临床研究进展[J]. 中国急救医学, 2021, 41(12): 1097-1101. DOI: 10.3969/j.issn.1002-1949.2021.12.017. LIU JZ, JIANG XG. Clinical research progress of veno-venous extracorporeal membrane oxygenation combined with prone position ventilation in the treatment of severe acute respiratory distress syndrome[J]. Chin J Crit Care Med, 2021, 41(12): 1097-1101. DOI: 10.3969/j.issn.1002-1949.2021.12.017.
[33]	PETIT M, FETITA C, GAUDEMER A, et al. Prone-positioning for severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation[J]. Crit Care Med, 2022, 50(2): 264-274. DOI: 10.1097/CCM.0000000000005145.
[34]	LAGHLAM D, CHARPENTIER J, HAMOU ZA, et al. Effects of prone positioning on respiratory mechanics and oxygenation in critically ill patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation[J]. Front Med (Lausanne), 2022, 8: 810393. DOI: 10.3389/fmed.2021.810393.
[35]	沈泽, 田洋洋, 周政, 等. 肾移植受者耶氏肺孢子菌肺炎的临床及流行病学特征分析[J]. 器官移植, 2023, 14(4): 570-577. DOI: 10.3969/j.issn.1674-7445.2023.04.014. SHEN Z, TIAN YY, ZHOU Z, et al. Clinical and epidemiological features analysis of pneumocystis jirovecii pneumonia in kidney transplant recipients[J]. Organ Transplant, 2023, 14(4): 570-577. DOI: 10.3969/j.issn.1674-7445.2023.04.014.

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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

doi: 10.3969/j.issn.1674-7445.2023115

作者简介:

通讯作者:
李克（ORCID：0009-0009-0729-7947），博士，主任医师，研究方向为器官移植受者围手术期管理，Email：like-icu@163.com

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

Corresponding author: Li Ke, Email: like-icu@163.com

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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

doi: 10.3969/j.issn.1674-7445.2023115

作者简介:

通讯作者: 李克（ORCID：0009-0009-0729-7947），博士，主任医师，研究方向为器官移植受者围手术期管理，Email：like-icu@163.com

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

Corresponding author: Li Ke, Email: like-icu@163.com

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通讯作者:
李克（ORCID：0009-0009-0729-7947），博士，主任医师，研究方向为器官移植受者围手术期管理，Email：like-icu@163.com