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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

田莉, 方晓楠, 张玲, 等. 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[J]. 器官移植, 2023, 14(6): 847-854. doi: 10.3969/j.issn.1674-7445.2023115
引用本文: 田莉, 方晓楠, 张玲, 等. 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[J]. 器官移植, 2023, 14(6): 847-854. doi: 10.3969/j.issn.1674-7445.2023115
Tian Li, Fang Xiaonan, Zhang Ling, et al. Application of prone position in severe ARDS caused by pneumocystis jirovecii pneumonia after kidney transplantation[J]. ORGAN TRANSPLANTATION, 2023, 14(6): 847-854. doi: 10.3969/j.issn.1674-7445.2023115
Citation: Tian Li, Fang Xiaonan, Zhang Ling, et al. Application of prone position in severe ARDS caused by pneumocystis jirovecii pneumonia after kidney transplantation[J]. ORGAN TRANSPLANTATION, 2023, 14(6): 847-854. 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
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

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

More Information
  • 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。

     

  • 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

    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

    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(d)俯卧位时间(d)ICU入住时间(d)预后
    细菌病毒真菌
    1518019重度阴性巨细胞病毒、乙型肝炎病毒马尔尼菲青霉菌、PJ0+210+1042死亡
    2534024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+130+714治愈
    32936622重度铜绿假单胞菌巨细胞病毒PJ、白假丝酵母2+132+716治愈
    432867重度阴性阴性PJ4+04+06治愈
    5549018中度阴性阴性PJ、白假丝酵母0+10010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。
    下载: 导出CSV

    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nSpO2(%)PaO2(mmHg)A-aDO2(mmHg)氧合指数(mmHg)
    治疗前496.05±1.1982±12533±3996±17
    治疗后1 d496.87±0.8285±11a422±58a112±13a
    治疗后4 d497.62±0.08a123±9a, b266±65a, b177±13a, b
      注:与治疗前比较,aP< 0.05;与治疗后1 d比较,bP< 0.05。
    下载: 导出CSV
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  • 收稿日期:  2023-06-18
  • 录用日期:  2023-09-11
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