目的 探讨无创正压通气(NIPPV)在高海拔地区治疗重症社区获得性肺炎(CAP)合并呼吸衰竭的疗效.方法 将海拔高度1500～3600 m的169例社区获得性重症肺炎合并呼吸衰竭患者分为99例早期接受NIPPV治疗者为治疗组,同时对痰量较多且黏稠者应用纤维支气管镜吸除气道分泌物、肺灌洗,并取深部分泌物或灌洗液行细菌培养加药敏实验治疗.70例拒绝NIPPV治疗者为对照组,比较两组患者治疗前后呼吸频率、血气分析变化、气管插管率、病死率及住院时间.结果 治疗组治疗2 h后PaO2较治疗前升高(P<0.05);治疗组24 h后呼吸频率、PaCO2较治疗前降低,pH、PaO2较治疗前升高(P<0.01);治疗组治疗24 h后PaO2较对照组升高(P<0.01).治疗组气管插管率、病死率、住院时间明显低于对照组 (P<0.01).结果 结论在高海拔地区早期应用NIPPV联合纤维支气管镜治疗技术是治疗重症CAP合并呼吸衰竭的有效手段,可显著改善患者的预后,降低病死率,且是有效遏制重症CAP并呼吸衰竭引向多脏器功能障碍综合征(MODS)的一项重要措施,值得临床推广应用.

AIM: To explore the roles of cell apoptosis and expression of bax and bcl-2 in lung tissue in the mechanism of lung injury induced by severe acute pancreatitis (SAP) and the effects of insulin-like growth factor-1(IGF-1) on cell apoptosis in lung tissue of rats with SAP. METHODS: Wistar rats were randomly divided into three groups: Control group (n=24), SAP group (n=24) and IGF-1 group (n=24). Every group was randomly divided into 3 time units (6,12,24 h), with 8 rats in each time unit. The models of SAP were established by retro-grade injection of 50 g/L sodium taurocholate solution into the bilio-pancrestic duct of rats. At the 6,12 and 24 h after establishment of models, serum amylase, histologic scoring of lung injury were determined. The lung tissue was taken for light and transmission electron microscopic observation. Cell apoptosis in lung tissue was determined by TUNEL method, the expressions of bax mRNA and bcl-2 mRNA were detected by RT-PCR. RESULTS: In the SAP group, serum amylase, histologic scoring of lung injury, apoptotic index, the expressions of bax mRNA and bcl-2 mRNA markedly increased. Apoptotic cells increased obviously under transmission electron microscope. As compared with SAP group at the same phase, serum amylase, histologic scoring of lung injury, apoptotic index, expressions of bax mRNA in IGF-1 group decreased significantl, while the expression of bcl-2 mRNA increased significantly. Apoptotic cells decreased obviously in transmission electron microscopic observation. CONCLUSION: The apoptosis and expression of bax and bcl-2 in lung tissue might be involved in pathogenesis of the lung injury induced by SAP. IGF-1 can alleviate the lung injury by inhibiting apoptosis of lung tissue cells, in which its effects on regulating the expression of bax and bcl-2 may play an important role.

Objective To investigate the protective effect of exogenous insulin-like growth factor-1(IGF-1) on the gut barrier function dysfunction induced by severe acute pancreatitis(SAP) and its possible mechanism.Methods 72 male Wistar rats were randomly divided into 3 equal groups:SAP group(SAP) undergoing retrograde infusion of 5.0 % sodium taurocholate so as to establish SAP models,IGF-1 treatment group,undergoing subcutaneous injection of IGF-1 30 min before and 3 h after the operation,and sham operation(SO) group,undergoing retrograde infusion of normal saline.6,12,and 24 hours later 8 rats in each group were killed with the blood samples taken from the right ventricles to detect the serum amylase,endotoxin,and diamine oxydase(DAO) .Specimens of small intestine were obtained to undergo pathological examination.TUNEL method was used to observe the apoptosis of mucosal cells.Results The serum amylase levels of the SAP group at different time points were all significantly higher than those of the SO group(all P 0.05) .,and the IGF-1 group was not significantly different from that of the SAP group(P 0.05) 6 h after operation,but significantly lower than that of the SAP group 12 h and 24 h after the operation(both P 0.05) ;however,the serum amylase levels of the IGF-1 group at different time points were not significantly different from those of the SO group(all P 0.05) .The serum endotoxin levels 12 h and 24 h after operation of the SAP group were both significantly higher than those of the SO group(both P 0.01) ,and 12 h after operation of the IGF-1 group was significantly lower than that of the SAP group(P 0.01) .The pathological scores of the small intestine at different time points of the SAP group were all significantly higher than those of the SO group(all P 0.05) ,and the IGF-1 group were all significantly lower than those of the SAP group(all P 0.05) .The apoptotic indexes at different time points of the SAP group were all significantly higher than those of the SO group(all P 0.01) ,and the IGF-1 group were all significantly lower than those of the SAP group(all P 0.01) ,but not significantly different from those of the SO group(all P 0.05) .Conclusion Exogenous IGF-1 alleviates SAP-induced injury to intestinal mucosal and endotoxemia.The mechanism may be that IGF-1 inhabits excessive apoptosis of the intestinal mucosal.

1 概述 定义:急性心力衰竭综合征(AHFS)是指心衰症状和体征逐渐加重或突然恶化以至需要紧急治疗的临床综合征,这一综合征是复杂的,包含多种诊断和病因[1].