UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

新生儿氧气监测与治疗

Author
Richard Martin, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD
Translators
程国强, 主任医师

引言

辅助供氧是新生儿重症监护的一个重要部分。需要进行仔细监测以尽量减轻肺毒性或低氧血症或高氧的后果。过度吸氧的2个主要并发症是肺损伤和早产儿视网膜病变(retinopathy of prematurity, ROP)。这两种并发症由不同的原因引起，肺损伤同吸入氧浓度过高相关，而视网膜病变同动脉血氧分压过高和极度不成熟相关(参见“早产儿视网膜病变”)。另一方面，会担心氧饱和度过低可能与死亡率升高或神经发育受损(neurodevelopmental impairment, NDI)的风险升高有关。

对新生儿(包括早产儿)氧气的给予、监测和目标水平，将总结在此。产房内新生儿复苏期间的给氧将单独讨论。 (参见“产房中的新生儿复苏”，关于‘辅助供氧’一节)

氧气运输

正常的细胞功能依赖于持续的氧供。吸入的氧气通过肺泡-毛细血管膜扩散并进入肺毛细血管血液中。肺泡氧分压(在海平面呼吸室内空气时大约为100mmHg)高于混合静脉血中氧分压(40mmHg)和线粒体内的氧分压(<10mmHg)。这一压力梯度可维持PaO2，并且在很大程度上是促进氧输送(即DO2)至细胞的驱动力。

氧气扩散进入血液后，主要与红细胞中的血红蛋白相结合，小部分溶于血浆中。PaO2与血红蛋白的关系，通过曲线形的氧合血红蛋白解离曲线描述(图 1)。PaO2高于90mmHg时，曲线几乎是平坦的，且血红蛋白几乎完全饱和。当PaO2较低时，曲线急剧下降，能促进氧气释放进入组织内。

氧亲和力是指血红蛋白结合或释放氧气的能力，受pH值、CO2(部分程度上独立于pH值)、2,3-二磷酸甘油酸(diphosphoglycerate, DPG)、温度和胎儿血红蛋白(fetal hemoglobin, HbF)的调节(图 1)。pH值较低、CO2较高、温度升高及HbF比例降低，可导致氧亲和力降低。氧亲和力的这些改变，促进肺毛细血管中氧气的摄取和氧气向组织内的释放。 (参见“Structure and function of normal hemoglobins”)

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-06-16.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Nunn JF. Nunn's Applied Respiratory Physiology, Butterworth-Heinemann, Oxford 1993. p.282.
  2. Hill JR, Rahimtulla KA. Heat balance and the metabolic rate of new-born babies in relation to environmental temperature; and the effect of age and of weight on basal metabolic rate. J Physiol 1965; 180:239.
  3. Marks KH, Nardis EE, Momin MN. Energy metabolism and substrate utilization in low birth weight neonates under radiant warmers. Pediatrics 1986; 78:465.
  4. Benaron DA, Benitz WE. Maximizing the stability of oxygen delivered via nasal cannula. Arch Pediatr Adolesc Med 1994; 148:294.
  5. Walsh M, Engle W, Laptook A, et al. Oxygen delivery through nasal cannulae to preterm infants: can practice be improved? Pediatrics 2005; 116:857.
  6. Verder H, Albertsen P, Ebbesen F, et al. Nasal continuous positive airway pressure and early surfactant therapy for respiratory distress syndrome in newborns of less than 30 weeks' gestation. Pediatrics 1999; 103:E24.
  7. Van Marter LJ, Allred EN, Pagano M, et al. Do clinical markers of barotrauma and oxygen toxicity explain interhospital variation in rates of chronic lung disease? The Neonatology Committee for the Developmental Network. Pediatrics 2000; 105:1194.
  8. Aly H, Milner JD, Patel K, El-Mohandes AA. Does the experience with the use of nasal continuous positive airway pressure improve over time in extremely low birth weight infants? Pediatrics 2004; 114:697.
  9. Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis PG. Continuous distending pressure for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev 2002; :CD002271.
  10. Miller MJ, Carlo WA, Martin RJ. Continuous positive airway pressure selectively reduces obstructive apnea in preterm infants. J Pediatr 1985; 106:91.
  11. Stark AR, Goldman MD, Frantz ID 3rd. Lung volume changes, occlusion pressure and chest wall configuration in human infants. Pediatr Res 1979; 13:250.
  12. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev 2003; :CD000143.
  13. Buzzella B, Claure N, D'Ugard C, Bancalari E. A randomized controlled trial of two nasal continuous positive airway pressure levels after extubation in preterm infants. J Pediatr 2014; 164:46.
  14. Beker F, Rogerson SR, Hooper SB, et al. The effects of nasal continuous positive airway pressure on cardiac function in premature infants with minimal lung disease: a crossover randomized trial. J Pediatr 2014; 164:726.
  15. Finer NN, Mannino FL. High-flow nasal cannula: a kinder, gentler CPAP? J Pediatr 2009; 154:160.
  16. Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ. High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol 2007; 27:85.
  17. Collins CL, Barfield C, Horne RS, Davis PG. A comparison of nasal trauma in preterm infants extubated to either heated humidified high-flow nasal cannulae or nasal continuous positive airway pressure. Eur J Pediatr 2014; 173:181.
  18. Roberts CT, Owen LS, Manley BJ, et al. Nasal High-Flow Therapy for Primary Respiratory Support in Preterm Infants. N Engl J Med 2016; 375:1142.
  19. Kotecha SJ, Adappa R, Gupta N, et al. Safety and Efficacy of High-Flow Nasal Cannula Therapy in Preterm Infants: A Meta-analysis. Pediatrics 2015; 136:542.
  20. Wilkinson D, Andersen C, O'Donnell CP, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2016; 2:CD006405.
  21. Williams AJ. ABC of oxygen: assessing and interpreting arterial blood gases and acid-base balance. BMJ 1998; 317:1213.
  22. Harsten A, Berg B, Inerot S, Muth L. Importance of correct handling of samples for the results of blood gas analysis. Acta Anaesthesiol Scand 1988; 32:365.
  23. Hansen JE, Simmons DH. A systematic error in the determination of blood PCO2. Am Rev Respir Dis 1977; 115:1061.
  24. Neff TA. Routine oximetry. A fifth vital sign? Chest 1988; 94:227.
  25. Hay WW Jr, Brockway JM, Eyzaguirre M. Neonatal pulse oximetry: accuracy and reliability. Pediatrics 1989; 83:717.
  26. Durand M, Ramanathan R. Pulse oximetry for continuous oxygen monitoring in sick newborn infants. J Pediatr 1986; 109:1052.
  27. Cummings JJ, Polin RA, Committee on Fetus and Newborn, American Academy of Pediatrics. Noninvasive Respiratory Support. Pediatrics 2016; 137.
  28. Levesque BM, Pollack P, Griffin BE, Nielsen HC. Pulse oximetry: what's normal in the newborn nursery? Pediatr Pulmonol 2000; 30:406.
  29. Brockmann PE, Poets A, Urschitz MS, et al. Reference values for pulse oximetry recordings in healthy term neonates during their first 5 days of life. Arch Dis Child Fetal Neonatal Ed 2011; 96:F335.
  30. Harigopal S, Satish HP, Taktak AF, et al. Oxygen saturation profile in healthy preterm infants. Arch Dis Child Fetal Neonatal Ed 2011; 96:F339.
  31. Hagadorn JI, Furey AM, Nghiem TH, et al. Achieved versus intended pulse oximeter saturation in infants born less than 28 weeks' gestation: the AVIOx study. Pediatrics 2006; 118:1574.
  32. Clucas L, Doyle LW, Dawson J, et al. Compliance with alarm limits for pulse oximetry in very preterm infants. Pediatrics 2007; 119:1056.
  33. Greenspan JS, Goldsmith JP. Oxygen therapy in preterm infants: hitting the target. Pediatrics 2006; 118:1740.
  34. Poets CF, Southall DP. Noninvasive monitoring of oxygenation in infants and children: practical considerations and areas of concern. Pediatrics 1994; 93:737.
  35. Vagedes J, Poets CF, Dietz K. Averaging time, desaturation level, duration and extent. Arch Dis Child Fetal Neonatal Ed 2013; 98:F265.
  36. Jennis MS, Peabody JL. Pulse oximetry: an alternative method for the assessment of oxygenation in newborn infants. Pediatrics 1987; 79:524.
  37. Dawson JA, Kamlin CO, Vento M, et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010; 125:e1340.
  38. Quine D, Stenson BJ. Arterial oxygen tension (Pao2) values in infants <29 weeks of gestation at currently targeted saturations. Arch Dis Child Fetal Neonatal Ed 2009; 94:F51.
  39. Castillo A, Sola A, Baquero H, et al. Pulse oxygen saturation levels and arterial oxygen tension values in newborns receiving oxygen therapy in the neonatal intensive care unit: is 85% to 93% an acceptable range? Pediatrics 2008; 121:882.
  40. Manja V, Lakshminrusimha S, Cook DJ. Oxygen saturation target range for extremely preterm infants: a systematic review and meta-analysis. JAMA Pediatr 2015; 169:332.
  41. Bancalari E, Claure N. Oxygenation targets and outcomes in premature infants. JAMA 2013; 309:2161.
  42. Polin RA, Bateman D. Oxygen-saturation targets in preterm infants. N Engl J Med 2013; 368:2141.
  43. Supplemental Therapeutic Oxygen for Prethreshold Retinopathy Of Prematurity (STOP-ROP), a randomized, controlled trial. I: primary outcomes. Pediatrics 2000; 105:295.
  44. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network, Carlo WA, Finer NN, et al. Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 2010; 362:1959.
  45. Schmidt B, Whyte RK, Asztalos EV, et al. Effects of targeting higher vs lower arterial oxygen saturations on death or disability in extremely preterm infants: a randomized clinical trial. JAMA 2013; 309:2111.
  46. BOOST II United Kingdom Collaborative Group, BOOST II Australia Collaborative Group, BOOST II New Zealand Collaborative Group, et al. Oxygen saturation and outcomes in preterm infants. N Engl J Med 2013; 368:2094.
  47. Poets CF, Roberts RS, Schmidt B, et al. Association Between Intermittent Hypoxemia or Bradycardia and Late Death or Disability in Extremely Preterm Infants. JAMA 2015; 314:595.
  48. BOOST-II Australia and United Kingdom Collaborative Groups, Tarnow-Mordi W, Stenson B, et al. Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants. N Engl J Med 2016; 374:749.
  49. Walsh MC, Di Fiore JM, Martin RJ, et al. Association of Oxygen Target and Growth Status With Increased Mortality in Small for Gestational Age Infants: Further Analysis of the Surfactant, Positive Pressure and Pulse Oximetry Randomized Trial. JAMA Pediatr 2016; 170:292.
  50. Navarrete CT, Wrage LA, Carlo WA, et al. Growth Outcomes of Preterm Infants Exposed to Different Oxygen Saturation Target Ranges from Birth. J Pediatr 2016; 176:62.
  51. van Zanten HA, Tan RN, van den Hoogen A, et al. Compliance in oxygen saturation targeting in preterm infants: a systematic review. Eur J Pediatr 2015; 174:1561.
  52. Lim K, Wheeler KI, Gale TJ, et al. Oxygen saturation targeting in preterm infants receiving continuous positive airway pressure. J Pediatr 2014; 164:730.
  53. Claure N, D'Ugard C, Bancalari E. Automated adjustment of inspired oxygen in preterm infants with frequent fluctuations in oxygenation: a pilot clinical trial. J Pediatr 2009; 155:640.
  54. Hallenberger A, Poets CF, Horn W, et al. Closed-loop automatic oxygen control (CLAC) in preterm infants: a randomized controlled trial. Pediatrics 2014; 133:e379.
  55. Waitz M, Schmid MB, Fuchs H, et al. Effects of automated adjustment of the inspired oxygen on fluctuations of arterial and regional cerebral tissue oxygenation in preterm infants with frequent desaturations. J Pediatr 2015; 166:240.