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酸素化の目標値をどこに設定するか
中川 聡
2082
4
気道抵抗と肺コンプライアンス
PICUのフェロー部屋
7649
17
Viral Pneumonia
国立成育医療研究センター
289
1
概要
PICUで遭遇する重症ウイルス性肺炎について、歴史的な大流行を基に解説します。SARS、鳥インフルエンザ、H1N1、麻疹など、各ウイルスの小児における臨床像と重症度の違いを整理し、呼吸管理の要点を学びます。
本スライドの対象者
研修医／専攻医／専門医
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テキスト全文
ウィルス性肺炎の歴史と課題
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Viral Pneumonia Historical challenges Satoshi Nakagawa National Center for Child Health and Development Tokyo, Japan
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目次 • 成育医療センターにおける呼吸器ウィルスPCR • ウィルス性肺炎の歴史 - SARS - Avian Influenza - H1N1 Influenza - その他のウィルス肺炎
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PICUで必要な知識や⼿技、 対応のポイントをスライド形式でまとめています ✓ 系統別に学ぶ⼩児集中治療の知識 ✓ ⼿技（挿管‧エコー等）の習得 ✓ ショック‧外傷など緊急対応の理解 スライドで詳しく学ぶ https://slide.antaa.jp/special/pediatric-intensive-care
PICUにおけるウィルスPCRの実施
ウィルス性肺炎の主な病原体
H1N1インフルエンザの症例と治療
H1N1インフルエンザの治療設定
麻疹に関連する急性呼吸不全の治療
#4.
Multiplex PCR at NCCHD, Tokyo Morota J, et al. presented at JSICM Meeting, 2024 • January 2020 to December 2022 • PICU patients of 15 years or younger with respiratory symptoms • Multiplex PCR (FilmArrayTM) was done in 181 patients • 150 patients showed positive for some virus (29 showed positive for multiple viruses) • • • • • • • Rinovirus/Enterovirus 88 (19% required mechanical ventilation ) RSV 58 Parainfluenza virus 18 Human metapneumovirus 8 Adenovirus 8 Coronavirus (non SARS CoV-2) 5 Influenza virus 2
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Presented at 2nd APMV, 2019 • PICU patients who required mechanical ventilation in 2016 ARDS was diagnosed by Berlin Definition Fast Track Diagnostics Respiratory Panel 21
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PCCM 2024; 25:e1-e11. 7 PICUs in US
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Viral pneumonias • 2002 to 2003 SARS • 2003 Avian Influenza (H5N1) • 2009 H1N1 Influenza • 2012 MERS • 2019 COVID-19
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Viral pneumonias • 2002 to 2003 SARS • 2003 Avian Influenza (H5N1) • 2009 H1N1 Influenza • 2012 MERS • 2019 COVID-19
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Viral pneumonias • 2002 to 2003 SARS • 2003 Avian Influenza (H5N1) • 2009 H1N1 Influenza • 2012 MERS • 2019 COVID-19
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Pediatrics 2012; 128: e1450-e1458.
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H1N1 Flu is not a typical ARDS • 4 year old male, 18 kg • Referred from the other hospital • Initial vent settings: FIO2 1.0, P 35/8, RR 20, Ti 0.8 • pH 7.17, PaCO2 84, PaO2 143, HCO3 24 • Vent settings were changed: FIO2 0.8, P 37/8, RR15, Ti 0.8
#22.
On the next morning FIO2 0.6, P 37/7, RR 15, Ti 0.7 • pH 7.34, PaCO2 46, PaO2 164, HCO3 23 • It looks like ventilating an asthma patient
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H1N1 experience at NCCHD (2009) • Total 13 cases （M:F＝8:5） • Age： 10 months～9 y 8 m（5.5 ± 2.2 years） • Weight： 6.1～32.0 kg （19.3 ± 6.3） • Predicted mortality by PIM2： 4.0％ (Observed mortality was 0) • MV Days： 4.5 ± 3.1 • ICU Days： 6.0 ± 3.3
#24.
H1N1 influenza cases Vent setting at NCCHD, Tokyo • Initial settings • FIO2 0.63±0.16 • PIP 31.9±6.5 • PEEP 8.4±2.9 • RR 14.0±3.8 • P/F 165±59 • PaCO2 55±12 • Settings on the 3rd Day • FIO2 0.43±0.07 * • PIP 24.5±6.0 * • PEEP 5.9±1.3 * • RR 14.5±4.8 • P/F 244±62 * • PaCO2 47±7 * * P<0.05
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Airway resistance change cmH2O/L/sec Day 1 Day 3
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Plastic bronchitis associated with H1N1 influenza
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Viral pneumonias • 2002 to 2003 SARS • 2003 Avian Influenza (H5N1) • 2009 H1N1 Influenza • 2012 MERS • 2019 COVID-19 Other viruses?
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From 2017 to 2019
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Extracorporeal Life Support for Acute Respiratory Distress Syndrome Associated with Measles Seguchi S, Nakagawa S, et al. Presented at the 4th World Congress on Pediatric Intensive Care, Boston, 2003 Methods: Retrospective review of medical records. Results: Four males and three females underwent ECLS treatment from 1997 to 2002 . The age range was 10 to 49 months (median 15) and weight range 7.5 to 13.0 kg (median 9.5). None of the patients were immunized for measles. The duration of mechanical ventilation before ECLS varied from 0 to 8 days (median 5). HFO and iNO were performed on 4 and 7 patients, respectively, before ECLS. All were treated with veno-arterial ECLS, where venous and arterial accesses were established at the right internal jugular vein and common carotid artery, respectively. Heparin was used as an anticoagulant, where activating clotting time was controlled to around 180 to 200 seconds. The duration of ECLS was from 6 to 55 days (median 9). Three (43%) survived and
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Results: Patient characteristics Patient Age Sex (months) Weight (kg) Pre-ECLS ventilation ECLS Mode days Highest mPaw or (PIP) OI days Flow (ml/kg/min) Outcome (died;D, survived;S) Complications 1** 10 M 9 HFOV 8 30 68 55 140 D Hemorrhage 2 11 F 7.5 HFOV 7 28 67 30 90 D Pneumonia 3 11 M 10 HFOV 0 28 54 8 70 S 4** 15 F 10 HFOV 5 28 80 6 90 D Renal failure 5** 16 M 10 CMV 7 (40) 71 9 100 S Sepsis, intracranial hemorrhage 6** 18 F 8 CMV 5 (35) 51 29 140 D Sepsis 7** 37 M 13 CMV 3 (40) 43 8 90 S Sepsis, hemorrhage *All were not immunized for measles. **iNO was incorporated before ECLS in patients 1,4,5,6, and 7.
#33.
Clinical Course of a Survival Case (Patient 3) HFOV ECLS 1 OI CMV 8 56 22 12 2.8 day
#34.
Viral pneumonias • 2002 to 2003 SARS • 2003 Avian Influenza (H5N1) • 2009 H1N1 Influenza • 2012 MERS • 2019 COVID-19 Other viruses?
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