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肺超音波検査を活用した早産児の肺病変分布評価および呼吸予後予測

星野, 雄介 筑波大学 DOI:10.15068/0002006055

2023.01.16

概要

早産児はその未熟性により,生後に中枢神経系・循環器系・消化器系・腎泌尿器系などで様々な合併症のリスクが高い.呼吸器系では,Ⅱ型肺胞上皮細胞からの肺サーファクタント分泌不全による新生児呼吸窮迫症候群(respiratory distress syndrome:RDS)を発症するリスクがある.RDS では肺サーファクタント欠乏により肺胞表面張力が低下しないために肺胞が虚脱し,そのことが重度の呼吸障害を引き起こす.肺サーファクタントは妊娠 20 週頃より生成され、胎児肺成熟とともに増加していく 1).本邦における新生児臨床研究ネットワークの 2017 年のデータによると,在胎 28 週未満で 77%,在胎 32 週未満で 53%,在胎 37 週未満で 20%未満が RDS を発症している 2).RDS を発症した際にはウシ肺から生成された人工肺サーファクタントを投与することで肺胞表面張力が低下し,呼吸状態は一時的に改善する 3).

早産児の循環器系の早期合併症として、未熟児動脈管開存症(patent ductus arteriosus:PDA)があげられる。通常は血中酸素濃度の上昇とプロスタグランジン E2 の低下のため、生後数日で動脈管は閉鎖する。しかし早産児はこの機序が未熟であり、動脈管が閉鎖しないことがある。動脈管を介した左右方向の血液短絡のために肺血流増多が起こると呼吸障害の一因となる.PDA の治療には内科的治療が優先されるが,無効である場合や,重篤な副作用を有する場合には外科的治療が必要なことがある.そのため PDA の発症は人工呼吸器管理を長期化させるリスクになる.

また早産児は呼吸中枢が未熟であるため,未熟児無呼吸発作を起こすリスクがある.遷延する無呼吸は低酸素血症や徐脈など循環動態に重篤な影響を及ぼすため,長期の人工呼吸管理を要することが多い 4).

様々な未熟性のために早産児にとって人工呼吸管理は必要不可欠な治療であるが,一方で人工呼吸器の使用は圧損傷や酸素毒性を引き起こし,慢性的な肺障害を引き起こす.経過中に人工呼吸器関連肺炎を発症することもある.このように生後より直面するさまざまな侵襲や長期化する人工呼吸器の使用は肺の発育に異常をきたし,その結果として肺の線維化や気腫状変化を呈するようになる.この病態が気管支肺異形成(bronchopulmonarydysplasia:BPD)として 1967 年に初めて報告された 5)が,その後に RDS が先行せずに類似の肺病変を呈する Wilson-Mikity 症候群 6)や,気腫状変化を呈さない病態 7)も報告され,その疾患概念に関する議論が続いた.

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