MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME IN A CHILD WITH ADENOVIRUS PNEUMONIA: CASE REPORT AND LITERATURE REVIEW

ABSTRACT Objective: To report the case of a child who developed acute respiratory distress syndrome (ARDS) from a pulmonary infection by adenovirus. Case description: A female patient aged 2 years and 6 months, weighting 10,295 grams developed fever, productive cough and vomiting, later on progressing to ARDS despite initial therapy in accordance with the institutional protocol for ARDS treatment. The child evolved to refractory hypoxemia and hypercapnia, requiring high parameters of mechanical pulmonary ventilation and use of vasoactive agents. In the treatment escalation, the patient received steroids, inhaled nitric oxide (iNO), was submitted to the prone position, started oscillatory high-frequency ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) was indicated due to severe refractory hypoxemia. During this time, the patient’s clinical response was favorable to HFOV, improving oxygenation index and hypercapnia, allowing the reduction of vasoactive medications and mechanical ventilation parameters, and then the indication of ECMO was suspended. The patient was discharged after 26 days of hospital stay without respiratory or neurological sequelae. Comments: Adenovirus infections occur mainly in infants and children under 5 years of age and represent 2 to 5% of respiratory diseases among pediatric patients. Although most children with adenovirus develop a mild upper respiratory tract disease, more severe cases can occur. ARDS is a serious pulmonary inflammatory process with alveolar damage and hypoxemic respiratory failure; Adenovirus pneumonia in children may manifest as severe pulmonary morbidity and respiratory failure that may require prolonged mechanical ventilation. Exclusive pulmonary recruitment and HFOV are advantageous therapeutic options.

摘要
研究目的：报告1例因腺病毒（adenovirus）肺部感染引发急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS）的儿童病例。
病例资料：患者为2岁6个月女性，体重10295克，初起表现为发热、咳嗽咳痰及呕吐，尽管初始治疗遵循机构ARDS诊疗方案，病情仍进展为ARDS，出现难治性低氧血症与高碳酸血症，需采用高参数肺机械通气及血管活性药物治疗。在治疗升级阶段，患者接受了糖皮质激素、吸入一氧化氮（inhaled nitric oxide，iNO）治疗，实施俯卧位通气，启动高频振荡通气（high-frequency oscillatory ventilation，HFOV）；因重度难治性低氧血症，拟行体外膜肺氧合（extracorporeal membrane oxygenation，ECMO）。治疗期间，患者对HFOV应答良好，氧合指数与高碳酸血症均得到改善，血管活性药物用量及机械通气参数可逐步下调，遂暂停ECMO置入计划。患者住院26天后出院，无呼吸或神经系统后遗症。
讨论：腺病毒感染主要发生于5岁以下婴幼儿，占儿科呼吸系统疾病的2%~5%。多数腺病毒感染患儿仅表现为轻症上呼吸道感染，但也可出现重症病例。急性呼吸窘迫综合征（ARDS）是以肺泡损伤、低氧性呼吸衰竭为特征的严重肺部炎症性病变；儿童腺病毒肺炎可表现为重度肺部病变与呼吸衰竭，往往需要长期机械通气治疗。个体化肺复张策略与高频振荡通气（HFOV）是颇具临床优势的治疗选择。