Ray Patrick, Birolleau Sophie, Lefort Yannick, Becquemin Marie-Hélène, Beigelman Catherine, Isnard Richard, Teixeira Antonio, Arthaud Martine, Riou Bruno, Boddaert Jacques
Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6 75651 Paris Cedex 13, France.
Crit Care. 2006;10(3):R82. doi: 10.1186/cc4926. Epub 2006 May 24.
Our objectives were to determine the causes of acute respiratory failure (ARF) in elderly patients and to assess the accuracy of the initial diagnosis by the emergency physician, and that of the prognosis.
In this prospective observational study, patients were included if they were admitted to our emergency department, aged 65 years or more with dyspnea, and fulfilled at least one of the following criteria of ARF: respiratory rate at least 25 minute-1; arterial partial pressure of oxygen (PaO2) 70 mmHg or less, or peripheral oxygen saturation 92% or less in breathing room air; arterial partial pressure of CO2 (PaCO2) > or = 45 mmHg, with pH < or = 7.35. The final diagnoses were determined by an expert panel from the completed medical chart.
A total of 514 patients (aged (mean +/- standard deviation) 80 +/- 9 years) were included. The main causes of ARF were cardiogenic pulmonary edema (43%), community-acquired pneumonia (35%), acute exacerbation of chronic respiratory disease (32%), pulmonary embolism (18%), and acute asthma (3%); 47% had more than two diagnoses. In-hospital mortality was 16%. A missed diagnosis in the emergency department was noted in 101 (20%) patients. The accuracy of the diagnosis of the emergency physician ranged from 0.76 for cardiogenic pulmonary edema to 0.96 for asthma. An inappropriate treatment occurred in 162 (32%) patients, and lead to a higher mortality (25% versus 11%; p < 0.001). In a multivariate analysis, inappropriate initial treatment (odds ratio 2.83, p < 0.002), hypercapnia > 45 mmHg (odds ratio 2.79, p < 0.004), clearance of creatinine < 50 ml minute-1 (odds ratio 2.37, p < 0.013), elevated NT-pro-B-type natriuretic peptide or B-type natriuretic peptide (odds ratio 2.06, p < 0.046), and clinical signs of acute ventilatory failure (odds ratio 1.98, p < 0.047) were predictive of death.
Inappropriate initial treatment in the emergency room was associated with increased mortality in elderly patients with ARF.
我们的目标是确定老年患者急性呼吸衰竭（ARF）的病因，并评估急诊科医生初始诊断的准确性以及预后情况。
在这项前瞻性观察研究中，纳入了入住我们急诊科、年龄65岁及以上且有呼吸困难，并至少符合以下ARF标准之一的患者：呼吸频率至少25次/分钟；动脉血氧分压（PaO₂）70mmHg或更低，或在室内空气中呼吸时外周血氧饱和度92%或更低；动脉血二氧化碳分压（PaCO₂）≥45mmHg，且pH≤7.35。最终诊断由专家小组根据完整的病历确定。
共纳入514例患者（年龄（均值±标准差）80±9岁）。ARF的主要病因是心源性肺水肿（43%）、社区获得性肺炎（35%）、慢性呼吸道疾病急性加重（32%）、肺栓塞（18%）和急性哮喘（3%）；47%的患者有两种以上诊断。住院死亡率为16%。101例（20%）患者在急诊科存在漏诊。急诊科医生诊断的准确性范围为：心源性肺水肿为0.76，哮喘为0.96。162例（32%）患者出现不恰当治疗，且导致更高的死亡率（25%对11%；p<0.001）。在多变量分析中，不恰当的初始治疗（比值比2.83，p<0.002）、高碳酸血症>45mmHg（比值比2.79，p<0.004）、肌酐清除率<50ml/分钟（比值比2.37，p<0.013）、NT-pro-B型利钠肽或B型利钠肽升高（比值比2.06，p<0.046）以及急性通气衰竭的临床体征（比值比1.98，p<0.047）是死亡的预测因素。
在老年ARF患者中，急诊科不恰当的初始治疗与死亡率增加相关。
