重症肺炎患者中急性呼吸窘迫综合征高危患者的早期识别：一项回顾性队列研究
Early identification of patients at risk for acute respiratory distress syndrome among severe pneumonia: a retrospective cohort study.
作者信息
Luo Jian, Yu He, Hu Yue-Hong, Liu Dan, Wang Yi-Wei, Wang Mao-Yun, Liang Bin-Miao, Liang Zong-An
机构信息
Department of Respiratory Diseases, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China.
Department of Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China.
出版信息
J Thorac Dis. 2017 Oct;9(10):3979-3995. doi: 10.21037/jtd.2017.09.20.
BACKGROUND
Severe pneumonia is the predominant cause for acute respiratory distress syndrome (ARDS). Identification of ARDS from patients with severe pneumonia remains a significant clinical problem due to the overlap of clinical presentations and symptoms. Early recognition of risks for ARDS from severe pneumonia is of great clinical value.
METHODS
From April 2014 to December 2015, patients with severe pneumonia at admission were retrieved from the hospital database, of which ARDS developed within 7 days were further identified. We compared the demographic and clinical characteristics at admission between severe pneumonia patients with and without ARDS development, followed by analysis of potential predictors for ARDS development and mortality. Multivariate logistic regression and receiver operating characteristic (ROC) curves were performed to screen independent risk factors and identify their sensitivity in predicting ARDS development and prognosis.
RESULTS
Compared with severe pneumonia without ARDS development, patients with ARDS development had shorter disease duration before admission, higher lung injury score (LIS), serum fibrinogen (FiB), and positive end-expiratory pressure (PEEP), lower Marshall score, sequential organ failure assessment score and proportion of cardiovascular and gastrointestinal diseases, but similar mortality. Serum FiB >5.15 g/L [adjusted odds ratio (OR) 1.893, 95% confidence interval (CI): 1.141-3.142, P=0.014] and PEEP >6.5 cmHO (adjusted OR 1.651, 95% CI: 1.218-2.237, P=0.001) were independent predictors for ARDS development with a sensitivity of 58.3% and 87.5%, respectively, and pH <7.35 (adjusted OR 0.832, 95% CI: 0.702-0.985, P=0.033) was an independent risk factor for ARDS mortality with a sensitivity of 95.2%.
CONCLUSIONS
ARDS development risk could be early recognized by PEEP >6.5 cmHO and serum FiB >5.15 g/L in severe pneumonia patients, and pH <7.35 is a reliable prognostic factor in predicting ARDS mortality risk.
背景
重症肺炎是急性呼吸窘迫综合征（ARDS）的主要病因。由于临床表现和症状重叠，从重症肺炎患者中识别ARDS仍然是一个重大的临床问题。早期识别重症肺炎患者发生ARDS的风险具有重要的临床价值。
方法
2014年4月至2015年12月，从医院数据库中检索入院时患有重症肺炎的患者，进一步确定其中在7天内发生ARDS的患者。我们比较了发生ARDS和未发生ARDS的重症肺炎患者入院时的人口统计学和临床特征，随后分析了ARDS发生和死亡的潜在预测因素。进行多因素逻辑回归和受试者工作特征（ROC）曲线分析以筛选独立危险因素，并确定它们在预测ARDS发生和预后方面的敏感性。
结果
与未发生ARDS的重症肺炎患者相比，发生ARDS的患者入院前病程较短，肺损伤评分（LIS）、血清纤维蛋白原（FiB）和呼气末正压（PEEP）较高，马歇尔评分、序贯器官衰竭评估评分以及心血管和胃肠道疾病的比例较低，但死亡率相似。血清FiB>5.15 g/L[调整后的优势比（OR）1.893，95%置信区间（CI）：1.141-3.142，P=0.014]和PEEP>6.5 cmH₂O（调整后的OR 1.651，95%CI：1.218-2.237，P=0.001）是ARDS发生的独立预测因素，敏感性分别为58.3%和87.5%，pH<7.35（调整后的OR 0.832，95%CI：0.702-0.985，P=0.033）是ARDS死亡的独立危险因素，敏感性为95.2%。
结论
重症肺炎患者中，PEEP>6.5 cmH₂O和血清FiB>5.15 g/L可早期识别ARDS发生风险，pH<7.35是预测ARDS死亡风险的可靠预后因素。
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