COVID-19 患者在重症监护病房发生气胸的发生率和危险因素。
Incidence and risk factors for pneumomediastinum in COVID-19 patients in the intensive care unit.
机构信息
Thoracic Surgery Department, Bakırköy Dr. Sadi Konuk Research and Education Hospital, İstanbul, Turkey.
Anesthesiology and Reanimation Department, Bakırköy Dr. Sadi Konuk Research and Education Hospital, İstanbul, Turkey.
出版信息
Interact Cardiovasc Thorac Surg. 2022 Jan 18;34(2):236-244. doi: 10.1093/icvts/ivab258.
OBJECTIVES
The incidence of pneumomediastinum (PNMD), its causes of development and its effect on prognosis in the coronavirus disease 2019 (COVID-19) are not clear.
METHODS
Between March 2020 and December 2020, 427 patients with real-time reverse transcriptase-polymerase chain reaction-confirmed COVID-19 admitted to the intensive care unit were analysed retrospectively. Using receiver operating characteristic analysis, the area under the curve (AUC) for initial invasive mechanical ventilation (MV) variables such as initial peak inspiratory pressure (PIP), PaO2/FiO2 (P/F ratio), tidal volume, compliance and positive end-expiratory pressure was evaluated regarding PNMD development.
RESULTS
The incidence of PNMD was 5.6% (n = 24). PNMD development rate was 2.7% in non-invasive MV and 6.2% in MV [odds ratio (OR) 2.352, 95% confidence interval (CI) 0.541-10.232; P = 0.400]. In the multivariate analysis, the independent risk factors affecting the development of PNMD were PIP (OR 1.238, 95% CI 1.091-1.378; P < 0.001) and P/F ratio (OR 0.982, 95% CI 0.971-0.994; P = 0.004). P/F ratio (AUC 0.815, 95% CI 0.771-0.854), PIP (AUC 0.780, 95% CI 0.734-0.822), compliance (AUC 0.735, 95% CI 0.677-0.774) and positive end-expiratory pressure (AUC 0.718, 95% CI 0.668-0.764) were the best predictors for PNMD development. Regarding the multivariate analysis, independent risk factors affecting mortality were detected as age (OR 1.015, 95% CI 0.999-1.031; P = 0.04), comorbidity (OR 1.940, 95% CI 1.100-3.419; P = 0.02), mode of breathing (OR 48.345, 95% CI 14.666-159.360; P < 0.001), PNMD (OR 5.234, 95% CI 1.379-19.857; P = 0.01), positive end-expiratory pressure (OR 1.305, 95% CI 1.062-1.603; P = 0.01) and tidal volume (OR 0.995, 95% CI 0.992-0.998; P = 0.004).
CONCLUSIONS
PNMD development was associated with the initial P/F ratio and PIP. Therefore, it was considered to be related to both the patient and barotrauma. PNMD is a poor prognostic factor for COVID-19.
目的
新型冠状病毒病 2019（COVID-19）患者中，气胸（PNMD）的发生率、发生原因及其对预后的影响尚不清楚。
方法
回顾性分析 2020 年 3 月至 2020 年 12 月期间 427 例经实时逆转录-聚合酶链反应确诊的 COVID-19 患者。采用受试者工作特征曲线分析，评估初始有创机械通气（MV）变量如初始峰吸气压（PIP）、氧分压/吸入氧浓度（P/F 比值）、潮气量、顺应性和呼气末正压（PEEP）等对 PNMD 发展的曲线下面积（AUC）。
结果
PNMD 的发生率为 5.6%（n=24）。在无创 MV 中，PNMD 发生率为 2.7%，在有创 MV 中为 6.2%[比值比（OR）2.352，95%置信区间（CI）0.541-10.232；P=0.400]。多因素分析显示，影响 PNMD 发生的独立危险因素为 PIP（OR 1.238，95%CI 1.091-1.378；P<0.001）和 P/F 比值（OR 0.982，95%CI 0.971-0.994；P=0.004）。P/F 比值（AUC 0.815，95%CI 0.771-0.854）、PIP（AUC 0.780，95%CI 0.734-0.822）、顺应性（AUC 0.735，95%CI 0.677-0.774）和 PEEP（AUC 0.718，95%CI 0.668-0.764）是预测 PNMD 发生的最佳指标。多因素分析显示，影响死亡率的独立危险因素为年龄（OR 1.015，95%CI 0.999-1.031；P=0.04）、合并症（OR 1.940，95%CI 1.100-3.419；P=0.02）、呼吸模式（OR 48.345，95%CI 14.666-159.360；P<0.001）、PNMD（OR 5.234，95%CI 1.379-19.857；P=0.01）、PEEP（OR 1.305，95%CI 1.062-1.603；P=0.01）和潮气量（OR 0.995，95%CI 0.992-0.998；P=0.004）。
结论
PNMD 的发生与初始 P/F 比值和 PIP 相关。因此，PNMD 被认为与患者和气压伤均有关。PNMD 是 COVID-19 的一个不良预后因素。
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