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中华肺部疾病杂志(电子版)

中华肺部疾病杂志(电子版) ›› 2021, Vol. 14 ›› Issue (02) : 164 -168. doi: 10.3877/cma.j.issn.1674-6902.2021.02.006

论著

肺炎合并低氧血症患者进展为ARDS危险因素分析
刘士琛1, 王美菊1, 刘刚1, 刘双林1, 徐静1, 徐卿甲2, 于鸿2, 李琦,1   
  1. 1. 400037　重庆，陆军（第三）军医大学第二附属医院呼吸与危重症医学科·全军呼吸内科研究所
    2. 400038　重庆，陆军（第三）军医大学基础医学学院
  • 收稿日期:2020-10-11 出版日期:2021-04-25
  • 通信作者: 李琦

Study on the risk factors of ARDS in patients with pneumonia complicated with hypoxemia

Shichen Liu1, Meiju Wang1, Gang Liu1, Shuanglin Liu1, Jing Xu1, Qingjia Xu2, Hong Yu2, Qi Li,1   

  1. 1. Institute of Respiratory Diseases, Pulmonary and Critical Care Medicine, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
    2. College of Basic Medical Sciences, Army Medical University, Chongqing 400038, China
  • Received:2020-10-11 Published:2021-04-25
  • Corresponding author: Qi Li
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刘士琛, 王美菊, 刘刚, 刘双林, 徐静, 徐卿甲, 于鸿, 李琦. 肺炎合并低氧血症患者进展为ARDS危险因素分析[J/OL]. 中华肺部疾病杂志(电子版), 2021, 14(02): 164-168.

Shichen Liu, Meiju Wang, Gang Liu, Shuanglin Liu, Jing Xu, Qingjia Xu, Hong Yu, Qi Li. Study on the risk factors of ARDS in patients with pneumonia complicated with hypoxemia[J/OL]. Chinese Journal of Lung Diseases(Electronic Edition), 2021, 14(02): 164-168.

目的

探究肺炎合并低氧血症患者进展为ARDS的早期危险因素。

方法

回顾性病例对照研究，选取2016年1月1日至2019年12月30日陆军军医大学新桥医院收治的64例肺炎合并低氧血症患者作为研究对象，根据患者是否发展为ARDS分为ARDS病例组32例和对照组32例。收集两组患者发生肺炎合并低氧血症时的性别、年龄、合并症、手术、生命体征、实验室检查、急性生理学和慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、肺炎严重程度评分(PSI)、肺损伤预测评分(LIPS)等临床资料，采用单因素分析、二元Logistic回归方法，分析ARDS发生的早期危险因素。绘制受试者工作特征曲线(ROC)，评估各指标的预测价值。

结果

单因素分析显示：呼吸次数(Z＝-2.18，P＝0.03)、脉搏(Z＝-2.70，P＝0.01)、AST(Z＝-2.14，P＝0.03)、ALT(Z＝-1.96，P<0.05)、PaO2/FiO2(t＝-3.43，P＝0.00)、LIPS(Z＝-3.87，P＝0.00)，两组间差异有统计学意义(P<0.05)；多因素Logistic回归分析中LIPS评分(OR＝2.24，95%CI：1.32～3.81)、100 mmHg<PaO2/FiO2≤200 mmHg(OR＝6.55，95%CI: 1.40～30.68)、PaO2/FiO2≤100 mmHg(OR＝14.29，95%CI：1.05～194.41)为发生ARDS的独立危险因素；ROC曲线分析显示，LIPS、PaO2/FiO2均可预测肺炎合并低氧血症患者发生ARDS，LIPS的AUC为0.78(P<0.01)，阈值为4分，敏感度为72.0%，特异度为72.0%，阳性预测价值为72.0%；PaO2/FiO2的AUC为0.73(P<0.01)，阈值为182.90 mmHg，敏感度为59.0%，特异度为81.0%，阳性预测价值为67.0%。两者联合预测时，AUC为0.83(P<0.01)，敏感度为72.0%，特异度为81.0%。

结论

LIPS、PaO2/FiO2是肺炎合并低氧血症患者进展为ARDS的独立危险因素，LIPS≥4分、PaO2/FiO2≤182.90 mmHg患者发生ARDS的风险显著升高。两者联合预测ARDS发生的价值较单一指标更优。

关键词: 肺炎, 低氧血症, 急性呼吸窘迫综合征, 危险因素
Objective

To explore the early risk factors of ARDS in patients with pneumonia complicated with hypoxemia.

Methods

In a retrospective case-control study, 64 patients with pneumonia complicated with hypoxemia treated in Xin qiao Hospital of the third military Medical University from January 1, 2016 to December 30, 2019 were divided into ARDS case group 32 and control group 32 according to whether the patients developed into ARDS. The clinical data of sex, age, complications, surgery, vital signs, laboratory examination, acute physiology and chronic health score Ⅱ (APACHE Ⅱ), pneumonia severity score (PSI) and lung injury prediction score (LIPS) were collected from the two groups of patients with pneumonia complicated with hypoxemia. Univariate analysis and binary logistic regression were used to analyze the early risk factors of ARDS. Receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of each index.

Results

Univariate analysis showed: respiratory frequency (Z=-2.18, P=0.03), pulse (Z=-2.70, P=0.01), AST (Z=-2.14, P=0.03), ALT (Z=-1.96, P<0.05), PaO2/FiO2 (t=-3.43, P=0.00), LIPS(Z=-3.87, P=0.00), the difference between the two groups was statistically significant(P<0.05); in the multivariate logistic regression analysis, LIPS Score (OR=2.24, 95%CI: 1.32-3.81), 100 mmHg<PaO2/FiO2≤200 mmHg(OR=6.55, 95%CI: 1.40-30.68), and PaO2/FiO2≤100 mmHg(OR=14.29, 95%CI: 1.05-194.41) were independent risk factors for the occurrence of ARDS; ROC curve analysis showed that both LIPS and PaO2/FiO2 could predict the occurrence of ARDS in patients with pneumonia and hypoxemia. The AUC of LIPS was 0.78 (P<0.01), and the threshold was 4 points, the sensitivity was 72.0%, the specificity was 72.0%, and the positive predictive value was 72.0%; The AUC of PaO2/FiO2 was 0.73 (P<0.01), the threshold was 182.90 mmHg, the sensitivity was 59.0%, the specificity was 81.0%, and the positive predictive value was 67.0%. When the both were jointly predicted, the AUC was 0.83 (P<0.01), the sensitivity was 72.0%, and the specificity was 81.0%.

Conclusion

LIPS and PaO2/FiO2 were independent risk factors for the progression of ARDS in patients with pneumonia complicated with hypoxemia. Patients with LIPS≥4 points and PaO2/FiO2≤182.90 mmHg had a significantly higher risk of ARDS. The combined prediction of ARDS was better than a single index.

Key words: Pneumonia, Hypoxemia, Acute respiratory distress syndrome, Risk factors
表1 肺炎合并低氧血症患者发生ARDS危险因素单因素分析
临床资料 ARDS组(n＝32) 非ARDS组(n＝32) χ2/t/Z P值
CRP[mg/L, M(QL，QU)] 146.00(77.20，200.00) 119.35(23.45，186.40) -1.24 0.22
PCT[ng/ml, M(QL，QU)] 0.71(0.21，2.79) 0.71(0.20，1.19) -0.69 0.49
TD3[个/nl, M(QL，QU)] 404.00(222.00，628.00) 440.00(315.00，624.00) -1.02 0.31
TD4[个/nl, M(QL，QU)] 160.00(84.00，298.00) 198.00(127.00，337.00) -0.88 0.38
TD8[个/nl, M(QL，QU)] 156.00(102.00，284.00) 202.00(140.00，320.00) -1.32 0.19
CD4/CD8[M(QL，QU)] 1.00(0.80，1.10) 0.90(0.80，1.10) -0.3 0.76
Ur[mmol/L, M(QL，QU)] 8.97(5.88，11.77) 7.49(5.07，11.91) -0.39 0.70
SCr[μmol/L, M(QL，QU)] 75.25(65.03，101.20) 65.65(56.63，117.65) -1.03 0.30
ALB(g/L，±s) 29.18±4.81 30.28±5.51 -0.85 0.40
AST[IU/L, M(QL，QU)] 27.55(19.39，53.78) 46.70(30.98，75.08) -2.14 0.03
ALT[IU/L, M(QL，QU)] 19.95(11.80，41.70) 40.65(14.73，79.05) -1.96 0.05
TBil[μmol/L, M(QL，QU)] 13.15(9.30，22.68) 13.60(8.50，21.18) -0.21 0.84
PT[s, M(QL，QU)] 12.40(11.08，13.90) 12.50(11.63，13.88) -0.51 0.61
HBAlC[%, M(QL，QU)] 6.00(5.50，7.20) 6.00(5.53，6.68) -0.15 0.88
血糖[mmol/L, M(QL，QU)] 5.00(4.22，7.49) 5.86(4.74，8.94) -1.63 0.10
pH值(±s) 7.43±0.06 7.44±0.06 -1.3 0.20
Lac[mmol/L, M(QL，QU)] 1.90(1.23，2.78) 1.60(1.20，2.18) -1.43 0.15
Ca2+[mmol/L, M(QL，QU)] 1.12(1.03，1.16) 1.11(1.05，1.15) -0.03 0.97
PaO2/FiO2(mmHg，±s) 151.82±44.01 189.10±43.04 -3.43 0.00
APACHE Ⅱ(分，±s) 13.34±4.82 12.41±4.63 0.79 0.43
LIPS[分，M(QL，QU)] 4.75(3.50，5.50) 3.50(2.50，4.50) -3.87 0.00
PSI(分，±s) 113.69±31.9 112.59±28.69 0.14 0.89
表2 肺炎合并低氧血症患者发生ARDS危险因素Logistic回归分析
指　标 OR值 95%CI P值
100 mmHg<PaO2/FiO2≤200 mmHg 6.55 1.40～30.68 0.02
PaO2/FiO2≤100 mmHg 14.29 1.05～194.41 <0.05(0.046)
LIPS 2.24 1.32～3.81 0.00
图1 PaO2/FiO2及LIPS对肺炎合并低氧血症患者发生ARDS受试者工作特征曲线(ROC)；注：A：PaO2/FiO2预测；B：LIPS预测；C：PaO2/FiO2和LIPS联合预测
表3 PaO2/FiO2和LIPS对肺炎合并低氧血症患者发生ARDS的预测价值
指　标 AUC 95%CI P值 阈值 敏感度 特异度 阳性预测值 阴性预测值
PaO2/FiO2 0.73 0.60～0.85 0.00 182.90 0.59 0.81 0.67 0.76
LIPS 0.78 0.66～0.89 0.00 4.00 0.72 0.72 0.72 0.72
两者联合 0.83 0.73～0.93 0.00 - 0.72 0.81 - -
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