切换至 "中华医学电子期刊资源库"
高级检索
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 Li1,†()   

  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
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

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]. 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]. 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 - -
1
Ary SN, Carmen SVB, Fabienne DS, et al. Epidemiological characteristics，practice of ventilation, and clinical outcome in patients at risk of acute respiratory distress syndrome in intensive care units from 16 countries (PRoVENT): an international, multicentre, prospective study[J]. Lancet Respir Med, 2016, 4(11): 882-893.
2
Andrés E, Fernando FV, Alfonso M, et al. Evolution of mortality over time in patients receiving mechanical ventilation[J]. Am J Respir Crit Care Med, 2013, 188(2): 220-230.
3
Elisabeth DR, Willy K, Theogene T, et al. Hospital incidence and outcomes of the acute respiratory distress syndrome using the Kigali modification of the Berlin definition[J]. Am J Respir Crit Care Med, 2016, 193(1): 52-59.
4
Giacomo B, John GL, Tài P, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries[J]. JAMA, 2016, 315(8): 788-800.
5
Michael AM, Rachel LZ, Guy AZ, et al. Acute respiratory distress syndrome[J]. Nat Rev Dis Primers, 2019, 5(1): 18.
6
Frat J, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure[J]. N Engl J Med, 2015, 372(23): 2185-2196.
7
Andrew JB, Fabiana M, John GL, et al. Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database[J]. Crit Care, 2018, 22(1): 268.
8
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin Definition[J]. JAMA, 2012, 307(23): 2526-2533.
9
Pablo CF, José AL, Aída BB, et al. Acute respiratory distress syndrome and diffuse alveolar damage. New insights on a complex relationship[J]. Ann Am Thorac Soc, 2017, 14(6): 844-850.
10
Kenneth TH, Mary BB. Pulmonary Manifestations of acute lung injury：More than just diffuse alveolar damage[J]. Arch Pathol Lab Med, 2017, 141(7): 916-922.
11
Trillo-Alvarez C, Cartin-Ceba R, Kor DJ, et al. Acute lung injury prediction score: derivation and validation in a population-based sample[J]. Eur Respir J, 2011, 37(3): 604-609.
12
Ognjen G, Ousama D, Pauline KP, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study[J]. Am J Respir Crit Care Med, 2011, 183(4): 462-470.
13
Soto GJ, Kor DJ, Park PK, et al. Lung injury prediction score in hospitalized patients at risk of acute respiratory distress syndrome[J]. Crit Care Med, 2016, 44(12): 2182-2191.
14
Ahmed ME, Hamed G, Fawzy S, et al. Lung injury prediction scores：Clinical validation and C-reactive protein involvement in high risk patients[J]. Med Intensiva, 2020, 44(5): 267-274.
15
Xu Z, Wu GM, Li Q, et al. Predictive value of combined LIPS and ANG-2 level in critically Ⅲ patients with ARDS risk factors[J]. Mediators Inflamm, 2018, 2018: 1739615.
16
Graeme R, Deborah C, Peter S, et al. Clinician predictions of intensive care unit mortality[J]. Crit Care Med, 2004, 32(5): 1149-1154.
[1] 李振翮, 魏长青, 甄国栋, 李振富. 脓毒症并发急性呼吸窘迫综合征患者血清S1P、Wnt5a变化及其临床意义[J]. 中华危重症医学杂志(电子版), 2024, 17(04): 293-300.
[2] 张烈, 严一核, 杜洁瑜. 分泌型白细胞蛋白酶抑制因子对无创呼吸机治疗重症肺炎患者的预测效能[J]. 中华危重症医学杂志(电子版), 2024, 17(04): 301-306.
[3] 张锦丽, 席毛毛, 褚志刚, 栾夏刚, 陈诺, 王德运, 谢卫国. 大面积烧伤患者发生早期急性肾损伤的危险因素分析[J]. 中华损伤与修复杂志(电子版), 2024, 19(04): 282-287.
[4] 李世杰, 申传安. 烧伤合并吸入性损伤患者呼吸机相关肺炎的研究现状[J]. 中华损伤与修复杂志(电子版), 2024, 19(04): 351-355.
[5] 罗文斌, 韩玮. 胰腺癌患者首次化疗后中重度骨髓抑制的相关危险因素分析及预测模型构建[J]. 中华普通外科学文献(电子版), 2024, 18(05): 357-362.
[6] 贺斌, 马晋峰. 胃癌脾门淋巴结转移危险因素[J]. 中华普外科手术学杂志(电子版), 2024, 18(06): 694-699.
[7] 黄俊龙, 刘柏隆, 罗瑞翔, 李晓阳, 李文双, 柳政, 陈嘉良, 周祥福. 联合盆底彩超数据和临床资料探讨压力性尿失禁的危险因素[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 323-330.
[8] 江杰, 沈城, 潘永昇, 陈新风, 刘振民, 朱华, 郑兵. 尿酸结石的危险因素分析及双能量CT特征研究[J]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(04): 361-365.
[9] 周劲鸿, 王鉴杰, 谢肖俊. 腹腔镜经腹腹膜前疝修补术后尿潴留发生率及危险因素分析[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(04): 390-395.
[10] 陈钊, 钟克力, 江志鹏, 傅宇翔, 范宝航, 吴文飞. 前列腺癌术后腹股沟疝的发生率及危险因素分析[J]. 中华疝和腹壁外科杂志(电子版), 2024, 18(04): 396-401.
[11] 燕红玲, 王岩岩, 陈树斌. PCT、NLR联合LUBS预测ICU CRKP致呼吸机相关肺炎撤机及预后分析[J]. 中华肺部疾病杂志(电子版), 2024, 17(04): 617-620.
[12] 张怡, 王宇洋, 司梦娇, 曹燕, 李欢欢. 脑卒中前白蛋白与肺炎发生风险相关性分析[J]. 中华肺部疾病杂志(电子版), 2024, 17(04): 648-651.
[13] 白若靖, 郭军. 维生素D对肺部疾病临床意义的研究进展[J]. 中华肺部疾病杂志(电子版), 2024, 17(04): 659-662.
[14] 冀旭, 朱峰, 冯业晨. 保留器官功能的胰腺切除术后胆道并发症发生危险因素分析[J]. 中华肝脏外科手术学电子杂志, 2024, 13(04): 509-514.
[15] 段伟, 刘飞, 许光源, 程宇豪, 陈星. 食管癌调强放疗计划剂量学参数差异对放射性肺炎发生及严重程度的影响[J]. 中华消化病与影像杂志(电子版), 2024, 14(04): 320-324.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号