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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) ›› 2024, Vol. 17 ›› Issue (03) : 363 -367. doi: 10.3877/cma.j.issn.1674-6902.2024.03.004

论著

体外膜肺氧合救治急性呼吸窘迫综合征不良预后危险因素分析
魏丁1, 乔艳艳2, 顾兴3, 张燕2, 李艳燕2, 钱卫生2, 潘蕾2, 高永恒2,†(), 金发光2,†()   
  1. 1. 710032　西安，空军军医大学唐都医院呼吸与危重症医学科；046002　长治，长治市人民医院呼吸与危重症医学科
    2. 710032　西安，空军军医大学唐都医院呼吸与危重症医学科
    3. 710061　西安，西安市胸科医院呼吸与危重症医学科
  • 收稿日期:2024-03-29 出版日期:2024-06-25
  • 通信作者: 高永恒, 金发光
  • 基金资助:
    陕西省重点产业创新链（群）-社会发展领域(2022ZDLSF01-10)

Risk factors of poor prognosis after extracorporeal membrane oxygenation in acute respiratory distress syndrome patients

Ding Wei1, Yanyan Qiao2, Xing Gu3, Yan Zhang2, Yanyan Li2, Weisheng Qian2, Lei Pan2, Yongheng Gao2,†(), Faguang Jin2,†()   

  1. 1. Department of Respiratory and Critical Care Medicine, The Tangdu Hospital of Military Medical University, PLA Air Force, Xi′an 710032, China; Department of Respiratory and Critical Care Medicine, Changzhi People′s Hospital, Changzhi 046002, China
    2. Department of Respiratory and Critical Care Medicine, The Tangdu Hospital of Military Medical University, PLA Air Force, Xi′an 710032, China
    3. Department of Respiratory and Critical Care Medicine, Xi′an Chest Hospital, Xi′an 710061, China
  • Received:2024-03-29 Published:2024-06-25
  • Corresponding author: Yongheng Gao, Faguang Jin
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魏丁, 乔艳艳, 顾兴, 张燕, 李艳燕, 钱卫生, 潘蕾, 高永恒, 金发光. 体外膜肺氧合救治急性呼吸窘迫综合征不良预后危险因素分析[J]. 中华肺部疾病杂志(电子版), 2024, 17(03): 363-367.

Ding Wei, Yanyan Qiao, Xing Gu, Yan Zhang, Yanyan Li, Weisheng Qian, Lei Pan, Yongheng Gao, Faguang Jin. Risk factors of poor prognosis after extracorporeal membrane oxygenation in acute respiratory distress syndrome patients[J]. Chinese Journal of Lung Diseases(Electronic Edition), 2024, 17(03): 363-367.

目的

分析体外膜肺氧合(extracorporeal membrane oxygenation, ECMO)辅助治疗急性呼吸窘迫综合征(acute respiratory distress syndrome, ARDS)预后不良的危险因素。

方法

选择2018年1月至2024年3月空军军医大学唐都医院呼吸与危重症团队管理诊断ARDS且接受ECMO救治的49例患者，收集临床资料，包括性别、年龄、平均动脉压、是否有基础疾病、呼气末正压通气(positive end-expiratory pressure, PEEP)、白细胞计数、血小板、肌酐、活化部分凝血活酶时间、丙氨酸氨基转移酶、C反应蛋白、白细胞介素-6(interleukin-6, IL-6)、降钙素原(procalcitonin, PCT)、ECMO上机时间、ECMO上机前气管插管时间、ARDS原发病、ARDS严重程度、ECMO相关并发症等参数，采用Logistic单因素及多因素回归分析ARDS患者ECMO救治中不良预后危险因素。

结果

ARDS生存者与死亡者相比，死亡者CRP升高[68.67 (40.82，113.92) vs. 19.78 (13.39，41.95)]，P<0.001，PCT升高[4.95 (2.44，7.31) vs. 1.57(0.23，3.97)]，P＝0.012，ECMO上机前气管插管时间延长[6(4，12) vs. 3(1，4)，P<0.001, ECMO相关并发症增多(32.7% vs. 14.3%)，P＝0.029。Logistic单因素回归分析显示，CRP(OR＝1.030，P＝0.003)、ECMO前气管插管天数(OR＝1.649，P＝0.005)及合并ECMO相关并发症(OR＝3.657，P＝0.033)与预后密切。Logistic多因素回归分析显示，ARDS基础疾病与ECMO救治中预后相关(OR＝5.128，95CI: 0.751～35.001)，P＝0.095。CRP、ECMO前气管插管时间及ECMO相关并发症与预后显著(OR＝1.043，95%CI：1.010～1.076，P＝0.01；OR＝1.691，95%CI：1.118～2.557，P＝0.013；OR＝9.482，95%CI：1.150～78.155，P＝0.037)。

结论

应用ECMO救治ARDS患者临床资料分析发现，CRP、ECMO前气管插管时间、ECMO并发症预测ARDS患者ECMO不良结局具有显著意义，早期识别和管理高危患者对提高生存率和救治成功率具有临床意义。

关键词: 急性呼吸窘迫综合征, 体外膜肺氧合, C反应蛋白, 降钙素原, 气管插管, 救治
Objective

To explore the risk factors of poor prognosis in patients with acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO) as an adjuvant therapy.

Method

Clinical data of 49 patients diagnosed with ARDS and treated with ECMO from the Respiratory and Critical Care Team of Tangdu Hosptial of Air Force Military Medical University, during January 2018 to March 2024 were collected, including gender, age, Mean arterial pressure, presence of underlying disease, PEEP(positive end-expiratory pressure), white blood cell count, platelets, creatinine, activated partial thromboplastin time, alanine aminotransferase, C-reactive protein, interleukin-6(IL-6), procalcitonin (PCT), ECMO on machine time (days), and tracheal intubation time before ECMO (days), Primary disease of ARDS, Severity of ARDS, Complications related to ECMO patients. Logistic univariate and multivariate regression analysis were used to screen the risk factors of poor prognosis in ARDS patients treated with ECMO.

Result

Compared with patients in the survival group, patients in the death group had higher CRP levels (68.67[40.82, 113.92] vs. 19.78[13.39, 41.95], P<0.001), higher PCT levels (4.95[2.44, 7.31] vs. 1.57[0.23, 3.97], P=0.012), longer tracheal intubation time before ECMO (6[4, 12] vs. 3[1, 4], P<0.001), and more patients with ECMO related complications (32.7% vs. 14.3%, P=0.029), with statistically significant differences. Logistic univariate regression analysis showed that CRP (OR=1.030, P=0.003), days of tracheal intubation before ECMO (OR=1.649, P=0.005), and comorbidities related to ECMO (OR=3.657, P=0.033) were closely related to mortality prognosis, and the differences were statistically significant. Logistic multiple regression analysis showed that patients with underlying diseases were associated with ECMO mortality prognosis (OR=5.128, 95CI: 0.751~35.001), but the difference was not statistically significant (P=0.095). CRP levels, pre ECMO tracheal intubation time, and ECMO related complications were significantly correlated with mortality prognosis (OR=1.043, 95%CI: 1.010-1.076), P=0.01; OR=1.691, 95%CI: 1.118~2.557, P=0.013; OR=9.482, 95%CI: 1.150~78.155, P=0.037).

Key words: Acute respiratory distress syndrome, Extracorporeal membrane oxygenation, C-reactive protein, Procalcitonin, Tracheal intubation, Bring a patient out of danger
表1 ARDS患者一般临床资料[n(%)，(±s)]
临床资料 生存者 死亡者 P值
例数 23 26  
原发病     0.852
急性肺栓塞 1(2.0) 2(4.1)  
重症肺炎(病毒感染) 14(28.6) 13(26.5)  
重症肺炎(真菌感染) 2(4.1) 2(4.1)  
重症肺炎(细菌感染) 9(18.4) 6(12.2)  
性别     0.765
女 8(16.3) 8(16.3)  
男 15(30.6) 18(36.7)  
年龄 48.87±20.125 55.077±17.657 0.256
基础疾病     0.070
无 12(24.5) 7(14.3)  
有 11(22.4) 19(38.8)  
上机时长(d) 5.348±3.601 7.875±7.811 0.817
PEEP(mH2O) 9.5652±2.9669 9.6923±2.6649 0.875
MAP(mmHg) 81.478±19.79 84.077±16.317 0.617
氧合指数(mmHg) 77.217±42.190 67.000±22.035 0.936
ARDS严重程度     0.550
中度 4(8.2) 2(4.1)  
重度 19(38.8) 24(49.0)  
乳酸(mmol/L) 4.661±2.674 7.013±4.556 0.341
APTT(s) 44.052±38.272 36.800±31.053 0.645
ALT(g/L) 653.652±1 491.963 97.125±1 169.296 0.748
肌酐(μmol/L) 140.757±135.268 90.163±45.129 0.711
CRP(mg/L) 34.478±31.564 94.959±58.754 0.000
IL-6(pg/ml) 42.454±37.891 99.693±144.283 0.378
PCT(μg/ml) 3.384±4.777 6.086±5.643 0.012
WBC(×109/L) 16.138±15.755 12.034±5.458 0.787
PLT(×109) 138.870±80.905 150.063±86.970 0.141
上机前插管时间(d) 3.000±2.132 9.625±8.077 0.000
并发症     0.029
无 16(32.7) 10(20.4)  
有 7(14.3) 16(32.7)  
表2 ARDS患者Logistic回归分析
临床资料及特征 例数 单因素分析 多因素分析
OR(95%CI) P值 OR(95%CI) P值
PEEP 49 1.017(0.829～1.247) 0.872    
MAP 49 1.008(0.977～ 1.041) 0.609    
氧合指数 49 0.992(0.969 ～1.014) 0.466    
乳酸 49 1.128(0.938 ～1.357) 0.201    
年龄 49 1.018(0.987～1.050) 0.251    
PCT 49 1.121(0.965 ～1.301) 0.134    
基础疾病 30 2.961(0.899～9.750) 0.074 5.128(0.751～35.001) 0.095
CRP 49 1.030(1.010～1.050) 0.003 1.043(1.010～1.076) 0.010
上机前插管时间(d) 49 1.649(1.162～2.339) 0.005 1.691(1.118～2.557) 0.013
并发症 23 3.657(1.114～12.006) 0.033 9.482(1.150～78.155) 0.037
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