摘要
目的探讨急性呼吸窘迫综合征（ARDS）患者机械通气（MV）不同时间点氧合指数对预后的评估价值。方法采用回顾性分析方法，选择2014年2月至2016年6月中国医科大学附属第一医院急诊科收治的228例ARDS患者。所有患者均进行MV治疗，在实施保护性通气策略30min后采用压力控制通气（PCV）实施肺复张（RM）。于MV即刻、RM后及MV6、12、24h进行动脉血气分析，计算氧合指数，并收集患者生命体征、实验室数据、超声心动图、序贯器官衰竭评分（SOFA）、MV时间及呼吸机相关参数等指标。将患者按28d预后分为存活组和死亡组，其中存活患者再分为高水平和低水平氧合指数组（氧合指数分别为≥150mmHg和〈150mmHg，1mmHg=0．133kPa）。比较存活租和死亡组各项临床指标的差异；RM后氧合指数与MV各时间点氧合指数的相关性采用双变量相关分析；绘制受试者工作特征曲线（ROC），评估各时间点氧合指数对ARDS患者28d预后的预测价值。结果228例患者28d内死亡99例，存活129例，病死率43．4％。①存活组和死亡组患者RM后及MV6、12、24h氧合指数均呈持续升高趋势，且死亡组显著低于存活组（均P〈0．05）。MV即刻及RM后高水平与低水平氧合指数组间MV时间无明显差异；而MV6、12、24h高水平氧合指数组MV时间明显短于低水平氧合指数组（均P〈0．01）。②MV24h死亡组血肌酐（SCr）、脑钠肽（BNP）、血乳酸（Lac）、右室内径、SOFA评分显著高于存活组，动脉血氧分压（PaO2）、血小板计数（PLT）、右室射血分数（RVEF）显著低于存活组（均P〈0．05）。③MV24h死亡组呼气末正压（PEEP）、潮气量（VT）、分钟通气量（VE）均显著高于存活组，肺动态顺应性（Cdyn）显著低于存活组（均P〈0．01）。④相关性分析显示，RM后氧合指数与MV6、12、24h氧合指数均呈显著正相关（r值分别为0．856、0．765、0．758，均P〈0．001）。⑤ROC曲线显示，RM后氧合指数预测28d预后的ROC曲线下面积（AUC）为0．688，当截断值为80．75mmHg时，敏感度为97．7％，特异度为42．4％，仅可用于初步判定预后；而MV6、12、24h氧合指数的AUC分别为0．719、0．727、0．754，当截断值为171．50、192．14、161．75mmHg时，敏感度分别为69．8％、67．4％、86．0％，特异度分别为78．8％、78．8％、63．6％，提示对ARDS患者28d预后预测价值均较高，但各时间点问差异无统计学意义。结论早期RM后氧合指数能初步判定患者预后；而MV后的氧合指数对ARDS患者28d预后有较好的预测价值，可以考虑用MV6h测得的氧合指数来评估患者的预后。
Objective To investigate the evaluation value of oxygenation index at different times of mechanical ventilation （MV） on the prognosis of patients with acute respiratory distress syndrome （ARDS）. Methods A retrospectively analysis was conducted. A total of 228 patients with ARDS admitted to Department of Emergency of China Medical University Affiliated First Hospital from February 2014 to June 2016 were enrolled. All patients underwent MV treatment, and recruitment maneuver （RM） was performed by pressure-controlled ventilation （PCV） 30 minutes after the implementation of the protective ventilation strategy. Arterial blood gas analysis was performed at MV immediately, after RM and at 6, 12, 24 hours of MV, and oxygenation index was calculated. Vital signs, laboratory data, ultrasonic echoeardiography, sequential organ failure assessment （SOFA） score, duration of MV, and ventilator related parameters of patients were collected. The patients were divided into survivors and non-survivors according to the prognosis of 28 days. The survivors were subdivided into high and low oxygenation group （oxygenation index was ≥ 150 mmHg and 〈 150 mmHg, respectively, 1 mmHg = 0.133 kPa）. Differences in clinical indicators between survivors and non-survivors were compared. The correlation between the oxygenation index after RM and the oxygenation index at each time after MV was analyzed by bivariate correlation analysis. Receiver operating characteristic （ROC） curve was plotted to analyze predictive value of oxygenation index measured at different times for the 28-day outcome of patients with ARDS. Results Among 228 patients, 99 patients died within 28 days, and 129 survived, with mortality rate of 43.4%. （1） The oxygenation index after RM and at 6, 12, 24 hours after MV in survivors and non-survivors showed a continuously increased tendency, which was significantly lower in non-survivors than that in survivors （all P 〈 0.05）. There was no significant difference in the duration of MV between high oxygenation group and low oxygenation group at MV immediately and after RM, but the duration of MV in high oxygenation group was significantly shorter than that of the low oxygenation group at 6, 12, 24 hour of MV （all P 〈 0.01）. （2） After ventilation for 24 hours, serum creatinine （SCr）, brain natriuretic peptide （BNP）, lactate （Lae）, right ventricular internal diameter, and SOFA score in non-survivors were significantly higher than those of survivors, and arterial partial pressure of oxygen （PaO2）, platelet （PLT） and right ventrieular ejection fraction （RVEF） were significantly lower than those of survivors （all P 〈 0.05）. （3） After 24 hours ventilation, positive end-expiratory pressure （PEEP）, tidal volume （VT）, and minute ventilation （VE） in non-survivors were significantly higher than those of survivors, and static compliance of thorax （Cdyn） was significantly lower than that of survivors （all P 〈 0.01）.（4） It was shown by correlation analysis that the oxygenation index after RM was positively correlated with those at 6, 12, 24 hours of MV （r values were 0.856, 0.765, and 0.758, respectively, all P 〈 0.001）. （~） It was shown by ROC curve that the area under the ROC curve （AUC） of the oxygenation index after RM for predicting 28-day prognosis was 0.688. When the cut-off value was 80.75 mmHg, the sensitivity was 97.7%, and the specificity was 42.4%, which could only be used for preliminary judgment of prognosis. The AUC of oxygenation index at 6, 12, 24 hours of MV for 28-day survival of ARDS patients were 0.719, 0.727, 0.754, respectively. When the cut-off values were 171.50, 192.14, and 161.75 mmHg, the sensitivity was 69.8%, 67.4%, 86.0%, and the specificity was 78.8%, 78.8%, and 63.6%, respectively. It indicated that the predictive value was higher, and no significant difference was found among the oxygenation index at different time points. Coneluslons The oxygenation index after the early stage of RM can preliminarily determine the prognosis of patients. The predictive value of oxygenation index after MV for 28-day survival of ARDS patients was higher, so the oxygenation index measured at 6 hours of MV may be considfred to evaluate the prognosis of patients with ARDS.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2017年第1期45-50,共6页
Chinese Critical Care Medicine
基金
辽宁省沈阳市科技计划项目（F16-206-9-02）
国家临床重点专科建设项目（2013-544）
关键词
急性呼吸窘迫综合征
机械通气
肺复张
氧合指数
预后
Acute respiratory distress syndrome
Mechanical ventilation
Recruitment maneuver
Oxygenation index
Prognosis
