作者：陈伟1，2 ，宋立强 2

单位：

1.716000 陕西省延安市中医医院呼吸科；2.710032 陕西省西安市，空军军医大学西京医院呼吸与危重症医学科；通信作者：宋立强，E-mail：songlq@fmmu.edu.cn

Units：

1.Department of Respiratory，Yan'an Traditional Chinese Medicine Hospital，Yan'an 716000，China；2.Department of Respiratory and Critical Care Medicine，Xijing Hospital of Air Force Military Medical University，Xi'an710032，China；Corresponding author：SONG Liqiang，E-mail：songlq@fmmu.edu.cn

关键词：

急性呼吸窘迫综合征；肺炎；预后；影响因素分析；预测

Keywords：

Acute respiratory distress syndrome；Pneumonia；Prognosis；Root cause analysis；Forecasting

CLC：

R 563.8

DOI：

DOI：10.3969/j.issn.1008-5971.2020.01.006

Funds：

国家自然科学基金面上项目（81570072）；陕西省社会发展科技攻关项目（2016SF-096）

摘要：

背景　急性呼吸窘迫综合征（ARDS）患者病死率约为 40%，而寻找精准评价、预测 ARDS 患者预后的临床标志物对改善患者预后具有重要意义。目的　探讨肺源性 ARDS 患者预后的影响因素。方法　选取 2017 年 3月—2019 年 3 月空军军医大学西京医院呼吸与危重医学科收治的肺源性 ARDS 患者 167 例，根据其预后分为生存组72 例和死亡组 95 例。比较两组患者临床资料、实验室检查指标，肺源性 ARDS 患者预后的影响因素分析采用多因素Logistic 回归分析；绘制受试者工作特征（ROC）曲线以评价氧合指数（OI）、活化部分凝血活酶时间（APTT）对肺源性 ARDS 患者预后的预测价值。结果　（1）两组患者年龄、男性比例、体质指数（BMI）、吸烟史、手术史、高血压病史、脓毒症病史、其他疾病病史及哮喘 - 慢性阻塞性肺疾病重叠综合征（ACOS）发生率比较，差异无统计学意义（P>0.05）；死亡组患者中有冠心病病史者所占比例、支气管哮喘发生率低于生存组，慢性阻塞性肺疾病（COPD）发生率、急性生理学与慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分高于生存组，住院时间长于生存组，住院花费多于生存组（P<0.05）。（2）两组患者白介素 6（IL-6）、乳酸、心肌肌钙蛋白 I（cTnI）及凝血酶原时间（PT）比较，差异无统计学意义（P>0.05）；死亡组患者肿瘤坏死因子 α（TNF-α）、C 反应蛋白（CRP）、降钙素原（PCT）、血肌酐（Scr）、脑钠肽前体（proBNP）、心肌肌钙蛋白 T（cTnT）高于生存组，OI 低于生存组，APTT 长于生存组（P<0.05）。（3）多因素 Logistic 回归分析结果显示，OI 是 ARDS 患者预后的保护因素〔OR=0.246，95%CI（0.015，4.368）〕，APTT 是肺源性 ARDS 患者预后的危险因素〔OR=2.979，95%CI（1.406，6.311）〕。（4）ROC 曲线显示，OI 预测肺源性 ARDS 患者预后的曲线下面积为 0.732〔95%CI（0.647，0.816）〕，最佳临界值为 179.85 mm Hg，灵敏度为 61.5%，特异度为 73.5%；APTT 预测肺源性 ARDS 患者预后的曲线下面积为 0.855〔95%CI（0.793，0.916）〕，最佳临界值为 61.79 s，灵敏度为 70.9%，特异度为 87.2%。结论　OI、APTT 是肺源性 ARDS 患者预后的独立影响因素，OI<179.85 mm Hg、APTT>61.79 s 的肺源性 ARDS 患者死亡风险较高。

Abstract：

Background　Fatality rate of acute respiratory distress syndrome（ARDS）is about 40%，thus it is ofgreat significance to find clinical markers to accurately evaluate and predict the prognosis in patients with ARDS. ObjectiveTo explore the influencing factors of prognosis in patients with pulmonary ARDS. Methods　From March 2017 to March 2019，a total of 167 patients with pulmonary ARDS were selected in the Department of Respiratory and Critical Care Medicine，Xijing Hospital of Air Force Military Medical University，and they were divided into survival group（n=72）and death group（n=95）according to their prognosis. Clinical data and laboratory examination results were compared between the two groups，and influencing factors of prognosis in patients with pulmonary ARDS were analyzed by multivariate Logistic regression analysis，moreover ROC curve was drawn to evaluate the predictive value of OI and APTT on prognosis in patients with pulmonary ARDS.Results　（1）There was no statistically significant difference in age，male proportion，BMI，operation history，smokinghistory，hypertension history，sepsis history，other disease history or incidence of ACOS between the two groups（P>0.05）；proportion of patients with CHD history and incidence of bronchial asthma in death group were statistically significantly lowerthan those in survival group，incidence of COPD and APACHE Ⅱ score in death group were statistically significantly higherthan those in survival group，hospital stays in death group was statistically significantly longer than that in the survival group，Hospitalization cost in death group was statistically significantly higher than that in survival group（P<0.05）.（2）There wasno statistically significant difference in IL-6，lactic acid，cTnI or PT between the two groups（P>0.05）；TNF-α，CRP，PCT，Scr，proBNP and cTnT in death group were statistically significantly higher than those in survival group，OI in deathgroup was statistically significantly lower than that in survival group，APTT in death group was statistically significantly longerthan that in survival group（P<0.05）.（3）Multivariate Logistic regression analysis results showed that，OI was the protectivefactor of prognosis in patients with pulmonary ARDS〔OR=0.246，95%CI（0.015，4.368）〕，while APTT was the riskfactor of prognosis in patients with pulmonary ARDS〔OR=2.979，95%CI（1.406，6.311）〕.（4）ROC curve showed that，AUC，the optimum critical value，sensitivity and specificity of IO in predicting prognosis in patients with pulmonary ARDS was0.732〔95%CI（0.647，0.816）〕，179.85 mm Hg，61.5% and 73.5%，respectively；AUC，the optimum critical value，sensitivity and specificity of APTT in predicting prognosis in patients with pulmonary ARDS was 0.855〔95%CI （0.793，0.916）〕，61.79 s，70.9% and 87.2%，respectively. Conclusion　OI and APTT are independent influencing factors of prognosis in patientswith pulmonary ARDS，risk of death is relatively high in pulmonary ARDS patients with OI<179.85 mm Hg or APTT> 61.79 s.

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