作者：徐汉瑾1，杨英1，张文华1，李婷2，张刘杰1

单位：

1.710043 陕西省西安市，陕西省第四人民医院重症医学科　2.710043 陕西省西安市，陕西省第四人民医院超声科

Units：

1.Department of Critical Care Medicine, the Fourth People's Hospital of Shaanxi, Xi'an 710043, China 2.Department of Ultrasound, the Fourth People's Hospital of Shaanxi, Xi'an 710043, China

关键词：

急性呼吸窘迫综合征；正压通气；死亡率；影响因素分析

Keywords：

Acute respiratory distress syndrome; Positive-pressure ventilations; Mortality; Root cause analysis

CLC：

R 563.8

DOI：

10.12114/j.issn.1008-5971.2021.00.149

Funds：

摘要：

　背景　无创正压通气作为急性呼吸窘迫综合征（ARDS）的重要治疗方法已得到临床认可，但正压通 气时间多依据临床经验，缺乏统一标准。目的　探讨正压通气时间对ARDS 患者死亡率的影响。方法　选择2014 年1 月—2018 年3 月于陕西省第四人民医院接受治疗的ARDS 患者105 例，根据患者病情转归情况将其分为存活组（n=60） 和死亡组（n=45）。收集患者临床资料，包括：性别、年龄、病因，转入ICU 时急性生理学及慢性健康状况评分系统 Ⅱ（APACHE Ⅱ）评分、序贯器官衰竭估计（SOFA）评分、潮气量（VT）、氧合指数、降钙素原（PCT）、血糖、 高血压发生情况、血管紧张素Ⅱ（Ang Ⅱ）、C 反应蛋白、脓毒症严重程度，抗凝剂使用情况、血管活性药物使用情 况、机械通气时间、正压通气时间、人工气道开放时间、入住ICU 时间、总住院时间。ARDS 患者预后影响因素分析 采用单因素、多因素Logistic 回归分析。采用ROC 曲线确定正压通气时间预测ARDS 患者死亡的最佳截断值。采用生 存曲线分析不同正压通气时间ARDS 患者的死亡率。结果　存活组年龄、病因为肺源性ARDS（ARD-Sp）者所占比例、 APACHE Ⅱ评分、SOFA 评分、PCT、Ang Ⅱ、使用血管活性药物者所占比例低于死亡组，使用抗凝剂者所占比例高于 死亡组，正压通气时间短于死亡组，入住ICU 时间、总住院时间长于死亡组（P ＜ 0.05）。多因素Logistic 回归分析 结果显示，年龄〔OR=1.36，95%CI（1.12，1.65）〕、APACHE Ⅱ评分〔OR=2.95，95%CI（1.78，4.89）〕、SOFA 评分〔OR=1.95，95%CI（1.04，3.66）〕、PCT〔OR=2.02，95%CI（1.33，3.07）〕、AngⅡ〔OR=2.75，95%CI（1.44，5.25）〕、 正压通气时间〔OR=1.52，95%CI（1.34，1.72）〕、入住ICU 时间〔OR=0.53，95%CI（0.32，0.88）〕、总住院时间 〔OR=0.76，95%CI（0.60，0.96）〕是ARDS 患者预后的独立影响因素（P ＜ 0.05）。ROC 曲线分析结果显示，正压 通气时间预测ARDS 患者死亡的AUC 为0.76〔95%CI（0.56，0.83）〕，最佳截断值为13.0 d。所有ARDS 患者中， 正压通气时间≤ 13.0 d 的有58 例，＞ 13.0 d 的有47 例。正压通气时间≤ 13.0 d 的ARDS 患者死亡率低于正压通气时 间＞ 13.0 d 的ARDS 患者（P ＜ 0.05）。结论　正压通气时间是ARDS 患者死亡率的独立影响因素，其对ARDS 患者 死亡率有一定预测价值，且正压通气时间控制在13 d 内更有利于患者预后。

Abstract：

Background　Noninvasive positive pressure ventilation as an important treatment for acute respiratory distress syndrome (ARDS) has been clinically recognized, but positive pressure ventilation time is based on clinical experience, and there is no uniform standard. Objective　To investigate the effect of positive pressure ventilation time on mortality in patients with ARDS. Methods　One hundred and five patients with ARDS who were treated in the Fourth People's Hospital of Shaanxi from January 2014 to March 2018 were selected and divided into survival group (n=60) and death group (n=45) according to the prognosis of the patients. The clinical data were collected, including gender, age, etiology, Acute Physiology and Chronic Health Evaluation Scoring System Ⅱ (APACHE Ⅱ ) score, sequential organ failure assessment (SOFA) score, tidal volume (VT) ,oxygenation index, procalcitonin (PCT) , blood glucose, incidence of hypertension, angiotensin Ⅱ (Ang Ⅱ ) , C-reactive protein and sepsis severity, anticoagulant use, vasoactive drugs use, mechanical ventilation time, positive pressure ventilation time, artificial airway opening time, ICU stay and total hospital stay. The factors affecting the prognosis of ARDS patients were analyzed by univariate and multivariate Logistic regression analysis. ROC curve was used to definite the best cut-off value of positive pressure ventilation time in predicting death of ARDS patients. Survival curve was used to analyze the mortality of ARDS patients with different positive pressure ventilation time. Results　In the survival group, the age, the proportion of patients with pulmonary acute respiratory distress syndrome (ARD-Sp) , APACHE Ⅱ score, SOFA score, PCT, Ang Ⅱ , the proportion of patients using vasoactive drugs were lower than those in the death group, the proportion of patients using anticoagulants was higher than that in the death group, the positive pressure ventilation time was shorter than that in the death group, and the ICU stay and total hospital stay were longer than those in the death group (P < 0.05) . Multivariate Logistic regression analysis showed that age [OR=1.36, 95%CI (1.12, 1.65) ] , APACHE Ⅱ score [OR=2.95, 95%CI (1.78, 4.89) ] , SOFA score [OR=1.95, 95%CI (1.04, 3.66) ] , PCT [OR=2.02, 95%CI (1.33, 3.07) ] , Ang Ⅱ [OR=2.75, 95%CI (1.44, 5.25) ] , positive pressure ventilation time [OR=1.52, 95%CI (1.34, 1.72) ] , ICU stay [OR=0.53, 95%CI (0.32, 0.88) ] and total hospital stay [OR=0.76, 95%CI (0.60, 0.96) ] were independent influencing factors for the prognosis of ARDS patients (P < 0.05) . ROC curve analysis showed that AUC of positive pressure ventilation time in predicting death of ARDS patients was 0.76 [95%CI (0.56, 0.83) ] , and the best cut-off value was 13.0 d. Among all ARDS patients, 58 cases had positive pressure ventilation time ≤ 13.0 d, and 47 cases had positive pressure ventilation time ≤ 13.0 d. The mortality of ARDS patients with positive pressure ventilation time ≤ 13.0 d was lower than that of ARDS patients with positive pressure ventilation time > 13.0 d (P < 0.05) . Conclusion　Positive pressure ventilation time is an independent influencing factor of the mortality of ARDS patients, and it has a certain predictive value for the mortality of ARDS patients, and positive pressure ventilation time which controlled within 13 d is more conducive to the prognosis of patients.

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