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序贯机械通气治疗慢性阻塞性肺疾病急性加重合并呼吸衰竭失败原因分析
武良权
杨健
仝春冉
余玉盛
张秀伟
作者及单位信息
·
DOI： 10.3760/cma.j.issn.1001-0939.2018.09.012
Analysis of factors associated with failure of sequential mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease complicated with respiratory failure
Wu Liangquan
Yang Jian
Tong Chunran
Yu Yusheng
Zhang Xiuwei
Authors Info & Affiliations
Wu Liangquan
Department of Pulmonary and Critical Care Medicine, Jiangning Hospital, Nanjing Medical University, Nanjing 211100, China
Yang Jian
Tong Chunran
Yu Yusheng
Zhang Xiuwei
·
DOI： 10.3760/cma.j.issn.1001-0939.2018.09.012
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摘要

目的回顾性分析慢性阻塞性肺疾病(慢阻肺)急性加重合并呼吸衰竭进行有创－无创序贯通气治疗患者的临床资料，探讨治疗失败的原因。

方法选择2013年1月1日至2017年9月30日南京医科大学呼吸ICU(RICU)收治的慢阻肺急性加重合并呼吸衰竭并进行有创－无创序贯通气治疗的患者64例，以7 d内再插管、死亡或自动出院为研究终点，比较成功组(43例)与失败组(21例)患者的入住RICU时的急性生理与慢性健康(APACHE)Ⅱ评分、慢阻肺ABCD分组、胸部CT中肺动脉干/升主动脉直径比值(肺/升比值)、N末端脑钠肽前体(NT－proBNP)、入住RICU及有创机械通气拔管时的PaCO 2、PaO 2、白细胞总数及降钙素原水平，分析两组之间各变量差异，并寻找差异变量的Cut－off值。

结果两组在单变量分析中入住RICU时的APACHE Ⅱ评分(成功组为23±4，失败组为27±6)、肺/升比值(成功组为0.88±0.09，失败组为1.03±0.10)、NT－proBNP、入住RICU时的白细胞总数及降钙素原水平差异均有统计学意义(均 P<0.05)。进一步多变量回归分析中，则只有入住RICU时的APACHE Ⅱ评分( P＝0.02)及肺/升比值( P＝0.012)差异有统计学意义。所有患者的肺/升比值的ROC曲线下面积为0.894，Cut－off值为0.98。

结论APACHE Ⅱ评分、CT中肺动脉干/升主动脉直径比值是慢阻肺急性加重合并呼吸衰竭患者进行有创－无创序贯通气治疗失败的独立危险因素，肺/升比值>0.98的患者失败率更高。

呼吸，人工;呼吸功能不全;肺疾病，阻塞性
ABSTRACT

ObjectiveBy retrospectively analyzing the clinical data of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated with respiratory failure, to find the associated factors for failure of invasive-noninvasive sequential ventilation therapy.

MethodsWe conducted a cohort study of 64 patients with AECOPD complicated with respiratory failure, who were treated by invasive-noninvasive sequential ventilation. We took re-intubation, death or spontaneous discharge within 7 days following extubation as the endpoints. By comparing the APACHE Ⅱ score at admission into RICU, the ABCD grouping for COPD, the ratio of the diameter of the pulmonary artery to the diameter of the ascending aorta in chest CT(PA: A ratio), the levels of NT-proBNP, PaCO 2, PaO 2, the total number of leukocytes and the level of procalcitonin, we analyzed the differences between the success group(43 cases) and the failure group(21 cases).

ResultsThe APACHE Ⅱ score at admission to RICU, the PA: A ratio, the level of NT-proBNP, the total leukocytes and the level of procalcitonin at admission to RICU showed significant differences in the univariate analysis( P<0.05). The average APACHE Ⅱ score was 23±4 in the success group and 27±6 in the failure group. The average PA: A ratio was 0.88±0.09 in the success group and 1.03±0.10 in the failure group. In the multivariate regression analysis, there were significant differences only in the APACHE Ⅱ score( P=0.02)and the PA: A ratio( P=0.012). The area under the ROC curve of the PA: A ratio for all patients was 0.894 and the cut-off value of the PA: A ratio was 0.98.

ConclusionThe APACHE Ⅱ score and the PA: A ratio in CT are independent risk factors for failure of sequential ventilation in AECOPD patients complicated with respiratory failure. In particular, patients with a PA: A ratio greater than 0.98 have a higher risk of treatment failure.

Respiration, artificial;Respiratory insufficiency;Lung disease, obstructive
Zhang Xiuwei, Email: mocdef.6ab21ywyiewuixgnahz
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引用本文

武良权,杨健,仝春冉,等. 序贯机械通气治疗慢性阻塞性肺疾病急性加重合并呼吸衰竭失败原因分析[J]. 中华结核和呼吸杂志,2018,41(9)：714-717.

DOI:10.3760/cma.j.issn.1001-0939.2018.09.012

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慢性阻塞性肺疾病(慢阻肺)是一个全球性的健康问题，有较高的住院率和病死率，每年有超过300万人死于慢阻肺，目前慢阻肺是全球第4位死因，2020年将可能成为第3位死因 [ 1 ]。慢阻肺急性加重是导致慢阻肺患者住院治疗的主要原因，而慢阻肺急性加重合并呼吸衰竭有较高的病死率 [ 2 ]。机械通气是治疗慢阻肺急性加重合并呼吸衰竭极其重要的一个环节 [ 3 ]。采用有创－无创机械通气序贯治疗慢阻肺急性加重合并呼吸衰竭在国内外已广泛应用，且多项研究结果证实这种方法可显著提高慢阻肺急性加重患者的撤机成功率，缩短住ICU的时间，降低院内感染率，增加患者存活率 [ 4 , 5 ]，但仍有一定的治疗失败率 [ 5 , 6 ]。目前针对有创－无创序贯治疗慢阻肺急性加重合并呼吸衰竭失败原因的研究仍较少，本研究通过回顾性分析南京医科大学附属江宁医院呼吸ICU(RICU)采用有创－无创机械通气序贯治疗慢阻肺急性加重合并呼吸衰竭的患者，从慢阻肺的疾病特征着手，分析导致治疗失败的因素，从而发现相关危险因素，以加强预防及管理，提高有创－无创序贯治疗慢阻肺急性加重成功率。
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张秀伟，Email： mocdef.6ab21ywyiewuixgnahz
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