中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
7期
595-600
,共6页
郭凤英%徐思成%刘光明%王秀岩
郭鳳英%徐思成%劉光明%王秀巖
곽봉영%서사성%류광명%왕수암
高龄%社区获得性肺炎%气管内插管%机械通气%无创通气%预后
高齡%社區穫得性肺炎%氣管內插管%機械通氣%無創通氣%預後
고령%사구획득성폐염%기관내삽관%궤계통기%무창통기%예후
Advanced-age%Community-acquired pneumonia%Endotracheal intubation%Mechanical ventilation%Noninvasive ventilation%Prognosis
目的：探讨有创-无创序贯性机械通气（MV）对高龄重症社区获得性肺炎（CAP）患者的疗效及预后因素。方法采用前瞻性研究方法，选择2012年11月至2014年7月入住新疆医科大学第一附属医院呼吸危重症医学科（RICU）年龄≥75岁的高龄重症CAP患者，患者符合CAP和重症CAP的诊断标准，首诊于急诊科，需要入RICU实行MV且无无创通气（NIV）绝对禁忌证。患者均拒绝气管切开计划，经气管内插管（ETI）MV后，按随机数字表法分为有创-无创序贯性通气组（序贯性通气组）和常规通气组。序贯性通气组达到早期拔管指征时拔除ETI，改为NIV；而常规通气组达到传统拔管指征时改为Venturi面罩氧疗（5 L/min）。记录两组患者基线资料与临床特征；采用多因素logistic回归分析预测死亡危险因素；Kaplan-Meier生存曲线分析患者60 d生存率。结果有91例高龄重症CAP患者纳入研究，60 d死亡28例，病死率为30.77%。序贯性通气组（44例）和常规通气组（47例）60 d病死率差异无统计学意义〔25.0%（11/44）比36.2%（17/47），χ2＝1.331，P＝0.249〕，但序贯性通气组呼吸机相关性肺炎（VAP）发生率较低〔27.3%（12/44）比55.3%（26/47），χ2＝7.350，P＝0.007〕，ETI次数≥2次的患者比例较大〔59.1%（26/44）比29.8%（14/47），χ2＝5.095， P＝0.024〕。与存活组比较，死亡组伴脑血管疾病比例大（60.7%比25.4%，P＝0.002），急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分高（分：26.46±2.59比24.41±2.47，P＝0.001），英国胸科协会改良肺炎评分（CURB-75）高（分：4.00±0.47比3.68±0.53，P＝0.013），总MV时间长（d：21.18±10.02比14.56±7.62， P＝0.002），ETI次数≥2次的患者比例大（53.6%比33.3%，P＜0.001）。多因素logistic回归分析显示， ETI次数≥2次及伴脑血管疾病是患者死亡的独立危险因素〔优势比（OR）＝9.677，95%可信区间（95%CI）＝3.075～30.457，P＜0.001；OR＝5.386，95%CI＝1.781～16.284，P＝0.003〕。Kaplan-Meier生存曲线分析表明， ETI次数和是否伴脑血管疾病对患者60 d生存率有显著影响（χ2＝40.805、P＝0.000，χ2＝4.425、P＝0.035）。结论有创-无创序贯性通气并不能改善高龄重症CAP患者的预后，ETI次数≥2次和伴脑血管疾病的患者生存率明显降低。
目的：探討有創-無創序貫性機械通氣（MV）對高齡重癥社區穫得性肺炎（CAP）患者的療效及預後因素。方法採用前瞻性研究方法，選擇2012年11月至2014年7月入住新疆醫科大學第一附屬醫院呼吸危重癥醫學科（RICU）年齡≥75歲的高齡重癥CAP患者，患者符閤CAP和重癥CAP的診斷標準，首診于急診科，需要入RICU實行MV且無無創通氣（NIV）絕對禁忌證。患者均拒絕氣管切開計劃，經氣管內插管（ETI）MV後，按隨機數字錶法分為有創-無創序貫性通氣組（序貫性通氣組）和常規通氣組。序貫性通氣組達到早期拔管指徵時拔除ETI，改為NIV；而常規通氣組達到傳統拔管指徵時改為Venturi麵罩氧療（5 L/min）。記錄兩組患者基線資料與臨床特徵；採用多因素logistic迴歸分析預測死亡危險因素；Kaplan-Meier生存麯線分析患者60 d生存率。結果有91例高齡重癥CAP患者納入研究，60 d死亡28例，病死率為30.77%。序貫性通氣組（44例）和常規通氣組（47例）60 d病死率差異無統計學意義〔25.0%（11/44）比36.2%（17/47），χ2＝1.331，P＝0.249〕，但序貫性通氣組呼吸機相關性肺炎（VAP）髮生率較低〔27.3%（12/44）比55.3%（26/47），χ2＝7.350，P＝0.007〕，ETI次數≥2次的患者比例較大〔59.1%（26/44）比29.8%（14/47），χ2＝5.095， P＝0.024〕。與存活組比較，死亡組伴腦血管疾病比例大（60.7%比25.4%，P＝0.002），急性生理學與慢性健康狀況評分繫統Ⅱ（APACHEⅡ）評分高（分：26.46±2.59比24.41±2.47，P＝0.001），英國胸科協會改良肺炎評分（CURB-75）高（分：4.00±0.47比3.68±0.53，P＝0.013），總MV時間長（d：21.18±10.02比14.56±7.62， P＝0.002），ETI次數≥2次的患者比例大（53.6%比33.3%，P＜0.001）。多因素logistic迴歸分析顯示， ETI次數≥2次及伴腦血管疾病是患者死亡的獨立危險因素〔優勢比（OR）＝9.677，95%可信區間（95%CI）＝3.075～30.457，P＜0.001；OR＝5.386，95%CI＝1.781～16.284，P＝0.003〕。Kaplan-Meier生存麯線分析錶明， ETI次數和是否伴腦血管疾病對患者60 d生存率有顯著影響（χ2＝40.805、P＝0.000，χ2＝4.425、P＝0.035）。結論有創-無創序貫性通氣併不能改善高齡重癥CAP患者的預後，ETI次數≥2次和伴腦血管疾病的患者生存率明顯降低。
목적：탐토유창-무창서관성궤계통기（MV）대고령중증사구획득성폐염（CAP）환자적료효급예후인소。방법채용전첨성연구방법，선택2012년11월지2014년7월입주신강의과대학제일부속의원호흡위중증의학과（RICU）년령≥75세적고령중증CAP환자，환자부합CAP화중증CAP적진단표준，수진우급진과，수요입RICU실행MV차무무창통기（NIV）절대금기증。환자균거절기관절개계화，경기관내삽관（ETI）MV후，안수궤수자표법분위유창-무창서관성통기조（서관성통기조）화상규통기조。서관성통기조체도조기발관지정시발제ETI，개위NIV；이상규통기조체도전통발관지정시개위Venturi면조양료（5 L/min）。기록량조환자기선자료여림상특정；채용다인소logistic회귀분석예측사망위험인소；Kaplan-Meier생존곡선분석환자60 d생존솔。결과유91례고령중증CAP환자납입연구，60 d사망28례，병사솔위30.77%。서관성통기조（44례）화상규통기조（47례）60 d병사솔차이무통계학의의〔25.0%（11/44）비36.2%（17/47），χ2＝1.331，P＝0.249〕，단서관성통기조호흡궤상관성폐염（VAP）발생솔교저〔27.3%（12/44）비55.3%（26/47），χ2＝7.350，P＝0.007〕，ETI차수≥2차적환자비례교대〔59.1%（26/44）비29.8%（14/47），χ2＝5.095， P＝0.024〕。여존활조비교，사망조반뇌혈관질병비례대（60.7%비25.4%，P＝0.002），급성생이학여만성건강상황평분계통Ⅱ（APACHEⅡ）평분고（분：26.46±2.59비24.41±2.47，P＝0.001），영국흉과협회개량폐염평분（CURB-75）고（분：4.00±0.47비3.68±0.53，P＝0.013），총MV시간장（d：21.18±10.02비14.56±7.62， P＝0.002），ETI차수≥2차적환자비례대（53.6%비33.3%，P＜0.001）。다인소logistic회귀분석현시， ETI차수≥2차급반뇌혈관질병시환자사망적독립위험인소〔우세비（OR）＝9.677，95%가신구간（95%CI）＝3.075～30.457，P＜0.001；OR＝5.386，95%CI＝1.781～16.284，P＝0.003〕。Kaplan-Meier생존곡선분석표명， ETI차수화시부반뇌혈관질병대환자60 d생존솔유현저영향（χ2＝40.805、P＝0.000，χ2＝4.425、P＝0.035）。결론유창-무창서관성통기병불능개선고령중증CAP환자적예후，ETI차수≥2차화반뇌혈관질병적환자생존솔명현강저。
ObjectiveTo investigate the efficacy of invasive-noninvasive sequential mechanical ventilation (MV) in senile patients with severe community-acquired pneumonia (CAP).Methods A prospective study was conducted. The patients with severe CAP aged≥ 75 years admitted to Department of Respiratory Intensive Care Unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University from November 2012 to July 2014, with refusal to have tracheostomy, were enrolled. All patients meeting the diagnostic criteria of CAP and severe CAP were first admitted into the Department of Emergency, and they were found to need MV without absolute contraindication for noninvasive ventilation (NIV) in RICU. The patients were mechanically ventilated via endotracheal intubation (ETI), and they were randomly divided into invasive-noninvasive sequential MV group (sequential MV group) and conventional MV group. NIV was initiated immediately when patients matched the conditions for early extubation in the sequential MV group. Oxygen therapy (5 L/min) via a Venturi mask was provided when the indications of conventional extubation were met. The baseline data and clinical characteristics were recorded, the risk factors of death were analyzed by logistic regression analysis, and 60-day survival rate was analyzed by Kaplan-Meier curve. Results Ninety-one senile patients with severe CAP were enrolled, among them 28 patients died within 60 days, with a mortality rate of 30.77%. No significant difference in 60-day mortality was found between sequential MV group (n = 44) and conventional MV group [n = 47, 25.0% (11/44) vs. 36.2% (17/47),χ2 = 1.331,P = 0.249]. In the sequential MV group, the incidence of ventilator-associated pneumonia (VAP) was significantly decreased [27.3%(12/44) vs. 55.3% (26/47),χ2 = 7.350,P = 0.007], and the rate of ETI≥2 times was increased [59.1% (26/44) vs. 29.8% (14/47),χ2 = 5.095,P = 0.024] as compared with conventional MV group. Compared with survival group, the patients in non-survival group showed a higher incidence of cerebrovascular disease (60.7% vs. 25.4%,P = 0.002), higher acute physiology and chronic health evaluationⅡ (APACHEⅡ) score (26.46±2.59 vs. 24.41±2.47,P = 0.001), British Thoracic Society confusion, uremia, respiratory rate, blood pressure,≥75 years (CURB-75 score, 4.00±0.47 vs. 3.68±0.53,P = 0.013), a longer total duration of MV (days: 21.18±10.02 vs. 14.56±7.62,P = 0.002), and a higher ratio of ETI≥ 2 times (53.6% vs. 33.3%,P< 0.001). It was revealed by multivariate logistic regression analysis that ETI≥ 2 times and comorbidity of cerebrovascular infarction were independent predictors of a worse outcome in the senile patients [odds ratio (OR) = 9.677, 95% confidence interval (95%CI) = 3.075 - 30.457,P< 0.001;OR = 5.386, 95%CI = 1.781 - 6.284,P = 0.003]. It was showed by Kaplan-Meir survival analysis that ETI times and concurrent cerebrovascular infarction imparted significant effects on the 60-day survival rate (χ2 = 40.805,P= 0.000;χ2 = 4.425, P = 0.035).ConclusionInvasive-noninvasive sequential MV may not improve the outcome of senile patients with severe CAP, and ETI≥ 2 times and concurrent cerebrovascular disorders drastically lowered the survival rate.
