摘要
目的:探讨无创-有创机械通气序贯性治疗慢性阻塞性肺疾病急性加重(AECOPD)时的切换时机,有效降低气管插管率。方法:回顾性分析2014年7月至2019年3月入住开封市中心医院急诊抢救室和呼吸科行机械通气的AECOPD患者临床资料。将入组时存在无创机械通气(NIV)相对禁忌证仍坚持使用NIV者纳入NIV组(118例),使用气管插管有创正压机械通气(IPPV)者纳入IPPV组(52例),比较两组患者总机械通气时间、住院时间和住院病死率。收集患者年龄、性别、体温、呼吸频率、体重指数(BMI)、平均动脉压(MAP)、氧合指数(PaO 2/FiO 2)、呼吸指数(RI)、pH值、D-二聚体、血红蛋白(HB)、白蛋白、血乳酸(Lac)、脑钠肽(BNP)、C-反应蛋白(CRP)、降钙素原(PCT)、血肌酐(SCr)、白细胞计数(WBC)、格拉斯哥昏迷评分(GCS)、是否存在排痰障碍等临床指标,对影响NIV失败的因素进行二分类Logistic逐步回归分析;用受试者工作特征曲线(ROC)检验NIV失败风险预测模型的价值。结果:NIV组与IPPV组间总机械通气时间、住院病死率差异无统计学意义(h:65.6±11.11比66.9±12.1,6.8%比9.6%,均P>0.05),但NIV组住院时间明显短于IPPV组(d:12.3±2.1比14.2±2.5,P<0.05)。NIV组有101例持续完成NIV,17例NIV失败转为IPPV,NIV失败率为14.4%。NIV失败患者与NIV成功患者性别、PaO 2/FiO 2、RI、pH值、D-二聚体、PCT、WBC、Lac、排痰障碍、GCS评分比较差异均具有统计学意义。将上述临床相关因素纳入Logistic回归分析,结果显示,RI、pH值、WBC、排痰障碍是NIV失败的独立危险因素〔RI:优势比(OR)=3.879,95%可信区间(95%CI)为1.258~11.963,P=0.018;pH值:OR=3.316,95%CI为1.270~8.660,P=0.014;WBC:OR=3.684,95%CI为1.172~11.581,P=0.026;排痰障碍:OR=0.125,95%CI为0.042~0.366,P=0.000〕。用上述独立危险因素建立的NIV失败风险预测模型具有较好的拟合优度(χ^2=9.02,P=0.34)。ROC曲线分析显示,NIV失败风险预测模型对AECOPD患者NIV失败具有较高预测价值〔ROC曲线下面积(AUC)为0.818±0.051,95%CI为0.718~0.918,P=0.000〕。结论:存在NIV相对禁忌证仍坚持使用NIV的AECOPD患者,需对NIV失败进行进一步危险分层,对于RI、pH值、WBC异常和排痰障碍者选择NIV风险显著增大,需要更加密切关注病情变化,及时切换成IPPV,避免延误病情。
Objective To explore the switch time of noninvasive-invasive mechanical ventilation sequential treatment for acute exacerbation of chronic obstructive pulmonary disease(AECOPD),and effectively reduce the rate of tracheal intubation.Methods A retrospective study was performed on patients with AECOPD,who underwent mechanical ventilation in emergency resuscitation room and admitted to department of respiration of Kaifeng Central Hospital Emergency Center from July 2014 to March 2019.The patients who used noninvasive mechanical ventilation(NIV)were included in NIV group(118 cases),and those who used invasive positive pressure ventilation(IPPV)were included in IPPV group(52 cases).The usage of breathing machine time,hospital days and hospital mortality were compared between the two groups.Clinical indicators such as age,gender,body temperature,respiratory rate,body mass index(BMI),mean arterial pressure(MAP),oxygenation index(PaO2/FiO2),respiratory index(RI),pH value,D-dimer,hemoglobin(HB),albumin,blood lactate(Lac),brain natriuretic peptide(BNP),C-reactive protein(CRP),procalcitonin(PCT),serum creatinine(SCr),white blood cell count(WBC),Glasgow coma scale(GCS),sputum excretion drainage were collected.The factors influencing the failure of NIV were analyzed by Logistic stepwise regression analysis.The receiver operating characteristic(ROC)curve was used to test the value of the NIV failure risk prediction model.Results There was no significant difference in total mechanical ventilation time and hospital mortality between NIV group and IPPV group(hours:65.6±11.11 vs.66.9±12.1,6.8%vs.9.6%,both P>0.05),but the hospital time in group NIV was significantly shorter than that in IPPV group(days:12.3±2.1 vs.14.2±2.5,P<0.05).In NIV group,101 cases completed NIV continuously,17 cases of NIV failure turned to IPPV,and the failure rate of NIV was 14.4%.There were statistically significant differences in gender,PaO2/FiO2,RI,pH value,D-dimer,PCT,WBC,Lac,sputum excretion drainage and GCS score between NIV failure patients and NIV success patients.Logistic regression analysis showed that RI,pH value,WBC and sputum excretion drainage were independent risk factors for NIV failure[RI:odds ratio(OR)=3.879,95%confidence interval(95%CI)was 1.258-11.963,P=0.018;pH value:OR=3.316,95%CI was 1.270-8.660,P=0.014;WBC:OR=3.684,95%CI was 1.172-11.581,P=0.026;sputum excretion drainage:OR=0.125,95%CI was 0.042-0.366,P=0.000].The NIV failure risk prediction model based on the above independent risk factors had a good goodness of fit(χ^2=9.02,P=0.34).ROC curve analysis showed that the NIV failure risk prediction model had a high predictive value for the patients with AECOPD[the area under ROC curve(AUC)was 0.818±0.051,95%CI was 0.718-0.918,P=0.000].Conclusions If patients with AECOPD have relative contraindications of NIV but still insist on using NIV,further risk stratification of NIV failure is needed.For those with RI,pH value,WBC abnormalities and sputum excretion drainage,the risk of choosing NIV is significantly increased.We need to pay more attention to the change of the condition and switch to IPPV in time to avoid exacerbation of the condition.
作者
翟红瑞
罗松平
林磊
杜德森
段宝民
Zhai Hongrui;Luo Songping;Lin Lei;Du Desen;Duan Baomin(Kaifeng Central Hospital Emergency Center,Kaifeng 475000,Henan,China)
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2020年第2期161-165,共5页
Chinese Critical Care Medicine
基金
河南省医学重点学科建设项目(2016-26-169)
河南省开封市科技发展计划项目(110329)。
关键词
慢性阻塞性肺疾病
无创机械通气
有创正压机械通气
序贯治疗
Chronic obstructive pulmonary disease
Noninvasive mechanical ventilation
Invasive positive pressure ventilation
Sequential treatment
