结核性毁损肺行有创机械通气治疗患者死亡相关因素分析

doi:10.19982/j.issn.1000-6621.20230054

摘要/Abstract

摘要：

目的: 探讨结核性毁损肺(tuberculosis-destroyed lung,TDL)行有创机械通气(invasive mechanical ventilation,IMV)治疗(TDL-IMV)患者临床特征及死亡相关因素。方法: 采用回顾性研究方法,选取2017年1月至2021年12月成都市公共卫生临床医疗中心重症监护室收治的107例TDL-IMV患者作为研究对象。收集研究对象流行病学资料,以及并发症、合并症、急性生理学与慢性健康状况评分(APACHE-Ⅱ评分)、序贯器官衰竭评分(SOFA评分)、IMV原因、实验室检查结果、临床结局等临床资料。对比分析不同临床结局患者上述各项指标情况,并采用非条件多因素logistic回归分析TDL-IMV患者死亡的影响因素。结果: 107例研究对象中,有42例(39.3%)死亡,65例(60.7%)存活。单因素分析显示,死亡组合并慢性阻塞性肺疾病者占52.4%(22/42),明显高于存活组的20.0%(13/65);因急性呼吸衰竭行IMV者占52.4%(22/42),明显高于存活组的23.1%(15/65);白蛋白水平[(25.34±4.22)g/L]明显低于存活组[(28.71±6.26)g/L];N末端B型钠尿肽前体水平[中位数(四分位数):993.45(869.32,1096.61)ng/L]明显高于存活组[中位数(四分位数):649.26(528.40,789.82)ng/L],差异均有统计学意义(χ²=12.154,P=0.000;χ²=9.685,P=0.002;t=3.065,P=0.002;U=-7.085,P=0.000)。进一步多因素logistic回归分析发现,合并慢性阻塞性肺疾病(OR=4.999,95%CI:1.253~19.937)、因急性呼吸衰竭行IMV治疗(OR=8.548,95%CI:2.045~35.729)、低蛋白血症(OR=13.069,95%CI:2.662~64.156)、N末端B型钠尿肽前体高水平(OR=11.354,95%CI:2.809~45.888)是TDL-IMV患者死亡的独立危险因素。结论: TDL-IMV患者有较高的死亡风险,尤其警惕合并慢性阻塞性肺疾病、因急性呼吸衰竭需要IMV治疗、低蛋白血症和高水平N末端B型钠尿肽前体者。

关键词: 结核,肺, 肺通气, 治疗应用, 死亡, 危险因素

Abstract:

Objective: To explore the clinical characteristics and death-related factors of patients with tuberculosis-destroyed lung (TDL) undergoing invasive mechanical ventilation (IMV). Methods: A retrospective study was conducted in 107 TDL-IMV patients admitted to the intensive care unit of Chengdu Public Health Clinical Center from January 2017 to December 2021.The epidemiological data, complications, comorbidities, acute physiology and chronic health status scores (APACHE Ⅱ score), sequential organ failure scores (SOFA score), causes of IMV, laboratory test results, and clinical outcomes, etc., of the patients were collected. The above indicators in patients with different clinical outcomes were compared and analyzed, and unconditional multivariate logistic regression was used to analyze the influencing factors of death in TDL-IMV patients. Results: Of the 107 subjects, 42 (39.3%) died and 65 (60.7%) survived. Univariate analysis showed that 52.4% (22/42) of the patients in the death group were complicated with chronic obstructive pulmonary disease, which was significantly higher than that in the survival group (20.0%, 13/65, χ²=12.154, P=0.000); IMV for acute respiratory failure accounted for 52.4% (22/42), which was significantly higher than that of survival group (23.1%, 15/65, χ²=9.685, P=0.002); the albumin level ((25.34±4.22) g/L) was significantly lower than that in the survival group ((28.71±6.26) g/L, t=3.065, P=0.002); N-terminal pro-B-type natriuretic peptide level (median (quartile): 993.45 (869.32, 1096.61) ng/L) was significantly higher than that of survival group (649.26 (528.40, 789.82) ng/L, U=-7.085, P=0.000). Further multivariate logistic regression analysis showed that comorbidities with chronic obstructive pulmonary disease (OR=4.999, 95%CI: 1.253-19.937), IMV treatment for acute respiratory failure (OR=8.548, 95%CI: 2.045-35.729), hypoproteinemia (OR=13.069, 95%CI: 2.662-64.156) and high levels of N-terminal pro-B-type natriuretic peptide (OR=11.354, 95%CI: 2.809-45.888) were independent risk factors for the death of patients with TDL-IMV. Conclusion: Patients with TDL-IMV have a high risk of death, especially those who complicated with chronic obstructive pulmonary disease, undergoing IMV treatment due to acute respiratory failure, hypoproteinemia and high level of N-terminal pro-B-type natriuretic peptide.

Key words: Tuberculosis, pulmonary, Pulmonary ventilation, Therapeutic uses, Death, Risk factors

中图分类号:

R521

程耀, 陈洪德, 吴桂辉, 赖敏, 罗海霞, 崔坤平, 李玉科. 结核性毁损肺行有创机械通气治疗患者死亡相关因素分析[J]. 中国防痨杂志, 2023, 45(7): 651-657. doi: 10.19982/j.issn.1000-6621.20230054

Cheng Yao, Chen Hongde, Wu Guihui, Lai Min, Luo Haixia, Cui Kunping, Li Yuke. Analysis of death related factors in tuberculosis destroyed lung patients undergoing invasive mechanical ventilation[J]. Chinese Journal of Antituberculosis, 2023, 45(7): 651-657. doi: 10.19982/j.issn.1000-6621.20230054

图/表 3

表1

行有创机械通气的结核性毁损肺患者发生死亡影响因素的单因素分析

因素		死亡组(42例)			存活组(65例)		统计检验值		P值
年龄(岁,$\bar{x}±s$)		41.15±10.23			43.24±9.61		t=1.071		0.288
体质量指数($\bar{x}±s$)		17.51±1.21			17.29±0.93		t=1.060		0.292
性别[例(构成比,%)]							χ²=0.734		0.392
男性		23(54.8)			41(63.1)
女性		19(45.2)			24(36.9)
居住地[例(构成比,%)]							χ²=3.370		0.066
农村		27(64.3)			30(46.2)
城镇		15(35.7)			35(53.8)
文化程度[例(构成比,%)]							χ²=0.378		0.539
初中及以下		16(38.1)			21(32.3)
初中以上		26(61.9)			44(67.7)
婚姻情况[例(构成比,%)]							χ²=0.048		0.828
已婚		28(66.7)			42(64.6)
未婚(离异、丧偶)		14(33.3)			23(35.4)
吸烟[例(构成比,%)]							χ²=4.136		0.042
是		32(76.2)			37(56.9)
否		10(23.8)			28(43.1)
饮酒[例(构成比,%)]							χ²=0.538		0.463
是		12(28.6)			23(35.4)
否		30(71.4)			42(64.6)
卡介苗接种史[例(构成比,%)]								χ²=0.296	0.587
有	36(85.7)			58(84.6)
无	6(14.3)			7(10.7)
结核病患者接触史[例(构成比,%)]								χ²=0.341	0.559
有	9(21.4)			11(16.9)
无	33(78.6)			54(83.1)
并发症[例(发生率,%)]
咯血	7(16.7)			8(12.3)				χ²=0.402	0.526
气胸	11(26.2)			9(13.8)				χ²=2.558	0.110
肺部感染	39(92.9)			55(84.6)				χ²=1.624	0.203
慢性肺源性心脏病	28(66.7)			26(40.0)				χ²=7.258	0.007
合并症[例(患病率,%)]
AIDS	6(14.3)			5(7.7)				χ²=0.594	0.441
糖尿病	15(35.7)			12(18.5)				χ²=4.025	0.045
支气管哮喘	9(21.4)			8(12.3)				χ²=1.588	0.208
慢性阻塞性肺疾病	22(52.4)			13(20.0)				χ²=12.154	0.000
慢性肝病	9(21.4)			12(18.5)				χ²=0.142	0.706
慢性肾病	10(23.8)			8(12.3)				χ²=2.412	0.120
有创机械通气原因[例(发生率,%)]
急性呼吸衰竭	22(52.4)			15(23.1)				χ²=9.685	0.002
慢性呼吸衰竭	15(35.7)			22(33.8)				χ²=0.039	0.843
感染性休克	6(14.3)			8(12.3)				χ²=0.041	0.839
急性左心功能不全	17(40.5)			14(21.5)				χ²=4.447	0.035
APACHE-Ⅱ评分^a[分,M(Q₁,Q₃)]	16.52(11.75,21.25)			14.52(11.00,17.50)				U=-1.803	0.071
SOFA评分^a(分,$\bar{x}±s$)	7.37±1.45			6.52±2.73				t=1.854	0.067
白细胞计数^b(×10⁹/L,$\bar{x}±s$)	10.19±2.33			11.05±3.71				t=1.340	0.183
血红蛋白水平^b(g/L,$\bar{x}±s$)	89.62±7.11			91.57±10.33				t=1.070	0.287
血小板计数^b(×10⁹/L,$\bar{x}±s$)	101.53±15.71			105.49±20.06				t=1.082	0.282
白蛋白水平^b(g/L,$\bar{x}±s$)	25.34±4.22			28.71±6.26				t=3.065	0.002
CD4⁺T淋巴细胞计数^b[个/μl,M(Q₁,Q₃)]	224.45(121.75,332.50)			271.52(195.50,345.00)				U=-1.933	0.048
N末端B型钠尿肽前体^b[ng/L,M(Q₁,Q₃)]	993.45(869.32,1096.61)			649.26(528.40,789.82)				U=-7.085	0.000
C反应蛋白^b(mg/L,$\bar{x}±s$)	62.13±15.41			69.26±20.02				t=1.962	0.052
降钙素原^b(μg/L,$\bar{x}±s$)	4.31±1.94			3.82±2.31				t=1.160	0.248
氧合指数^c(mmHg,$\bar{x}±s$)	198.52±50.52			281.65±70.14				t=6.642	0.000
二氧化碳分压^c(mmHg,$\bar{x}±s$)	64.29±10.13			60.43±9.61				t=1.986	0.049
病原学检测[例(构成比,%)]						χ²=0.187			0.666
阳性			35(83.3)		52(80.0)
阴性			7(16.7)		13(20.0)

表1

表2

表3

参考文献 22

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因素	赋值	因素	赋值
因变量(临床结局)	存活=0;死亡=1	因急性左心功能不全行有创机械通气治疗	否=0;是=1
吸烟	否=0;是=1	因急性左心功能不全行有创机械通气治疗	否=0;是=1
吸烟	否=0;是=1	白蛋白水平	≥30.0g/L=0;<30.0g/L=1
合并慢性肺源性心脏病	否=0;是=1	白蛋白水平	≥30.0g/L=0;<30.0g/L=1
合并慢性肺源性心脏病	否=0;是=1	CD4⁺T淋巴细胞计数	≥400 个/μl=0;<400个/μl=1
合并糖尿病	否=0;是=1	CD4⁺T淋巴细胞计数	≥400 个/μl=0;<400个/μl=1
合并糖尿病	否=0;是=1	N末端B型钠尿肽前体	低水平^a=0;高水平^b=1
合并慢性阻塞性肺疾病	否=0;是=1	N末端B型钠尿肽前体	低水平^a=0;高水平^b=1
合并慢性阻塞性肺疾病	否=0;是=1	氧合指数	≥200mmHg=0;<200mmHg=1
因急性呼吸衰竭行有创机械通气治疗	否=0;是=1	氧合指数	≥200mmHg=0;<200mmHg=1
因急性呼吸衰竭行有创机械通气治疗	否=0;是=1	二氧化碳分压	≤50mmHg=0;>50mmHg=1

因素	β值	s$\bar{x}$值	Wald χ²值	P值	OR(95%CI)值
合并慢性阻塞性肺疾病	1.609	0.706	5.198	0.023	4.999(1.253~19.937)
因急性呼吸衰竭行有创机械通气治疗	2.146	0.730	8.645	0.003	8.548(2.045~35.729)
低蛋白血症	2.570	0.812	10.024	0.002	13.069(2.662~64.156)
高水平N末端B型钠尿肽前体	2.430	0.713	11.626	0.001	11.354(2.809~45.888)