急诊肺结核患者死亡的危险因素及风险模型建立

doi:10.19982/j.issn.1000-6621.20240321

中国防痨杂志 ›› 2025, Vol. 47 ›› Issue (2): 189-194.doi: 10.19982/j.issn.1000-6621.20240321

急诊肺结核患者死亡的危险因素及风险模型建立

薛玉¹, 杨新婷², 王桂荣³, 柳芳超⁴, 雷轩¹, 张静¹, 李亮⁵()

¹首都医科大学附属北京胸科医院急诊科,北京 101149
²首都医科大学附属北京胸科医院结核二科,北京 101149
³首都医科大学附属北京胸科医院检验科,北京 101149
⁴首都医科大学附属北京胸科医院科技处,北京 101149
⁵首都医科大学附属北京胸科医院,北京 101149

收稿日期:2024-08-01 出版日期:2025-02-10 发布日期:2025-02-08
通信作者: 李亮,Email: liliang69@vip.sina.com
基金资助:
国家重点研发计划(2022YFC2304800)

Analysis of risk factors for death in emergency pulmonary tuberculosis patients and risk model construction

Xue Yu¹, Yang Xinting², Wang Guirong³, Liu Fangchao⁴, Lei Xuan¹, Zhang Jing¹, Li Liang⁵()

¹Department of Emergency, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
²The Second Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
³Department of Clinical Laboratory, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
⁴Department of Science and Technology, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China
⁵General Administration Office, Beijing Chest Hospital, Capital Medical University, Beijing 101149, China

Received:2024-08-01 Online:2025-02-10 Published:2025-02-08
Contact: Li Liang, Email: liliang69@vip.sina.com
Supported by:
National Key Research and Development Program of China(2022YFC2304800)

摘要/Abstract

摘要：

目的: 分析急诊肺结核患者死亡的危险因素并建立风险预警模型。方法: 采用回顾性分析方法,连续纳入2024年1—6月首都医科大学附属北京胸科医院237例急诊肺结核患者作为研究对象。收集研究对象一般人口学信息、临床症状、急诊实验室检查结果、影像分级、细菌学检测结果等资料。根据研究对象是否死亡分为存活组和死亡组,比较两组间各项指标的差异,采用多因素logistic回归模型分析影响急诊肺结核患者发生死亡的危险因素,明确独立危险因素并建立死亡风险模型,绘制受试者工作特征曲线(receiver operating characteristic curve,ROC曲线)分析此模型对急诊肺结核患者死亡的预测价值。结果: 237例研究对象中,存活189例,死亡48例,病亡率为20.3%。多因素logistic回归分析显示,血尿素氮>8.3mmol/L、影像分级为重度、发生呼吸窘迫、呼吸衰竭、意识障碍为急诊肺结核患者死亡的独立危险因素[OR(95%CI)值分别为:4.550(1.761~11.758)、4.429(1.443~13.588)、27.507(3.985~189.847)、2.687(1.042~6.926)、27.184(6.926~106.699)]。多因素logistic 回归方程为:logit P=In [P/(1-P)]=-1.433+1.515×(血尿素氮>8.3mmol/L)+1.488×(影像分级重度)+3.314×(呼吸窘迫)+0.988×(呼吸衰竭)+3.303×(意识障碍)。ROC曲线分析显示,5种危险因素联合检测时曲线下面积为0.8968,预测急诊肺结核患者死亡的敏感度和特异度分别为87.50%和74.60%。结论: 综合考虑急诊肺结核患者的血尿素氮水平、影像分级程度,以及是否出现呼吸窘迫、呼吸衰竭、意识障碍等症状可较好地预测其预后情况。

关键词: 结核,肺, 急诊处理, 死亡, 因素分析,统计学

Abstract:

Objective: To identify the risk factors associated with mortality in patients with pulmonary tuberculosis admitted to the emergency department and to develop a predictive risk model to assist clinical decision-making and improve patient outcomes. Methods: A retrospective analysis was conducted on 237 patients with pulmonary tuberculosis who were treated in the emergency department of Beijing Chest Hospital, Capital Medical University, between January 2024 and June 2024. Data collected included baseline demographic characteristics, clinical symptoms, laboratory findings, radiographic severity, and bacteriological evidence. Patients were categorized into two groups—the survival group and the mortality group—based on their clinical outcomes. Comparative analyses of clinical data between the two groups were performed. Multivariate logistic regression was employed to identify independent risk factors associated with mortality in the emergency setting. A predictive risk model was subsequently developed, and its performance in forecasting poor outcomes was evaluated using the receiver operating characteristic (ROC) curve. Results: Of the 237 patients included in the study, 189 survived and 48 succumbed, resulting in an overall mortality rate of 20.3%. Multivariate logistic regression analysis identified five independent risk factors associated with mortality in the emergency department: elevated blood urea nitrogen (BUN) levels (>8.3 mmol/L), advanced radiographic lesions, respiratory distress, respiratory failure, and consciousness disorders. The respective odds ratios (ORs) and 95%CIs for these factors were 4.550 (1.761-11.758), 4.429 (1.443-13.588), 27.507 (3.985-189.847), 2.687 (1.042-6.926), and 27.184 (6.926-106.699). The predictive risk model was expressed as: logit P=ln(P/(1-P))=-1.433+1.515×(BUN>8.3 mmol/L)+1.488×(advanced radiographic lesions)+3.314×(respiratory distress)+0.988×(respiratory failure)+3.303×(consciousness disorder). ROC curve analysis demonstrated that the area under the curve (AUC) was 0.8968 when the five risk factors were combined. The predictive model achieved a sensitivity of 87.50% and a specificity of 74.60% for identifying mortality in emergency pulmonary tuberculosis patients. Conclusion: Incorporating blood urea nitrogen levels, radiographic grading, and clinical indicators such as respiratory distress, respiratory failure, and consciousness disorders provides a robust framework for effectively predicting the prognosis of patients with pulmonary tuberculosis in the emergency setting.

Key words: Tuberculosis, pulmonary, Emergency treatment, Death, Factor analysis, statistical

中图分类号:

R521

薛玉, 杨新婷, 王桂荣, 柳芳超, 雷轩, 张静, 李亮. 急诊肺结核患者死亡的危险因素及风险模型建立[J]. 中国防痨杂志, 2025, 47(2): 189-194. doi: 10.19982/j.issn.1000-6621.20240321

Xue Yu, Yang Xinting, Wang Guirong, Liu Fangchao, Lei Xuan, Zhang Jing, Li Liang. Analysis of risk factors for death in emergency pulmonary tuberculosis patients and risk model construction[J]. Chinese Journal of Antituberculosis, 2025, 47(2): 189-194. doi: 10.19982/j.issn.1000-6621.20240321

图/表 3

表1

急诊肺结核患者死亡危险因素单因素分析

因素	存活组(189例)	死亡组(48例)	统计检验值	P值
年龄[岁,M(Q₁,Q₃)]	66.0(49.5,79.0)	69.5(40.5,79.0)	U=-0.192	0.849
性别[例(构成比,%)]			χ²=0.000	0.985
男性	142(75.1)	36(75.0)
女性	47(24.9)	12(25.0)
患者分类[例(构成比,%)]			χ²=0.414	0.520
初治	137(72.5)	37(77.1)
复治	52(27.5)	11(22.9)
发热[例(发生率,%)]	106(56.1)	27(56.2)	χ²=0.000	0.984
纳差[例(发生率,%)]	122(64.6)	27(56.2)	χ²=1.130	0.317
呼吸窘迫[例(发生率,%)]	105(55.6)	44(91.7)	χ²=21.380	<0.001
胸痛[例(发生率,%)]	11(5.8)	1(2.0)	χ²=1.110	0.468
意识障碍[例(发生率,%)]	12(6.3)	22(45.8)	χ²=48.570	<0.001
休克[例(发生率,%)]	5(2.6)	10(20.8)	χ²=21.360	<0.001
呼吸衰竭[例(发生率,%)]	70(37.0)	34(70.8)	χ²=17.750	<0.001
既往抗结核治疗时间[月,M(Q₁,Q₃)]	0.0(0.0,4.5)	0.0(0.0,1.8)	U=-1.856	0.063
影像分级[例(构成比,%)]			χ²=10.270	<0.05
轻度	18(9.5)	1(2.1)
中度	60(31.8)	7(14.6)
重度	111(58.7)	40(83.3)
病原学检测[例(构成比,%)]			χ²=5.800	0.012
阳性	140(74.1)	40(83.3)
阴性	38(20.1)	2(4.2)
无结果	11(5.8)	6(12.5)
心率(次/min, $x ˉ$ ±s)	101.10±17.70	109.4±27.05	t=2.583	0.010
白细胞计数[×10⁹/L,M(Q₁,Q₃)]	7.93(5.81,10.06)	7.67(5.61,14.21)	U=-0.231	0.818
血红蛋白(g/L, $x ˉ$ ±s)	113.70±23.80	104.40±24.63	t=2.388	0.018
血小板计数[×10⁹/L,M(Q₁,Q₃)]	258.0(198.0,352.0)	227.5(136.0,295.3)	U=-1.891	0.059
淋巴细胞计数[×10⁹/L,M(Q₁,Q₃)]	0.78(0.50,1.13)	0.48(0.25,0.76)	U=-4.008	<0.001
单核细胞计数[×10⁹/L,M(Q₁,Q₃)]	0.47(0.32,0.66)	0.29(0.13,0.57)	U=-3.836	<0.001
中性粒细胞计数[×10⁹/L,M(Q₁,Q₃)]	5.96(4.42,8.44)	6.64(4.54,11.15)	U=-1.443	0.150
粒淋比[M(Q₁,Q₃)]	7.93(4.88,13.17)	14.71(8.60,28.97)	U=-4.345	<0.001
单淋比[M(Q₁,Q₃)]	0.62(0.41,0.99)	0.65(0.41,0.90)	U=-0.272	0.787
白蛋白(g/L, $x ˉ$ ±s)	31.83±6.078	27.18±5.621	t=4.806	<0.001
总胆红素[μmol/L,M(Q₁,Q₃)]	12.0(8.9,17.4)	14.9(9.9,20.2)	U=-1.957	0.050
胆碱酯酶[IU/L,M(Q₁,Q₃)]	3666(2340,5305)	2451(1661,3390)	U=-4.320	<0.001
尿素氮[mmol/L,M(Q₁,Q₃)]	5.42(4.10,7.45)	9.05(5.91,16.25)	U=-4.582	<0.001
肌酐[μmol/L,M(Q₁,Q₃)]	57.60(47.10,75.10)	62.25(45.38,115.40)	U=-1.224	0.222
钾[mmol/L,M(Q₁,Q₃)]	3.9(3.6,4.3)	3.9(3.7,4.2)	U=-0.050	0.961
钠[mmol/L,M(Q₁,Q₃)]	132.4(129.2,135.8)	134.1(129.6,140.7)	U=-2.371	0.017
氯[mmol/L,M(Q₁,Q₃)]	99.1(96.1,103.6)	99.9(95.4,105.7)	U=-0.560	0.577
乳酸脱氢酶[IU/L,M(Q₁,Q₃)]	217(171,288)	296(212,400)	U=-3.777	<0.001
C反应蛋白[mg/L,M(Q₁,Q₃)]	53.14(23.01,103.10)	77.44(37.01,143.50)	U=-2.255	0.018
D-二聚体[ng/ml,M(Q₁,Q₃)]	2.355(1.053,4.500)	4.120(2.145,5.970)	U=-2.946	0.003
pH值[M(Q₁,Q₃)]	7.46(7.42,7.49)	7.44(7.37,7.50)	U=-1.273	0.204
二氧化碳分压[mmHg,M(Q₁,Q₃)]	37.0(33.0,41.8)	38.5(30.3,48.0)	U=-0.473	0.638
氧分压[mmHg,M(Q₁,Q₃)]	109.0(80.0,143.0)	99.5(67.5,150.0)	U=-1.396	0.163

表1

表2

表3

急诊肺结核患者死亡危险因素的多因素logistic回归分析

因素	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
血尿素氮>8.3mmol/L	1.515	0.484	9.784	0.002	4.550(1.761~11.758)
影像分级重度	1.488	0.572	6.768	0.009	4.429(1.443~13.588)
有呼吸窘迫	3.314	0.986	11.308	0.001	27.507(3.985~189.847)
有呼吸衰竭	0.988	0.483	4.186	0.041	2.687(1.042~6.926)
有意识障碍	3.303	0.698	22.409	0.001	27.184(6.926~106.699)

表3

参考文献 19

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变量	赋值	变量	赋值
心率(次/min)	≤100=0,>100=1	C反应蛋白(mg/L)	0~5=0,6~74=1,≥75=2
血红蛋白(g/L)	≥120=0,90~119=1,60~89=2,<60=3	D-二聚体(ng/ml)	≤3.63=0,>3.63=1
淋巴细胞计数(×10⁹/L)	<0.4=0,0.4~0.7=1,0.8~4=2,>4=3	休克	无=0,有=1
粒淋比	≤10.35=0,>10.35=1	影像分级	非重度=0,重度=1
白蛋白(g/L)	<25=0,25~34=1,≥35=2	呼吸窘迫	无=0,有=1
血尿素氮(mmol/L)	≤8.3=0,>8.3=1	呼吸衰竭	无=0,有=1
血钠(mmol/L)	≤120=0,121~129=1,130~134=2,135~145=3,>145=4	意识障碍	无=0,有=1
血钠(mmol/L)	≤120=0,121~129=1,130~134=2,135~145=3,>145=4	病原学检测	阴性=1,阳性=2

急诊肺结核患者死亡的危险因素及风险模型建立

Analysis of risk factors for death in emergency pulmonary tuberculosis patients and risk model construction

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