早期乳酸清除率对重症慢性阻塞性肺疾病患者预后的评估

The evaluation of early lactate clearance rate in respect of prognosis in patients with severe COPD

目的探讨早期乳酸清除率对重症慢性阻塞性肺疾病（COPD）患者的临床意义。方法选取COPD合并呼吸衰竭住院患者108例进行前瞻性观察研究，根据患者病情转归分为存活组82例、死亡组26例；存活组中根据是否行有创机械通气治疗再分为常规治疗组55例、有创机械通气组27例。测定患者治疗前与治疗6h后的动脉血乳酸、动脉血气、急性生理勺慢性健康状况（APACHE）Ⅱ评分及早期（6h）乳酸清除率。同时以早期乳酸清除率10％为临界值分为高、低乳酸清除率两组，分析早期乳酸清除率与预后的关系。结果治疗前有创机械通气组与死亡组比较，动脉血乳酸、pH值、PaCO2、PaO2、APACHEⅡ、氧合指数等差异均无统计学意义。治疗6h后常规治疗组、有创机械通气组分别与死亡组比较，早期乳酸清除率有统计学意义（P〈0．01），APACHEⅡ评分、pH值差异均无统计学意义。存活病例两组比较，治疗6h后各项指标包括早期乳酸清除率差异均无统计学意义（P〉0．05）。三组治疗前、后自身对比中每组APACHEⅡ评分均无统计学意义。高乳酸清除率组病死率4．2％，显著低于低乳酸清除率组62．2％，差异有统计学意义（P〈0．01）。结论早期乳酸清除率可作为评估重症COPD患者病情严重程度、初始治疗效果和预后的指标之一。

Objective To investigate the clinical significance of early lactate clearance rate in respect of the prognosis of patients with severe chronic obstructive pulmonary disease （COPD） . Methods A total of 108 COPD patients with respiratory failure were studied prospectively. The patients were divided into survival group （n = 82） and the death group （n =26） , and the survival group further divided into the conventional treatment subgroup （ n = 55 ） and the invasive ventilation subgroup （ n =27 ） . Arterial blood lactate, arterial gas analysis, APACHE II score and the 6-hour clearance rate were measured before and 6 hours after treatment in 3 groups. The high lactate clearance rate group （n = 71 ） was defined as a lactate clearance rate 〉 10% , and the low lactate clearance rate group （n = 37 ） with a lactate clearance rate 〈 10%. The correlation between 6-hour lactate clearance rate and prognosis in patients was analyzed. Results Compared the survival patients in invasive ventilation group with the death group, there were no statistical differences in arterial blood lactate, pH value, PaCO2, PaO2, oxygenation index and APACHE Ⅱ score before the treatment. The 6-hour lactate clearance rate in survival patients in conventional treatment group or invasive ventilation group was significantly higher than that in the death group （t =31.2, P 〈0. 01 ; t =34. 6, P 〈0. 01, respectively） , while there were no statistical differences in APACHE Ⅱ score and pH value between these 3 groups. Between the conventional ventilation treatment group and the invasive ventilation treatment group, there was no statistical difference in 6- hour lactate clearance rate （ P 〉 0. 05 ） . There was no statistical difference in APACHE Ⅱ score between before treatment and after treatment in 3 groups. Mortality in high lactate clearance rate group （4. 2% ） was significantly lower than that in low lactate clearance rate group （62. 2% ） （X^2 = 121.9, P 〈 0.01 ） . Conclusions The early （6h） lactate clearance rate could be used as a marker for evaluating the severity, therapeutic efficacy and prognosis of patients with severe COPD.