肺炎及英国胸科协会改良肺炎评分对慢性阻塞性肺疾病急性加重患者早期病死率的评估价值

The value of coexisting pneumonia and British Thoracic Society CURB-65 score in predicting early mortality rate in patients with acute exacerbation of chronic obstructive pulmonary disease

目的探讨是否合并肺炎及英国胸科协会改良肺炎评分（CURB一65评分）对慢性阻塞性肺疾病（简称慢阻肺）急性加重期患者早期病死率的临床评估价值。方法选取东南大学附属中大医院呼吸科2010年1月至2012年9月因慢阻肺急性加重人院483例患者，其中男295例，女188例，年龄45～92岁。根据人院时胸部影像学检查结果及肺炎诊断标准分为合并肺炎组和不合并肺炎组，以患者入住呼吸科即刻为研究起点，以30d为研究终点，比较CURB-65评分相同的两组患者住院病死率和30d病死率；按照CURB-65评分将患者进行分层，比较相同分层的两组患者住院病死率和30d病死率及各组内不同CURB-65评分患者的住院病死率和30d病死率。应用受试者工作特征（ROC）曲线评价CURB-65评分对慢阻肺急性加重患者30d病死率的评估价值。计数资料采用x。检验，计量资料采用t检验，多组间比较采用方差分析。结果本研究纳入457例，其中男278例，女179例，平均年龄（75±9）岁；合并肺炎组120例（26．3％），不合并肺炎组337例（73．7％）。合并肺炎组住院期间需要辅助通气者59例（49．2％），住院病死率为18．3％（22／120），30d病死率为21．7％（26／120），均显著高于不合并肺炎组[9l例（27．0％）、4．7％（16／337）和7．4％（25／337）]，差异均有统计学意义（X。值为18．1—21．4，均P〈0．01）。低、中、高危险程度的住院病死率：合并肺炎组分别为4．4％（2／45）、15．2％（7／46）和44．8％（13／29），不合并肺炎组分别为0．9％（1／113）、3．4％（4／119）和10．5％（11／105）；30d病死率：合并肺炎组分别为4．4％（2／45）、19．6％（9／46）和51．7％（15／29），不合并肺炎组分别为0．9％（1／113）、5．O％（6／119）和17．1％（18／105），两组比较，中、高危险程度的差异均有统计学意义（X2值为5．8～10．1，P〈0．05和P〈0．01）。用CURB-65评分评估慢阻肺急性加重患者30d病死率的ROC曲线下面积为0．744（95％CI为0．674—0．814）。结论合并肺炎是慢阻肺急性加重患者需要辅助通气及住院死亡的预后因素，CURB-65评分对慢阻肺急性加重患者早期病死率有较好的临床评估价值。

Objective To investigate the value of coexisting pneumonia and British Thoracic Society CURB-65 score in predicting early mortality in patients with acute exacerbation of chronic obstructive pulmonary disease （AECOPD）. Methods In this prospective study, 483 consecutive in-patients with AECOPD were recruited between January 2010 and September 2012, including 295 males and 188 females. The patients were aged 45 to 92 years. They were divided into 2 groups： non-pneumonia （npAECOPD） and with pneumonia （pAECOPD）. The start point of this study was the date when the patients were admitted into the respiratory ward, and the endpoint was the 30 day mortality. Clinical and demographic data were collected for all the patients, and the value of coexisting pneumonia and CURB-65 in predicting in-hospital mortality and 30 day mortality were assessed and compared. Results According to the inclusion/exclusion criteria, eventually 457 patients were included in this research, with 278 males and 179 females, and an average age of （75 ~ 9） years. Of the 457 patients, 120 （26. 3% ） patients were in the pAECOPD group and 337 （73.7%） patients in the npAECOPD group. The in-hospital mortality, the 30 day mortality and the assisted ventilation rate were significantly higher in the pAECOPD group as compared to the npAECOPD group 18.3% （22/120）vs4.7% （16/337）, 21.7% （26/120）vs7.4% （25/337）;49.2% （59/120） vs 27.0% （ 91/337 ）, X2 = 18. 1 - 21.4, all P 〈 O. 05, respectively. Furthermore, the in-hospital mortality of the pAECOPD patients with CURB-65 score 〈2, =2 and 〉2 was 4.4% （2/45）, 15.2% （7/46） and 44. 8% （ 13/29）, respectively, while that of the npAECOPD patients was 0.9% （ 1/113 ）, 3.4% （4/119） and 10. 5% （11/105）, respectively. The 30 day mortality of the pAECOPD patients with CURB-65 score 〈2, =2 and 〉2 was4.4% （2/45）, 19.6% （9/46）and 51.7% （15/29）, respectively, while that of the npAECOPD patients was 0. 9% （ 1/113）, 5.0% （6/119） and 17.1% （ 18/105）, respectively. Stratified by CURB-65 Score, the in-hospital and 30 day mortality were both significantly higher in the pAECOPD group than in the npAECOPD group when CURB-65 was t〉 2 （ X2 = 5.8 - 10. 1, P 〈 0.05 and P 〈0. O1, respectively）. The AUROC analysis of CURB-65 as a predictor for early mortality resulted in an area under curve of 0. 744. Conclusions In patients with AECOPD, coexisting pneumonia is not only a risk factor for in-hospital mortality, but also a predictor for the treatment of assisted ventilation. CURB-65 score may be a good predictor for early mortality in patients with AECOPD.