慢性阻塞性肺疾病对重症监护病房患者合并呼吸机相关性肺炎病死率的影响

Impact of chronic obstructive pulmonary disease on ICU mortality in patients with ventilator-associated pneumonia

目的研究慢性阻塞性肺疾病（COPD）对重症监护病房（ICU）患者合并呼吸机相关性肺炎（VAP）病死率的影响。方法本前瞻性研究是在我院急诊重症监护病房用一年半年时间完成的。患者选择标准为接受机械通气超过48h并且经过微生物学标准证实罹患VAP。ICU病死率的危险因子通过单变量和多变量分析决定。结果90例经微生物学证实的VAP患者纳入了研究。84％的VAP患者属于迟发。39％的VAP患者痰液中分离出了铜绿假单胞菌。结果显示，没有合并COPD的患者（n=63）病死率显著低于合并COPD的患者（n=27）[42．9％VS59．3％，P=0．038，OR（95％CI）=1．67（1．04～6．85）]。没有合并COPD的患者接受机械通气天数和ICU入住天数的中位数分别是24（16—41）d和31（17—46）d，合并COPD的患者对应是30（18—43）d和37（21—50）d（P〉0．05），没有合并COPD的患者和合并COPD患者（GOI，DIV期）机械通气时间和ICU入住时间有显著性差异（P值分别为0．001，0．002）。多变量分析显示：在VAP[3．70（1．86—7．34）]患者中，COPD[OR（95％a）2．52（1．34～5．12）]是ICU病死率的独立危险因子。结论COPD与ICU中VAP患者病死率相关。

Objective To determine the impact of chronic obstructive pulmonary disease （COPD） on intensive care unit （ICU） mortality in patients with VAP. Methods This prospective observational study was preformed in EICU of Taizhou Hospital during a 1.5-yearperiod. Eligible patients received mechanical ventilation for 〉48 h and met criteria for microbiologically confirmed VAP, Risk factors for ICU mortality were determined using univariate and multivariable analyses. Results Ninty patients with microbiologically confirmed VAP were included. Most VAP episodes were late-onset （84%）, and Pseudomonas aeruginosa was the most frequently isolated bacterium （39% of VAP episodes）. ICU mortality was significantly lower in non-COPD patients （ n =63） compared to COPD patients （ n = 27） [42.9 % vs 59.3 %, P= 0. 038, OR （95 % CI ） = 1.67 （1.04 - 6.85）1. Duration （days） of mechanical ventilation and ICU stay median （IQR） in non-COPD patients were 24 （16-41） d and 31 （17-46） d. Whereas in COPD patients were 30（18-43） d and 37（21-50） d （ P 〉0.05）. The differences in duration （days） of mechanical ventilation and ICU stay were significant between non-COPD patients and severe COPD （GOLD stage IV ） patients （ P = 0. 001 and P = 0. 002, respectively）. Multivariable analysis identified COPD [ OR （95% CI） 2.52 （1.34-5.12）] at VAP diagnosis [-3.70 （1.86-7.34）] as independent risk factors for ICU mortality. Conclusions COPD at VAP diagnosis are independently associated with ICU mortality in patients who present VAP.