急性呼吸窘迫综合征呼吸机捆绑式治疗及其与炎症生物标志物的关系

Ventilator bundle treatment of acute respiratory distress syndrome and its correlation with biomarkers of inflammation

目的 通过观察血中可溶性尿激酶型纤溶酶原激活物受体（suPAR）、高级糖基化终产物受体（RAGE）、降钙素原（PCT）及C-反应蛋白（CRP）水平变化,探讨呼吸机捆绑式治疗对急性呼吸窘迫综合征（ARDS）患者预后的影响.方法 采用前瞻性对照研究方法,选择兰州大学第二医院重症医学科2013年1月至12月接受有创机械通气治疗的ARDS患者共54例,给予呼吸机捆绑式治疗措施,依据实施的依从性分为完全依从组（VB组,29例）和非完全依从组（NVB组,25例）.比较两组患者机械通气时间、重症监护病房（ICU）住院时间、呼吸机相关性肺炎（VAP）及相关并发症的发生率以及28 d病死率;检测患者治疗前后血中suPAR、RAGE、PCT、CRP水平;对氧合指数（PaO2/FiO2）与其他变量的相关性进行Pearson相关分析和多元线性回归分析.结果 ①两组患者性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分及PaO2/FiO2等基础状态无明显差异.②两组患者治疗前suPAR、RAGE、PCT、CRP水平无明显差异;治疗后上述标志物水平均明显下降,其中VB组suPAR及RAGE水平较NVB组下降显著[suPAR （ng/L）：189.87（135.57）比309.38（278.00）,RAGE（μg/L）：2.17（0.75）比3.17（2.64）,均P＜0.01].③与NVB组比较,VB组机械通气时间、ICU住院时间、VAP发生率明显降低[机械通气时间（h）：131.52±44.94比166.28±38.09,t=-3.039,P=0.004;ICU住院时间（h）：171.14±74.25比210.92±54.89,t=-2.208,P=0.032;VAP发生率：17.24％比44.00％,x2=4.611,P=0.041],而VB组和NVB组28 d病死率（27.59％比36.00％,x2=0.441,P=0.566）及其他相关并发症发生率均无明显差异.④Pearson相关分析显示,PaO2/FiO2与年龄（r=-0.290,P=0.033）、suPAR（r=-0.898,P=0.000）、RAGE（r=-0.898,P=0.000）、PCT（r=-0.486,P=0.000）及CRP（r=-0.280,P=0.040）均呈负相关.⑤多元线性回归分析显示,PaO2/FiO2与suPAR（t=2.645,P=0.011）、RAGE（t=-2.885,P=0.006）、PCT（t=2.649,P=0.011）显著相关.结论 血中suPAR、RAGE、PCT、CRP水平与ARDS患者病情严重程度相关.呼吸机捆绑式治疗实施的依从性能够影响ARDS患者预后,完全依从者上述炎症标志物水平显著降低,且能缩短机械通气及ICU住院时间,降低VAP发生率,改善患者预后.

Objective To observe the levels of blood soluble urokinase plasminogen activator receptor （suPAR）,receptor of advanced glycation end products （RAGE）,procalcitonin （PCT） and C-reactive protein （CRP）,and to investigate the effect of ventilator bundle （VB） on prognosis of patients with acute respiratory distress syndrome （ARDS）.Methods A prospective controlled study was conducted.A total of 54 cases of ARDS patients admitted to Department of Critical Care Medicine of the Second Hospital of Lanzhou University who received treatment of invasive mechanical ventilation between January 2013 and December 2013 were enrolled.All of the patients were given VB,and then divided into completely dependent group （VB group,n =29） and non-completely dependent group （NVB group,n =25） according to the dependence.The mechanical ventilation time,intensive care unit （ICU） length of stay,the incidence of ventilator associated pneumonia （VAP）,the incidence of complications and 28-day mortality rate were compared between two groups.The blood suPAR,RAGE,PCT and CRP levels before and after treatment were determined.The correlations between oxygenation index （PaO2/FiO2） and other variables were analyzed by Pearson correlation and linear regression analysis.Results ① There was no significant difference in gender,age,acute physiology and chronic health evaluation]] （APACHE Ⅱ） score and PaO2/FiO2,as well as other basic state between two groups.② There was no obvious difference in suPAR,RAGE,PCT and CRP levels before treatment between two groups.The levels of above parameters were significantly decreased after treatment.The blood suPAR and RAGE levels in VB group were significantly decreased compared with those in NVB group [suPAR （ng/L）：189.87 （135.57） vs.309.38 （278.00）,RAGE （μg/L）：2.17 （0.75） vs.3.17 （2.64）,both P〈0.01].③ Compared with NVB group,the mechanical ventilation time,ICU length of stay,and the incidence of VAP in VB group were significantly reduced [mechanical ventilation time （hours）：131.52 ±44.94 vs.166.28 ± 38.09,t=-3.039,P=0.004; ICU length of hospital stay （hours）：171.14 ± 74.25 vs.210.92 ± 54.89,t=-2.208,P=0.032; incidence of VAP：17.24% vs.44.00%,x 2=4.611,P=0.041],but 28-day mortality rate （27.59% vs.36.00%,x 2=0.441,P=0.566） and rates of other related complication showed no significant difference between VB group and NVB group.④ Correlation analysis showed that PaO2/FiO2 was negatively correlated with age （r=-0.290,P=0.033）,suPAR （r=-0.898,P=0.000）,RAGE （r=-0.898,P=0.000）,PCT （r=-0.486,P=0.000）and CRP （r=-0.280,P=0.040）.⑤The linear regression analysis showed PaO2/FiO2 and suPAR （t=2.645,P=0.011）,RAGE （t=-2.885,P=0.006）,PCT （t=2.649,P=0.011） were significantly negatively co-related.Conclusions Blood suPAR,RAGE,PCT and CRP levels were correlated with the severity of ARDS patients.Compliance of VB can affect the prognosis of patients with ARDS.The high compliance of patients can significantly decrease the levels of blood pro-inflammatory markers,shorten the mechanical ventilation time and ICU length of stay,reduce the incidence of VAP,and it showed a positive impact on patients＇ prognosis.