重症H7N9禽流感合并急性肺源性心脏病的临床特点分析

The characteristics of acute cor pulmonale in critically ill patients with H7N9 influenza virus infection

目的初步分析重症H7N9禽流感患者合并急性肺源性心脏病（ACP）的发生率、危险因素及预后。方法采用回顾性研究方法，分析2013年3月至2015年9月在苏州大学附属第一医院及苏州市第五人民医院重症监护室住院治疗的H7N9禽流感确诊病例的临床资料，将数据完整的21例患者纳入本研究。ACP定义为右心室扩张合并室间隔矛盾运动，根据患者是否合并ACP分为两组，对比分析两组患者之间临床表现、呼吸机参数、床边心电图及超声心动图特点。结果21例重症H7N9禽流感患者中发生ACP6例，发生率为28．6％。ACP组患者从出现流感症状至发生ACP的中位时间为11．00（6．25，20．50）d；临床主要表现为心率加快、血流动力学不稳定及脉搏血氧饱和度（SpO2）下降，发生ACP当日心率最差值为（102．83±20．53）次／min，平均动脉压最差值为（81．83±12．14）mmHg（1mmHg=0．133kPa），氧合指数最差值为（132．40±74．90）mmHg，SpO2最差值为0．863±0．051；除SpO2外各指标与非ACP组最差值比较差异无统计学意义。ACP组患者从使用呼吸机至发生ACP的中位时间为3．50（1．75，6．75）d，呼气末正压（PEEP）及气道平台压（Pplat）明显高于非ACP组lPEEP（cmH2O，1cmH2O=0．098kPa）：15．17±3．71比11．73±2．57，Pplat（cmH2O）：27．50±1．05比23．09±4．37，均P〈0．05]，急性呼吸窘迫综合征（ARDS）及感染性休克发生率略高于非ACP组（83．3％比53．3％，50．0％比26．7％，均P〉0．05）。ACP组电轴右偏的比例较非ACP组明显增高（83．3％比13．3％，P〈0．01），中一重度三尖瓣反流（TR）及下腔静脉（Ivc）塌陷指数〈50％的患者比例高于非ACP组（100．0％比60．0％，P〉0．05；100．O％比20．0％，P〈0．01），三尖瓣反流压差（TRPG）及IVC内径明显大于非ACP组[TRPG（mmHg）：45．00±8．65比28．01±9．02，IVC内径（mm）：2．25±0．14比1．87±0．15，均P〈0．01]；急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）和序贯器官衰竭评分（SOFA）与非ACP组比较差异无统计学意义（分：23．33±7．06比19．27±5．50，7．33±1．21比7．80±3．01，均P〉O．05）；而ACP组重症加强治疗病房（ICU）病死率显著高于非ACP组（83．3％比26．7％，P〈0．05）。结论重症H7N9禽流感患者ACP发生率较高，机械通气是导致重症H7N9禽流感发生ACP的重要因素。ACP患者预后差，临床表现无特异性，加强重症H7N9禽流感患者右心功能的早期监测和干预很有必要。

Objective To explore the incidence, causal factors and prognosis of acute cot pulmonale （ACP） complicating H7N9 influenza virus infection. Methods A retrospective study was conducted. Twenty-one laboratory-confirmed H7N9 patients who required intensive care during March 2013 to September 2015 in the Affiliated First Hospital of Soochow University and Suzhou 5th People＇s Hospital were enrolled. The ACP was defined as fight ventricular （RV） dilatation with a paradoxical septal motion at end-systole. All patients were divided into two groups （ACP group and non-ACP group）, and the clinical data of all patients were analyzed retrospectively. The presentation, mechanical ventilation （MV） setting, the characteristics of bedside electrocardiogram （ECG） and echocardiography between the two groups were compared and analyzed. Results Six of 21 patients with H7N9 influenza virus infection developed ACP during hospitalization with the incidence of 28.6%, and with the presentation of tachycardia, unstabilized hemodynamics and decreased pulse blood oxygen saturation （SpO2）. The media time from onset of influenza symptom to ACP occurrence was 11.00 （6.25, 20.50） days. On the day of ACP occurrence, the worst value of heart rate was （102.83 ± 20.53） bpm, mean arterial pressure was （81.83± 12.14） mmHg （1 mmHg = 0.133 kPa）, and oxygenation index was （132.4± 74.90） mmHg, and SpO2 was 0.863±0.051, there were no statistically significant differences in above parameters as compared with those of non-ACP group except SpOz. The media from MV to ACP occurrence was 3.50 （1.75, 6.75） days. The level of positive end-expiratory pressure （PEEP） and airway plateau pressure （Pplat） in ACP group were significantly higher than those of non-ACP group [PEEP （emH20, 1 emH20 = 0.098 kPa）： 15.17 ± 3.71 vs. 11.73 ± 2.57, Pplat （emH20）： 27.50± 1.05 vs. 23.09± 4.37, both P 〈 0.05]. The incidence of acute respiratory distress syndrome （ARDS） and septic shock in ACP group were slightly higher than those of non-ACP group （83.3% vs. 53.3%, 50.0% vs. 26.7%, both P 〉 0.05）. The proportion of right axis deviation in ACP group was significantly higher than that of non-ACP group （83.3% vs. 13.3%, P 〈 0.01）, moderate-to-severe tricuspid regurgitation （TR） and inferior vena cava （IVC） collapse-index less than 50% were more common in ACP patients as compared with those of non-ACP patients （100.0% vs. 60.0%, P 〉 0.05; 100.0% vs. 20.0%, P 〈 0.01）. The value of tricuspid regurgitation pressure gradient （TRPG） and IVC diameter in ACP group were significantly higher than those of non-ACP group [TRPG （mmHg）： 45.00 ± 8.65 vs. 28.01±9.02, IVC diameter （ram）： 2.25±0.14 vs. 1.87±0.15, both P 〈 0.01]. No statistical difference in acute physiology and chronic health evaluation II （APACHE U ） and sequential organ failure assessment （SOFA） were found between ACP and non-ACP groups （23.33± 7.06 vs. 19.27 ±5.50, 7.33±1.21 vs. 7.80＋ 3.01, both P 〉 0.05）, while the intensive care unit （ICU） mortality in ACP patients was significantly higher than that of non-ACP patients （83.3% vs. 26.7%, P 〈 0.05）. Conclusions The prevalence of ACP in critically ill patients with H7N9 influenza virus irlfeetion was high. MV was an important factor responsible for the development of ACP with severe H7N9 influenza virus infection. Strengthen the monitoring and management of RV dysfunction at early stage was indispensable because of the poor prognosis and non specificity clinical symptoms of ACP in severe H7N9 virus infected patients.