间接能量代谢测定值与经验能量估算值在COPD患者中的差异性分析

Analysis of the difference between indirect calorimetry and predicted energy estimation in patients with chronic obstructive pulmonary disease

目的 分析间接能量代谢测定法（IC）与经验能量估算法测定慢性阻塞性肺疾病（COPD）患者静息能量目标值的偏离情况及其影响因素，为COPD患者提供合理能量供给依据。方法 采用前瞻性队列研究方法，选择2016年1至12月浙江省杭州市富阳区第一人民医院重症医学科（ICU）收治的26例接受机械通气（MV）的COPD患者。分别采用IC测定法和经验估算法计算患者的静息能量目标值，根据IC测定值偏离经验能量估算值的程度将患者分为能量接近组（IC测定值偏离经验估算值≤15%）和能量偏离组（IC测定值偏离经验估算值〉15%）。绘制Bland-Altman图，分析两种方法测定能量目标值的一致性；采用多因素Logistic回归和线性回归分析筛选导致两种测定方法能量目标值偏离的影响因素。结果 26例患者均纳入最终分析，IC测定值明显高于经验估算值（kJ：7？079.3±1？213.4比6？527.0±949.8），差异有统计学意义（P〈0.01）；Bland-Altman分析显示，经验估算值与IC测定值整体一致性尚可。能量接近组14例，能量偏离组12例；两组患者性别、年龄、体重指数（BMI）、COPD疾病类型和急性生理学与慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分差异均无统计学意义。能量偏离组患者IC测定值明显高于经验估算值（kJ：7？711.1±1？125.5比6？556.3±907.9，P〈0.01）；而能量接近组IC测定值与经验估算值差异无统计学意义（kJ：6？539.6±1？037.6比6？501.9±1？016.7，P〉0.05）。多因素Logistic回归分析显示，APACHE Ⅱ评分是导致IC测定值与经验估算值偏离的独立危险因素〔优势比（OR）=1.403，95%可信区间（95%CI）=1.019~1.932，P=0.038〕。多因素线性回归分析显示，APACHE Ⅱ评分每增加1分，能量偏离值增加2.0 kJ（β=0.476，95%CI=0.004~0.956，P=0.047）。结论 对于COPD患者，经验估算法与IC测定法测得的静息能量目标值一致性尚可；APACHE Ⅱ评分是导致IC测定值与经验估算值偏离的独立危险因素，提示对于APACHE Ⅱ评分较高的患者，建议应用IC测定法测定静息能量目标值。

Objective To analyze the difference between indirect calorimetry （IC） and predicted energy estimation in patients with chronic obstructive pulmonary disease （COPD）, and its possible factors affecting the difference, to provide reasonable energy supply basis for COPD patients.Methods A prospective cohort study was conducted. Twenty-six patients with COPD undergoing mechanical ventilation （MV） admitted to intensive care unit （ICU） of Hangzhou City Fuyang District First People＇s Hospital in Zhejiang Province from January to December in 2016 were enrolled. The energy values of patients were calculated by IC and predicted energy estimation, respectively. According to the degree of IC values deviating from the predicted energy estimation, the patients were divided into energy approaching group （IC values deviating from the empirical energy estimation ≤15%） and energy deviation group （IC values deviating from the empirical energy estimation 〉 15%）. Bland-Altman diagram was drawn, and the consistency of the energy target values assessing by two methods was analyzed. The factors influencing the energy value deviation of the two measuring methods were screened by the multivariate Logistic regression and linear regression analysis.Results Twenty-six patients were enrolled in the final analysis. The energy target value of IC was significantly higher than that of predicted energy estimation （kJ： 7？079.3±1？213.4 vs. 6？527.0±949.8）, and the difference between two values was statistically significant （P 〈 0.01）. Bland-Altman heterogeneity analysis showed that the overall consistency of the energy values between the predicted energy estimation and IC was quite good. There were 14 patients in energy approaching group, and 12 in energy deviation group. There was no significant difference in gender, age, body mass index （BMI）, type of COPD, or acute physiology and chronic health evaluation Ⅱ （APACHEⅡ） score between the two groups. In energy deviation group, the IC value of patients was significantly higher than predicted energy estimation （kJ： 7？711.1±1？125.5 vs. 6？556.3±907.9, P 〈 0.01）. However, in energy approaching group, there was no significant difference between the energy values of IC and predicted energy estimation （kJ： 6？539.6±1？037.6 vs. 6？501.9±1？016.7, P 〉 0.05）. Multivariate Logistic regression analysis showed that APACHEⅡ score was an independent risk factor inducing the deviation of energy evaluation between IC and predicted energy estimation [odds ratio （OR） = 1.403, 95% confidence interval （95%CI） = 1.019-1.932, P = 0.038]. Multivariate linear regression analysis showed that the APACHEⅡ score increased by 1, and the energy deviation increased by 2.0 kJ （β = 0.476, 95%CI = 0.004-0.956, P = 0.047）.Conclusions For patients with COPD, there was a good correlation between predicted energy estimation and the resting energy expenditure measured by IC. APACHE Ⅱ score was an independent risk factor inducing the deviation of energy evaluation between IC and predicted energy estimation. It is suggested that the target value of energy should be determined by IC for patients with high APACHE Ⅱ score.