特重度烧伤伴吸入性损伤患者支气管壁厚度动态变化趋势及对预后的意义

Dynamic variation trend and prognostic value of bronchial wall thickness in severely burned patients combined with inhalation injury

目的 探讨特重度烧伤伴吸入性损伤患者支气管壁厚度（BWT）动态变化趋势，并确定BWT对患者预后诊断的意义。方法 2016年7—11月，南开大学附属医院（天津市第四医院）重症烧伤科收治43例符合入选标准的特重度烧伤伴吸入性损伤患者，将其根据入院14 d内预后情况分为存活组27例和死亡组16例。所有患者均在入院时完成纤维支气管镜检查，依据简明损伤定级行吸入性损伤评级。分别于入院时及入院24 h、3 d、7 d、14 d对2组患者行胸部高分辨率CT检查，测量右肺上叶支气管主干开口处的BWT。绘制43例患者入院时吸入性损伤评级及入院时BWT的受试者工作特征曲线，评估其对死亡的预测效果。对数据行χ^2检验、独立样本t检验、Wilcoxon秩和检验、重复测量方差分析、LSD－t检验。结果 （1）存活组中吸入性损伤评级0、1、2、3、4级患者数分别为0、19、6、2、0例，死亡组中分别为0、2、7、7、0例，2组差异明显（Z＝－3.79，P〈0.01）。（2）死亡组患者入院时及入院24 h、3 d、7 d、14 d的BWT分别为（2.72±0.26）、（3.18±0.22）、（2.98±0.18）、（2.29±0.17）、（1.45±0.21）mm，明显大于存活组的（2.24±0.15）、（2.49±0.15）、（1.51±0.17）、（1.04±0.16）、（1.01±0.13）mm（t＝7.55、12.14、27.11、19.99、7.11，P〈0.01）。存活组、死亡组患者入院24 h、3 d、7 d、14 d的BWT均与对应组内入院时有明显差异（t＝5.97、16.63、28.21、38.57，5.34、3.31、4.39、6.48，P〈0.01），入院3、7、14 d的BWT均较对应组内入院24 h减小（t＝22.27、34.02、45.03，2.77、10.53、10.59，P〈0.01），入院7、14 d的BWT均较对应组内入院3 d减小（t＝10.49、18.26，9.57、11.44，P〈0.01），入院14 d的BWT均较对应组内入院7 d减小（t＝6.97、6.15，P〈0.01）。（3）预测43例患者死亡的入院时吸入性损伤评级、入院时BWT的受试者工作特征曲线下总面积分别为0.880、0.956（95%置信区间分别为0.768-0.991、0.882-1.000，P〈0.05），入院时吸入性损伤评级、入院时BWT的最佳阈值分别为1.5级、2.75 mm，其对死亡预测的敏感度分别为87.50%、83.33%，特异度分别为77.78%、96.00%。结论 存活和死亡的特重度烧伤伴吸入性损伤患者伤后BWT均明显增大，而存活患者的BWT恢复至正常水平较快。BWT可用于特重度烧伤伴吸入性损伤患者的吸入性损伤严重程度评估及死亡预测。

Objective To explore the dynamic variation trend of bronchial wall thickness （BWT） in severely burned patients combined with inhalation injury, and to determine the value of BWT to prognosis of patients.Methods Forty-three severely burned patients with inhalation injury hospitalized in Intensive Burn Department of the Affiliated Hospital of Nankai University （Tianjin No.4 Hospital） from July to November 2016, conforming to the study criteria, were divided into survival group （n=27） and death group （n=16） according to the prognosis of patients within 14 days after admission. All patients underwent fiberoptic bronchoscopy and inhalation injury rating based on abbreviated injury scale at admission. High resolution CT examination was performed in patients of two groups at admission and 24 h post admission, 3, 7, and 14 d post admission to measure the BWT of right superior lobar bronchus trunk opening. Receiver operating characteristic curves of rating of inhalation damage at admission and BWT at admission were drawn to evaluate the predictive value for death of 43 patients. Data were processed with chi-square test, independent sample t test, Wilcoxon rank sum test, analysis of variance for repeated measurement and least-significant difference-t test.Results （1） The numbers of patients rated as 0, 1, 2, 3, and 4 grade for inhalation injury in survival group and death group were 0, 19, 6, 2, and 0, and 0, 2, 7, 7, and 0, respectively. There were statistically significant differences between the two groups （Z=-3.79, P〈0.01）. （2） BWT of patients in death group at admission and 24 h post admission, 3, 7, and 14 d post admission was respectively （2.72±0.26）, （3.18±0.22）, （2.98±0.18）, （2.29±0.17）, and （1.45±0.21） mm, which was significantly larger than （2.24±0.15）, （2.49±0.15）, （1.51±0.17）, （1.04±0.16）, and （1.01±0.13） mm in survival group （t=7.55, 12.14, 27.11, 19.99, 7.11, P〈0.01）. BWT of patients in survival group and death group at 24 h post admission, 3, 7, and 14 d post admission showed statistically significant difference when compared with that at admission within the corresponding group （t=5.97, 16.63, 28.21, 38.57, 5.34, 3.31, 4.39, 6.48, P〈0.01）. BWT of patients in survival group and death group on 3, 7, and 14 d post admission was significantly smaller than that at 24 h post admission within the corresponding group （t=22.27, 34.02, 45.03, 2.77, 10.53, 10.59, P〈0.01）. BWT of patients in survival group and death group on 7 and 14 d post admission was significantly smaller than that on 3 d post admission within the corresponding group （t=10.49, 18.26, 9.57, 11.44, P〈0.01）. BWT of patients in survival group and death group on 14 d post admission was significantly smaller than that on 7 d post admission within the corresponding group （t=6.97, 6.15, P〈0.01）. （3） The total areas under ROC curves of inhalation injury rating at admission and BWT at admission for predicting death of 43 patients were 0.880 and 0.956, respectively （with 95% confidence intervals 0.768-0.991, 0.882-1.000, P〈0.05）. Grade 1.5 and 2.75 mm were respectively chosen as the optimal threshold values of inhalation injury rating at admission and BWT at admission, with sensitivity of 87.50%, 83.33% and specificity of 77.78%, 96.00%, respectively.Conclusions The BWT of survived and dead patients with severe burn and inhalation injury increases significantly post burn, while the BWT of survived patients restores to normal level faster. BWT can be used to assess the severity of inhalation injury and to predict death in severely burned patients combined with inhalation injury.