螺旋型鼻肠管幽门后喂养预防神经重症患者呼吸机相关性肺炎:一项来自3个临床随机对照试验数据的回顾性分析

Effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia in neurocritical care patients:a retrospective analysis of three clinical randomized controlled trials

目的探讨螺旋型鼻肠管幽门后喂养对神经重症患者呼吸机相关性肺炎(VAP)的影响。方法回顾性分析2012年4月至2019年3月参与广东省人民医院3个幽门后置管随机对照试验(RCT)的175例机械通气超过48h的神经重症成人患者临床资料。收集患者性别、年龄、神经系统疾病病因、基础疾病、用药情况、气管导管重插管、纤维支气管镜(纤支镜)检查、鼻肠管远端置管位置,以及患者入选临床试验时的急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、格拉斯哥昏迷评分(GCS)、急性胃肠功能损伤(AGI)分级等临床资料。根据是否发生VAP将患者分为VAP组和非VAP组,比较两组各指标的差异,然后将单因素分析中P<0.1的影响因素纳入多因素Logistic回归分析,确定VAP的危险因素。此外,根据鼻肠管远端置管位置将患者分为胃内组和幽门后组,对不同置管位置以及不同人群VAP发病进行亚组分析。结果①175例机械通气神经重症患者中有42例发生VAP,VAP发生率为24.0%。②单因素分析显示,P<0.1的VAP影响因素有幽门后喂养、APACHEⅡ评分、GCS评分及纤支镜检查,其中VAP组幽门后喂养比例和GCS评分显著低于非VAP组〔幽门后喂养:19.0%(8/42)比36.8%(49/133),GCS(分):5(3,7)比6(4,9),均P<0.05〕。多因素Logistic回归分析显示,幽门后喂养是减少VAP的独立保护因素〔优势比(OR)=0.360,95%可信区间(95%CI)=0.151~0.857,P=0.021〕,纤支镜检查是VAP的独立危险因素(OR=2.210,95%CI=1.051~4.647,P=0.036)。③经床旁X线证实的鼻肠管远端置管位置在胃内、十二指肠第一段(D1)、第二段(D2)、第三段(D3)、第四段(D4)及空肠段患者的VAP发生率分别为28.8%(34/118)、0%(0/4)、8.3%(1/12)、26.7%(4/15)、22.2%(2/9)及5.9%(1/17)。与胃内置管相比,幽门后各段置管患者的VAP发生率相对较低,但差异均无统计学意义(均P>0.05)。④在全体患者中,幽门后组VAP发生率显著低于胃内组〔14.0%(8/57)比28.8%(34/118),OR=0.403,95%CI=0.173~0.941,P=0.032〕。根据年龄、性别、APACHEⅡ评分、SOFA评分及AGI分级对胃内喂养及幽门后喂养患者进行分层分析,结果显示,在SOFA<12分及AGI≥Ⅱ级的患者中,幽门后组VAP发生率均显著低于胃内组(SOFA<12分:OR=0.392,95%CI=0.154~0.995,P=0.044;AGI≥Ⅱ级:OR=0.086,95%CI=0.011~0.705,P=0.006)。结论幽门后喂养可降低神经重症患者VAP发生率。

Objective To explore the effect of post-pyloric feeding by spiral nasoenteric tubes on ventilator-associated pneumonia(VAP)in neurocritical care patients.Methods A retrospective study was performed to analyze the clinical data of 175 neurocritical care adult patients with mechanical ventilation(MV)more than 48 hours,who were enrolled in three randomized controlled trials(RCT)conducted by Guangdong Provincial People's Hospital for post-pyloric tube placement between April 2012 to March 2019.The following patient clinical data were collected when patients were enrolled:gender,age,neurologic diagnosis,comorbidities,medication,endotracheal reintubation,bronchoscope treatment,the distal site of nasoenteric tubes,and acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,sequential organ failure assessment(SOFA)score,Glasgow coma scale(GCS)score,and acute gastrointestinal injury(AGI)grade assessed.Patients were divided into VAP group and non-VAP group according to the occurrence of VAP,and the differences of each index between the two groups were compared.Then the influencing factors of P<0.1 were included in multivariate Logistic regression analysis to identify the potential risk factors affecting the incidence of VAP.Furthermore,patients were divided into gastric feeding group and post-pyloric feeding group according to the distal site of nasoenteric tubes,and subgroup analysis was performed to evaluate the variety of VAP in patients with different tube sites and status.Results①Forty-two patients occurred VAP in 175 MV patients,and the incidence of VAP was 24.0%.②Univariate analysis showed the P value of post-pyloric feeding,APACHEⅡscore,GCS score and bronchoscope treatment were less than 0.1,and post-pyloric feeding and GCS score in VAP group were significantly lower than those in non-VAP group[post-pyloric feeding:19.0%(8/42)vs.36.8%(49/133),GCS:5(3,7)vs.6(4,9),both P<0.05].Multivariate Logistic regression analysis indicated that post-pyloric feeding was independent protective factor[odds ratio(OR)=0.360,95%confidence internal(95%CI)=0.151-0.857,P=0.021]and bronchoscope treatment was the independent risk factor(OR=2.210,95%CI=1.051-4.647,P=0.036)for VAP.③The incidence of VAP was 28.8%(34/118),0%(0/4),8.3%(1/12),26.7%(4/15),22.2%(2/9)and 5.9%(1/17)respectively when tube tip in stomach,D1,D2,D3,D4 and jejunum confirmed by abdominal radiography.Post-pyloric feeding in each proportion seemed to present lower VAP rate compared with gastric feeding,however,no significant difference was found(all P>0.05).④The incidence of VAP in post-pyloric feeding group was significantly lower than that in gastric feeding group[14.0%(8/57)vs.28.8%(34/118),OR=0.403,95%CI=0.173-0.941,P=0.032].Lower VAP rate appeared on patients with SOFA<12(OR=0.392,95%CI=0.154-0.995,P=0.044)and AGI grade≥Ⅱ(OR=0.086,95%CI=0.011-0.705,P=0.006)fed by post-pyloric route according to the result of subgroup analysis stratified by age,gender,APACHEⅡscore,SOFA score and AGI grade.Conclusion Post-pyloric feeding would decrease the incidence of VAP in neurocritical care patients on MV.