重症社区获得性肺炎高龄患者有创通气序贯无创通气的时机探讨

Timing of sequential noninvasive mechanical ventilation following early extubation in aged patients with severe community-acquired pneumonia

目的:探讨重症社区获得性肺炎(SCAP)高龄患者经气管插管机械通气(ETI-MV)拔管后序贯无创正压通气(NIPPV)的时机。方法:采用前瞻性队列研究方法,选择2017年7月至2019年8月新疆医科大学第一附属医院呼吸加强医疗病房(RICU)连续收治的年龄≥75岁、符合中华医学会呼吸病学分会《中国成人社区获得性肺炎诊断和治疗指南(2016年版)》诊断标准的SCAP高龄患者作为研究对象。患者入RICU后均以ETI-MV作为初始呼吸支持治疗手段;当达到肺部感染减轻窗口时拔除气管导管,然后序贯NIPPV治疗。记录患者性别、年龄、基础疾病以及入RICU时体温、心率(HR)、呼吸频率(RR)、氧合指数(PaO 2/FiO 2)和入RICU 24 h内急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、英国胸科协会改良肺炎评分(CURB-65)、肺炎严重度指数(PSI)评分,同时记录患者ETI时间和次数、呼吸机相关性肺炎(VAP)和误吸发生情况、总机械通气(MV)时间、RICU住院时间、总住院时间和RICU预后。根据ETI时间将患者分为ETI≤7 d组和ETI>7 d组,比较两组患者临床资料;采用多因素Logistic回归分析筛选SCAP高龄患者ETI>7 d的危险因素;绘制受试者工作特征曲线(ROC),评估危险因素的预测价值。结果:共50例SCAP高龄患者纳入最终分析,其中ETI≤7 d组24例,ETI>7 d组26例。单因素分析结果显示,与ETI≤7 d组比较,ETI>7 d组患者合并脑血管疾病的比例及VAP、误吸发生率均明显升高〔46.2%(12/26)比16.7%(4/24),61.5%(16/26)比16.7%(4/24),69.2%(18/26)比25.0%(6/24),均P<0.05〕。多因素Logistic回归分析显示,VAP和误吸是SCAP高龄患者ETI>7 d的独立危险因素〔VAP:优势比(OR)=4.852,95%可信区间(95%CI)为1.076~21.877,P=0.040;误吸:OR=5.903,95%CI为1.474~23.635,P=0.012〕。ROC曲线分析显示,VAP预测SCAP高龄患者ETI>7 d的ROC曲线下面积(AUC)为0.724,其敏感度为61.54%,特异度为83.33%,阳性预测值(PPV)为80.00%,阴性预测值(NPV)为66.67%,阳性似然比(PLR)为3.69,阴性似然比(NLR)为0.46,约登指数为0.45;误吸的AUC为0.721,其敏感度为69.23%,特异度为75.00%,PPV为75.00%,NPV为69.23%,PLR为2.77,NLR为0.41,约登指数为0.44。预后指标分析显示,与ETI≤7 d组相比,ETI>7 d组患者再插管率和RICU病死率均明显升高〔53.8%(14/26)比4.2%(1/24),38.5%(10/26)比12.5%(3/24),均P<0.05〕,且总MV时间、RICU住院时间和总住院时间均明显延长〔总MV时间(d):23.8±11.8比11.3±3.1,RICU住院时间(d):30.6±14.1比16.0±5.1,总住院时间(d):33.0±14.9比20.2±6.1,均P<0.01〕。结论:SCAP高龄患者如在7 d内拔除气管导管序贯NIPPV治疗,则可能有助于降低病死率,缩短MV时间;如患者发生VAP和误吸导致ETI时间延长,则序贯NIPPV的作用较小,预后较差。

Objective To explore the timing of sequential noninvasive positive pressure ventilation(NIPPV)following endotracheal intubation mechanical ventilation(ETI-MV)in aged patients with severe community-acquired pneumonia(SCAP).Methods A prospective cohort study was conducted.The SCAP patients aged≥75 years old admitted to respiratory intensive care unit(RICU)of the First Affiliated Hospital of Xinjiang Medical University from July 2017 to August 2019 were enrolled.SCAP was diagnosed according to the criteria of Guidelines for the diagnosis and treatment of community-acquired pneumonia in adults in China(2016)published by Chinese Thoracic Society.ETI-MV was initially performed as respiratory support after RICU admission.Sequential NIPPV was performed immediately following extubation when the patients exhibited pulmonary infection abated(PIA)window.The gender,age,underlying diseases,and body temperature,heart rate(HR),respiratory rate(RR),oxygenation index(PaO2/FiO2)after RICU admission,as well as acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,improved pneumonia score of British Thoracic Society(confusion,uremia,respiratory,blood pressure,age 65 years,CURB-65),and pneumonia severity index(PSI)score within 24 hours after RICU admission were recorded.The duration and times of ETI,the incidences of ventilator associated pneumonia(VAP)and aspiration,the duration of mechanical ventilation(MV),the length of RICU and hospital stay and RICU prognosis were also recorded.The patients were divided into the ETI≤7 days group and the ETI>7 days group according to the duration of ETI,and the clinical data were compared between the two groups.Multivariate Logistic regression analysis was used to screen the risk factors of aged patients with SCAP whose ETI was more than 7 days,and receiver operator characteristic(ROC)curve was drawn to evaluate the predictive value of risk factors.Results Fifty aged patients with SCAP were enrolled,with 24 patients in the ETI≤7 days group and 26 in the ETI>7 days group.Univariate analysis showed that compared with the patients with ETI≤7 days,the incidences of concurrent cerebrovascular diseases[46.2%(12/26)vs.16.7%(4/24)],VAP[61.5%(16/26)vs.16.7%(4/24)]and aspiration[69.2%(18/26)vs.25.0%(6/24)]were significantly increased in patients with ETI>7 days(all P<0.05).Multivariate Logistic regression analysis indicated that VAP and aspiration were independent risk factors of ETI>7 days in the aged SCAP patients[VAP:odds ratio(OR)=4.852,95%confidence interval(95%CI)was 1.076-21.877,P=0.040;aspiration:OR=5.903,95%CI was 1.474-23.635,P=0.012].ROC curve analysis showed that the area under ROC curve(AUC)of VAP for predicting ETI>7 days in aged patients with SCAP was 0.724,the sensitivity,specificity,positive predictive value(PPV),negative predictive value(NPV),positive likelihood ratio(PLR),negative likelihood ratio(NLR)and Youden index were 61.54%,83.33%,80.00%,66.67%,3.69,0.46 and 0.45,respectively.Similarly,the AUC of aspiration was 0.721,the sensitivity,specificity,PPV,NPV,PLR,NLR and Youden index were 69.23%,75.00%,75.00%,69.23%,2.77,0.41 and 0.44,respectively.Analysis of prognostic indicators showed that compared with patients with ETI≤7 days,the reintubation rate and RICU mortality were significantly increased in patients with ETI>7 days[53.8%(14/26)vs.4.2%(1/24),38.5%(10/26)vs.12.5%(3/24),both P<0.05].Moreover,the patients with ETI>7 days had significantly prolonged total duration of MV,the length of RICU stay and total hospital stay as compared with the patients with ETI≤7 days[total duration of MV(days):23.8±11.8 vs.11.3±3.1,length of RICU stay(days):30.6±14.1 vs.16.0±5.1,total length of hospital stay(days):33.0±14.9 vs.20.2±6.1,all P<0.01].Conclusions Sequential NIPPV performed immediately following extubation within 7 days in the aged SCAP patients might reduce the mortality and shorten the duration of MV.The prolonged ETI duration because of the VAP or aspiration would lead to a reduced function of sequential NIPPV and an increased mortality of the aged patients with SCAP.