老年急性呼吸窘迫综合征患者的预后及影响因素分析

Prognosis and related risk factors of acute respiratory distress syndrome in elder patients

目的调查中国大陆地区老年急性呼吸窘迫综合征(ARDS)患者院内死亡情况及其相关影响因素。方法采用前瞻性多中心非干预性队列研究。收集2016年3月1日至2018年2月28日中国大陆19家医院的20个ICU内符合柏林ARDS标准定义的老年(≥65岁)ARDS患者。收集患者的基本信息、ARDS高危因素、呼吸支持数据和预后数据,描绘老年ARDS预后情况并分析相关危险因素。结果共入组170例老年ARDS患者,轻度、中度和重度患者分别为15例(8.8%)、73例(42.9%)和82例(48.2%)。老年ARDS最常见的诱发因素是肺炎(134例,78.8%)。在ICU住院期间,共64例(37%)老年患者接受了无创通气,其中28例(43.8%)转为有创机械通气。ICU期间使用有创通气的老年ARDS患者为130例(76.5%),其中80岁以上老年人最终全部使用了有创通气。88例(51.8%)患者合并了其他脏器功能衰竭。105例(61.8%)患者发生院内死亡。多因素分析提示入组24 h后的序贯性脏器功能衰竭(SOFA)评分和氧合指数、入ICU前7 d累积液体平衡及休克为院内存活的独立影响因素(入组24 h氧合指数:P=0.0300,RR=0.196,95%CI为0.045~0.853;入组24 h SOFA:P=0.030,RR=0.725,95%CI为0.543~0.969;前7 d累积液体平衡:P=0.026,RR=1.000,95%CI为1.000~1.000;合并休克:P=0.034,RR=0.140,95%CI为0.023~0.863)。结论入住ICU的老年ARDS患者住院病死率高,入组24 h后更高的SOFA评分、更低的氧合指数、入ICU前7 d更高的累积液体正平衡及休克会增加老年患者的住院病死率。入ICU后的前7 d在循环稳定的前提下维持液体负平衡可能改善ARDS的住院存活。

Objective To study the risk factors associated with the hospital survival rate of elder patients with acute respiratory distress syndrome(ARDS)in Medical/Respiratory Intensive Care Units(MICUs/RICUs)by evaluating the prognosis,and therefore to provide insight into patient treatment strategy.Methods Twenty MICUs/RICUs of 19 general hospitals in China's Mainland participated in the multicenter prospective cohort study carried out from Mar 1st,2016 to Feb 28th,2018.Patients who met the criteria of Berlin ARDS and older than 65 years were recruited.Baseline data,risk factors of ARDS,ventilator setup and prognosis data were collected from all patients.Univariant and multivariant regression analysis were conducted to analyze the factors associated with the prognosis.Results 170 elder ARDS patients(age≥65 years)met the Berlin ARDS criteria,among whom 8.8%(15/170),42.9%(73/170)and 48.2%(82/170)patients had mild,moderate and severe ARDS,respectively.The most common predisposing factor for elder ARDS was pneumonia,which was present in 134 patients(78.8%).37.6%(64/170)patients were treated with noninvasive mechanical ventilation(NIV),but 43.8%(28/64)cases experienced treatment failure.76.5%(130/170)patients were treated with invasive mechanical ventilation.All patients 80 years or older were given invasive mechanical ventilation.51.8%(88/170)cases had complications of non-pulmonary organ failure.61.8%(105/170)patients deceased during hospital stay.Multivariant logistic analysis showed that the independent risk factors for hospital survival rate in elder patients with ARDS were SOFA score(P=0.030,RR=0.725,95%CI 0.543-0.969),oxygen index after 24 hours of ARDS diagnosis(P=0.030,RR=0.196,95%CI 0.045-0.853),accumulated fluid balance within 7 days after diagnosis of ARDS(P=0.026,RR=1.000,95%CI 1.000-1.000)and shock(P=0.034,RR=0.140,95%CI 0.023-0.863).Conclusion Among 20 ICUs,the high mortality rate of elder patients with ARDS was correlated with higher 24 hour SOFA score,lower 24 hour oxygen index after ARDS diagnosis,more positive fluid balance within 7 days and concomitant shock.The conservative fluid strategy within 7 days of ARDS diagnosis may benefit the elder ARDS patients.