AECOPD患者无创通气成败的危险因素评估

Risk factors evaluation for the success or failure of noninvasive ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease

目的分析慢性阻塞性肺病急性加重期AECOPD患者无创通气成败的危险因素,以指导临床风险评估及治疗。方法回顾性分析2015-01至2019-12入住我院EICU的行无创通气的78例AECOPD患者的临床资料,根据使用无创呼吸机成功与否,将患者分为无创通气成功组(n=48)与无创通气失败组(n=30),比较两组患者的性别、年龄、BMI、APACHE-II评分、合并MODS比率、COPD病程时间、意识障碍比率、排痰困难比率、循环障碍比率、T、HR、RR、PH值、PCO_(2)、PO_(2)、血红蛋白、白蛋白、白细胞计数、中性粒细胞百分比、PCT、CRP等情况。结果两组患者在性别、年龄、BMI、合并MODS比率、COPD病程时间、T、HR、PH值、PO_(2)方面无显著性差异(P>0.05);无创通气成功组的APACHE-Ⅱ评分、RR、血红蛋白水平、PCO_(2)小于无创通气失败组,存在意识障碍、排痰困难、循环障碍的比率少于无创通气失败组,白蛋白水平大于无创通气失败组,差异有统计学意义(P<0.05);无创通气成功组患者的白细胞计数、中性粒细胞百分比、PCT、CRP等炎症指标均小于无创通气失败组,但差异无统计学意义(P>0.05)。多因素Logistic回归分析显示PCO_(2)、白蛋白水平是无创通气失败的独立危险因素(P<0.05)。ROC分析显示,PCO_(2)的AUC为0.768(95%CI 0.655~0.881),最佳截断值63.6,灵敏度76.7%,特异度70.8%;白蛋白水平的AUC为0.665(95%CI 0.539~0.790),最佳截断值30.4,灵敏度85.4%,特异度50.0%;PCO_(2)联合白蛋白水平的AUC为0.840(95%CI 0.737~0.944),灵敏度86.7%,特异度81.2%,其预测能力优于单一指标。结论AECOPD患者存在意识障碍、排痰困难、循环障碍、RR增快、PCO_(2)升高、血红蛋白升高、白蛋白水平下降等是引起其无创通气失败的危险因素,PCO_(2)升高、白蛋白水平下降是其独立危险因素。PCO_(2)升高、白蛋白水平下降对AECOPD患者无创通气失败的有一定的预测价值,两指标联合的预测能力更强。临床医生应早期识别危险因素,以评估患者机械通气方式及治疗措施。

Objective To analyze the risk factors of success or failure of noninvasive ventilation in patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease(AECOPD)so as to guide clinical risk assessment and treatment.Methods The clinical data of 78 AECOPD patients admitted to the Emergency Intensive Care Unit of our hospital from January 2015 to December 2019 were analyzed retrospectively.According to the success or failure of using the noninvasive ventilator,the patients were divided into the noninvasive ventilation success group(n=48)and the noninvasive ventilation failure group(n=30).Gender,age,Body Mass Index(BMI),Acute Physiology and Chronic Health EvaluationⅡscore(APACHE-II),combined MODS ratio,COPD course time,consciousness disturbance ratio,sputum excretion difficulty ratio,circulatory disturbance ratio,Temperature(T),Heart Rate(HR),Respiratory Rate(RR),PH value,Partial Pressure of Carbon Dioxide(PCO_(2)),Partial Pressure of Oxygen(PO_(2)),hemoglobin,albumin,white blood cell count,neutrophil percentage,Procalcitonin(PCT),and C-Reactive Protein(CRP)were compared between the two groups.Results There was no significant difference in gender,age,BMI,combined MODS ratio,COPD course time,T,HR,PH value,and PO_(2) between the two groups(P>0.05).APACHE-II score,RR,PCO_(2),and hemoglobin level in the noninvasive ventilation success group were lower than those in the noninvasive ventilation failure group;the consciousness disturbance ratio,sputum excretion difficulty ratio,and circulatory disturbance ratio were lower than that in the noninvasive ventilation failure group;the albumin level was higher than that in the noninvasive ventilation failure group,the differences were statistically significant(P<0.05).Inflammatory indicators in the noninvasive ventilation success group,including white blood cell count,neutrophils percentage,PCT,and CRP,were all lower than those in the noninvasive ventilation failure group,but the differences were not statistically significant(P>0.05).Multivariate Logistic regression analysis showed that PCO_(2) and albumin levels were the independent risk factors for noninvasive ventilation failure(P<0.05).ROC analysis showed that the AUC of PCO_(2) was 0.768(95%CI 0.655~0.881),the optimal cutoff value was 63.6,the sensitivity was 76.7%,and the specificity was 70.8%;the AUC of albumin level was 0.665(95%CI 0.539~0.790),the best cutoff value was 30.4,the sensitivity was 85.4%,and the specificity was 50.0%;the AUC of PCO_(2) combined with albumin was 0.840(95%CI 0.737~0.944),the sensitivity was 86.7%,the specificity was 81.2%.The predictive ability of PCO_(2) combined with albumin was better than that of the single index.Conclusion In AECOPD patients,consciousness disturbance,sputum excretion difficulty,circulatory disturbance,increased RR,increased PCO_(2),increased hemoglobin,and decreased albumin level are the risk factors for noninvasive ventilation failure,among which the increased PCO_(2) and decreased albumin level are the independent risk factors.The increase of PCO_(2) and the decrease of albumin level can predict the failure of noninvasive ventilation in AECOPD patients,and the predictive ability of the combination of the two indicators is even stronger.Clinicians should identify the risk factors at an early stage to evaluate the patients'mechanical ventilation methods and treatment measures.