严重胸部创伤并发急性呼吸窘迫综合征的相关危险因素分析

Risk factors for severe chest trauma complicated by acute respiratory distress syndrome

目的探讨严重胸部创伤并发急性呼吸窘迫综合征(ARDS)的相关危险因素。方法采用病例对照研究分析2018年1月至2020年12月联勤保障部队第九〇九医院(厦门大学医学院附属东南医院)收治的120例严重胸部创伤患者临床资料,其中男75例,女45例;年龄21~72岁[(42.2±4.8)岁]。致伤原因:交通伤57例,挤压伤21例,坠落伤21例,砸伤11例,其他10例。损伤部位:单纯胸外伤55例,合并四肢脊柱骨盆骨折34例,合并腹腔脏器损伤23例,合并头颅损伤8例。根据是否并发ARDS分为ARDS组(25例)和非ARDS组(95例)。比较各组性别、年龄、致伤原因、呼吸频率、肺挫伤、肺部感染、连枷胸、胸部简明损伤定级标准(AIS)、血气胸、血压、动脉血氧分压(PaO_(2))、入院初始中心静脉压(CVP),以及合并四肢脊柱骨盆骨折、头颅损伤和腹腔脏器损伤等情况。采用单因素分析上述指标与严重胸部创伤并发ARDS的相关性。采用多因素Logistic回归分析确定严重胸部创伤并发ARDS的独立危险因素。结果单因素分析结果显示,年龄、呼吸频率、肺挫伤、肺部感染、连枷胸、胸部AIS、血气胸、血压、PaO_(2)、入院初始CVP、合并四肢脊柱骨盆骨折、合并腹腔脏器损伤与严重胸部创伤并发ARDS有一定的相关性(P<0.05或0.01);性别、致伤原因、合并头颅损伤与严重胸部创伤并发ARDS不相关(P均>0.05)。多因素Logistic回归分析结果表明,年龄≥60岁(OR=2.45,95%CI 1.81~7.50,P<0.01)、呼吸困难(呼吸频率≥28次/min或<10次/min)(OR=9.55,95%CI 2.26~9.38,P<0.01)、肺挫伤(OR=6.78,95%CI 1.84~6.96,P<0.01)、肺部感染(OR=27.71,95%CI 11.97~64.14,P<0.01)、连枷胸(OR=8.97,95%CI 2.29~14.97,P<0.01)、胸部AIS(OR=5.77,95%CI 2.85~9.20,P<0.01)、中等量以上血气胸(OR=6.84,95%CI 1.69~13.39,P<0.01)、血压<90 mmHg(OR=7.93,95%CI 1.64~11.84,P<0.01)、PaO_(2)<60 mmHg(OR=6.39,95%CI 1.06~9.47,P<0.01)、入院无初始CVP(OR=4.56,95%CI 1.86~8.44,P<0.01)与严重胸部创伤并发ARDS显著相关。结论年龄≥60岁、呼吸困难(呼吸频率≥28次/min或<10次/min)、肺挫伤、肺部感染、连枷胸、胸部AIS、中等量以上血气胸、血压<90 mmHg、PaO_(2)<60 mmHg、入院无初始CVP是严重胸部创伤并发ARDS的独立危险因素。

Objective To investigate the risk factors of severe chest trauma complicated by acute respiratory distress syndrome(ARDS).Methods A case control study was conducted to analyze the clinical data of 120 patients with severe chest trauma admitted to 909th Hospital of Joint Logistics Support Force(Affiliated Dongnan Hospital of Xianmen University Medical College)from January 2018 to December 2020.There were 75 males and 45 females;aged 21-72 years[(42.2±4.8)years].The causes of injury were traffic injury in 57 patients,crush injury in 21,fall injury in 21,smash injury in 11 and others in 10.There were 34 patients accompanied by fracture of the limb,spine and pelvis,23 by abdominal organ injury and 8 by head trauma,with the exception of simple thoracic trauma in 55 patients.The patients were divided into ARDS group(n=25)and non-ARDS group(n=95)according to the condition of concurrent ARDS.The two groups were compared regarding the gender,age,causes of injury,respiratory rate,lung contusion,lung infection,flail chest,chest abbreviated injury scale(AIS),hemothorax,blood pressure,partial arterial oxygen pressure(PaO_(2)),initial central venous pressure(CVP)on admission,combined fracture of the limb,spine and pelvis,combined head injury and combined abdominal organ injury.The correlation between the above indexes and ARDS after severe chest trauma was analyzed by univariate analysis.Multivariate Logistic regression analysis was used to determine the independent risk factors for ARDS after severe chest trauma.Results Univariate analysis showed a positive correlation of ARDS with age,respiratory rate,lung contusion,lung infection,flail chest,chest AIS,hemothorax,blood pressure,PaO_(2),initial CVP on admission,combined fracture of the limb,spine and pelvis and combined abdominal organ injury(P<0.05 or 0.01),but not with gender,causes of injury or combined head injury(all P>0.05).Multivariate Logistic regression analysis revealed that age≥60 years(OR=2.45,95%CI 1.81-7.50,P<0.01),dyspnea(respiratory rate≥28 times/minute or<10 times/minute)(OR=9.55,95%CI 2.26-9.38,P<0.01),lung contusion(OR=6.78,95%CI 1.84-6.96,P<0.01),lung infection(OR=27.71,95%CI 11.97-64.14,P<0.01),flail chest(OR=8.97,95%CI 2.29-14.97,P<0.01),chest AIS score(OR=5.77,95%CI 2.85-9.20,P<0.01),above medium amount of hemothorax(OR=6.84,95%CI 1.69-13.39,P<0.01),blood pressure<90 mmHg(OR=7.93,95%CI 1.64-11.84,P<0.01),PaO_(2)<60 mmHg(OR=6.39,95%CI 1.06-9.47,P<0.01)and absent initial CVP on admission(OR=4.56,95%CI 1.86-8.44,P<0.01)were significantly correlated with ARDS.Conclusion Age≥60 years,dyspnea(respiratory rate≥28 times/minute or<10 times/minute),lung contusion,lung infection,flail chest,chest AIS,above medium l amount of hemothorax,blood pressure<90 mmHg,PaO_(2)<60 mmHg and absent initial CVP on admission are independent risk factors for ARDS in patients with severe chest trauma.