HACOR评分对无创正压通气治疗慢性阻塞性肺疾病合并肺性脑病临床结局的预测价值

Predictive value of HACOR score on the clinical outcome of non-invasive positive pressure ventilation in the treatment of chronic obstructive pulmonary disease with pulmonary encephalopathy

目的探讨HACOR评分〔包括心率(H)、酸中毒(A)、意识(C)、氧合(O)和呼吸频率(R)〕对无创正压通气治疗慢性阻塞性肺疾病(COPD)合并肺性脑病患者临床结局的预测价值。方法采用前瞻性研究方法,选择2017年1月1日至2021年6月1日河南省人民医院收治的COPD合并肺性脑病且初始进行无创正压通气治疗的患者。患者在无创正压通气的同时,接受规范的内科治疗。将需要进行气管插管判定为无创通气治疗失败;其中早期失败为治疗48 h内需要气管插管,48 h及以后需要气管插管则定义为晚期失败。记录患者无创通气不同时间点HACOR评分,以及重症监护病房(ICU)住院时间、总住院时间和临床结局等。比较无创通气治疗成功与失败两组患者间上述指标的差异;绘制受试者工作特征曲线(ROC曲线),评价HACOR评分对无创正压通气治疗COPD合并肺性脑病失败的预测效能。结果共评估630例患者,最终51例纳入分析,其中男性42例(占82.35%),女性9例(占17.65%);中位年龄为70.0(62.0,78.0)岁。51例患者中有36例(70.59%)初始无创正压通气治疗成功且好转出院;15例(29.41%)初始无创正压通气治疗失败,切换为有创通气,其中10例(19.61%)为早期失败,5例(9.80%)为晚期失败。无创通气治疗失败组患者ICU住院时间和总住院时间均较成功组显著延长〔ICU住院时间(d):13.0(10.0,16.0)比5.0(3.0,8.0),总住院时间(d):23.0(12.0,28.0)比12.0(9.0,15.0),均P<0.01〕。无创通气治疗失败组患者无创通气治疗1~2 h的HACOR评分明显高于成功组〔分:10.47(6.00,16.00)比6.00(3.25,8.00),P<0.05〕;但两组无创通气治疗前及无创通气治疗3~6 h HACOR评分差异均无统计学意义。ROC曲线分析显示,无创通气治疗1~2 h HACOR评分预测无创正压通气治疗COPD合并肺性脑病失败的ROC曲线下面积(AUC)为0.686,95%可信区间(95%CI)为0.504~0.868;当最佳截断值为10.50分时,敏感度为60.03%,特异度为86.10%,阳性预测值为91.23%,阴性预测值为47.21%。结论无创正压通气治疗COPD合并肺性脑病,可使70.59%的患者避免气管插管;HACOR评分有助于临床预测COPD合并肺性脑病患者无创正压通气治疗失败。

Objective To explore the predictive value of HACOR score[heart rate(H),acidosis(A),consciousness(C),oxygenation(O),and respiratory rate(R)]on the clinical outcome of non-invasive positive pressure ventilation in patients with pulmonary encephalopathy due to chronic obstructive pulmonary disease(COPD).Methods A prospective study was conducted.The patients with COPD combined with pulmonary encephalopathy who were admitted to Henan Provincial People's Hospital from January 1,2017 to June 1,2021 and initially received non-invasive positive pressure ventilation were enrolled.Besides non-invasive positive pressure ventilation,standard medical treatments were delivered to these patients according to guidelines.The need for endotracheal intubation was judged as failure of non-invasive ventilation treatment.Early failure was defined as the need for endotracheal intubation within 48 hours of treatment,and late failure was defined as the need for endotracheal intubation 48 hours and later.The HACOR score at different time points after non-invasive ventilation,the length of intensive care unit(ICU)stay,the total length of hospital stay,and the clinical outcome were recorded.The above indexes of patients with non-invasive ventilation were compared between successful and failed groups.The receiver operator characteristic curve(ROC curve)was drawn to evaluate the predictive effect of HACOR score on the failure of non-invasive positive pressure ventilation in the treatment of COPD with pulmonary encephalopathy.Results A total of 630 patients were evaluated,and 51 patients were enrolled,including 42 males(82.35%)and 9 females(17.65%),with a median age of 70.0(62.0,78.0)years old.Among the 51 patients,36 patients(70.59%)were successfully treated with non-invasive ventilation and discharged from the hospital eventually,and 15 patients(29.41%)failed and switched to invasive ventilation,of which 10 patients(19.61%)were defined early failure,5 patients(9.80%)were late failure.The length of ICU and the total length of hospital stay of the non-invasive ventilation successful group were significantly longer than those of the non-invasive ventilation failure group[length of ICU stay(days):13.0(10.0,16.0)vs.5.0(3.0,8.0),total length of hospital stay(days):23.0(12.0,28.0)vs.12.0(9.0,15.0),both P<0.01].The HACOR score of patients at 1-2 hours in the non-invasive ventilation failure group was significantly higher than that in the successful group[10.47(6.00,16.00)vs.6.00(3.25,8.00),P<0.05].However,there was no significant difference in HACOR score before non-invasive ventilation and at 3-6 hours between the two groups.The ROC curve showed that the area under the ROC curve(AUC)of 1-2 hour HACOR score after non-invasive ventilation for predicting non-invasive ventilation failure in COPD patients with pulmonary encephalopathy was 0.686,and the 95%confidence interval(95%CI)was 0.504-0.868.When the best cut-off value was 10.50,the sensitivity was 60.03%,the specificity was 86.10%,positive predictive value was 91.23%,and negative predictive value was 47.21%.Conclusions Non-invasive positive pressure ventilation could prevent 70.59%of COPD patients with pulmonary encephalopathy from intubation.HACOR score was valuable to predict non-invasive positive pressure ventilation failure in pulmonary encephalopathy patients due to COPD.