慢性阻塞性肺疾病急性加重期合并肺栓塞的患病率及临床特征分析

Incidence Rate and Clinical Characteristics of Pulmonary Embolism in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

目的评估慢性阻塞性肺疾病急性加重期(AECOPD)中肺栓塞(PE)的患病率,比较AECOPD合并PE的辅助检查及临床特征。方法一项前瞻性、多中心研究纳入2016年12月—2023年1月在中国8所医院呼吸科住院的AECOPD患者,行CT肺动脉造影明确是否合并PE,收集并比较患者临床资料。结果共纳入731例AECOPD患者,PE患病率为15.3%。AECOPD合并PE者少痰(81.3%vs 42.0%,P<0.01)、胸痛(24.1%vs 9.2%)、咯血(11.6%vs 2.0%)、心悸(24.1%vs 0.5%)和晕厥(6.3%vs 0.2%)的发生率均明显高于单纯AECOPD者(P<0.001)。AECOPD合并PE组与单纯AECOPD组相比,PaO_(2)为(76.27±26.22)mm Hg vs(76.01±25.67)mm Hg,PaCO_(2)为(45.63±15.13)mm Hg vs(47.23±13.11)mm Hg,两组未见统计学差异(P>0.05)。多因素逻辑回归分析显示D-二聚体(OR=52.608,95%CI 10.610~206.068)、N末端脑钠肽前体(OR=3.013,95%CI 1.532~4.013)和少痰(OR=5.103,95%CI 2.953~8.635)是AECOPD发生PE的相关因素。影像学方面,112例PE患者中,双侧PE有69例(61.6%),多发PE有73例(65.2%)。血栓位置在主肺动脉干者有5例(4.5%),在左、右肺动脉干以上的有16例(14.3%),在叶支肺动脉及以上者有44例(39.3%),在段、亚段及以下肺动脉者的有13例(11.6%)。按照PE危险分层,高危PE有0例;中危PE有44例(39.3%),其中,中高危PE有15例(13.4%),中低危PE有29例(25.9%);低危PE有68例(60.7%)。结论AECOPD合并PE的比例很高,出现胸痛、咯血、心悸和晕厥需考虑到合并PE的可能性;D-二聚体、N末端脑钠肽前体水平升高和少痰是AECOPD患者发生PE的重要相关因素,提示住院AECOPD合并PE患者可能无明显的咳痰症状,导致慢性阻塞性肺疾病急性加重的原因并非感染,可能是合并了PE。AECOPD患者合并PE的血栓位置符合一般PE的解剖学特点,危险分层以低危为主,高危少见。

Objective To evaluate the prevalence of pulmonary embolism(PE)in acute exacerbation of chronic obstructive pulmonary disease(AECOPD),and to compare the auxiliary examinations and clinical features of AECOPD combined with PE.Methods A prospective,multicenter study was conducted on AECOPD patients admitted to the respiratory department in 8 Chinese hospitals from December 2016 to January 2023.Computed tomographic pulmonary angiography was performed to determine whether PE was present,and clinical data of patients were collected and compared.Results A total of 731 AECOPD patients were included,with a PE prevalence rate of 15.3%.The incidence of reduced sputum(81.3%vs 42.0%,P<0.01),chest pain(24.1%vs 9.2%),hemoptysis(11.6%vs 2.0%),palpitations(24.1%vs 0.5%)and syncope(6.3%vs 0.2%)in AECOPD patients with PE were significantly higher than those in AECOPD patients alone(P<0.001).Compared with the AECOPD group with PE alone,the PaO_(2) was(76.27±26.22)mm Hg vs(76.01±25.67)mm Hg and PaCO_(2) was(45.63±15.13)mm Hg vs(47.23±13.11)mm Hg,and there was no statistically significant difference between the two groups(P>0.05).Multivariate logistic regression analysis showed that D-dimer(OR=52.608,95%CI 10.610~206.068),N-terminal pro-brain natriuretic peptide(OR=3.013,95%CI 1.532~4.013),and reduced sputum(OR=5.103,95%CI 2.953~8.635)were related factors for the occurrence of PE in AECOPD.In terms of imaging,among the 112 cases of PE,there were 69 cases(61.6%)of bilateral PE and 73 cases(65.2%)of multiple PE.There were 5 cases(4.5%)with thrombus located on the main pulmonary artery trunk,16 cases(14.3%)above the left and right pulmonary artery trunk,44 cases(39.3%)above the lobar pulmonary artery,and 13 cases(11.6%)above the segmental,subsegmental and lower pulmonary arteries.According to the risk stratification of PE,there were 0 case of high-risk PE;44 cases of medium risk PE(39.3%),among them,there were 15 cases of medium high risk PE(13.4%)and 29 cases of medium low risk PE(25.9%);68 cases of low risk PE(60.7%).Conclusion The proportion of AECOPD combined with PE is high,and the possibility of PE should be considered when chest pain,hemoptysis,palpitations and syncope occur.D-dimer,elevated N-terminal pro-brain natriuretic peptide,and reduced sputum are important factors related to the occurrence of PE in AECOPD.This suggests that hospitalized AECOPD patients with PE may not have obvious sputum symptoms,and the cause of chronic obstructive pulmonary disease with acute exacerbation is not infection,but may be combined with PE.The location of thrombosis in AECOPD patients with PE conforms to the anatomical characteristics of general PE,and the risk stratification is mainly low risk,with high risk being rare.