俯卧位在重症监护病房重症肺炎患者治疗中的应用和意义

Application and significance of prone position in the treatment of patients with severe pneumonia in intensive care unit

目的探讨俯卧位治疗对重症监护病房(ICU)重症肺炎患者预后的影响。方法采用回顾性队列研究方法,选择2022年5月至2023年8月青岛市市立医院重症医学科收治的重症肺炎患者作为研究对象。收集患者一般资料、病因、基础疾病、入ICU时生命体征和实验室指标、ICU住院期间临床治疗手段及预后。比较不同预后患者上述临床资料的差异;采用多因素Logistic回归分析筛选重症肺炎患者ICU住院期间存活的影响因素。于首次俯卧位前1 h、首次俯卧位1 h及首次俯卧位结束后1 h观察重症肺炎患者氧合指数(PaO_(2)/FiO_(2))变化,分析俯卧位对重症肺炎患者氧合的影响;采用Spearman相关性分析探究重症肺炎患者首次俯卧位时间与俯卧位前后PaO_(2)/FiO_(2)变化的相关性。结果最终纳入144例重症肺炎患者,ICU住院期间存活45例,死亡99例,病死率68.8%。与存活组比较,死亡组患者年龄更大〔岁:81.00(70.75,86.00)比71.00(60.50,81.50),P<0.01〕,既往存在肺部疾病比例、心率(HR)、呼吸频率(RR)、血乳酸(Lac)及连续性肾脏替代治疗(CRRT)比例更高〔既往存在肺部疾病比例:23.2%(23/99)比8.9%(4/45),HR(次/min):99.61±22.47比91.49±18.76,RR(次/min):22.50(19.75,29.25)比20.00(17.50,24.50),Lac(mmol/L):2.00(1.55,3.25)比1.60(1.20,1.95),CRRT比例:25.3%(25/99)比6.7%(3/45),均P<0.05〕,俯卧位比例更低〔41.4%(41/99)比68.9%(31/45),P<0.01〕。多因素Logistic回归分析显示,年龄〔优势比(OR)=0.946,95%可信区间(95%CI)为0.912~0.980,P=0.002〕和Lac(OR=0.563,95%CI为0.340~0.930,P=0.025)与重症肺炎患者ICU住院期间存活存在负相关关系,而俯卧位与存活存在正相关关系(OR=2.551,95%CI为1.067~6.095,P=0.035),说明俯卧位有利于改善重症肺炎患者ICU住院期间预后。俯卧位不同时间点PaO_(2)/FiO_(2)观察结果显示,重症肺炎患者首次俯卧位1 h PaO_(2)/FiO_(2)即较首次俯卧位前1 h明显升高〔mmHg(1 mmHg≈0.133 kPa):146.69(113.92,257.25)比111.75(70.15,212.20),P<0.01〕,说明俯卧位对患者氧合改善具有相关影响。Spearman相关性分析显示,重症肺炎患者首次俯卧位时间与首次俯卧位1 h氧合改善程度呈显著正相关(r=0.565,P<0.001)。结论俯卧位是可以独立影响重症肺炎患者ICU住院期间预后的治疗措施;俯卧位可以有效改善重症肺炎患者氧合,且患者首次氧合改善与俯卧位时间有关。

Objective To investigate the effect of prone position on the prognosis of patients with severe pneumonia in intensive care unit(ICU).Methods A retrospective cohort study was conducted.The patients with severe pneumonia admitted to the ICU of Qingdao Municipal Hospital from May 2022 to August 2023 were enrolled.The general information,etiology,underlying diseases,vital signs and laboratory indicators at ICU admission,clinical treatment and prognosis during ICU hospitalization were collected.The above clinical data of patients with different prognosis were compared.Multifactorial Logistic regression analysis was used to screen the related factors affecting survival during ICU in patients with severe pneumonia.The change in oxygenation index(PaO_(2)/FiO_(2))of patients with severe pneumonia were observed at 1 hour before the first prone position,1 hour after the first prone position,and 1 hour after the end of the first prone position.The effect of prone position on oxygenation in patients with severe pneumonia was analyzed.Spearman correlation analysis was used to investigate the correlation between the duration to first prone position and the change in the PaO_(2)/FiO_(2)before and after prone position in patients with severe pneumonia.Results Finally,a total of 144 patients with severe pneumonia were enrolled,45 survived and 99 died during ICU hospitalization,with a mortality of 68.8%.Compared with the survival group,the patients in the death group were older[years old:81.00(70.75,86.00)vs.71.00(60.50,81.50),P<0.01],the proportion of pre-existing lung disease,heart rate(HR),respiratory rate(RR),blood lactic acid(Lac)and the ratio of continuous renal replacement therapy(CRRT)were higher[ratio of pre-existing lung disease:23.2%(23/99)vs.8.9%(4/45),HR(bpm):99.61±22.47 vs.91.49±18.76,RR(times/min):22.50(19.75,29.25)vs.20.00(17.50,24.50),Lac(mmol/L):2.00(1.55,3.25)vs.1.60(1.20,1.95),CRRT ratio:25.3%(25/99)vs.6.7%(3/45),all P<0.05],and the proportion of prone position was lower[41.4%(41/99)vs.68.9%(31/45),P<0.01].Multifactorial Logistic regression analysis showed that age[odds ratio(OR)=0.946,95%confidence interval(95%CI)was 0.912-0.980,P=0.002]and Lac(OR=0.563,95%CI was 0.340-0.930,P=0.025)were negatively correlated with survival during ICU hospitalization in severe pneumonia patients,while prone position was positively correlated with survival(OR=2.551,95%CI was 1.067-6.095,P=0.035),indicating that prone position was beneficial for improving ICU prognosis in severe pneumonia patients.The results of PaO_(2)/FiO_(2)at different time points in prone position showed that PaO_(2)/FiO_(2)at 1 hour of the first prone position in the patients with severe pneumonia was significantly higher than that at 1 hour before the first prone position[mmHg(1 mmHg≈0.133 kPa):146.69(113.92,257.25)vs.111.75(70.15,212.20),P<0.01],indicating that the prone position had a relevant effect on the improvement of oxygenation in patients.Spearman correlation analysis showed that the duration of the first prone position in patients with severe pneumonia was significantly and positively correlated with the improvement of oxygenation at 1 hour of the first prone position(r=0.565,P<0.001).Conclusions The prone position is a therapeutic measure that can independently influence the prognosis of patients with severe pneumonia during ICU hospitalization.The prone position effectively improves oxygenation in patients with severe pneumonia and the first change in oxygenation in patients is related to the duration of the prone position.