早期清醒俯卧位在轻中度ARDS患者中的应用效果及影响因素分析

Application effect and influencing factors of early awake prone position in patients with mild-to-moderate acute respiratory distress syndrome

目的探讨早期清醒俯卧位在轻中度急性呼吸窘迫综合征(ARDS)患者中的应用效果,并分析影响俯卧位结局的相关因素。方法采用前瞻性队列研究方法,选择2020年1月至2023年6月颍上县人民医院急诊科收治的轻中度ARDS患者作为研究对象,根据俯卧位耐受测试结果将患者分为清醒俯卧位组和非俯卧位组。所有患者均按照常规方法给予经鼻高流量氧疗(HFNC);清醒俯卧位组患者在常规治疗的基础上,于入科12 h内接受俯卧位治疗,可分多次进行,至少每日1次,每次至少2 h,为尽量长时间俯卧位,允许患者进行活动或保持身体小角度侧俯。记录入科0、24、48、72 h氧合指数(PaO_(2)/FiO_(2))变化,重症监护病房(ICU)转入率,无创通气(NIV)使用率和使用时间,总住院时间,以及俯卧位患者每日俯卧位时间和俯卧位2 h ROX指数〔脉搏血氧饱和度/吸入氧浓度(SpO_(2)/FiO_(2))与呼吸频率(RR)比值〕。以HFNC顺利停机定义为俯卧位成功,以患者改用NIV或转入ICU治疗定义为俯卧位失败,进行亚组分析,采用二元多因素Logistic回归分析筛选早期清醒俯卧位结局的影响因素。结果最终共纳入107例患者,清醒俯卧位组61例,非俯卧位组46例。两组患者PaO_(2)/FiO_(2)均随入科时间延长逐渐升高;清醒俯卧位组PaO_(2)/FiO_(2)入科24 h即较0 h明显升高〔mmHg(1 mmHg≈0.133 kPa):191.94±17.86比179.24±29.27,P<0.05〕,非俯卧位组72 h时才较0 h出现统计学差异(mmHg:198.24±17.99比181.24±16.62,P<0.05),且清醒俯卧位组入科48 h和72 h PaO_(2)/FiO_(2)均明显高于非俯卧位组。清醒俯卧位组患者NIV使用率明显低于非俯卧位组〔36.1%(22/61)比56.5%(26/46),P<0.05〕;Kaplan-Meier曲线分析进一步证实,清醒俯卧位组患者NIV使用时间更晚,且累积NIV使用率明显低于非俯卧位组(Log-Rank检验:χ^(2)=5.402,P=0.020)。与非俯卧位组比较,清醒俯卧位组ICU转入率明显降低〔11.5%(7/61)比28.3%(13/46),P<0.05〕,HFNC时间、NIV时间、总住院时间明显缩短〔HFNC时间(d):5.71±1.45比7.24±3.36,NIV时间(d):3.27±1.28比4.40±1.47,总住院时间(d):11(7,13)比14(10,19),均P<0.05〕。61例清醒俯卧位患者中,俯卧位成功39例,失败22例。与成功组比较,失败组体质量指数(BMI)更高(kg/m^(2):26.61±4.70比22.91±5.50,P<0.05),PaO_(2)/FiO_(2)、无症状低氧血症比例及俯卧位2 h ROX指数更低〔PaO_(2)/FiO_(2)(mmHg):163.73±24.73比185.69±28.87,无症状低氧血症比例:18.2%(4/22)比46.2%(18/39),俯卧位2 h ROX指数:5.75±1.18比7.21±1.45,均P<0.05〕,每日俯卧位时间更短(h:5.87±2.85比8.05±1.99,P<0.05);二元多因素Logistic回归分析显示,上述因素均为清醒俯卧位结局的影响因素(均P<0.05),其中BMI〔优势比(OR)=1.447,95%可信区间(95%CI)为1.105~2.063〕、非无症状低氧血症(OR=13.274,95%CI为1.548~117.390)为俯卧位失败的危险因素,PaO_(2)/FiO_(2)(OR=0.831,95%CI为0.770~0.907)、每日俯卧位时间(OR=0.482,95%CI为0.236~0.924)、俯卧位2 h ROX指数(OR=0.381,95%CI为0.169~0.861)为保护因素。结论应用HFNC支持的轻中度ARDS患者进行早期清醒俯卧位安全可行,减少了NIV的使用率及使用时间,降低了ICU转入率,缩短了住院时间;较高的BMI和非无症状低氧血症是俯卧位失败的危险因素,较高的PaO_(2)/FiO_(2)和俯卧位2 h ROX指数(即患者对俯卧位的反应性较好)及每日长时间俯卧位可以提高俯卧位成功率。

Objective To investigate the application effect of early awake prone position in mild-to-moderate acute respiratory distress syndrome(ARDS)patients,and analyze the related factors affecting the prone position outcome.Methods A prospective cohort study was conducted.The mild-to-moderate ARDS patients admitted to the emergency department of Yingshang County People's Hospital from January 2020 to June 2023 were enrolled as the research subjects.According to the results of prone tolerance test,the patients were divided into awake prone position group and non-prone position group.All patients were given high flow nasal cannula(HFNC)according to the standard procedures.The patients in the awake prone position group received prone position treatment within 12 hours after admission,in addition to the standard treatment.This could be performed in several times,at least once a day,and at least 2 hours each time.In order to prolong the prone position as much as possible,the patients were allowed to move or keep a small angle side prone.The changes of oxygenation index(PaO_(2)/FiO_(2))at 0,24,48,and 72 hours after admission,the rate of intensive care unit(ICU)transfer,the use rate and use time of non-invasive ventilation(NIV),the total hospital stay,and the daily prone position time and 2-hour ROX index[ratio of pulse oxygen saturation/fraction of inspired oxygen(SpO_(2)/FiO_(2))and respiratory rate(RR)]of prone position patients were recorded.The successful termination of HFNC was defined as the successful prone position,and the failure of prone position was defined as switching to NIV or transferring to ICU.Subgroup analysis was performed,and the binary multivariate Logistic regression analysis was used to screen the influencing factors of the early awake prone position outcome.Results A total of 107 patients were finally enrolled,with 61 in the awake prone position group and 46 in the non-prone position group.Both groups showed a gradual increase in PaO_(2)/FiO_(2)with prolonged admission time.The PaO_(2)/FiO_(2)at 24 hours after admission in the awake prone position group was significantly higher than that at 0 hour[mmHg(1 mmHg≈0.133 kPa):191.94±17.86 vs.179.24±29.27,P<0.05],while the difference in the non-prone position group was only statistically significant at 72 hours(mmHg:198.24±17.99 vs.181.24±16.62,P<0.05).Furthermore,the PaO_(2)/FiO_(2)at 48 hours and 72 hours after admission in the awake prone position group was significantly higher than that in the non-prone position group.The use rate of NIV in the awake prone position group was significantly lower than that in the non-prone position group[36.1%(22/61)vs.56.5%(26/46),P<0.05];Kaplan-Meier curve analysis further confirmed that the patients in the awake prone position group used NIV later,and the cumulative rate of NIV usage was significantly lower than that in the non-prone position group(Log-Rank test:χ^(2)=5.402,P=0.020).Compared with the non-prone position group,the ICU transfer rate in the awake prone position group was significantly lowered[11.5%(7/61)vs.28.3%(13/46),P<0.05],and the HFNC time,NIV time,and total hospital stay were significantly shortened[HFNC time(days):5.71±1.45 vs.7.24±3.36,NIV time(days):3.27±1.28 vs.4.40±1.47,total hospital stay(days):11(7,13)vs.14(10,19),all P<0.05].Of the 61 patients who underwent awake prone positioning,39 were successful,and 22 failed.Compared with the successful group,the patients in the failure group had a higher body mass index[BMI(kg/m^(2)):26.61±4.70 vs.22.91±5.50,P<0.05],lower PaO_(2)/FiO_(2),proportion of asymptomatic hypoxemia and 2-hour ROX index of prone position[PaO_(2)/FiO_(2)(mmHg):163.73±24.73 vs.185.69±28.87,asymptomatic hypoxemia proportion:18.2%(4/22)vs.46.2%(18/39),2-hour ROX index of prone position:5.75±1.18 vs.7.21±1.45,all P<0.05],and shorter daily prone positioning time(hours:5.87±2.85 vs.8.05±1.99,P<0.05).Binary multivariate Logistic regression analysis showed that all these factors were influencing factors for the outcome of awake prone positioning(all P<0.05),among which BMI[odds ratio(OR)=1.447,95%confidence interval(95%CI)was 1.105-2.063]and non-asymptomatic hypoxemia(OR=13.274,95%CI was 1.548-117.390)were risk factors for failure of prone position,while PaO_(2)/FiO_(2)(OR=0.831,95%CI was 0.770-0.907),daily prone positioning time(OR=0.482,95%CI was 0.236-0.924),and 2-hour ROX index of prone position(OR=0.381,95%CI was 0.169-0.861)were protective factors.Conclusions Early awake prone positioning in patients with mild-to-moderate ARDS supported by HFNC is safe and feasible,reducing the use rate and duration of NIV,lowering the ICU transfer rate,and shortening the hospital stay.High BMI and non-asymptomatic hypoxemia are risk factors for failed prone position,while higher PaO_(2)/FiO_(2)and the ROX index within 2 hours of prone position(the patient's good response to prone position),and prolonged daily prone position can improve the success rate of prone position.