高海拔地区急性呼吸窘迫综合征和多器官功能障碍综合征诊断标准的研究——附高海拔地区急性呼吸窘迫综合征诊断标准重修意见稿

Study of diagnostic criteria of acute respiratory distress syndrome and multiple organ dysfunction syndrome at high altitude:revised draft of the diagnostic criteria of high acute respiratory distress syndrome drawn in Lanzhou conference

目的 :判别高海拔地区急性呼吸窘迫综合征 ( H ARDS)和多脏器功能障碍综合征 ( H MODS)诊断指标参数和平原的差异 ,重估原 H ARDS诊断标准 ( 1999年兰州会议 )的实用性和可操作性。方法 :将资料齐全且符合庐山、Marshall ARDS/ MODS诊断标准的 36 0例患者 ,根据所在海拔高度分为平原对照组 ( CG,n=93) ,≥ 15 17m高度组 ( H1G,n=2 2 3) ,2 2 6 1～ 2 40 0 m高度组 ( H2 G,n=44 )。 3组均按庐山、Marshall和自拟ARDS/ MODS的标准 (简称兰州标准 )建成 3个标准数据模型 ,绘制 ROC曲线。根据曲线下面积、最佳截断点对比 3个标准在不同海拔梯度上预测 ARDS/ MODS结局的准确性。结果 :用庐山标准验证 CG组 ROC下面积、敏感度、特异度优于 Marshall标准 ,两者相比 ROC下面积、敏感度、特异度依次为 0 .82 3、0 .833、0 .731比0 .815、0 .76 7、0 .76 3;但用于验证高海拔区如 H2 G则庐山标准明显低于兰州标准 ,两标准的 ROC下面积、敏感度、特异度依次为 0 .85 5、0 .5 83、0 .96 9比 0 .914、1.0 0 0、0 .6 5 7;氧合指数 ( Pa O2 / Fi O2 )的最佳界值在 CG、 H1G和 H2 G依次为 198.32 m m Hg、131.5 0 mm Hg、97.5 8m m Hg;3组 ARDS/ MODS按平原标准评分分级 ,CG比较均匀分布在 1～ 3级 ,而 H1G和 H2 G的病例?

Objective:To compare the difference of the diagnostic parameters of acute respiratory distress syndrome/multiple organ dysfunction syndrome(ARDS/MODS) at high altitude(HARDS/MODS) with that on plains and reevaluate the practicality and feasibility of the diagnostic criteria of HARDS(Lanzhou conference, 1999).Methods:Three hundred and sixty cases with relatively complete data were divided into three groups according to their originating altitude: control group on plains (CG,n=93), high altitude group 1 at the altitude of 1 517 m(H1G,n=223), high altitude group 2 at the altitude of 2 2612 400 m(H2G,n=44). The ARDS/MODS scorings of the three groups were carried out according to the diagnostic criteria of Lushan Conference, Marshall(1995) and Lanzhou criteria drafted by the authors and the receiver operating characteristic curves (ROC curve) were made to predict the outcome of MODS. Results:In CG group, the area of ROC, the susceptibility and specificity were 0 823, 0 833, 0 731,respectively according to Lushan criteria, which were better than those (0 815, 0 767, 0 763) according to Marshall criteria. Then in group H2G, the area of ROC, the susceptibility and specificity according to Lushan criteria were lower than those according to Marshall criteria: 0 855, 0 583, 0 969 vs 0 914,1 000, 0 657.The optimum cutoff points of partial pressure of oxygen in artery(PaO 2)/fractional concentration of inspired oxygen(FiO 2) were 198 32 mm Hg, 131 50 mm Hg and 97 58 mm Hg in group CG, H1G and H2G. Conclusion:①There are significant differences between the diagnostic criteria of ARDS at high altitude and that on plains.The altitude of 1 517 m would be an important border line in diagnosing HARDS.②The drafted diagnostic criteria of ARDS at high altitude are feasible and practical in this region, but the range of the parameters is still wide, which need to be properly amended. ③The changing tendency of the parameters of MODS at high altitude is different from that on plains, but the amount of sample needs to be accumulated further and the Lanzhou criteria needs to be perfected.