急性呼吸窘迫综合征发生及预后危险因素的多中心前瞻性队列研究  

Risk factors of the occurence and death of acute respiratory distress syndrome：a prospective multicenter cohort study

作　　者：葛庆岗[1] 姚智渊[1] 王铁华[1] 刘壮[2] 李昂[2] 王书鹏[3] 李刚[3] 边伟帅[4] 陈炜[4] 易亮[5] 杨志旭[6] 陶立元 朱曦[1] 

机构地区：[1]北京大学第三医院危重医学科,100191 [2]北京友谊医院,100050 [3]中日友好医院,北京100029 [4]北京世纪坛医院,100038 [5]中国中医科学院西苑医院,北京100091 [6]北京大学第三医院临床流行病研究中心,100191 [7]临床流行病研究中心

出　　处：《中华危重病急救医学》2014年第11期773-779,共7页Chinese Critical Care Medicine

基　　金：国家自然科学基金（81372043）;首都医学发展科研基金项目（2009-1014）

摘　　要：目的：探讨重症监护病房（ICU）急性呼吸窘迫综合征（ARDS）的发生及28 d死亡的危险因素。方法采用多中心前瞻性队列研究方法，入选2009年7月至2014年3月在北京地区5家三级甲等医院ICU住院的脓毒症、感染性休克、创伤、肺炎、误吸、大量输血、菌血症、肺挫伤患者。各中心研究人员按照统一的病例报告表格记录患者24 h内人口学、既往史、全身状况、原发病、病情严重程度等。根据入ICU当日诊断分为ARDS组和重症对照组。采用单因素分析、多因素logistic回归、多因素COX回归方法分析ARDS发生及预后的危险因素，应用Kaplan-Meier方法绘制两组患者28 d生存曲线。结果入选343例患者中，ARDS组163例中失访2例，死亡49例；重症对照组180例中失访1例，死亡34例；ARDS组28 d病死率明显高于重症对照组〔30.43%（49/161）比18.99%（34/179），χ2＝6.013，P＝0.014〕。多因素logistic回归分析显示：误吸〔优势比（OR）＝6.390，95%可信区间（95%CI）＝2.046～19.953，P＝0.001〕、有酗酒史（OR＝4.854，95%CI＝1.730～13.617，P＝0.003）、脓毒症（OR＝2.859，95%CI＝1.507～5.425，P＝0.001）、肺炎（OR＝2.822，95%CI＝1.640～4.855，P＜0.001）、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分（OR＝1.050，95%CI＝1.007～1.094，P＝0.022）能够增加ARDS发生的风险；重症患者一旦呼吸频率＞30次/min（OR＝3.305，95%CI＝1.910～5.721，P＜0.001）、心率＞100次/min（OR＝2.101，95%CI＝1.048～4.213，P＝0.037）高度提示ARDS的发生；ARDS患者血肌酐＞176.8μmol/L的比例较重症患者低（OR＝0.387，95%CI＝0.205～0.733， P＝0.004）。多因素COX回归分析显示：高龄和感染性休克能够增加ARDS患者28 d死亡的风险〔年龄：相对危险度（HR）＝1.040，95%CI＝1.018～1.064，P＜0.001；感染性休克：HR＝3.209，95%CI＝1.676～6.146， P＜0.001〕。Kaplan-Meier生�Objective To explore the risk factors of the occurence and 28-day death of acute respiratory distress syndrome （ARDS） in intensive care unit （ICU）. Methods A prospective multicentral cohort study was conducted. The patients from five ICUs of grade A tertiary hospitals in Beijing from July 2009 to March 2014, including sepsis,septic shock,trauma,pneumonia,aspiration,massive blood transfusion,bacteremia and pulmonary contusion,were enrolled. Researchers in each center reported the records with uniform tables,which included demographic,systemic conditions,the primary disease,and the severity within 24 hours,past history and so on. According to the admission diagnosis in ICU,these patients were divided into ARDS group and other severe disease control group. The risk factors of occurence and prognosis of ARDS were analyzed by univariate analysis,multivariate logistic regression and multivariate COX regression analysis. Kaplan-Meier method was applied to draw the 28-day survival curves of the two groups. Results There were 343 critical patients included in this prospective multicenter cohort study,of which 163 patients who developed ARDS were considered as ARDS group（2 case lost to follow-up, and 49 died）and 180 patients who did not developed ARDS regarded as severe control group（1 case lost to follow-up, and 34 died）. The 28-day mortality of ARDS group was significantly higher than that of severe control group〔30.43%（49/161）vs. 18.99%（34/179）,χ2=6.013,P=0.014〕. Multivariate logistic analysis showed that aspiration〔odds ratio（OR）=6.390,95% confidence interval（95%CI）=2.046-19.953,P=0.001〕,history of alcohol （OR=4.854,95%CI=1.730-13.617,P=0.003）,sepsis（OR=2.859,95%CI=1.507-5.425,P=0.001）, pneumonia（OR=2.822,95%CI=1.640-4.855,P〈0.001）,acute physiology and chronic health evaluation Ⅱ（APACHEⅡ）score（OR=1.050,95%CI=1.007-1.094,P=0.022）were significantly associated with increased risk of ARDS occurence. When respiratory rate〉30 beats/min（OR=3.305,95%CI=1.91

关 键 词：重症监护病房 急性呼吸窘迫综合征 发生危险因素 预后危险因素 病死率 

分 类 号：R563.8[医药卫生—呼吸系统]