探讨中重型颅脑损伤机械通气患者拔管的预测因素  

Exploring predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury

作　　者：高敏 韩小彤[1] 张兴文[1] 贾爱军 曹焕新 文辉[1] 徐芙蓉[1] 樊麦英[1] 徐静[1] GAO Min;HAN Xiaotong;ZHANG Xingwen;JIA Aijun;CAO Huanxin;WEN Hui;XU Furong;FAN Maiying;XU Jing(Department of Emergency Medicine,Clinical Research Center For Emergency and Critical Care In Hunan Province,Hunan Provincial Institute of Emergency Medicine,Hunan Provincial Key Laboratory of Emergency and Critical Care Metabonomics,Hunan Provincial People's Hospital,The First Affiliated Hospital of Hunan Normal University,Changsha,Hunan 410005,P.R.China)

机构地区：[1]湖南省人民医院(湖南师范大学附属第一医院)急诊医学科、湖南省急危重症临床医学研究中心、湖南省急救医学研究所、急危重症代谢组学湖南省重点实验室,湖南长沙410005

出　　处：《中国呼吸与危重监护杂志》2023年第4期274-280,共7页Chinese Journal of Respiratory and Critical Care Medicine

基　　金：湖南省卫生健康委科研计划项目(202217012537、202210003085)。

摘　　要：目的探讨中重型颅脑损伤机械通气患者拔管的预测因素方法选择2020年4月—2022年3月湖南省人民医院收治的中重型颅脑损伤的机械通气成人患者为研究对象,收集患者的一般资料、神经功能状况及气道保护能力的相关指标。按照拔管结局分为拔管成功组与失败组,比较两组间各项指标的差异,应用单因素及多因素Logistic回归分析,确定中重型颅脑损伤患者气管导管拔管的影响因素,绘制受试者工作特征(receiver operating characteristic,ROC)曲线,分析各指标对颅脑损伤患者拔管的预测价值。结果最终纳入263例中重型颅脑损伤患者进行分析,拔管成功组183例,拔管失败组80例。拔管成功组的格拉斯哥昏迷评分(Glasgow coma scale,GCS)及咳嗽峰流速(cough peak flow,CPF)高于失败组,成功组的呼吸机相关性肺炎(ventilator associated pneumonia,VAP)发生率、机械通气时间、重症监护病房住院时间及医院住院时间均低于失败组。单因素及多因素的Logistic回归分析显示影响中重型颅脑损伤患者气管导管拔管的独立预测因素为拔管时CPF、GCS。校正了混杂因素的影响,拔管时CPF每增加1 L/min,拔管失败的风险减低2%[比值比(odds ratio,OR)=0.98,95%置信区间(confidence interval,CI)0.97~0.99],GCS每增加1分,拔管失败的风险降低12%(OR=0.88,95%CI 0.79~0.98)。ROC曲线分析结果显示,CPF、GCS、睁眼反应、运动反应对中重型脑损伤患者的气管导管拔管均有预测价值,当患者同时满足GCS≥8分(睁眼反应≥3分,运动反应≥5分)和CPF≥68.5 L/min的条件下,预测拔管成功的诊断价值最高,ROC曲线下面积为0.946(95%CI 0.917~0.975),敏感性为0.850,特异性为0.907。结论CPF≥68.5 L/min和GCS≥8分对中重型颅脑损伤机械通气患者拔管成功具有临床指导价值。Objective To explore the predictive factors for extubation in mechanically ventilated patients with moderate to severe traumatic brain injury(TBI).Methods Mechanically ventilated adult patients with moderate to severe brain injuries admitted to the People’s Hospital of Hunan province were selected between April 2020 and March 2022.The general data,neurological function and airway protective ability of the patients were collected.The patients were divided into successful extubation and failed extubation groups based on extubation outcomes.The differences in various indicators between the two groups were compared.Univariate and multivariate logistic regression analyses were conducted to determine the influencing factors for tracheal tube extubation in patients with moderate to severe TBI.Receiver operating characteristic(ROC)curves were plotted to analyze the predictive value of each indicator for extubation in TBI patients.Results A total of 263 patients with moderate to severe TBI were included in the analysis,with 183 patients in the successful extubation group and 80 patients in the failed extubation group.The successful extubation group had higher Glasgow coma scale(GCS)and cough peak flow(CPF)compared to the failed extubation group.The incidence of ventilator-associated pneumonia(VAP),duration of mechanical ventilation,length of ICU stay,and length of hospital stay were all lower in the successful extubation group.Univariate and multivariate logistic regression analyses showed that the predictive factors for tracheal tube extubation in patients with moderate to severe TBI were CPF and GCS at the time of extubation.Adjusting for confounding factors,every 1 L/min increase in CPF at the time of extubation reduced the risk of extubation failure by 2%[odds ratio(OR)=0.98,95%confidence interval(CI)0.97-0.99],and every 1-point increase in GCS reduced the risk of extubation failure by 12%(OR=0.88,95%CI 0.79-0.98).ROC curve analysis showed that CPF,GCS,GCS eye,and GCS motor had predictive value for tracheal tube ext

关 键 词：颅脑损伤 拔管 咳嗽峰流速 格拉斯哥昏迷评分 

分 类 号：R651.15[医药卫生—外科学]