【摘要】 目的 分析急诊抢救室应用无创通气治疗患者的临床特征和相关流行病学信息。方法 回顾分析2016年4月至2020年4月在深圳市宝安区人民医院急诊抢救室应用无创通气治疗的150例患者的临床资料。记录患者首发疾病类型、无创通气维持和转换时间、7d和28 d临床结局。以无创通气72 h为观察节点,根据无创通气维持状态将患者分为无创通气成功组[包括无创通气维持组(75例)和无创通气转吸氧组(36例)]以及无创通气失败组(39例)。收集患者入室生命体征(体温、心率、血压、呼吸频率、休克指数)、实验室检查指标[N末端脑钠肽前体(NT-proBNP)、降钙素原(PCT)、血pH值、血氧分压、血二氧化碳分压、白细胞计数(WBC)、血红蛋白(Hb)、C-反应蛋白(CRP)、血肌酐(SCr)、总蛋白(TP)、白蛋白(ALB)]等数据,比较各指标的差异。采用多因素Logistic回归分析急诊患者无创通气失败的危险因素。绘制受试者工作特征曲线(ROC),评价各危险因素对急诊抢救室患者无创通气成功的预测价值。结果 共纳入150例无创通气患者,首发疾病以慢性肺部疾病急性加重和肺部感染为主,其次为急性冠脉综合征、慢性心力衰竭(心衰)急性发作。24h内无创通气成功的有123例(82.0%)、72 h内无创通气成功的有111例(74.0%),7 d内死亡的有16例(10.7%),28 d内死亡的有24例(16.0%),其中脓毒症患者7 d和28 d病死率(分别为50.0%、60.0%)以及24 h和72 h转为气管插管的比例(分别为20.0%、50.0%)均明显高于其他疾病患者(均P<0.05)。无创通气失败患者转插管时间多为48 h内,尤其是前12 h。无创通气失败组的心率、休克指数、WBC和CRP均明显高于无创通气成功组,收缩压和舒张压均明显低于无创通气成功组,两组间其余指标比较差异均无统计学意义;其中无创通气维持组和无创通气转吸氧组的休克指数、WBC和CRP均明显低于无创通气失败组。二项式Logistic逐步回归分析结果显示,有统计学差异的变量包括心率、收缩压、舒张压、休克指数、WBC和CRP;多因素Logistic逐步回归分析结果显示,CRP是预警无创通气失败的独立危险因素[优势比(OR)=0.992,95%可信区间(95%CI)为0.986～0.998,P=0.007]。ROC曲线分析显示,所纳入变量的ROC曲线下面积(AUC)均大于0.6(均P<0.05),相应最佳截断值分别为心率≤97.5次/min、收缩压>152mmHg(1 mmHg≈0.133 kPa)、舒张压>84mmHg、休克指数≤0.7、WBC≤13.14×109/L、CRP≤70.72 g/L,组合方案中,休克指数+WBC+CRP的敏感度和特异度分别为84.68%、61.54%,6项指标联合检测的敏感度和特异度分别为91.89%、56.41%。结论 无创通气在急诊抢救室有较高的应用价值,其中休克指数+WBC+CRP以及6项指标联合检测对无创通气成功的预测价值均较高。更多还原

【Abstract】 Objective To analyze the clinical characteristics of patients treated with non-invasive ventilation in emergency room,and provide relevant epidemiological information.Methods The clinical data of 150 patients admitted into the emergency department of People’s Hospital of Shenzhen Baoan District from April 2016 to April 2020 and treated by non-invasive ventilation were analyzed retrospectively.Their diagnosis and treatment information were collected,including the original diseases,conversion time,maintenance duration of non-invasive ventilation,and outcomes in 7 days and 28 days of intervention.At the time point of 72 hours since starting non-invasive ventilation,the patients were divided into a successfully using non-invasive ventilation group [including maintenance of non-invasive ventilation group(75 cases)and conversing to oxygen inhalation group(36 cases)] and failure of using non-invasive ventilation group(39 cases).After admission,the data of vital signs(body temperature.,heart rate,blood pressure,respiratory rate and shook index) and the results of laboratory examinations [N-terminal probrain natriuretic peptide(NT-proBNP),procalcitonin(PCT),serum pH,partial pressure of oxygen,partial pressure of carbon dioxide,white blood cell count(WBC),hemoglobin(Hb),C-reactive protein(CRP),serum creatinine(SCr),total protein and albumin(ALB)] were collected for statistically comparing the significance of differences of various indexes between various groups.Multivariate Logistic regression analysis was applied to assess the emergency patients’ risk factors of failure in using non-invasive ventilation.The receiver operating characteristic(ROC) curves were drawn to evaluate the values of various risk factors in predicting success in patients receiving non-invasive ventilation in the emergency rescue department.Results A total of 150 patients with non-invasive ventilation were included.The predominant original disease was acute exacerbations of chronic obstructive pulmonary disease and pulmonary infection,followed by acute coronary syndrome and acute exacerbation of chronic heart failure.There were 123 cases(82.0%)and 111 cases(74.0%) successfully receiving non-invasive ventilation in 24 hours and 72 hours respectively,and 16 patients(10.7%) died in 7 days and 24 patients(16.0%) died in 28 days after intervention.Among the above patients,compared with other groups of patients,the sepsis patients presented higher mortality within 7 days(50.0%) and 28 days(60.0%),and higher ratios of being transferred to endotracheal intubation within 24 hours(20.0%) and 72 hours(50.0%),respectively(all P <0.05).The failure patients of using non-invasive ventilation were mostly transferred to using endotracheal intubation within 48 hours to inhale oxygen,especially in the first 12 hours following the ventilation.The heart rate,shock index,WBC and CRP were higher in failure group than those in successful group of using non-invasive ventilation,while the systolic and diastolic blood pressures in failure group were significantly lower than those in successful group of using non-invasive ventilation.The comparisons of other indicators between the two groups had no statistical significant differences;the shock index,WBC and CRP in maintenance group of using non-invasive ventilation and in the group being transferred to the oxygen inhalation group were obviously lower than those in the failure group with non-invasive ventilation.Binomial Logistic stepwise regression analysis showed that the variables with statistical differences included heart rate,systolic blood pressure,diastolic blood pressure,shock index,WBC and CRP.Multivariate Logistic stepwise regression analysis showed that CRP was an independent risk factor for non-invasive ventilation failure [odds ratio(OR)=0.992,95% confidence interval(95%CI) was 0.986-0.998,P=0.007].ROC curve analyses showed that the areas under the ROC curves(AUC) of all the involved variables were larger than 0.6(all P <0.05).The best corresponding cut-off values were as follows:heart rate-97.5 beats/min,systolic blood pressure> 152 mmHg(1 mmHg ≈ 0.133 kPa),diastolic blood pressure> 84 mmHg,shock index ≤ 0.7,WBC≤13.14 × 10~9/L and CRP ≤ 70.72 g/L.In combined schemes,sensitivity and specificity of combining shock index+WBC+CRP were 84.68% and 61.54%,while the sensitivity and specificity of 6 markers were92.89% and 56.41%,respectively.Conclusion Non-invasive ventilation has relatively high application value in emergency rescue room,the predictive value either measured by using combination of the shock index+WBC+CRP or by the combined scheme of 6 markers is relatively high for the patient’s success in receiving non-invasive ventilation.更多还原