机械通气脓毒症患者肺部超声重力依赖失充气表型与不良预后的相关性

doi:10.3969/j.issn.1004-583X.2024.04.003

摘要/Abstract

摘要：

目的分析脓毒症机械通气患者不同肺部超声表型的临床特征,探讨肺部超声重力依赖肺失充气表型对脓毒症机械通气患者不良预后的相关性。方法回顾性分析2019年4月至2020年10月四川大学华西医院重症医学科收治的机械通气脓毒症患者155例,按照28 d预后情况分为生存组(n=124)和死亡组(n=31),通过单因素和多因素Cox回顾分析肺部超声重力依赖失充气表型对患者28 d预后结局的影响。绘制Kaplan-Meier 曲线分析重力依赖性和非重力依赖失充气表型与28 d预后生存的关系。结果单因素Cox回归分析发现,白细胞介素-6、SOFA评分、机械通气时间(h)、间质性失充气、实变性失充气、不张性失充气、存在重力依赖性失充气改变与患者28 d预后结局相关(P<0.05),进一步通过多因素Cox分析校正后发现存在间质性失充气肺部超声模式、机械通气时间和存在重力依赖性失充气改变与患者不良预后结局相关(P<0.05),重力依赖肺失充气表型的死亡风险是非重力依赖肺失充气表型的的2.003倍(HR=2.003, P=0.028, 95%CI=1.112-6.387)。结论重力依赖肺失充气肺部超声表型可作为脓毒症机械通气患者不良预后的预测指标。

关键词: 脓毒症, 肺部超声表型, 重力依赖失充气, 预后

Abstract:

Objective To analyze the clinical characteristics of sepsis patients requiring mechanical ventilation who presented varying lung ultrasound phenotypes, and to explore the correlation between the lung ultrasound phenotype of gravity-dependent deaeration and poor prognosis in this population. Methods This retrospective study involving 155 sepsis patients requiring mechanical ventilation who were admitted to the Department of Critical Care Medicine, West China Hospital, Sichuan University from April 2019 to October 2020. According to the 28-day prognosis, they were assigned into survival group (n=124) and death group (n =31). The influence of the lung ultrasound phenotype of gravity-dependent deaeration on the 28-day prognosis was analyzed by univariate and multivariate Cox analysis. Kaplan-Meier curves were plotted to analyze the correlation of gravity-dependent and non-gravity-dependent deaeration with 28-day prognosis of sepsis patients requiring mechanical ventilation. Results Univariate Cox regression analysis showed that interleukin-6 (IL-6), Sequential Organ Failure Assessment (SOFA) score, mechanical ventilation time (h), interstitial deaeration, consolidation deaeration, atelectasis deaeration, and gravity-dependent deaeration changes were significantly correlated with 28-day prognosis (P<0.05). Multivariate Cox analysis with adjustment further identified the correlation of interstitial deaeration, mechanical ventilation time and gravity-dependent deaeration changes were significantly correlated with the poor prognosis of sepsis (P <0.05). The risk of death was 2.003 times greater for gravity-dependent lung deaeration than for non-gravity-dependent lung deaeration (HR=2.003, P =0.028, 95%CI=1.112-6.387). Conclusion The lung ultrasound phenotype of gravity-dependent deaeration can be used as an independent risk factor for the prognosis of sepsis patients with mechanical ventilation.

Key words: sepsis, lung ultrasound phenotype, gravity-dependent deaeration, prognosis

中图分类号:

R563.8

王茜, 尹万红, 邹同娟, 铁馨, 朱俊臣, 陈侣林, 曾学英. 机械通气脓毒症患者肺部超声重力依赖失充气表型与不良预后的相关性[J]. 临床荟萃, 2024, 39(4): 314-319.

Wang Qian, Yin Wanhong, Zou Tongjuan, Tie Xin, Zhu Junchen, Chen Lyulin, Zeng Xueying. Correlation between the lung ultrasound phenotype of gravity-dependent deaeration and poor prognosis in sepsis patients requiring mechanical ventilation[J]. Clinical Focus, 2024, 39(4): 314-319.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2024.04.003

https://huicui.hebmu.edu.cn/CN/Y2024/V39/I4/314

图/表 7

表1 各区域肺部超声病理生理模式

Tab.1 Lung ultrasound pathophysiological patterns in each region

定义	肺部超声病理生理模式定义	MLUS (分)
A	检查区域胸膜正常+A线	0
A1	检查区域胸膜滑动征消失+A线,可见“肺点”	NM
B1	检查区域3根以上少量B线	1
B2	检查区域多根融合的B线	1
C1	检查区域胸膜下肺小叶完全失充气,直径0.5 cm~1 cm,即“碎片征”	3
C2	检查区域实质回声混杂不均,大片实变,动态支气管征,胸水较少(液性暗区小于3 cm)	3
C3	检查区域实质回声相对均一,肺组织容积减少,大量胸水压迫,不张肺组织呈“水母征”,外缘胸膜光滑,支气管气相征早期明显,且动态支气管气征较多	3
C4	检查区域实质回声相对均一,类似肝脏回声(肝样变),肺组织容积明显减少,胸水量少,早期呈静态支气管征,后期减少或无支气管征	3

图1 不同肺部超声模式红色箭头显示高回声的A线,黄色箭头显示“肺点”提示气胸,绿色箭头显示“碎片征”,橙色箭头显示“水母征”提示胸腔积液;单片雪花形成的孤立高回声垂直线B线; 雪花聚集形成的融合的高回声垂直的B线

Fig.1 Different lung ultrasound patterns The red arrows presented A-lines(hyperechoic horizontal line); The yellow arrow presented “lung point” indicating pneumothorax; The green arrow presented “fragment sign”; The orange arrow presented “jellyfish sign” indicating pleural effusion; Presented B1-lines (isolated hyperechoic vertical line, marked by snowflake), Presented B2-lines(coalescent hyperechoic vertical line, marked by snowflakes)

图2 典型的肺部超声表型

Fig.2 Typical lung ultrasound phenotypes

表2 两组临床资料比较

Tab.2 Comparison of clinical data between the two groups

指标	总体( $n$ =155)	生存组( $n$ =124)	死亡组( $n$ =31)	统计值	$P$ 值
年龄(岁)	57.5±15.2	56.02±14.43	62.08±16.75	$t$ =-2.160	0.032
性别[例(%)]
男性女性	103(66.5) 52(33.5)	79(67.52) 38(32.48)	24(63.16) 14(36.84)	χ²=0.245	0.621
体温(℃)	37.6±0.9	37.6±0.95	37.48±0.82	$t$ =0.730	0.465
心率(次/min)	115.00±24.00	112.8±24.43	119.6±21.85	$t$ =-1.52	0.130
MAAP(mmHg)	70.3±12.0	70.81±11.66	68.61±11.35	$t$ =1.020	0.309
血氧饱和度(%)	96.7±3.5	96.82±3.58	96.42±3.26	$t$ =0.610	0.542
呼吸频率 (次/min)	24.4±4.6	24.1±4.33	25.42±5.22	$t$ =-1.550	0.124
乳酸(mmol/L)	2.0(1.5, 2.6)	1.9(1.4, 2.3)	2.5(1.8, 3)	$U$ =3.319	0.006
氧合指数	221.25(149.8, 288.29)	224(153.75, 279.75)	204.665(121, 309)	$U$ =-0.541	0.294
白细胞计数(×10⁹/L)	11.17(7.42, 14.34)	10.57(7.42, 13.64)	11.935(8.32, 17.09)	$U$ =1.606	0.054
C-反应蛋白(mg/L)	79.0(16.2, 137)	72(10.2, 137)	94.9(39, 140)	$U$ =1.413	0.079
白细胞介素6(ng/L)	64.0(18.77, 164.0)	61.08(39.34, 109.4)	93(48, 306.3)	$U$ =2.020	0.022
降钙素原(μg/L)	1.16(0.26, 8.4)	0.81(0.17, 3.9)	6.59(0.78, 12.1)	$U$ =3.184	0.008
APACHE Ⅱ评分(分)	25.1±6.5	23.69±6.04	29.26±6.34	$t$ =-4.880	<0.01
SOFA评分(分)	10.1±4.0	9.48±3.9	11.82±3.94	$t$ =-3.200	0.002
合并高血压[例(%)]
是否	58(37.4) 97(62.6)	43(36.7) 74(63.2)	15(39.5) 23(60.5)	χ²=0.091	0.763
合并糖尿病[例(%)]
是否	30(19.4) 125(80.6)	19(16.2) 98(83.8)	11(28.9) 27(71.1)	χ²=2.968	0.085
主要感染部位[例(%)]
肺部	93(60.0)	76(64.9)	17(44.7)
腹部	50(32.3)	31(26.5)	19(50.0)
颈部脓肿	4(2.6)	4(3.4)	0	-	0.079
泌尿系	4(2.6)	3(2.6)	1(2.6)
肛周脓肿	2(1.3)	1(0.9)	1(2.6)
血源性	2(1.3)	2(1.7)	0
NE[μg/(kg·min)]	0.19(0.10, 0.46)	0.05(0, 0.15714)	0.344155(0.18182, 0.8)	$U$ =5.148	<0.01
MLUS(分)	16.88±8.38	16.06±7.81	19.39±9.64	$t$ =-2.160	0.032
间质性失充气模式[例(%)]
否是	98(63.2) 57(36.8)	79(67.5) 38(32.5)	19(50.0) 19(50.0)	χ²=3.7874	0.052
不张性失充气模式[例(%)]
否是	111(71.6) 44(28.4)	83(70.9) 34(29.1)	28(73.7) 10(26.3)	χ²=0.1062	0.742
实变性失充气模式[例(%)]
否是	57(36.8) 98(63.2)	46(39.3) 71(60.7)	11(28.9) 27(71.1)	χ²=1.326	0.250
住院时间(d)	23(14, 38)	26(16, 44)	14.5(8, 29)	$U$ =-3.660	0.001
ICU住院时间(d)	16(8, 29)	17(9, 33)	13(7, 24)	$U$ =-1.648	0.050
机械通气时间(h)	241(114, 472.29)	227(97, 443.65)	305(183.53, 572.07)	$U$ =1.940	0.026

表2 两组临床资料比较

Tab.2 Comparison of clinical data between the two groups

指标	总体( $n$ =155)	生存组( $n$ =124)	死亡组( $n$ =31)	统计值	$P$ 值
年龄(岁)	57.5±15.2	56.02±14.43	62.08±16.75	$t$ =-2.160	0.032
性别[例(%)]
男性女性	103(66.5) 52(33.5)	79(67.52) 38(32.48)	24(63.16) 14(36.84)	χ²=0.245	0.621
体温(℃)	37.6±0.9	37.6±0.95	37.48±0.82	$t$ =0.730	0.465
心率(次/min)	115.00±24.00	112.8±24.43	119.6±21.85	$t$ =-1.52	0.130
MAAP(mmHg)	70.3±12.0	70.81±11.66	68.61±11.35	$t$ =1.020	0.309
血氧饱和度(%)	96.7±3.5	96.82±3.58	96.42±3.26	$t$ =0.610	0.542
呼吸频率 (次/min)	24.4±4.6	24.1±4.33	25.42±5.22	$t$ =-1.550	0.124
乳酸(mmol/L)	2.0(1.5, 2.6)	1.9(1.4, 2.3)	2.5(1.8, 3)	$U$ =3.319	0.006
氧合指数	221.25(149.8, 288.29)	224(153.75, 279.75)	204.665(121, 309)	$U$ =-0.541	0.294
白细胞计数(×10⁹/L)	11.17(7.42, 14.34)	10.57(7.42, 13.64)	11.935(8.32, 17.09)	$U$ =1.606	0.054
C-反应蛋白(mg/L)	79.0(16.2, 137)	72(10.2, 137)	94.9(39, 140)	$U$ =1.413	0.079
白细胞介素6(ng/L)	64.0(18.77, 164.0)	61.08(39.34, 109.4)	93(48, 306.3)	$U$ =2.020	0.022
降钙素原(μg/L)	1.16(0.26, 8.4)	0.81(0.17, 3.9)	6.59(0.78, 12.1)	$U$ =3.184	0.008
APACHE Ⅱ评分(分)	25.1±6.5	23.69±6.04	29.26±6.34	$t$ =-4.880	<0.01
SOFA评分(分)	10.1±4.0	9.48±3.9	11.82±3.94	$t$ =-3.200	0.002
合并高血压[例(%)]
是否	58(37.4) 97(62.6)	43(36.7) 74(63.2)	15(39.5) 23(60.5)	χ²=0.091	0.763
合并糖尿病[例(%)]
是否	30(19.4) 125(80.6)	19(16.2) 98(83.8)	11(28.9) 27(71.1)	χ²=2.968	0.085
主要感染部位[例(%)]
肺部	93(60.0)	76(64.9)	17(44.7)
腹部	50(32.3)	31(26.5)	19(50.0)
颈部脓肿	4(2.6)	4(3.4)	0	-	0.079
泌尿系	4(2.6)	3(2.6)	1(2.6)
肛周脓肿	2(1.3)	1(0.9)	1(2.6)
血源性	2(1.3)	2(1.7)	0
NE[μg/(kg·min)]	0.19(0.10, 0.46)	0.05(0, 0.15714)	0.344155(0.18182, 0.8)	$U$ =5.148	<0.01
MLUS(分)	16.88±8.38	16.06±7.81	19.39±9.64	$t$ =-2.160	0.032
间质性失充气模式[例(%)]
否是	98(63.2) 57(36.8)	79(67.5) 38(32.5)	19(50.0) 19(50.0)	χ²=3.7874	0.052
不张性失充气模式[例(%)]
否是	111(71.6) 44(28.4)	83(70.9) 34(29.1)	28(73.7) 10(26.3)	χ²=0.1062	0.742
实变性失充气模式[例(%)]
否是	57(36.8) 98(63.2)	46(39.3) 71(60.7)	11(28.9) 27(71.1)	χ²=1.326	0.250
住院时间(d)	23(14, 38)	26(16, 44)	14.5(8, 29)	$U$ =-3.660	0.001
ICU住院时间(d)	16(8, 29)	17(9, 33)	13(7, 24)	$U$ =-1.648	0.050
机械通气时间(h)	241(114, 472.29)	227(97, 443.65)	305(183.53, 572.07)	$U$ =1.940	0.026

表3 影响脓毒症机械通气患者28 d预后的单因素COX比例风险分析

Tab.3 Univariate COX proportional risk analysis of 28-day prognosis in sepsis patients requiring mechanical ventilation

因素		$H R$	95% $C I$	$P$ 值
年龄		1.021	0.996, 1.047	0.094
乳酸		0.934	0.444, 1.963	0.857
氧合指数		0.801	0.531, 1.206	0.288
白细胞介素6		1.374	1.17, 1.614	0.000
APACHE Ⅱ评分		1.000	0.996, 1.004	0.960
SOFA评分		1.055	1.018, 1.093	0.003
是否应用血管活性药物	是 vs 否	1.002	0.998, 1.006	0.309
MLUS		1.000	0.999, 1.001	0.767
间质性失充气模式	是 vs 否	1.019	1.001, 1.038	0.042
不张性失充气模式	是 vs 否	1.111	1.057, 1.167	<0.01
实变性失充气模式	是 vs 否	1.148	1.06, 1.243	0.001
机械通气时间		3.324	1.271, 8.694	0.014
重力依赖失充气	是 vs 否	2.665	1.26, 4.768	0.008

表3 影响脓毒症机械通气患者28 d预后的单因素COX比例风险分析

Tab.3 Univariate COX proportional risk analysis of 28-day prognosis in sepsis patients requiring mechanical ventilation

因素		$H R$	95% $C I$	$P$ 值
年龄		1.021	0.996, 1.047	0.094
乳酸		0.934	0.444, 1.963	0.857
氧合指数		0.801	0.531, 1.206	0.288
白细胞介素6		1.374	1.17, 1.614	0.000
APACHE Ⅱ评分		1.000	0.996, 1.004	0.960
SOFA评分		1.055	1.018, 1.093	0.003
是否应用血管活性药物	是 vs 否	1.002	0.998, 1.006	0.309
MLUS		1.000	0.999, 1.001	0.767
间质性失充气模式	是 vs 否	1.019	1.001, 1.038	0.042
不张性失充气模式	是 vs 否	1.111	1.057, 1.167	<0.01
实变性失充气模式	是 vs 否	1.148	1.06, 1.243	0.001
机械通气时间		3.324	1.271, 8.694	0.014
重力依赖失充气	是 vs 否	2.665	1.26, 4.768	0.008

表4 影响脓毒症机械通气患者28 d预后的多因素COX比例风分析

Tab.4 Multivariate COX proportional risk analysis of 28-day prognosis in sepsis patients requiring mechanical ventilation

因素		$H R$	95% $C I$	$P$ 值
年龄		0.968	0.933, 1.005	0.086
乳酸		0.841	0.345, 2.05	0.703
氧合指数		0.496	0.267, 0.924	0.027
白细胞介素6		1.500	1.117, 2.016	0.007
APACHE Ⅱ评分		1.007	1.001, 1.014	0.035
SOFA评分		1.027	0.974, 1.083	0.320
间质性失充气模式	是 vs 否	0.998	0.964, 1.033	0.910
不张性失充气模式	是 vs 否	1.147	1.053, 1.249	0.002
实变性失充气模式	是 vs 否	1.146	0.995, 1.321	0.059
机械通气时间		1.616	0.431, 6.058	0.476
重力依赖性失充气	是 vs 否	2.003	1.112, 6.387	0.028

表4 影响脓毒症机械通气患者28 d预后的多因素COX比例风分析

Tab.4 Multivariate COX proportional risk analysis of 28-day prognosis in sepsis patients requiring mechanical ventilation

因素		$H R$	95% $C I$	$P$ 值
年龄		0.968	0.933, 1.005	0.086
乳酸		0.841	0.345, 2.05	0.703
氧合指数		0.496	0.267, 0.924	0.027
白细胞介素6		1.500	1.117, 2.016	0.007
APACHE Ⅱ评分		1.007	1.001, 1.014	0.035
SOFA评分		1.027	0.974, 1.083	0.320
间质性失充气模式	是 vs 否	0.998	0.964, 1.033	0.910
不张性失充气模式	是 vs 否	1.147	1.053, 1.249	0.002
实变性失充气模式	是 vs 否	1.146	0.995, 1.321	0.059
机械通气时间		1.616	0.431, 6.058	0.476
重力依赖性失充气	是 vs 否	2.003	1.112, 6.387	0.028

图3 不同肺部超声表型住院28 d生存分析

Fig.3 28-day survival analysis of various lung ultrasound phenotypes

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