Correlation between the lung ultrasound phenotype of gravity-dependent deaeration and poor prognosis in sepsis patients requiring mechanical ventilation

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

Abstract

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

CLC Number:

R563.8

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.

Add to citation manager EndNote|Ris|BibTeX

URL: https://huicui.hebmu.edu.cn/EN/10.3969/j.issn.1004-583X.2024.04.003

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

Figures/Tables 7

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

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)

Fig.2 Typical lung ultrasound phenotypes

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

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

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

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

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

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

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

References 20

[1]	Gorman EA, O'Kane CM, McAuley DF. Acute respiratory distress syndrome in adults: Diagnosis, outcomes, long-term sequelae, and management[J]. Lancet, 2022, 400(10358):1157-1170. doi: 10.1016/S0140-6736(22)01439-8 pmid: 36070788
[2]	Joffre J, Hellman J, Ince C, et al. Endothelial responses in sepsis[J]. Am J Respir Crit Care Med, 2020, 202(3):361-370.
[3]	Bode C, Weis S, Sauer A, et al. Targeting the host response in sepsis: Current approaches and future evidence[J]. Crit Care, 2023, 27(1):478.
[4]	Buda N, Mendrala K, Skoczyński S, et al. Basics of Point-of-Care Lung Ultrasonography[J]. N Engl J Med, 2023, 389(21):e44.
[5]	Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome[J]. N Engl J Med, 2013, 368(23):2159-2168.
[6]	Papazian L, Schmidt M, Hajage D, et al. Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis[J]. Intensive Care Med, 2022, 48(3):270-280. doi: 10.1007/s00134-021-06604-x pmid: 35037993
[7]	Wang Q, Zhu J, Chen L, et al. Successful treatment of severe ARDS caused by accidental inhalation of nitric acid fumes with veno-venous ECMO: A case report and literature review[J]. Medicine (Baltimore), 2022, 101(30):e29447.
[8]	Haaksma ME, Smit JM, Heldeweg MLA, et al. Extended lung ultrasound to differentiate between pneumonia and atelectasis in critically ill patients: A diagnostic accuracy study[J]. Crit Care Med, 2022, 50(5):750-759.
[9]	Smit MR, Hagens LA, Heijnen NFL, et al. Lung ultrasound prediction model for acute respiratory distress syndrome: A multicenter prospective observational study[J]. Am J Respir Crit Care Med, 2023, 207(12):1591-1601.
[10]	Dargent A, Chatelain E, Si-Mohamed S, et al. Lung ultrasound score as a tool to monitor disease progression and detect ventilator-associated pneumonia during COVID-19-associated ARDS[J]. Heart Lung, 2021, 50(5):700-705. doi: 10.1016/j.hrtlng.2021.05.003 pmid: 34107394
[11]	Costamagna A, Pivetta E, Goffi A, et al. Clinical performance of lung ultrasound in predicting ARDS morphology[J]. Ann Intensive Care, 2021, 11(1):51. doi: 10.1186/s13613-021-00837-1 pmid: 33779834
[12]	Smit JM, Haaksma ME, Winkler MH, et al. Lung ultrasound in a tertiary intensive care unit population: A diagnostic accuracy study[J]. Crit Care, 2021, 25(1):339.
[13]	Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021[J]. Intensive Care Med, 2021, 47(11):1181-1247. doi: 10.1007/s00134-021-06506-y pmid: 34599691
[14]	Chiumello D, Mongodi S, Algieri I, et al. Assessment of lung aeration and recruitment by CT scan and ultrasound in acute respiratory distress syndrome patients[J]. Crit Care Med, 2018, 46(11):1761-1768. doi: 10.1097/CCM.0000000000003340 pmid: 30048331
[15]	Wang Y, Shen Z, Lu X, et al. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: A systematic review and meta-analysis[J]. Med Ultrason, 2018, 1(1):32-36. doi: 10.11152/mu-1223 pmid: 29400365
[16]	Yin W, Zou T, Qin Y, et al. Poor lung ultrasound score in shock patients admitted to the ICU is associated with worse outcome[J]. BMC Pulm Med, 2019, 19(1):1. doi: 10.1186/s12890-018-0755-9 pmid: 30606165
[17]	Zou T, Yin W, Diddams M, et al. The global and regional lung ultrasound score can accurately evaluate the severity of lung disease in critically ill patients[J]. J Ultrasound Med, 2020, 39(9):1879-1880. doi: 10.1002/jum.15278 pmid: 32302014
[18]	曾学英, 尹万红, 邹同娟, 等. 机械通气的休克患者肺部非重力依赖区超声评分与不良预后的相关性研究[J]. 四川大学学报(医学版), 2019, 50(6):798-802.
[19]	Zou T, Yin W, Kang Y. Application of critical care ultrasound in patients with COVID-19: Our experience and perspective[J]. IEEE Trans Ultrason Ferroelectr Freq Control, 2020, 67(11):2197-2206.
[20]	Zochios V, Yusuff H, Schmidt M, et al. Acute right ventricular injury phenotyping in ARDS[J]. Intensive Care Med, 2023, 49(1):99-102.