优化无创机械通气:哪个科室应护理这些患者?一项队列研究

背景:无创通气(NIV)已经不局限于在重症监护室(ICUs)使用,在急诊科(EDs)和普通病房,NIV也逐渐成为常规手段。目的:分析不同临床科室中,护理和NIV结局的关系。方法:根据患者特点、所提供的护理和所使用的医疗程序、评估治疗的成功和失败、接口不耐受以及并发症。并发症分析包括支气管吸引术、气胸、皮肤损伤、气道分泌物过多、眼刺激、意识水平恶化、胃扩张和面罩周围过量的空气消耗。结果:387例患者中,194例(50.1%)来自ICU,121例(31.3%)来自ED,38例(9.8%)来自术后病房,34例(8.8%)来自普通病房。校正APACHE评分和NIV适应证后,进行回归分析。结果显示,与社区医院ICU比较,在一所每年NIV病例数低于50例的大学医院的ICU,NIV失败的风险升高3.3倍[95%CI(1.2~9.2)];在ICUs和普通病房,12%的患者由于接口不耐受而中止使用NIV;急慢性肺病(ACLD)患者的NIV失败风险更低[OR 0.2,95%CI(0.06~0.69)];缺乏湿化与治疗失败没有相关性[OR 0.2,95%CI(0.1~0.4)];气道分泌物过多的相关因素是肺炎[OR 2.5,95%CI(1.1~5.9)]和早期中止和(或)拔管[OR 3.3,95%CI(1.2~8.9)];接口不耐受的相关因素是使用传统ICU呼吸机[OR 4.4,95%CI(2.1~9.2)]和过度空气消耗造成的鼻部皮肤损伤[OR 2.4,95%CI(1.1~5.3)],尤其是口鼻面罩的使用[OR 3.5,95%CI(1.1~11.3)]。结论:普通病房收治的急性呼吸衰竭的肺炎患者,其接口不耐受和NIV失败的风险增加。在任何给予NIV治疗的科室,旋转型面罩均能促进NIV的成功。     

无创正压通气治疗急性低氧性呼吸衰竭前瞻性队列研究

目的 探讨无创正压通气(NPPV)对急性低氧性呼吸衰竭(AHRF)的治疗作用和治疗失败的危险因素.方法 采用前瞻性队列研究方法,收集2004年1月-2007年12月北京朝阳医院呼吸重症监护病房应用NPPV治疗AHRF患者的临床资料,根据NPPV成功与否将患者分为成功组和失败组,比较两组患者的基本临床资料、NPPV模式和时间以及NPPV前和2 h、24 h的生命体征、血气分析和氧合指数(PaO2/FiO2)的变化.结果 ①59例患者NPPV成功率为62.7%(37/59).②与NPPV失败组比较,成功组平均年龄及因肺部感染导致AHRF比例较低(P均<0.01).NPPV前成功组PaO2/FiO2与失败组无显著差异,但成功组NPPV后2 h和24 h PaO2/FiO2均较失败组显著改善(P<0.05和P<0.01),且NPPV后24 h成功组心率和呼吸频率均较失败组显著降低(P均<0.01).③logistic回归分析显示:NPPV失败的危险因素为年龄≥60岁[比值比(OR)=8.30,95%可信区间(CI)2.49～27.60,P=0.002]、呼衰诱因为肺部感染(OR=6.19,95%CI 1.90～20.20,P=0.027)、NPPV后2 h PaO2/FiO2<150 mm Hg(1 mm Hg=0.133 kPa,OR=3.65,95%CI 1.20～11.04,P=0.044)、NPPV后24 h心率>100次/min(OR=7.45,95%CI 2.15～25.58,P=0.010)和呼吸频率>30次/min(OR=7.26,95%CI 1.88～24.49,P=0.018).结论 NPPV可作为无绝对禁忌证AHRF的一线呼吸支持方式,但对老龄和肺部感染诱发的AHRF患者失败率较高;短期应用NPPV治疗后呼吸、循环和氧合状况无显著改善的AHRF患者,应及早改为有创通气.     

无创通气辅助预测危重患者拔除气管导管失败的危险因子

目的:探讨无创通气(NIV)辅助预测危重患者拔管失败的危险因子。方法:选择2014-01—2016-12期间在本院ICU接受有创机械通气治疗超过48h、达到拔管标准、拔管后继续使用NIV治疗预防拔管失败的125例患者。随后患者如再插管即认为NIV治疗失败(失败组)。记录并比较两组患者的一般资料及重要体征、疾病严重性评分、ICU期间的治疗措施、开始和终止NIV时间、再插管时间、ICU病死率、28d病死率和住院病死率。结果:125例患者再插管率为46.4%。失败组与成功组比较,SOFA评分、液体潴留量、拔管到使用NIV的时间、NIV 1小时后心率、NIV使用的时程、入ICU诊断为肺炎等方面差异有统计学意义。从ROC曲线导出的截断值如下:SOFA评分3.5,NIV 1小时后心率100次/min,拔管到开始NIV时间12h,NIV总时间96h以及液体聚集100ml/kg。多元逻辑回归分析显示入ICU诊断为肺炎是危重患者NIV辅助拔管失败的高危因素,且再插管患者较拔管成功患者病死率高。结论:入ICU诊断为肺炎是NIV辅助拔管失败的危险因子。     

无创通气治疗重症心源性肺水肿失败的相关因素分析

目的探讨应用无创通气（NIV）治疗重症急性心源性肺水肿（ACPE）失败的相关因素。方法46例重症ACPE患者应用NIV治疗后根据治疗结果分为NIV成功组和NIV失败组,比较两组患者相关指标的变化,分析与NIV治疗失败相关的因素。结果NIV治疗失败9例（19.6%）,与NIV成功组比较,NIV失败组患者年龄偏大,急性心肌梗死居多,血压（BP）偏低,动脉血二氧化碳分压（PaCO2）下降,pH升高（P〈0.05）。NIV成功组治疗后6h动脉血氧分压（PaO2）升高,心率（HR）和呼吸频率（RR）减慢,与治疗前比较差异有显著性意义（P〈0.05）。NIV失败组治疗后6 h动脉血气和HR、RR虽有改善,但与治疗前比较无统计学意义（P〉0.05）。结论ACPE患者高龄、有急性心肌梗死、低血压、低碳酸血症,以及NIV治疗初期（6 h）动脉血气、HR和RR有无明显改善可作为预测NIV治疗是否能获得成功的相关指标。     

老年股骨粗隆间骨折患者内固定治疗失败的影响因素分析

目的 分析老年股骨粗隆间骨折(IFF)患者内固定治疗失败的影响因素。方法 选取2017年1月～2020年12月我院收治的老年IFF患者76例,均接受股骨近端防旋髓内钉治疗。统计所有患者内固定治疗效果,并设计基线资料调查表,询问并统计患者基线资料,分析老年IFF患者内固定治疗失败的影响因素。结果 76例老年IFF患者中内固定治疗成功66例(86.84%),失败10例(13.16%);失败组患者中伴有骨质疏松、不稳定性骨折、合并外侧壁骨折比例均高于成功组,差异均有统计学意义(P0.05);经Logistic回归分析后建立多元回归模型,结果显示,伴有骨质疏松、不稳定性骨折、合并外侧壁骨折是老年IFF患者内固定治疗失败的危险因素(OR1,P0.05)。结论 老年IFF患者内固定治疗失败的影响因素为骨质疏松、不稳定性骨折、合并外侧壁骨折。     

老年慢阻肺急性加重并发呼吸衰竭患者序贯机械通气治疗失败的影响因素分析

目的探讨老年慢阻肺急性加重(AECOPD)并发呼吸衰竭患者序贯机械通气治疗失败的影响因素。方法选取2018年4月～2019年4月我院收治的AECOPD并发呼吸衰竭患者116例,按照序贯机械通气治疗成功或失败分为两组。比较两组一般资料,将AECOPD并发呼吸衰竭患者序贯机械通气治疗失败的影响因素纳入自变量并进行赋值,经多项logistic回归分析,找出AECOPD并发呼吸衰竭患者序贯机械通气治疗失败的影响因素。结果经非条件logistic回归分析结果得出,糖尿病史、APACHEⅡ≥15分、pH异常、营养不良均是影响老年AEPOCD并发呼吸衰竭患者序贯机械通气治疗失败的影响因素(OR1,P0.05)。结论糖尿病史、APACHEⅡ≥15分、pH异常及营养不良均可能是AECOPD并发呼吸衰竭患者序贯机械通气治疗失败的影响因素,临床应根据存在的风险积极给予干预,提高治疗成功率。     

经鼻高流量湿化氧疗对急性呼吸衰竭患者呼吸循环参数、凝血指标和并发症的影响

目的：通过与无创机械通气(non-invasive mechanical ventilation,NIV)对比,探讨经鼻高流量湿化氧疗(high-flow nasal cannula,HFNC)对急性呼吸衰竭(acute respiratory failure,ARF)患者呼吸循环参数、凝血指标和并发症的影响。方法：选取2018年9月至2020年8月池州市人民医院收治的ARF患者作为研究对象。根据氧疗方法不同将90例ARF患者分为HFNC组(n=45)与NIV组(n=45),HFNC组予以HFNC治疗,NIV组予以NIV治疗。比较2组治疗前后呼吸循环参数[呼吸频率(respiratory rate,RR)、脉搏血氧饱和度(pulse oxygen saturation,SpO₂)、动脉二氧化碳分压(arterial partial pressure of carbon dioxide,PaCO₂)和氧合指数(arterial partial pressure of oxygen/fraction of inspiratory oxygen,P...     

早期预测经鼻高流量湿化氧疗治疗结局的指标

目的探索早期预测经鼻高流量湿化氧疗(HFNC)治疗非肺炎所致急性低氧性呼吸衰竭(AHRF)结局的指标, 并探讨其预测患者结局的价值。方法本研究为回顾性队列研究, 选取2019年1月至2022年12月江汉大学附属湖北省第三人民医院呼吸与危重症医学科收治的80例采用HFNC治疗的非肺炎所致的AHRF患者, 男48例, 女32例, 年龄(64.13±11.23)岁, 年龄范围为37～87岁。根据HFNC治疗是否成功分为成功组(n=50)与失败组(n=30), 比较两组患者的一般资料、基线呼吸生理参数、急性生理与慢性健康(APACHE Ⅱ)评分、序贯性器官功能衰竭(SOFA)评分、呼吸速率氧合(ROX)指数、一项包含心率、酸中毒、意识、氧合和呼吸频率组成的综合评分(简称HACOR评分)之间的差异, 同时比较治疗2、12、24 h后的ROX指数、HACOR评分。建立HFNC治疗的多因素回归分析模型, 并评估其危险因素预测HFNC结局的价值。结果成功组患者基线心率[(103.26±9.07)次/分]、呼吸频率[(28.54±2.97)次/分]低于失败组[(109.63±10.60)次/分、(31....     

老年髋部骨折患者术后谵妄风险预测模型的构建及验证

目的 构建老年髋部骨折患者术后谵妄风险预测模型,并验证模型预测效果。方法 采用便利抽样法从山东省泰山医院老年病科2018年1月—2020年8月收治的老年髋部骨折患者中选取340例作为研究对象,其中2018年1月—2019年4月收治的老年髋部骨折患者240例为构建组,2019年5月—2020年8月收治的老年髋部骨折患者100例为验证组,通过回顾性分析法整理患者基础信息,经多因素Logistic回归分析筛选术后谵妄风险因素,据此构建术后谵妄风险预测模型,并将模型应用于验证组以检验其预测效果。结果 结果显示,构建组术后谵妄患者共72例,发生率为30.00%;经单因素分析、多因素Logistic回归分析,老年髋部骨折患者术后谵妄风险因素包括年龄>70岁、术前白蛋白≤35 g/L、微型营养评分法(Mini Nutritional Assessment, MNA)评分<17分、全麻术、手术时间≥120 min、术中出血量>150 mL、术后疼痛视觉模拟评分(Visual Analogue Scale, VAS)≥7分;经验证分析得到,所构建的老年髋部骨折患者术后谵妄风险预测模型的...     

β-受体阻滞剂对脓毒症早期急性低氧性呼吸衰竭患者的保护作用

目的:探索β受体阻滞剂对脓毒症早期急性低氧性呼吸衰竭(AHRF)患者临床特征及结局的影响。方法:回顾性收集2015-01-01—2019-12-31期间所有入住中国人民解放军战略支援部队特色医学中心重症医学科的脓毒症患者数据,根据入院后有无使用β受体阻滞剂分为β受体阻滞剂组和non-β受体阻滞剂组,比较两组患者血气指标、生化指标、循环状态以及机械通气天数、ICU住院天数、28 d存活情况。结果:总共有105例脓毒症早期AHRF患者纳入研究,其中β受体阻滞剂组47例,non-β受体阻滞剂组58例。与non-β受体阻滞剂组相比,β受体阻滞剂可以改善PO_2和氧合指数,降低乳酸水平,增加淋巴细胞数量,减少血管活性药物的使用(P0.05)。并且β受体阻滞剂可明显减少脓毒症早期AHRF患者的机械通气天数,ICU住院天数和28 d病死率(P0.05)。多因素COX回归分析显示,β受体阻滞剂可以降低脓毒症早期AHRF患者的死亡风险(OR=0.781,95%CI:0.726～0.841,P0.05),而高乳酸(OR=1.198,95%CI:1.178～1.218,P0.01)、高SOFA评分(OR=1.222,95%CI:1.207～1.238,P0.01)以及男性(OR=1.676,95%CI:1.559～1.806,P0.01)可增加28 d病死率。结论:β受体阻滞剂是脓毒症早期AHRF患者的保护因素,而高乳酸、高SOFA评分以及男性是危险因素。     

Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure

Objective This study compared the effectiveness of noninvasive ventilation (NIV) and the risk factors for NIV failure in hypercapnic acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) vs. non-COPD conditions.Design and setting Prospective cohort study in the medical intensive care unit of a university hospital.Patients and participants 111 patients with hypercapnic ARF, 43 of whom had COPD exacerbations and 68 other conditions. Baseline characteristics of the two groups were similar.Measurements and results The risk of NIV failure, defined as the need for endotracheal intubation, was significantly lower in COPD than in other conditions (19% vs. 47%). High APACHE II score was an independent predictor of NIV failure in COPD (OR 5.38 per 5 points). The presence of pneumonia (OR 5.63), high APACHE II score (OR 2.59 per 5 points), rapid heart rate (OR 1.22 per 5 beats/min), and high PaCO₂ 1 h after NIV (OR 1.22 per 5 mmHg) were independent predictors of NIV failure in the non-COPD group. Failure of NIV independently predicted mortality (OR 10.53).Conclusions Noninvasive ventilation was more effective in preventing endotracheal intubation in hypercapnic ARF due to COPD than non-COPD conditions. High APACHE II score predicted NIV failure in both groups. Noninvasive ventilation was least effective in patients with hypercapnic ARF due to pneumonia.This revised version was published online in March 2005. In the abstract all occurrences of 95% CI were deleted, and in the main text some orthographical corrections were made.     

不同预后评分在老年呼吸衰竭患者中的应用

目的 比较不同评分系统对老年呼吸衰竭患者预后的评价能力.方法 收集解放军总医院2009年1月至2010年3月收住的老年呼吸衰竭患者159例,均存在2个或以上器官功能不全,符合老年多器官功能障碍综合征(MODSE)诊断标准,分别在入院时用急性生理学与慢性健康状况评分系统(APACHE Ⅱ、APACHE Ⅲ)、简化急性生理学评分Ⅱ(SAPS Ⅱ)、多器官功能障碍评分(Marshall评分)预测患者预后,并比较其诊断能力.结果 159例呼吸衰竭患者平均年龄(75.26±7.87)岁,28 d病死率为53.5%.死亡组患者各种预后评分、器官衰竭发生率均明显高于存活组[APACHE Ⅱ评分(分):27.88±8.19比17.73±6.21;APACHE Ⅲ评分(分):101.10±29.81比64.24±21.98;SAPS Ⅱ评分(分):59.70±17.68比38.05±12.10 ;Marshall评分(分):8.59±3.15比4.90±2.66;器官衰竭数目(个):4.60±1.14比2.88±0.88,均P＜0.01＝;4种评分中敏感性以SAPS Ⅱ最佳,为91.76%;特异性以APACHE Ⅲ最佳,为91.89%;各评分曲线下面积均可达0.820或以上(APACHE Ⅱ为0.829,APACHE Ⅲ为0.836,SAPS Ⅱ为0.844,Marshall评分0.820).结论 现行APACHE Ⅱ、APACHEⅢ、SAPS Ⅱ、Marshall评分4种评分均可较好地预测老年呼吸衰竭患者的预后情况.

Abstract：

Objective To evaluate the predictive power of current scoring systems applied in elderly patients with respiratory failure. Methods Data of 159 elderly patients with respiratory failure, also meeting the criteria of multiple organ dysfunction syndrome in the elderly (MODSE), being admitted to PLA General Hospital from January 2009 to March 2010 were analyzed with four scoring systems, i.e. acute physiology and chronic health evaluation (APACHE Ⅱ , APACHE Ⅲ ), simplified acute physiology score Ⅱ (SAPS Ⅱ ),as well as multiple organ dysfunction score (Marshall score), for the prediction of their outcome on the first day after admission, and the predictive power of respective system was compared. Results One hundred and fifty-nine patients were involved, with a mean age of (75.26±7. 87) years, and a 28-day mortality of 53. 5%. Incidence of organ failure and prognosis scores in nonsurvivors were significantly higher than those in survivors (APACHE Ⅱ score: 27. 88 ± 8. 19 vs. 17.73 ± 6.21; APACHE Ⅲ score: 101.10 ± 29. 81 vs.64. 24±21.98; SAPS Ⅱ score: 59. 70±17.68 vs. 38. 05±12. 10; Marshall score: 8. 59±3. 15 vs. 4. 90±2. 66; organ failure: 4. 60±1.14 vs. 2. 88±0. 88, all P＜0. 01). Among the four scoring systems, SAPS Ⅱpresented excellence in sensitivity (91.76 % ), while APACHE Ⅲ in specificity (91.89 % ). Area under curve of receiver operator characteristic of all scoring systems reached 0. 820 (0. 829 for APACHE Ⅱ , 0. 836 for APACHE Ⅲ , 0. 844 for SAPS Ⅱ , 0. 820 for Marshall score). Conclusion All the four current scoring systems, i.e. APACHE Ⅱ , APACHE Ⅲ , SAPS Ⅱ and Marshall score, presented satisfactory predictive power in prognosis of elderly patients with respiratory failure.     

Comparison of non-invasive ventilation and standard medical therapy in acute hypercapnic respiratory failure: a randomised controlled study at a tertiary health centre in SE Turkey

This study was designed in a tertiary health centre in south-eastern Turkey to compare the effectiveness of non-invasive ventilation (NIV) plus standard medical therapy (ST) to ST alone, in acute hypercapnic respiratory failure (AHRF) due to chronic obstructive pulmonary disease (COPD) exacerbation. Thirty-four consecutive patients were randomly assigned to receive either NIV plus ST or ST alone. NIV was applied with a simple non-invasive ventilator through a full face mask in the general ward. Initial settings for inspiratory and expiratory positive airway pressures were 9 cm HO2, and 3 cm HO2, respectively. We observed statistically significant improvements in the first hour of NIV regarding respiratory rate (p<0.001), pH (p<0.05), PaO2 (p<0.05), and PaCO2 (p<0.001). PaO2 (p<0.05) showed significant improvement only in the first hour of ST. The intubation rate and duration of hospitalisation in the NIV group were significantly shorter than those in the ST group (p<0.05). We conclude that NIV provides adjunctive therapeutic benefits compared with ST alone, and should be the choice of first step treatment in the AHRF due to COPD exacerbation in the appropriate setting and in selected patients.     

Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure

Purpose  

The use of non-invasive ventilation (NIV) in severe acute respiratory failure (ARF) due to community-acquired pneumonia (CAP) is controversial, and the risk factors for NIV failure in these patients are not well known. We assessed the characteristics and predictors of outcome of patients with CAP and severe ARF treated with NIV.     

无创通气在老年慢性阻塞性肺疾病合并Ⅱ型呼吸衰竭中的临床应用

目的 观察无创通气（NIV）治疗老年慢性阻塞性肺疾病（COPD）合并Ⅱ型呼吸衰竭患者的临床疗效.方法 选取65例老年COPD合并呼吸衰竭患者,随机分为观察组33例与对照组32例.2组均给予祛痰、抗感染、扩张支气管等常规治疗,对照组在此基础上给予持续低流量吸氧,观察组在此基础上给予NIV治疗.观察2组临床症状改善情况,治疗前、治疗3h后及7d后的呼吸频率（RR）、心率（HR）、动脉血气分析、临床肺部感染评分（CPIS）及急性生理学和慢性健康状况评分系统Ⅱ（APACHEⅡ）评分等指标变化.结果 观察组症状改善率87.88％,高于对照组的81.25％,但差异无统计学意义（P＞0.05）;2组治疗前RR、HR、动脉血气分析、CPIS及APACHEⅡ评分无显著差异（P＞0.05）;治疗3h、7d后,2组上述指标均较治疗前显著改善（P＜0.05或P＜0.01）,组间比较差异显著（P＜0.01）.结论 NIV对老年COPD合并Ⅱ型呼吸衰竭患者的疗效确切,在纠正低氧血症、改善二氧化碳潴留、呼吸性酸中毒及改善肺功能方面显著优于鼻导管吸氧.     

Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer

Noninvasive ventilation (NIV) is widely used in the treatment of acute respiratory failure (ARF), but not in patients with end-stage solid cancer in whom any form of mechanical ventilation tends to be avoided. In a prospective study, we investigated the use of NIV in 23 patients with solid malignancies receiving palliative care and who were affected by severe hypoxic or hypercapnic ARF. The most frequent causes of ARF were exacerbations of pre-existing pulmonary diseases and pneumonia. After one hour, NIV significantly improved PaO2/FiO2 (from 154+/-48 to 187+/-55) and the Borg dyspnoea score (from 5.5+/-1.2 to 2.3+/-0.3). NIV also improved pH, but only in the subset of hypercapnic patients. Thirteen of 23 (57%) patients were successfully ventilated and discharged alive, while 10/23 patients (43%) met the criteria for intubation or died after an initial trial of NIV. Only two of these patients accepted invasive ventilation. The mortality rate in this subgroup was 9/10 (90%). A higher Simplified Acute Physiology Score (SAPS II) and a lower PaO2/FiO2 on admission were associated with a lower probability of survival. Patients with ARF and end-stage solid malignancies have an overall ICU and 1-year mortality rate of 39% and 87%, respectively, but despite this, a consistent subset of patients may still be successfully treated with NIV, if the cause of ARF is reversible.     

Cephalic versus oronasal mask for noninvasive ventilation in acute hypercapnic respiratory failure

Objective  Compared to oronasal interfaces, a cephalic mask has a larger inner volume, covers the entire anterior surface of the face and limits the risk of deleterious cutaneous side effects during noninvasive ventilation (NIV). The present clinical study aimed to compare the clinical efficacy of a cephalic mask versus an oronasal mask in patients with acute hypercapnic respiratory failure (AHRF). Design and setting  Randomized controlled study in a Respiratory Intermediate Care Unit. Patients  All consecutive patients admitted for AHRF were randomly assigned to receive bilevel NIV either with a cephalic mask (n = 17) or an oronasal mask (n = 17) during the first 48 h. Measurements  The main outcome criterion was the improvement of arterial pH, 24 h after NIV initiation. Secondary criteria included PaCO₂ and physiological parameters. Results  Compared to values at inclusion, pH, PaCO₂, encephalopathy score, respiratory distress score and respiratory frequency improved significantly and similarly with both masks. None of these parameters showed statistically significant differences between the masks at each time point throughout the study period. Mean delivered inspiratory and expiratory pressures were similar in both patient groups. Tolerance of the oronasal mask was improved at 24 h and further. One patient with the cephalic mask suffered from claustrophobia that did not lead to premature study interruption. Conclusions  In spite of its larger inner volume, the cephalic mask has the same clinical efficacy and requires the same ventilatory settings as the oronasal mask during AHRF.     

老年肺炎合并感染性休克患者预后相关因素分析

目的 探讨老年肺炎合并感染性休克患者预后相关因素.方法 分析88例老年肺炎合并感染性休克患者的临床资料,用单因素分析比较不同预后组患者预后可能相关因素,再将有统计学差异的因素用多因素回归分析筛选出与死亡相关的独立危险因素.结果 老年肺炎合并感染性休克患者病死率56.8％,单因素分析结果提示死亡组年龄、APACHEⅡ评分、功能不全脏器的数量、干预前及治疗6h后血乳酸水平均显著高于存活组（均P ＜0.05）,且神经、凝血、肾功能不全的发生率均高于存活组（均P＜0.05）,多因素Logistic分析提示入ICU时APACHEⅡ评分≥26.5分、治疗6h后血乳酸水平≥4.0 mmol/L、器官衰竭数量≥3.6个、神经功能不全为不良预后的独立危险因素.结论 老年肺炎患者一旦合并感染性休克病死率就会高,其治疗前病情危重程度、早期干预后血乳酸水平、脏器功能不全的数量（尤其是脑）与预后密切相关,因此如何尽早干预以降低血乳酸水平、避免脏器功能受损对患者预后有极其重要的意义.     

Risk factors for non-invasive ventilation failure in influenza infection with acute respiratory failure in emergency department

ObjectiveNon-invasive ventilation (NIV) has been widely used in hypoxemic acute respiratory failure (ARF) due to influenza pneumonia in the emergency department (ED). However, NIV used in influenza-associated acute respiratory failure had a variable rate of failure. Previous studies have reported that prolonged use of NIV was associated with increased mortality. Our study aimed to identify risk factors for NIV failure in influenza infection with acute respiratory failure in ED.MethodWe performed a retrospective cohort observational study. Enrolled patients were older than 18 years who used NIV due to influenza infection with ARF between 1 January 2017 to 31 December 2018 in Ramathibodi Emergency Department. Patients characteristics, comorbidity, clinical, laboratory outcome, chest imaging, initial NIV setting, and parameters were collected in ED setting. Sequential organ failure assessment (SOFA) score and PaO2/FiO2 (PF) ratio were calculated from the first arterial blood gas in ED. We followed the outcome success or failure of the NIV used.ResultsA total of 162 patients were enrolled and 72 (44%) suffered NIV failure in influenza infection with ARF. We used univariate and multivariate logistic analyses to assess risk factors for NIV failure. The ability of risk factor to predict NIV failure was analyzed using the area under the receiver operating characteristic (AUROC). Risk factors of NIV failure included SOFA score (P = 0.001), PF ratio (P = 0.001) and quadrant infiltrations in chest x-rays (CXR) (P = 0.001). SOFA score, PF ratio, and number quadrant infiltrations in chest radiography have good ability to predict NIV failure, AUROC 0.894 (95%CI 0.839–0.948), 0.828 (95%CI 0.764–0.892), and 0.792 (95%CI 0.721–0.863), respectively and no significant difference in the ability to predict NIV failure among three parameters. The use of PF ratio plus number quadrant infiltrations in chest radiography demonstrated a higher predictive ability for NIV failure in influenza infection with ARF.ConclusionsSOFA score, PF ratio, and quadrant infiltrations in chest radiography were good predictors of NIV failure in influenza infection with ARF.     

无创正压通气治疗免疫抑制合并急性呼吸衰竭患者的临床分析

目的 探讨免疫抑制(ICH)合并急性呼吸衰竭(ARF)患者接受无创正压通气(NPPV)的疗效及影响NPPV成功的因素。方法 选择2008年3月至2011年3月在本院呼吸重症监护病房(RICU)应用NPPV治疗的ICH合并ARF患者,记录其各项临床资料;采用单因素Logistic回归分析NPPV治疗成功的独立影响因素;按临床转归进行免疫状态评估。结果 33例ICH合并ARF患者初始均接受NPPV治疗;其中9例(27.3％)NPPV失败后改用有创机械通气(IMV,失败组),最终全部死亡;24例(72.7％)仅用NPPV并成功（成功组）,最终死亡7例(29.2％),两组间病死率比较差异有统计学意义(P＜0.01)。除成功组简化急性生理学评分Ⅱ (SAPS Ⅱ,分)显著低于失败组外(33±9比43±5,P＜0.01),两组其他临床资料比较差异无统计学意义。Logistic回归分析显示,SAPS Ⅱ是NPPV治疗成功的独立影响因素[优势比(OR)=0.83,95％可信区间(95％CI)0.709～0.964,P＜0.05],且SAPS Ⅱ≥38分是NPPV失败的高危因素[受试者工作特征曲线(ROC)下面积为0.73]。另外,生存组肺损伤评分(LIS,分)显著低于死亡组(1.95±0.48比2.57±0.52,P＜0.01),CD3+、CD8+T淋巴细胞亚群均高于死亡组(CD3+:0.73±0.16比0.41±0.20;CD8+:0.51±0.18比0.21±0.15,均P＜0.01)。结论 NPPV可用于ICH肺部感染合并ARF的早期治疗,以SAPS Ⅱ ＜38分作为NPPV治疗的选择时机,能有效改善缺氧,避免IMV相关并发症,利于ICH的预后;CD3+、CD8+及LIS评分可以作为评价预后的指标。