基于柏林标准诊断的急性呼吸窘迫综合征患者预后影响因素研究

背景　急性呼吸窘迫综合征（ARDS）是引起重症患者死亡的主要原因之一，随着对其认识的加深，关于ARDS的诊断标准也随之改变，2012年提出的ARDS柏林标准使得ARDS的诊断更为准确，然而基于这个标准诊断的ARDS患者的预后影响因素研究较少。目的　探讨影响基于ARDS柏林标准诊断的ARDS患者的预后影响因素。方法　选取浙江省人民医院重症医学科（ICU）2012-10-01至2017-09-30收治的177例符合ARDS柏林标准的ARDS患者为研究对象。177例患者均经积极治疗，根据住院28 d时生存结局分为生存组和死亡组。详细记录患者的基本临床资料、疾病及治疗情况、入院时疾病严重程度评分、入院时实验室检查指标，采用多因素Logistic回归分析分析ARDS患者预后的影响因素。结果　177例患者中79例（44.6%）存活（生存组），98例（55.4%）死亡（死亡组）。单因素分析显示，生存组和死亡组年龄、BMI、ARDS类型、ARDS分级、慢性阻塞性肺疾病（COPD）病史、合并休克率、入院72 h液体累积平衡情况、接受连续性肾脏替代治疗（CRRT）率、有创机械通气时间、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、序贯器官衰竭评估（SOFA）评分和血肌酐比较，差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示，年龄（>65岁）〔OR（95%CI）=2.536（1.120，4.653），P<0.01〕、ARDS类型（肺内型）〔OR（95%CI）=1.055（0.424，3.423），P<0.01〕、ARDS分级（重度）〔OR（95%CI）=3.363（1.763，5.236），P<0.01〕、入院72 h液体累积平衡（正平衡）〔OR（95%CI）=1.163（0.512，3.563），P<0.01〕、APACHEⅡ评分（15~25分）〔OR（95%CI）=2.224（1.046，4.255），P<0.01〕是ARDS患者预后的独立危险因素，而BMI>24.0 kg/m2〔OR（95%CI）=0.856（0.326，1.563），P<0.05〕则是其保护因素。结论　年龄>65岁、肺内型ARDS、重度ARDS和入院72 h液体累积正平衡、APACHEⅡ评分（15~25分）是ARDS患者预后的独立危险因素，而BMI>24.0 kg/m2是其保护因素。

Risk Factors for the Prognosis of Acute Respiratory Distress Syndrome in the Berlin Definition

Background　Acute respiratory distress syndrome（ARDS） is one of the major causes of death for severe patients.With the deepening of people's understanding about ARDS，the diagnostic criteria for ARDS are also changing.The Berlin definition proposed in 2012 makes the diagnosis of ARDS more accurate.However，the risk factors affecting the prognosis of ARDS in the Berlin definition have been rarely studied.Objective　To explore the risk factors for the prognosis of ARDS in the Berlin definition.Methods　From the Intensive Care Unit，Zhejiang Provincial People's Hospital，177 cases of ARDS in the Berlin definition were enrolled during 2012-10-01 to 2017-09-30.All of them received active treatment.General clinical data，disease and treatment，baseline disease severity scores，and baseline laboratory results were collected.According to the survival outcome at 28 h after ICU admission，they were divided into the survival group and death group.Multivariable Logistic regression analysis was conducted to analyze the risk factors for the prognosis of ARDS.Results　Of the 177 cases，79 survived（44.6%，survival group） and 98 died（55.4%，death group）．Univariate analysis showed that both groups had significant differences in the percent distributions of age，BMI，grade and pathogenetic pathway of ARDS，COPD history，rates of having shock，cumulative fluid balance （CFB） at 72 h after admission，continuous renal replacement therapy，average days of receiving invasive mechanical ventilation，Acute Physiology and Chronic Health Evaluation（APACHE）Ⅱscore，Sequential Organ Failure Assessment（SOFA） score，and average baseline serum creatinine（P<0.05）．Multivariable Logistic regression analysis showed that age>65 years〔OR（95%CI）=2.536（1.120，4.653），P<0.01〕，pulmonary ARDS〔OR（95%CI）=1.055（0.424，3.423），P<0.01〕，severe ARDS〔OR（95%CI）=3.363（1.763，5.236），P<0.01〕，positive CFB at 72 h after admission〔OR（95%CI）=1.163（0.512，3.563），P<0.01〕，APACHEⅡscores of 15-25 〔OR（95%CI）=2.224（1.046，4.255），P<0.01〕，were independent risk factors for death of ARDS，while BMI>24.0 kg/m2〔OR（95%CI）=0.856（0.326，1.563），P<0.05〕was a protective factor.Conclusion　Age>65 years，pulmonary ARDS，severe ARDS，positive CFB at 72 h after admission，APACHEⅡ scores of 15-25,were independent risk factors for death of ARDS while BMI>24.0 kg/m2 was a protective factor.