重症患者血清PCT，sTREM-1和YKL-40水平与呼吸机相关性肺炎发生的相关性研究

目的　探讨血清可溶性髓系细胞触发受体(soluble triggering receptor expressed on myeloid -1，sTREM-1)、降钙素原（procalcitonin，PCT）和人软骨糖蛋白39 ( human cartilage glycoprotein-39，YKL-40)对呼吸机相关性肺炎(ventilator-associated pneumonia，VAP)患者的表达意义、VAP预后的预测价值及VAP发生的危险因素。方法　选取2018年1月~2020年6月在河北省邢台市第三医院ICU进行呼吸机通气并发生VAP的120例患者为VAP组，纳入同期未发生VAP的120例患者为非VAP组，收集两组一般资料和进入ICU 1，3，5和7天的血清PCT，sTREM-1和YKL-40水平，Logistic回归分析VAP发生的危险因素。将120例VAP患者根据28天的生存情况分为生存组（74例）和死亡组（36例），测定两组患者的PCT，sTREM-1和YKL-40水平，采用ROC曲线图判定其预测价值。结果　①VAP组和非VAP组相比较，两组的血清清蛋白水平、血糖水平、APACHE II评分、胃内容物反流、机械通气时间、抗生素使用种类差异均有统计学意义（χ2=13.019，11.793，9.932，8.957，20.057，28.884，均P＜0.05），其它资料差异均无统计学意义（P＞0.05）。②VAP组和非VAP组1天血清指标差异无统计学意义（t=0.928~1.315，均P＞0.05）。与非VAP组相比，VAP组的3，5和7天 PCT，sTREM-1和YKL-40水平显著升高（t=15.203~37.340，均P＜0.001）。③Logistic回归分析表明:年龄≥60岁，血清清蛋白＜30g/L，血糖水平≥7.8mmol/L，广谱抗生素使用种类≥3种，胃内容物反流、气管切开，机械通气时间≥5天，APACHE II评分≥15分，PCT水平升高，sTREM-1水平升高，YKL-40水平升高均是发生VAP的危险因素（χ2=4.404~14.185，均P＜0.05）。④生存组和死亡组1天PCT，sTREM-1和YKL-40水平差异无统计学意义（t=1.191，0.842和1.838，均P＞0.05），3，5和7天死亡组三个血清学指标显著高于存活组（t=13.342~26.950，均P＜0.001）。⑤3，5和7天 PCT，sTREM-1，YKL-40水平联合检测均具有较好的敏感度和特异度，对VAP患者的预后均有较高的诊断价值（AUC:0.879~0.945）。结论　 血清PCT，sTREM-1和YKL-40水平升高是ICU呼吸机通气患者发生VAP的危险因素，临床进行动态监测可对VAP患者的预后进行良好的预测，有效地改善VAP患者的预后生存。

Correlation between Serum PCT,sTREM-1, YKL-40 Levels andVentilator-Associated Pneumonia in Severe Patients

Objective　To investigate the significance of serum soluble triggering on myeloid-1 (sTREM-1), Procalcitonin (PCT)and human cartilage glycoprotein 39(YKL-40)in patients with Ventilator-associated pneumonia (VAP) and the predictive value ofVAP prognosis and the risk factors of VAP. Methods　120 patients with VAP who were ventilated in the ICU of the ThirdHospital of Xingtai City, Hebei Province from January 2018 to June 2020 were selected as the VAP group, and 120 patientswithout VAP during the same period were included as the non-VAP group. General data of the two groups and serum PCT of 1, 3,5 and 7d in the ICU were collected.STREM-1 and YKL-40 levels, and Logistic regression was performed to analyze risk factorsfor VAP.120 patients with VAP were divided into survival group (74 cases) and death group (36 cases) according to their survivalat 28 days. Serum PCT, sStreM-1 and YKL-40 levels of the two groups were measured, and their predictive value was determinedby ROC curve. Results　①Compared with the non-VAP group, there were statistically significant differences in serum albumin level,blood glucose level, APACHEII score, gastric content reflux, mechanical ventilation time and types of antibiotics used between thetwo groups (χ2=13.019，11.793，9.932，8.957，20.057 and 28.884，all P < 0.05), while there were no statistically significantdifferences in other data (P > 0.05). ② There was no significant difference in serum indexes between VAP group and non-VAPgroup on day 1 (t=0.928~1.315，all P > 0.05)，and compared with non-VAP group, PCT, sTREM-1 and YKL-40 levels in VAPgroup on day 3, 5 and 7 were significantly increased (t=15.203~37.340, all P < 0.001). ③ Logistic regression analysis showed that:age≥60 years old, serum albumin < 30g/L, blood glucose levels ≥ 7.8mmol/L, broad spectrum antibiotics used ≥ 3, gastric contentreflux tracheotomy, mechanical ventilation time ≥ 5day, APACHE II score ≥ 15, PCT, sTM-1 and increased YKL-40 level wererisk factors for VAP (χ2=4.404~14.185, all P < 0.05). ④ There were no significant differences in PCT, sTREM-1 and YKL-40 levelsbetween survival group and death group on day 1 (t=1.191, 0.842 and 1.838, all P > 0.05), and the three serologic indexes of deathgroup on day 3, 5 and 7 were significantly higher than those of survival group (t=13.342~26.950, all P < 0.001). ⑤ The combineddetection of PCT, sTREM-1 and YKL-40 levels at 3, 5 and 7d showed good sensitivity and specificity, and had high diagnosticvalue for the prognosis of VAP patients (AUC: 0.879~0.945). Conclusion　Elevated serum PCT, sTREM-1 and YKL-40 are riskfactors for VAP in ICU patients with ventilator ventilation. Dynamic clinical monitoring of above indexes can predict the prognosisof VAP patients.