吉兰—巴雷综合征患者呼吸困难的预测因素分析
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摘要
为了系统地探讨吉兰-巴雷综合征患者出现呼吸困难的预测因素,本研究对我院2003年3月1日至2009年2月28日间收治的吉兰-巴雷综合征患者共228例进行了回顾性研究,将其分为呼吸困难组(80例)和非呼吸困难组(148例),对比分析他们的基线、临床、辅助检查指标,单因素分析后得出如下指标具有统计学意义:纤维蛋白原、病情达峰时间、达峰时四肢肌力评分、前驱胃肠道感染史、感觉症状、腱反射减弱或消失、双侧周围性面神经麻痹、延髓功能障碍、自主神经功能障碍、肺内感染、白细胞计数高、低钾、肝转氨酶高和肌电图脱髓鞘合并轴索损伤。将上述指标(最后一项因病例数过于少故除外)导入多因素Logistic回归分析模型,筛选出6个预测因素,进一步分析预测因素数量和呼吸困难、需要辅助呼吸的关系,得出如下结论:病情达峰时间(P=0.001,OR=0.772)、四肢肌力评分(P=0.004,OR=0.880)、双侧周围性而神经麻痹(P=0.021,OR=2.871)、延髓功能障碍(P=0.004,OR=3.553)、自主神经功能障碍(P=0.002,OR=4.361)、低钾(P=0.011,OR=6.017)对吉兰.巴雷综合征患者呼吸困难具有预测意义,且相关性依次增强。其中前2项为保护性因素,后4项为危险因素。随着预测因素数量的增多,出现呼吸困难的几率随之增大,需要辅助呼吸的几率办增大。当患者存在3个危险因素时,出现呼吸困难的几率为59.38%,需要辅助呼吸的几率为31.25%,此时应密切观察病情,防治并发症,及时应用丙种球蛋白治疗,阻断病情进展。当患者存在4-5个危险因素时,出现呼吸困难的几率均为100%,需要辅助呼吸的儿率分别为56.52%和85.71%,故对这类患者应随时做好气管切开、呼吸机辅助呼吸的准备。尚无同时存在6个预测因素的患者。在本研究中,低钾是唯一在短期内可干预的危险因素,故入院时检测血钾和住院期间监测血钾是十分必要的。
Objectives:Guillain-Barre syndrome(GBS),also known as acute inflammatory demyelinating polyneuritis(AIDP),is the most common cause of acute paralysis.The prognosis for recovery in patients with GBS can be favorable.However,the mortality rate ranges from 2%to 12%.Respiratory failure is the dangerest risk of this disease.As it is reported,25%-30%GBS patients would appear respiratory failure.The onset of respiratory failure in GBS is insidious and the progress is not gradual but skipping as failure-compensation-decompensation. If we can not identify and manage it early,the most appropriate salvage chance will miss.Because of the acute respiratory failure,anoxic damage and the complications of the whole body will happen. Then the inconvertible bad result will happen.Therefore,it is crucial to identify predictors of dyspnea in Guillain-Barre syndrome.The large-scale and systemic studies both at home and abroad are few,and the predictors they obtained are not identified with each other.On the basis of the conditions in our country,we selected convenient and practical factors and sought to identify clinical predictors of dyspnea in Guillain-Barre syndrome.
Methods:We retrospectively review the medical records of 228 patients with GBS admit(?)ed to the department of neurology in the first hospital of Jilin University between March 1st 2003 and February 28th 2009.All the patients are divided into dyspnea group and non-dyspnea group.Compare base line,clinical, auxiliary inspection index sign.Calculate datas include age,dose of protein in the Cerebrospinal fluid,fibrinogen,time to peak disability,disability grade (summation of muscle strength of all legs and arms when the state is lowest). Count datas include sex,season,rheum,diarrhea,sensory sign,sensory syndrome,tendon reflex,abducens paralysis,bifacial paralysis,bulbar paralysis, autonomic dysfunction,pneumonia,high WBC,hypokalium,hypohepatia,EMG indicates demyelinating injury,axonal injury,both demyelinating and axonal injury.Calculate datas use t test and count datas useχ~2 test.After Univariate Analyses and Multivariate Analyses,we identify the predictors of dyspnea.At last,we analyze the relationship between the number of predictors and dyspnea and mechanical ventilation.
Result:The result of our study show amid the 228 patients with GBS, dyspnea appeared in 80 patients(35.09%).Univariate Analyses identify the predictors as follws:fibrinogen,time to peak disability,disability grade, diarrhea,sensory syndrome,tendon reflex,bifacial paralysis,bulbar paralysis, autonomic dysfunction,pneumonia,high WBC,hypokalium,hypohepatia,both demyelinating and axonal injury.Though both demyelinating and axonal injury has statistics meaning,wo exclude it because the datas are few.Multivariate analyses identify seven predictors of dyspnea:time to peak disability(P=0.001, OR=0.772),disability grade(P=0.004,OR=0.880),bifacial paralysis(P=0.021, OR=2.871),bulbar paralysis(P=0.004,OR=3.553),autonomic dysfunction (P=0.002,OR=4.361),hypokalium(P=0.011,OR=6.017),the pertinence is that time to peak disability is the lowest and hypokalium is the highest.The further study of the relationship between the number of predictors and dyspnea shows: when the patients have 0 to 3 predictors,the dyspnea rate is 6.67%、13.21%、38.78%and 59.38%,respectively.When the patients have 4 to 5 predictors,both of the dyspnea rate is 100%.There are no patients with all the 6 predictors in our study.The further study of the relationship between the number of predictors and mechanical ventilation shows:None of the patients who have 0 predictors requires mechanical ventilation.When the patients have 1 to 5 predictors,the mechanical ventilation rate is 1.89%、14.29%、31.25%、56.52%and 85.71%, respectively.
Conclusions:Time to peak disability,disability grade,bifacial paralysis, bulbar paralysis,autonomic dysfunction,hypokalium are the predictors of dyspnea in GBS patients.Time to peak disability and disability grade are the sheltered factors.And bifacial paralysis,bulbar paralysis,autonomic dysfunction and hypokalium are the dangerous factors.The more the number of predictors,the higher the rate of dyspnea will be,and so is the mechanical ventilation.When the patients have 3 predictors,the dyspnea rate is 59.38%,and the mechanical ventilation rate is 31.25%.So we must pay more attention to these patients,prevent and treat complications,use IVIG in time and stop the illness.When the patients have 4-5 predictors,the dyspnea rate is 100%,and the mechanical ventilation rates are 56.2%and 85.71%,respectively.We must prepare well for the tracheotomy and the mechanical ventilation at any moment. There are no patients with all the 6 predictors in our study.In this study, hypokalium is the only predictor that we can treat at short time.So detecting and inspecting kalium in blood plasma are crucial.
Objectives:Guillain-Barre syndrome(GBS),also known as acute inflammatory demyelinating polyneuritis(AIDP),is the most common cause of acute paralysis.The prognosis for recovery in patients with GBS can be favorable.However,the mortality rate ranges from 2%to 12%.Respiratory failure is the dangerest risk of this disease.As it is reported,25%-30%GBS patients would appear respiratory failure.The onset of respiratory failure in GBS is insidious and the progress is not gradual but skipping as failure-compensation-decompensation. If we can not identify and manage it early,the most appropriate salvage chance will miss.Because of the acute respiratory failure,anoxic damage and the complications of the whole body will happen. Then the inconvertible bad result will happen.Therefore,it is crucial to identify predictors of dyspnea in Guillain-Barre syndrome.The large-scale and systemic studies both at home and abroad are few,and the predictors they obtained are not identified with each other.On the basis of the conditions in our country,we selected convenient and practical factors and sought to identify clinical predictors of dyspnea in Guillain-Barre syndrome.
Methods:We retrospectively review the medical records of 228 patients with GBS admit(?)ed to the department of neurology in the first hospital of Jilin University between March 1st 2003 and February 28th 2009.All the patients are divided into dyspnea group and non-dyspnea group.Compare base line,clinical, auxiliary inspection index sign.Calculate datas include age,dose of protein in the Cerebrospinal fluid,fibrinogen,time to peak disability,disability grade (summation of muscle strength of all legs and arms when the state is lowest). Count datas include sex,season,rheum,diarrhea,sensory sign,sensory syndrome,tendon reflex,abducens paralysis,bifacial paralysis,bulbar paralysis, autonomic dysfunction,pneumonia,high WBC,hypokalium,hypohepatia,EMG indicates demyelinating injury,axonal injury,both demyelinating and axonal injury.Calculate datas use t test and count datas useχ~2 test.After Univariate Analyses and Multivariate Analyses,we identify the predictors of dyspnea.At last,we analyze the relationship between the number of predictors and dyspnea and mechanical ventilation.
Result:The result of our study show amid the 228 patients with GBS, dyspnea appeared in 80 patients(35.09%).Univariate Analyses identify the predictors as follws:fibrinogen,time to peak disability,disability grade, diarrhea,sensory syndrome,tendon reflex,bifacial paralysis,bulbar paralysis, autonomic dysfunction,pneumonia,high WBC,hypokalium,hypohepatia,both demyelinating and axonal injury.Though both demyelinating and axonal injury has statistics meaning,wo exclude it because the datas are few.Multivariate analyses identify seven predictors of dyspnea:time to peak disability(P=0.001, OR=0.772),disability grade(P=0.004,OR=0.880),bifacial paralysis(P=0.021, OR=2.871),bulbar paralysis(P=0.004,OR=3.553),autonomic dysfunction (P=0.002,OR=4.361),hypokalium(P=0.011,OR=6.017),the pertinence is that time to peak disability is the lowest and hypokalium is the highest.The further study of the relationship between the number of predictors and dyspnea shows: when the patients have 0 to 3 predictors,the dyspnea rate is 6.67%、13.21%、38.78%and 59.38%,respectively.When the patients have 4 to 5 predictors,both of the dyspnea rate is 100%.There are no patients with all the 6 predictors in our study.The further study of the relationship between the number of predictors and mechanical ventilation shows:None of the patients who have 0 predictors requires mechanical ventilation.When the patients have 1 to 5 predictors,the mechanical ventilation rate is 1.89%、14.29%、31.25%、56.52%and 85.71%, respectively.
Conclusions:Time to peak disability,disability grade,bifacial paralysis, bulbar paralysis,autonomic dysfunction,hypokalium are the predictors of dyspnea in GBS patients.Time to peak disability and disability grade are the sheltered factors.And bifacial paralysis,bulbar paralysis,autonomic dysfunction and hypokalium are the dangerous factors.The more the number of predictors,the higher the rate of dyspnea will be,and so is the mechanical ventilation.When the patients have 3 predictors,the dyspnea rate is 59.38%,and the mechanical ventilation rate is 31.25%.So we must pay more attention to these patients,prevent and treat complications,use IVIG in time and stop the illness.When the patients have 4-5 predictors,the dyspnea rate is 100%,and the mechanical ventilation rates are 56.2%and 85.71%,respectively.We must prepare well for the tracheotomy and the mechanical ventilation at any moment. There are no patients with all the 6 predictors in our study.In this study, hypokalium is the only predictor that we can treat at short time.So detecting and inspecting kalium in blood plasma are crucial.
引文
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[1]Anis-ur-Rehman,Idris,Muhammad,elc,Guillain Barre syndrome:the leading cause of acute flaccid paralysis in Hazara division,J Ayub Med Coll Abbottabad,2007,19(1):26-8.
[2]Seneviratne U.Guillain-Barré syndrome.Postgrad Med,2000,76(902):774-782.
[3]Lawn ND,Fletcher DD,Henderson RD,et al.Anticipating mechanical ventilation in Guillain-Barre syndrome,Arch Neurol,2001,58:893.
[4]Schottlender JG,Lombardi D,Toledo A,et al.Medicina,1999,59:705.
[5]彭茂,贾建平.吉兰-巴雷综合征严重程度早期预测因素.中华神经科杂志,2004,37:154-157.
[6]Wijdicks EF,Borel CO.Respiratory management in acute neurologic illness.Neurology,1998,50(1):11-20.
[7]彭茂,贾建平.吉兰-巴雷综合征严重程度早期预测因素.中华神经科杂志,2004,37:154-157
[8]Sharshar T,Chevret S,Bourdain F,et al.Early predictors of mechanical ventilation in Guillain-Barre syndrome[J].Crit Care Med,2003,31(1):278-283.
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[16]张晨.格林-巴利综合征的植物神经功能障碍.国外医学:神经病学神经外科学分册,1991,18(4):194-195.
[17]陈清堂主编.临床神经病学.北京:北京科学技术出版社,2000:695.
[18]方锦华,李志祥,张梅.格林-巴利综合征植物神经功能障碍132例临床分析.中国基层医药,2004,11(4):414-415.
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[25]Wijdicks EF,Borel CO.Respiratory management in acute neurologic illness.Neurology,1998,50(1):11-20.
[2]Seneviratne U.Guillain-Barré syndrome.Postgrad Med,2000,76(902):774-782.
[3]Fletcher DD,Lawn ND,Wolter TD,et al.Neurology,2000,54:231 I.
[4]Chiò A,Cocito D,Leone M,et al.Guillain-Barré syndrome:a prospective,population-based incidence and outcome survey[J].Neurology,2003,60:1146-1150.
[5]van Koningsveld R,van Doom PA,Schmitz PIM,et al.Mild forms of Guillain-Barré syndrome in an epidemiologic survey in the Netherlands[J].Neurology,2000,54:620-625.
[6]吴冬燕,陈琳.吉兰-巴雷综合征患者急性期病情严重程度及相关因素分析.中国神经免疫学和神经病学杂志,2009,16(1):8-11
[7]彭茂,贾建平.吉兰一巴雷综合征严重程度早期预测因素.中华神经科杂志,2004,37(2):154-157.
[8]Schottlender JG,Lombardi D,Toledo A,et al.Medicina,1999,59:705.
[9]陈丽,陈立国.格林-巴利综合征前驱病毒感染与临床关系研究.天津医科大学学报,2005,11(3):437-439.
[10]Visser LH,KanekoM,Dowling P,et al.Cytomegalovirus infection and Gullain-Barre syndrome[J].Neruology,1996,47(5):668.
[11]Jacobs BC,Jacobs BC,Bray PF,et al.The spectrum of antecedent infections in Guillain-barre syndrome[J].Neurology,1998,51(5):1110.
[12]Lawn ND,Fletcher DD,Henderson RD,et al.Anticipating mechanical ventilation in Guillain-Barre syndrome,Arch Neurol,2001,58:893.
[13]Sharshar T,Chevret S,Bourdain F,et al.Early predictors of mechanical ventilation in Guillain-Barre syndrome[J].Crit Care Med,2003,31(1):278-283.
[14]Schottlender JG,Lombardi D,Toledo A,et al.Medicina,1999,59:705.
[15]张晨.格林-巴利综合征的植物神经功能障碍.国外医学:神经病学神经外科学分册,1991,18(4):194-195.
[16]陈清堂主编.临床神经病学.北京:北京科学技术出版社,2000:695.
[17]方锦华,李志祥,张梅.格林-巴利综合征植物神经功能障碍132例临床分析.中国基层医药,2004,11(4):414-415.
[18]Wijdicks EF,Borel CO.Respiratory management in acute neurologic illness.Neurology,1998,50(1):11-20.
[19]Chevrolet JC,Deleamont P.Repeated vital capacity measurements as predictive parameters for mechanical ventilation need and weaning success in the Guillain-Barre syndrome.Am Rev Respir Dis,1991,144(4):814-818.
[20]Vilke GM,Chan TC,Neuman T,et al.Spirometry in normal subjects in sitting,prone,and supine positions.Respir Care,2000,45(4):407-410.
[21]Fromageot C,Lofaso F,Annane D,et al.Supine fall in lung volumes in the assessment of diaphragmatic weakness in neuromuscular disorders.Arch Phys Med Rehabil,2001,82(1):123-128.
[22]Wijdicks EF,Borel CO.Respiratory management in acute neurologic illness.Neurology,1998,50(1):11-20.
[23]Zifko U,Chen R,Remtulla H,et al.Respiratory electrophysiological studies in Guillain-Barre syndrome.Neurol Neurosurg Psychiatry,1996,60(2):191-194.
[24]Akassoglou,Katerina,Fibrin inhibits peripheral nerve remyelination by regulating Schwann cell differentiation,Neuron,2002,33:861-75.
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