166例急性呼吸窘迫综合征肺内组和肺外组临床分析
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摘要
目的比较肺部原因诱发的急性呼吸窘迫综合征(acute respiratorydistress yndrome of pulmonary origin,ARDSp)和肺外原因诱发的ARDS(ARDS of extra-pulmonary origin,ARDSexp)临床特征差异性。
方法收集我院重症加强治疗病房(ICU)2003—2008年确诊的166例ARDS患者的临床资料,比较肺内外诱因所致ARDS患者各项临床特征及预后的差异。
结果166例患者中,肺内组99例,男67例,女32例,平均年龄47.19±17.22岁;肺外组67例,男38例,女29例,平均年龄45.79±17.91岁;两组患者年龄、性别、急性生理学与慢性健康状况评分系统Ⅲ(APACHEⅢ)、接受机械通气治疗时间、住ICU时间、肺内分流比值(Q_S/Q_T)等的差异无显著性(P＞0.05)。两组病人在诊断ARDS时氧和指数(PaO_2/FiO_2)无差异性,但是机械通气48小时后肺外组患者的PaO_2/FiO_2要明显高于肺内组。肺内外组自身对照48小时前后的PaO_2/FiO_2差异有显著性。肺内、肺外组病死率分别为79.8%和64.2%,两者差异具有显著性(P＜0.05)。ARDSp以重症肺炎多见,占91.9%;ARDSexp多见于脓毒症、急性重症胰腺炎,分别占31.3%和26.9%;ARDSp常见死因为多器官功能障碍综合征(MODS)(60.8%),呼吸衰竭(13.9%),感染性休克(11.4%)。ARDSexp常见的死因为MODS(81.4%),感染性休克(11.6%).两组患者使用糖皮质激素的情况具有差异性,激素不能降低ARDS病死率。肺外组MODS发生率要高于肺内组,MODS是影响ARDS预后的重要因素。
结论ARDS病死率高,ARDSp和ARDSexp在机械通气治疗、病死率、MODS发生率等方面有差异;MODS是影响ARDS预后的重要因素;使用糖皮质激素对降低ARDS的病死率无益处。
Objective to compare the clinical differences between ARDSp & ARDSexp.
Methods Clinical data of patients with ARDS in intensive care units in our hospital from February 2003 to February 2008 were collected, and they were divided into pulmonary (ARDSp) and extra-pulmonary (ARDSexp) groups according to the inducing factors.
Results there were 99 cases with ARDSp and 67 cases with ARDSexp including male/female 67/32 and 38/29,age (47.19±17.22) and (45.79±17.91) years old, respectively .There were no significant differences between the two groups on the following items as age,gender ,APACHE (acute physiology and chronic health evaluation) III score, Q_S/Q_T,time of ventilation support,time of treatment in ICU (P > 0.05). The oxygenation of ARDSexp was improved more significant than ARDSp by ventilation support. The mortality rate was higher in ARDSp group than that in ARDSexp (P=0.025) .Major primary disease for ARDSp was severe pneumonia,for ARDSexp were sepsis, severe acute pancreatitis.The incidence rate of MODS (multiple organ dysfunction syndrome) was higher in ARDSexp than that in ARDSp.MODS was the major lethal cause. The use of Corticosteroids was not helpful to reduce the mortality rate of ARDS.
Conclusion The mortality rate of ARDS is high. There are differences between ARDSp and ARDSexp in mechanical ventilation effect and mortality rate; MODS is the major lethal cause; The use of Corticosteroids is not helpful to reduce the mortality rate of ARDS.
方法收集我院重症加强治疗病房(ICU)2003—2008年确诊的166例ARDS患者的临床资料,比较肺内外诱因所致ARDS患者各项临床特征及预后的差异。
结果166例患者中,肺内组99例,男67例,女32例,平均年龄47.19±17.22岁;肺外组67例,男38例,女29例,平均年龄45.79±17.91岁;两组患者年龄、性别、急性生理学与慢性健康状况评分系统Ⅲ(APACHEⅢ)、接受机械通气治疗时间、住ICU时间、肺内分流比值(Q_S/Q_T)等的差异无显著性(P＞0.05)。两组病人在诊断ARDS时氧和指数(PaO_2/FiO_2)无差异性,但是机械通气48小时后肺外组患者的PaO_2/FiO_2要明显高于肺内组。肺内外组自身对照48小时前后的PaO_2/FiO_2差异有显著性。肺内、肺外组病死率分别为79.8%和64.2%,两者差异具有显著性(P＜0.05)。ARDSp以重症肺炎多见,占91.9%;ARDSexp多见于脓毒症、急性重症胰腺炎,分别占31.3%和26.9%;ARDSp常见死因为多器官功能障碍综合征(MODS)(60.8%),呼吸衰竭(13.9%),感染性休克(11.4%)。ARDSexp常见的死因为MODS(81.4%),感染性休克(11.6%).两组患者使用糖皮质激素的情况具有差异性,激素不能降低ARDS病死率。肺外组MODS发生率要高于肺内组,MODS是影响ARDS预后的重要因素。
结论ARDS病死率高,ARDSp和ARDSexp在机械通气治疗、病死率、MODS发生率等方面有差异;MODS是影响ARDS预后的重要因素;使用糖皮质激素对降低ARDS的病死率无益处。
Objective to compare the clinical differences between ARDSp & ARDSexp.
Methods Clinical data of patients with ARDS in intensive care units in our hospital from February 2003 to February 2008 were collected, and they were divided into pulmonary (ARDSp) and extra-pulmonary (ARDSexp) groups according to the inducing factors.
Results there were 99 cases with ARDSp and 67 cases with ARDSexp including male/female 67/32 and 38/29,age (47.19±17.22) and (45.79±17.91) years old, respectively .There were no significant differences between the two groups on the following items as age,gender ,APACHE (acute physiology and chronic health evaluation) III score, Q_S/Q_T,time of ventilation support,time of treatment in ICU (P > 0.05). The oxygenation of ARDSexp was improved more significant than ARDSp by ventilation support. The mortality rate was higher in ARDSp group than that in ARDSexp (P=0.025) .Major primary disease for ARDSp was severe pneumonia,for ARDSexp were sepsis, severe acute pancreatitis.The incidence rate of MODS (multiple organ dysfunction syndrome) was higher in ARDSexp than that in ARDSp.MODS was the major lethal cause. The use of Corticosteroids was not helpful to reduce the mortality rate of ARDS.
Conclusion The mortality rate of ARDS is high. There are differences between ARDSp and ARDSexp in mechanical ventilation effect and mortality rate; MODS is the major lethal cause; The use of Corticosteroids is not helpful to reduce the mortality rate of ARDS.
引文
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4.王今达,王宝恩.多脏器功能失常综合征(MODS)病情分期诊断及严重程度评分标准.中国危重病急救医学,1995,7:346-347.
5.上海市ARDS协作组,108例急性呼吸窘迫综合征患者肺内和肺外源性因素分析,中华急诊医学杂志,2007,25(5):521-524.
6.邱海波,代静泓,杨毅,等.1991-2001年急性呼吸窘迫综合征的临床流行病学调查[J].中国急救医学,2003,23(7):489-491.
7.Suntharalingam G,Regan K,Keogh BF,et al.Influence of direct and indirect etiology on acute outcome and 6-month functional recovery in acute respiratory distress syndrome.Crit Care Med,2001,29(3):562-566.
8.Suchyta M,Clemmer T,Elliot C,et al.The adult respiratory distress syndrome:a report of survival and modifying factors.Chest,1992,101(4):1074-1079.
9.葛庆岗,朱曦,么改琦,等,1998-2003年北京地区重症加强治疗病房急性呼吸窘迫综合征的临床流行病学调查.中国危重病急救医学,2007,19(4):201-204.
10.Eisner MD,Thompson T,Hudson LD,et al.Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome.Am J Respir Crit Care Med,2001,164(2):231-236.
11.Desai SR.Acute respiratory distress syndrome:imaging of the injured lung.Clin Radiol,2002,57:8-17.
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15.Lu Y,Song Z,Zhou X,et al.A 12-month clinical survey of incidence and outcome of acute respiratory distress syndrome in Shanghai intensive care unites[J].Intensive Care Med,2004,30(12):2197-2203.
16.邱海波,陈德昌,刘大为,等.急性呼吸窘迫综合征患者病死危险因素的调查[J].中国危重病急救医学,1998,10(9):523-527.
17.张淑文,王超,苏强,等.多器官功能障碍综合征诊断标准与病情严重度评分系统的多中心临床研究.中国危重病急救医学,2004;16:328-33.
18.宋鹏,李琦,钱桂生,等.17例重症呼吸窘迫综合征临床资料回顾性分析.中国呼吸与危重监护,2006,5(1):35-38.
19.Chollet-Martin S,Montravers P,Gilbert C,et al.High levels of IL-8 in the blood and alveolar space in paients with pneumonia and ARDS.infec immune,1993,61(11):4553-4559.
20.Bauer TT,Monton C,Torres A,et al.Comparison of systemic cytokine levels in patients with acute respiratory distress syndrome,severe pneumonia and controls.Thorax,2000,55(1):46-52.
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2.钱桂生.全身炎症反应综合征、急性肺损伤与急性呼吸窘迫综合征[J].解放军医学杂志,1999,24(5):313-316.
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2.American College of Chest Physicians/Socirty of Critical Care Medicine Consensus Conference.Definitions for sepsis and organ failure and guide-lines for the use of innovatives therapies in sepsis[J].Crit Care Med,1992,20:864-874.
3.中华医学会呼吸病学分会.急性肺损伤/急性呼吸窘迫综合征的诊断标准(草案)[J].中华结核和呼吸杂志,2000,23(4):203.
4.王今达,王宝恩.多脏器功能失常综合征(MODS)病情分期诊断及严重程度评分标准.中国危重病急救医学,1995,7:346-347.
5.上海市ARDS协作组,108例急性呼吸窘迫综合征患者肺内和肺外源性因素分析,中华急诊医学杂志,2007,25(5):521-524.
6.邱海波,代静泓,杨毅,等.1991-2001年急性呼吸窘迫综合征的临床流行病学调查[J].中国急救医学,2003,23(7):489-491.
7.Suntharalingam G,Regan K,Keogh BF,et al.Influence of direct and indirect etiology on acute outcome and 6-month functional recovery in acute respiratory distress syndrome.Crit Care Med,2001,29(3):562-566.
8.Suchyta M,Clemmer T,Elliot C,et al.The adult respiratory distress syndrome:a report of survival and modifying factors.Chest,1992,101(4):1074-1079.
9.葛庆岗,朱曦,么改琦,等,1998-2003年北京地区重症加强治疗病房急性呼吸窘迫综合征的临床流行病学调查.中国危重病急救医学,2007,19(4):201-204.
10.Eisner MD,Thompson T,Hudson LD,et al.Efficacy of low tidal volume ventilation in patients with different clinical risk factors for acute lung injury and the acute respiratory distress syndrome.Am J Respir Crit Care Med,2001,164(2):231-236.
11.Desai SR.Acute respiratory distress syndrome:imaging of the injured lung.Clin Radiol,2002,57:8-17.
12.Tugrul S,Akinci O,Ozcan PE,et al.Effects of sustained inflation and postinflation positive end-expiratory pressure in acute respiratory distress syndrome:focusing on pulmonary and extra-pulmonary forms.Crit Care Med.2003;31:738-744
13.Rialp G,Betbese AJ,Perez-Marquez M,et al.Short-term effects of inhaled nitre oxide and prone position in pulmonary and extrapulmonary acute respiratory distress syndrome.Am J Respire Crit Care Med,2001,164(2):243-249.
14.Lanken PN,Kenneth P.Steinberg,et al.Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome.N.Engl.J.Med.,April 20,2006;354(16):1671-1684.
15.Lu Y,Song Z,Zhou X,et al.A 12-month clinical survey of incidence and outcome of acute respiratory distress syndrome in Shanghai intensive care unites[J].Intensive Care Med,2004,30(12):2197-2203.
16.邱海波,陈德昌,刘大为,等.急性呼吸窘迫综合征患者病死危险因素的调查[J].中国危重病急救医学,1998,10(9):523-527.
17.张淑文,王超,苏强,等.多器官功能障碍综合征诊断标准与病情严重度评分系统的多中心临床研究.中国危重病急救医学,2004;16:328-33.
18.宋鹏,李琦,钱桂生,等.17例重症呼吸窘迫综合征临床资料回顾性分析.中国呼吸与危重监护,2006,5(1):35-38.
19.Chollet-Martin S,Montravers P,Gilbert C,et al.High levels of IL-8 in the blood and alveolar space in paients with pneumonia and ARDS.infec immune,1993,61(11):4553-4559.
20.Bauer TT,Monton C,Torres A,et al.Comparison of systemic cytokine levels in patients with acute respiratory distress syndrome,severe pneumonia and controls.Thorax,2000,55(1):46-52.
1.Bone R C,Balk R A,Cerra F B,et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.The ACCP/SCCM Consensus Conference Committee American College of Chest Physicians/Society of Critical Care Medicine Chest,1992,101:1644-1655.
2.钱桂生.全身炎症反应综合征、急性肺损伤与急性呼吸窘迫综合征[J].解放军医学杂志,1999,24(5):313-316.
3.Bone R C.Immunologic dissonance:A continuing evolution in our understanding of the systemic inflammatory response syndrome(SIRS)and the multiple organ dysfunction syndrome(MODS).Ann Intern Med,1996,125:680-687.
4.中华医学会呼吸病学分会.急性肺损伤/急性呼吸窘迫综合征的诊断标准(草案)[J].中华结核和呼吸杂志,2000,23(4):203.
5.邱海波,代静泓,杨毅,等.1991-2001年急性呼吸窘迫综合征的临床流行病学调查[J].中国急救医学,2003,23(7):489-491.
6.Gattinoni L,Pelosi P,Suter PM,et al.Acute respiratory distress syndromecaused by pulmonary and extrapulmonary disease.Different syndromes? AmJ Respir Crit Care Med,1998;158:3-11
7.Teder P,Vandivier RW,Jiang D,et al.Resolution of lung inflammation by CD44[J].Science,2002,296:155-158.
8. Huynh ML ,Fadok VA ,Henson PM. Phosphatidylserine - dependent ingestion of apoptotic cells promotes TGF - betal secretion and the resolution of inflammation [J] . J Clin Invest , 2002 ,109 :41～50.
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