Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China
Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China
复制标题
DOI：
10.1001/jamainternmed.2020.0994
复制
发表时间：
2020-07-01
影响因子：
39
通讯作者：
Song, Yuanlin
中科院分区：
文献类型：
--
作者：
Wu, Chaomin;Chen, Xiaoyan;Song, Yuanlin
问题：在新型冠状病毒肺炎（COVID - 19）患者中，哪些临床特征与急性呼吸窘迫综合征（ARDS）的发生以及从ARDS进展至死亡相关？
研究结果：在这项涉及201例确诊COVID - 19肺炎患者的队列研究中，与ARDS发生以及从ARDS进展至死亡相关的风险因素包括年龄较大、中性粒细胞增多以及器官和凝血功能障碍。使用甲泼尼龙治疗可能对发生ARDS的患者有益。
意义：发生ARDS的风险因素包括与免疫激活一致的因素；年龄较大与ARDS的发生和死亡均相关，可能是由于免疫反应较弱。这项队列研究描述了201例发生急性呼吸窘迫综合征或死亡的新型冠状病毒肺炎（COVID - 19）患者的风险因素、临床特征和结局。
重要性：新型冠状病毒肺炎（COVID - 19）是一种新兴传染病，首次在中国武汉报道，随后在全球传播。COVID - 19肺炎临床结局的风险因素尚未明确界定。
目的：描述发生急性呼吸窘迫综合征（ARDS）或死亡的COVID - 19肺炎患者的临床特征和结局。
设计、地点和参与者：对2019年12月25日至2020年1月26日期间在中国武汉金银潭医院收治的201例确诊COVID - 19肺炎患者进行回顾性队列研究。随访截止日期为2020年2月13日。
暴露因素：确诊COVID - 19肺炎。
主要结局指标：ARDS的发生和死亡。还收集并分析了流行病学、人口统计学、临床、实验室、管理、治疗和结局数据。
结果：201例患者的中位年龄为51岁（四分位间距为43 - 60岁），128例（63.7%）为男性。84例患者（41.8%）发生ARDS，在这84例患者中，44例（52.4%）死亡。在发生ARDS的患者中，与未发生ARDS的患者相比，更多患者出现呼吸困难（分别为84例中的50例[59.5%]和117例中的30例[25.6%]，差异为33.9%；95%置信区间为19.7% - 48.1%），并且有高血压（分别为84例中的23例[27.4%]和117例中的16例[13.7%]，差异为13.7%；95%置信区间为1.3% - 26.1%）和糖尿病（分别为84例中的16例[19.0%]和117例中的6例[5.1%]，差异为13.9%；95%置信区间为3.6% - 24.2%）等合并症。在二元Cox回归分析中，与ARDS发生以及从ARDS进展至死亡相关的风险因素包括年龄较大（风险比[HR]分别为3.26；95%置信区间为2.08 - 5.11；以及6.17；95%置信区间为3.26 - 11.67）、中性粒细胞增多（HR分别为1.14；95%置信区间为1.09 - 1.19；以及1.08；95%置信区间为1.01 - 1.17）以及器官和凝血功能障碍（例如，较高的乳酸脱氢酶[HR分别为1.61；95%置信区间为1.44 - 1.79；以及1.30；95%置信区间为1.11 - 1.52]和D - 二聚体[HR分别为1.03；95%置信区间为1.01 - 1.04；以及1.02；95%置信区间为1.01 - 1.04]）。高热（≥39℃）与ARDS发生的可能性较高相关（HR为1.77；95%置信区间为1.11 - 2.84），与死亡的可能性较低相关（HR为0.41；95%置信区间为0.21 - 0.82）。在ARDS患者中，使用甲泼尼龙治疗降低了死亡风险（HR为0.38；95%置信区间为0.20 - 0.72）。
结论和相关性：年龄较大与ARDS发生和死亡的风险较高相关，可能是由于免疫反应较弱。尽管高热与ARDS的发生相关，但在ARDS患者中它也与较好的结局相关。此外，使用甲泼尼龙治疗可能对发生ARDS的患者有益。
Question What clinical characteristics are associated with the development of acute respiratory distress syndrome (ARDS) and progression from ARDS to death among patients with coronavirus disease 2019 (COVID-19) pneumonia? Findings In this cohort study involving 201 patients with confirmed COVID-19 pneumonia, risk factors associated with the development of ARDS and progression from ARDS to death included older age, neutrophilia, and organ and coagulation dysfunction. Treatment with methylprednisolone may be beneficial for patients who develop ARDS. Meaning Risk for developing ARDS included factors consistent with immune activation; older age was associated with both ARDS development and death, likely owing to less robust immune responses.This cohort study describes risk factors and clinical characteristics and outcomes in 201 patients with coronavirus disease 2019 (COVID-19) pneumonia who developed acute respiratory distress syndrome or died.Importance Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in Wuhan, China, and has subsequently spread worldwide. Risk factors for the clinical outcomes of COVID-19 pneumonia have not yet been well delineated. Objective To describe the clinical characteristics and outcomes in patients with COVID-19 pneumonia who developed acute respiratory distress syndrome (ARDS) or died. Design, Setting, and Participants Retrospective cohort study of 201 patients with confirmed COVID-19 pneumonia admitted to Wuhan Jinyintan Hospital in China between December 25, 2019, and January 26, 2020. The final date of follow-up was February 13, 2020. Exposures Confirmed COVID-19 pneumonia. Main Outcomes and Measures The development of ARDS and death. Epidemiological, demographic, clinical, laboratory, management, treatment, and outcome data were also collected and analyzed. Results Of 201 patients, the median age was 51 years (interquartile range, 43-60 years), and 128 (63.7%) patients were men. Eighty-four patients (41.8%) developed ARDS, and of those 84 patients, 44 (52.4%) died. In those who developed ARDS, compared with those who did not, more patients presented with dyspnea (50 of 84 [59.5%] patients and 30 of 117 [25.6%] patients, respectively [difference, 33.9%; 95% CI, 19.7%-48.1%]) and had comorbidities such as hypertension (23 of 84 [27.4%] patients and 16 of 117 [13.7%] patients, respectively [difference, 13.7%; 95% CI, 1.3%-26.1%]) and diabetes (16 of 84 [19.0%] patients and 6 of 117 [5.1%] patients, respectively [difference, 13.9%; 95% CI, 3.6%-24.2%]). In bivariate Cox regression analysis, risk factors associated with the development of ARDS and progression from ARDS to death included older age (hazard ratio [HR], 3.26; 95% CI 2.08-5.11; and HR, 6.17; 95% CI, 3.26-11.67, respectively), neutrophilia (HR, 1.14; 95% CI, 1.09-1.19; and HR, 1.08; 95% CI, 1.01-1.17, respectively), and organ and coagulation dysfunction (eg, higher lactate dehydrogenase [HR, 1.61; 95% CI, 1.44-1.79; and HR, 1.30; 95% CI, 1.11-1.52, respectively] and D-dimer [HR, 1.03; 95% CI, 1.01-1.04; and HR, 1.02; 95% CI, 1.01-1.04, respectively]). High fever (>= 39 degrees C) was associated with higher likelihood of ARDS development (HR, 1.77; 95% CI, 1.11-2.84) and lower likelihood of death (HR, 0.41; 95% CI, 0.21-0.82). Among patients with ARDS, treatment with methylprednisolone decreased the risk of death (HR, 0.38; 95% CI, 0.20-0.72). Conclusions and Relevance Older age was associated with greater risk of development of ARDS and death likely owing to less rigorous immune response. Although high fever was associated with the development of ARDS, it was also associated with better outcomes among patients with ARDS. Moreover, treatment with methylprednisolone may be beneficial for patients who develop ARDS.