IDENTIFICATION OF PATIENTS WITH ACUTE LUNG INJURY - PREDICTORS OF MORTALITY
IDENTIFICATION OF PATIENTS WITH ACUTE LUNG INJURY - PREDICTORS OF MORTALITY
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DOI：
10.1164/ajrccm.152.6.8520742
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发表时间：
1995-12-01
影响因子：
24.7
通讯作者：
MATTHAY, MA
中科院分区：
文献类型：
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作者：
DOYLE, RL;SZAFLARSKI, N;MATTHAY, MA
最近的北美-欧洲共识会议提出了急性肺损伤定义的新的统一标准，部分原因是为了更早地识别临床试验患者。然而，这些标准尚未经过前瞻性评估。我们设计了一项前瞻性队列研究，纳入了 123 名连续患有急性肺损伤的患者，这些患者是在三级甲等大学医院的成人重症监护病房入院时前瞻性发现的。目的是确定与先前对成人呼吸窘迫综合征（ARDS）患者的研究相比，使用急性肺损伤新标准选择患者是否会导致临床特征、危险因素或死亡率预测因素发生显着变化；并确定急性肺损伤严重程度的定量指标对于识别急性肺损伤的非幸存者是否具有预后价值。我们使用了三种方法：（1）使用 Pa-O2/Fl(O2) 比值 < 300 以及在没有左心衰竭的情况下胸部 X 线照片上的双侧浸润来前瞻性识别急性肺损伤患者； (2)采用四分制评分法评价肺损伤的严重程度； (3) 逐步逻辑回归分析，以确定与医院死亡率显着相关的变量。总体住院死亡率为 58%。脓毒症是与急性肺损伤发生相关的最常见的临床疾病（50/123 或 41%）。使用急性肺损伤的新定义，123 名患者中的 66 名患者的 Pa-O2/Fl(O2) 比率在 150 至 299 之间； 123 名患者中有 57 名在进入研究时 Pa-O2/Fl(O2) < 150。两组患者的死亡率相似（Pa-O2/Fl(O2) 在 150 至 299 之间的患者死亡率为 59%，Pa-O2/Fl(O2) < 150 的患者死亡率为 57%）。第 1 天、第 2 天或第 3 天的肺损伤程度不能预测生存率。逐步逻辑回归分析确定了与死亡率独立相关的三个因素：（1）入院和入住重症监护病房之间的非肺器官系统功能障碍（比值比（OR）= 8.1；p < 0.0001）； (2) 慢性肝病（OR = 5.2；p < 0.05）； (3) 败血症（OR = 2.8；p < 0.05）。急性肺损伤患者的识别（使用 Pa-O2/Fl(O2) 比值 < 300 的最新定义以及胸片上的双侧浸润）不会改变医院死亡率或与使用更严格的氧合标准的更传统 ARDS 定义相关的临床特征。因此，氧合缺陷的最初严重程度似乎没有主要的预后价值。由于详细的四点肺损伤评分并不能预测生存率，因此该结果还强调，通过生理标准评估肺损伤的预后价值有限。在多变量分析中，非肺因素对死亡率的决定性影响显而易见，其中死亡的三个主要预测因素是入住重症监护室之前的非肺器官系统功能障碍、慢性肝病和脓毒症。这些结果对于急性肺损伤新治疗策略临床试验的患者选择和分层具有重要意义。
A recent North American-European Consensus Conference proposed new, uniform criteria for the definition of acute lung injury, in part to facilitate earlier identification of patients for clinical trials. However, these criteria have not been evaluated prospectively. We designed a prospective cohort study of 123 consecutive patients with acute lung injury prospectively identified on admission to the adult intensive care units of a tertiary care university hospital. The objectives were to determine if selection of patients using the new criteria for acute lung injury results in a significant change in the clinical characteristics, risk factors, or predictors of mortality when compared with prior studies of patients with adult respiratory distress syndrome (ARDS); and to determine if a quantitative index of the severity of acute lung injury has prognostic value in identifying nonsurvivors of acute lung injury. We used three methods: (1) prospective identification of patients with acute lung injury using a Pa-O2/Fl(O2) ratio < 300 and bilateral infiltrates on chest radiograph in the absence of left heart failure; (2) evaluation of the severity of lung injury using a four-point scoring system; and (3) stepwise logistic regression analysis to identify variables significantly associated with hospital mortality. Overall hospital mortality was 58%. Sepsis was the most common clinical disorder (50/123 or 41%) associated with the development of acute lung injury. Using the new definition for acute lung injury, 66 of the 123 patients were enrolled with a Pa-O2/Fl(O2) ratio between 150 and 299; 57 of the 123 patients had a Pa-O2/Fl(O2) < 150 at the time of entry into the study. The mortality of the patients was similar in the two groups (59% for the patients identified with a Pa-O2/Fl(O2) between 150 and 299 and 57% for the patients with a Pa-O2/Fl(O2) < 150). The degree of lung injury on days 1, 2, or 3 was not predictive of survival. Stepwise logistic regression analysis identified three factors that were independently associated with mortality: (1) nonpulmonary organ system dysfunction between hospital admission and admission to the intensive care unit (odds ratio (OR) = 8.1; p < 0.0001); (2) chronic liver disease (OR = 5.2; p < 0.05); and (3) sepsis (OR = 2.8; p < 0.05). The identification of patients with acute lung injury (using the recent definition of a Pa-O2/Fl(O2) ratio < 300 and bilateral infiltrates on the chest radiograph) does not alter the hospital mortality or the clinical characteristics associated with more traditional definitions of ARDS that have used stricter oxygenation criteria. Thus, the initial severity of the oxygenation defect does not appear to have major prognostic value. Since a detailed four-point lung injury score did not predict survival, this result also emphasizes that assessment of lung injury by physiologic criteria is of limited prognostic value. The overriding influence of nonpulmonary factors in determining mortality was evident in the multivariate analysis in which the three major predictors of nonsurvival were nonpulmonary organ system dysfunction before admission to an intensive care unit, chronic liver disease, and sepsis. These results have important implications for the selection and stratification of patients for clinical trials of new therapeutic strategies for acute lung injury.