中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

三种评分系统在老年社区获得性肺炎危险度分层及病情评估中的应用

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目的采用肺炎严重度指数(pneumonia severity index,PSI)和 CURB-65、急性生理学和慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluation Ⅱ,APACHEⅡ)三种评分系统对老年社区获得性肺炎(community-acquired pneumonia,CAP)危险度分层及严重程度和预后进行评估比较,以获得可靠的诊治依据。方法采用回顾性分析方法选取 2012 年 1 月至 2015 年 4 月上海市徐汇区大华医院呼吸内科住院收治的 125 例 65 岁以上老年 CAP 患者作为研究对象,分别在入院第 1~3 d 内进行 PSI 和 CURB-65、APACHEⅡ评分,根据评分结果进行危险度分层,分为低危、中危、高危组。比较各组病死率和重症监护病房(intensive care unit,ICU)入住率,评估各系统预测死亡和入住 ICU 的敏感性、特异性、阳性预测值、阴性预测值、受试者工作特征(receiver operating characteristic,ROC)曲线下面积(area under ROC curve,AUC)、比较三种评分预测患者病死率方面两两之间的一致性及吻合度。结果PSI、CURB-65、APACHEⅡ评分三种评分方法将大部分患者划分为低危组(分别为 48.8%、64.0%、52.8%),划为中危组的患者分别为 37.6%、23.2%、32.0%,小部分划为高危组(分别为 13.6%、12.8%、15.2%)。PSI 评分高危组、CURB-65 评分高危组、APACHEⅡ评分高危组的病死率分别为 41.3%、62.5%、47.4%,三种评分高危组 ICU 入住率分别为 88.3%、100.0%、94.7%。PSI、CURB-65、APACHEⅡ三种评分预测死亡的敏感性分别为 50.0%、71.4%、64.3%;三种评分预测入住 ICU 的敏感性分别为 46.8%、50.0%、59.3%;而 PSI、CURB-65、APACHEⅡ三种评分对预测死亡及入住 ICU 的特异性均在 90% 以上。三种评分预测死亡及入住 ICU 的 AUC 差别不大:PSI、CURB-65、APACHEⅡ三种评分预测死亡的 AUC 分别为 0.893、0.871、0.880;三种评分预测入住 ICU 的 AUC 分别为 0.949、0837、0.949。而三种评分预测患者死亡的风险两两之间的一致性均较好(P>0.05)。结论三种评分系统对预测老年 CAP 患者的住院病死率、ICU 入住率均有较高的预测价值,对预测老年 CAP 患者死亡风险较一致。CURB65 评分预测死亡风险敏感性最高,对识别高死亡风险患者更有意义;而 APACHEⅡ评分预测入住 ICU 敏感性最高,在识别重症患者有较好的价值,对于选择合适的诊疗地点更有意义。

ObjiectiveTo obtain reliable evidence of diagnosis and treatment through evaluating the validity of pneumonia severity index (PSI), CURB-65 and acute physiology and chronic health evaluationⅡ(APACHEⅡ) scores in predicting risk stratification, severity evaluation and prognosis in elderly community-acquired pneumonia (CAP) patients.MethodsClinical and demographic data were collected and retrospectively analyzed in 125 in-hospital patients with CAP admitted in Shanghai Dahua Hospital from January 2012 to April 2015. The severity of pneumonia was calculated with PSI, CURB-65 and APACHEⅡgroups during 1 to 3 days after admission. Mortality and intensive care unit (ICU) admission rates were evaluated among patients in each scores and was categorized into three classes, namely mild, moderate and severe groups during 1 to 3 days after admission. Mortality and ICU admission rates were evaluated among patients in each severity level. Through evaluating the sensitivity, specificity, the predicting values and the area under receiver operating characteristic (ROC) curve (AUC) among PSI, CURB-65 and APACHEⅡ, the validity and consistency of these three scoring systems were assessed.ResultsUsing PSI, CURB-65 and APACHEⅡ scoring systems, the patients were categorized into mild severity (48.8%, 64.0% and 52.8%, respectively), moderate severity (37.6%, 23.2% and 32.0%, respectively) and severe severity (13.6%, 12.8% and 15.2%, respectively). In PSI, CURB-65 and APACHEⅡ systems, the mortality in high risk groups was 41.3%, 62.5% and 47.4%, respectively; The ICU-admission rate in high risk groups was 88.3%, 100.0% and 94.7%, respectively. The sensitivity of PSI, CURB-65 and APACHEⅡ was 50.0%, 71.4% and 64.3% in predicting mortality, and was 46.8%, 50.0% and 59.3% in predicting ICU-admission, respectively. PSI, CURB-65 and APACHEⅡ showed similar specificity (approximately 90%) in predicting mortality and ICU admission. ROC was conducted to evaluate the sensitivity of PSI, APACHEⅡ and CURB-65 in predicting mortality and ICU admission. The AUC had no significant difference among these three scoring systems. The AUC of PSI, CURB-65 and APACHEⅡwas 0.893, 0.871, 0.880, respectively for predicting mortality, and was 0.949, 0.837, 0.949, respectively for predicting ICU admission. There was no significant difference among these three scoring in predicting mortality and ICU admission (all P>0.05).ConclusionsPSI, CURB-65 and APACHEⅡ performed similarly and achieved high predictive values in elderly patients with CAP. The three scoring systems are consistent in predicting mortality risk in elderly CAP patients. The CURB-65 is more sensitive in predicting the risk of death, and more early in identifing patients with high risk of death. The APACHEⅡ is more sensitive in predicting the risk of ICU admission, and has good value in identifying severe patients and choosing the right treatment sites.

关键词: 社区获得性肺炎; 肺炎严重度指数; CURB-65; 急性生理学和慢性健康状况评分系统Ⅱ

Key words: Community-acquired pneumonia; Pneumonia severity index; CURB-65; Acute physiology and chronic health evaluationⅡ

引用本文: 孔庆华, 白久武, 王晓如, 徐金富. 三种评分系统在老年社区获得性肺炎危险度分层及病情评估中的应用. 中国呼吸与危重监护杂志, 2018, 17(2): 138-143. doi: 10.7507/1671-6205.201705044 复制

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