中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

社区获得性肺炎病情严重度评估指标预测效能的临床研究

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目的比较社区获得性肺炎(CAP)患者入院时的急性生理学和慢性健康状况评分系统Ⅱ(APACHEⅡ)、肺炎严重指数(PSI)、CURB-65 评分及血清降钙素原(PCT)在预测临床转归中的价值并探讨预后的影响因素。方法回顾性分析 2015 年 1 月至 2016 年 12 月山西医科大学第一医院呼吸与危重症医学科收治的 CAP 患者的临床资料,记录患者入院 24 h 内的 APACHEⅡ评分、PSI 评分、CURB-65 评分和血清 PCT 水平。以此次住院的临床结局(痊愈或好转,恶化或死亡)作为研究终点,分别利用受试者工作特征(ROC)曲线及二分类 Logistic 回归评价相关指标对预后的判定能力并确定界值;筛选 CAP 患者病情恶化及死亡的高危因素。结果共纳入 CAP 患者 235 例,其中男 146 例,女 89 例,平均年龄(60.4±18.1)岁。全部患者分为 2 组:好转痊愈组 205 例,恶化死亡组 30 例。ROC 曲线结果显示,预测 CAP 患者病情恶化及死亡风险的 ROC 曲线下面积从大到小依次为 APACHEⅡ评分(0.889)、PSI 评分(0.850)、CURB-65 评分(0.789)和血清 PCT(0.720)。当 APACHEⅡ评分和 PSI 评分分别以≥11 分和≥91 分为截点时预测性能最佳。Logistic 回归分析结果显示,APACHEⅡ评分和 PCT 是 CAP 患者病情恶化死亡的独立危险因素。结论在预测 CAP 患者病情及临床转归的 4 项指标中,预测效能从高到低依次为 APACHEⅡ评分>PSI 评分>CURB-65 评分>PCT。其中,APACHEⅡ评分和 PCT 是 CAP 患者病情恶化死亡的独立危险因素。但单次血清 PCT 水平预测能力有限,联合 APACHEⅡ评分及 PCT 可以提高预测的特异度,但会降低灵敏度。

ObjectiveTo compare the value of the acute physiology and chronic health evaluationⅡ (APACHEⅡ) scores, the pneumonia severity index (PSI) scores), the CURB-65 scores, and serum procalcitonin (PCT) concentration in prediction of prognosis for inpatients with community-acquired pneumonia (CAP) and discuss the influence factors.MethodsRetrospective analysis was conducted based on the APACHEⅡ scores, the CURB-65 scores, the PSI scores and PCT concentration of hospitalized CAP patients admitted in the Department of Respiratory Medicine of First Hospital of Shanxi Medical University between January 2015 and December 2016, and within 24 hours of their admission. The end point of this study was the clinical outcome of hospitalization (recovery, improvement, exacerbation or death). Receiver operating characteristic (ROC) curve analysis and binary logistic regression models were used to assess the ability of prognostic evaluation and determine the boundary value, to screen risk factors that influence deterioration and death in CAP patients.ResultsTwo hundred and thirty-five CAP patients were enrolled with 146 males and 89 females at an average age of (60.4±18.1) years old. All patients were divided into 2 groups: improving recovery group had 205 cases, and deteriorating group had 30 cases. The rank of areas under the ROC curve for predicting the deterioration and death risk of CAP, from big to small were APACHEⅡ(0.889), PSI (0.850), CURB-65 (0.789), and PCT (0.720). APACHEⅡ score over 11 points and PSI score over 91 points were optimal cut-off values for the prognostic assessment. Moreover, the logistic regression analysis revealed that APACHEⅡ score and PCT were independent risk factors of deterioration and death in CAP patients.ConclusionsThe better predictability of clinic outcome of CAP is APACHEⅡ score, PSI score, CURB-65 score, and PCT respectively in order, while the APACHEⅡ score and PCT concentration were independent risk factors for exacerbation and mortality in CAP patients. The predictive ability of a single PCT measurement is limited. The combination of APACHEⅡ score and PCT may increase specificity, but reduce sensitivity.

关键词: 社区获得性肺炎; 预后评估; APACHEⅡ评分; 降钙素原; PSI 评分

Key words: Community-acquired pneumonia; Prognostic value; Acute Physiology and Chronic Health EvaluationⅡ; Procalcitonin; Pneumonia severity index scores

引用本文: 王健珍, 曹大伟, 张新日. 社区获得性肺炎病情严重度评估指标预测效能的临床研究. 中国呼吸与危重监护杂志, 2018, 17(5): 456-460. doi: 10.7507/1671-6205.201710029 复制

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