肺外源性急性呼吸窘迫综合征患者临床特征及死亡危险因素分析

Clinical characteristics and risk factors for mortality in patients with indirect acute respiratory distress syndrome

摘要

目的：分析肺外源性急性呼吸窘迫综合征（ARDS）患者的临床特征及预后影响因素。方法：对2022年1月至2023年12月收治于武汉大学人民医院重症医学科的164名肺外源性ARDS患者的临床特征进行单因素及多因素分析。绘制受试者工作特征(ROC)曲线，评估各指标对肺外源性ARDS患者30 d预后的预测价值。结果：单因素分析显示，幸存者和非幸存者之间的急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、连续性肾脏替代治疗（CRRT)、动脉氧分压/吸入氧浓度（P/F）比值、乳酸、碱性磷酸酶（ALP）、尿素（Urea）、肌酐（Cr）、估算肾小球滤过率（eGFR）、血磷（P）、左室射血分数（LVEF）差异有统计学意义（P<0.05）。多变量回归分析发现，APACHE Ⅱ评分高、CRRT占比高、高乳酸水平、低P/F、低eGFR为肺外源性ARDS患者入院30 d内死亡的危险因素，效应值均有统计学意义（均P<0.05）。ROC曲线分析结果显示，APACHE Ⅱ评分、CRRT、P/F比值、乳酸、eGFR及5个变量联合预测肺外源性ARDS患者30 d内死亡的曲线下面积（AUC）及其95%置信区间（CI)分别为0.773（0.702~0.843）、0.590（0.502~0.679）、0.867（0.810~0.925）、0.815（0.751~0.879）、0.745（0.670~0.819）和0.952（0.923~0.982），联合诊断的曲线下面积最高，诊断价值最高。结论：APACHE Ⅱ评分、是否CRRT、乳酸水平、P/F比值及eGFR是肺外源性ARDS患者30 d内死亡的独立影响因素。联合这些指标可显著提升预测效能，为临床早期识别高危患者和优化治疗策略提供重要参考。

Abstract

Objective: To analyze the clinical characteristics of patients with indirect acute respiratory distress syndrome (ARDS) and identify factors influencing prognosis. Methods: We conducted univariate and multivariate analyses of the clinical characteristics of 164 patients with indirect ARDS admitted to the Intensive Care Unit of Renmin Hospital of Wuhan University from January 2022 to December 2023. Additionally, Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of various indicators for the 30-day prognosis of these patients. Results: Univariate analysis revealed statistically significant differences between survivors and non-survivors in terms of APACHE Ⅱ score, continuous renal replacement therapy (CRRT) (P<0.001), arterial oxygen partial pressure/inspired oxygen concentration (P/F), lactate, alkaline phosphatase (ALP), blood urea nitrogen (Urea), creatinine (Cr), estimated glomerular filtration rate (eGFR), serum phosphate (P), and left ventricular ejection fraction (LVEF) (P=0.01). Multivariate logistic regression analysis identified high APACHE Ⅱ score, high proportion of CRRT, elevated lactate levels, low P/F, and low eGFR as risk factors for 30-day mortality in patients with indirect ARDS, with all effect values being statistically significant (all P<0.05). ROC analysis showed that the area under the curve (AUC) for predicting 30-day mortality in patients with indirect ARDS was 0.773 (0.702-0.843) for APACHE Ⅱ score, 0.590 (0.502-0.679) for CRRT, 0.867 (0.810-0.925) for P/F, 0.815 (0.751-0.879) for lactate, 0.745 (0.670-0.819) for eGFR, and 0.952 (0.923-0.982) for the combined prediction using all five variables, with the highest diagnostic value for the combined prediction. Conclusion: APACHE Ⅱ score, CRRT, lactate level, P/F ratio, and eGFR are independent factors affecting 30-day mortality in patients with indirect ARDS. Combining these indicators can significantly enhance predictive efficacy, providing an important reference for early identification of high-risk patients and optimization of therapeutic strategies in clinical practice.

关键词

肺外源性ARDS / 30天死亡率 / 预测因子 / 临床特征

Key words

Indirect ARDS / 30-Day Mortality / Predictors / Clinical Characteristics

参考文献

[1] GORMAN E A, O'KANE C M, MCAULEY D F. Acute respiratory distress syndrome in adults: Diagnosis, outcomes, long-term sequelae, and management[J]. Lancet, 2022, 400(10358): 1157-1170.

[2] GRASSELLI G, CALFEE C S, CAMPOROTA L, et al. ESICM guidelines on acute respiratory distress syndrome: Definition, phenotyping and respiratory support strategies[J]. Intensive Care Med, 2023, 49(7): 727-759.

[3] BELLANI G, PHAM T, LAFFEY J G. Missed or delayed diagnosis of ARDS: A common and serious problem[J]. Intensive Care Med, 2020, 46(6): 1180-1183.

[4] AL-HUSINAT L, AZZAM S, AL SHARIE S, et al. A narrative review on the future of ARDS: Evolving definitions, pathophysiology, and tailored management[J]. Crit Care, 2025, 29(1): 88.

[5] MATTHAY M A, THOMPSON B T, WARE L B. The Berlin definition of acute respiratory distress syndrome: Should patients receiving high-flow nasal oxygen be included? [J]. Lancet Respir Med, 2021, 9(8): 933-936.

[6] KHAN Y A, FAN E, FERGUSON N D. Precision medicine and heterogeneity of treatment effect in therapies for ARDS[J]. Chest, 2021, 160(5): 1729-1738.

[7] XU J, WANG J H, WANG X L, et al. Soluble PD-L1 improved direct ARDS by reducing monocyte-derived macrophages[J]. Cell Death Dis, 2020, 11(10): 934.

[8] SARGE T, BAEDORF-KASSIS E, BANNER-GOODSPEED V, et al. Effect of esophageal pressure-guided positive end-expiratory pressure on survival from acute respiratory distress syndrome: A risk-based and mechanistic reanalysis of the EPVent-2 trial[J]. Am J Respir Crit Care Med, 2021, 204(10): 1153-1163.

[9] MATTHAY M A, WARE L B, ZIMMERMAN G A. The acute respiratory distress syndrome[J]. J Clin Invest, 2012, 122(8): 2731-2740.

[10] TANG W, TANG R, ZHAO Y, et al. Comparison of clinical characteristics and predictors of mortality between direct and indirect ARDS[J]. Medicina, 2022, 58(11): 1563.

[11] 齐红蕾, 杨小娟, 杨晓军, 等 . 脓毒症导致的肺内源性与肺外源性ARDS患者炎症指标差异及预后影响因素分析[J]. 重庆医学, 2025, 54(6): 1300-1306.

[12] QI H L, YANG X J, YANG X J, et al. Differences in inflammatory indicators and prognostic factors between pulmonary and extrapulmonary ARDS caused by sepsis[J]. Chongqing Med J, 2025, 54(6): 1300-1306.

[13] 靳亚丽, 揭致乾, 范贤明 . 脓毒症并发ARDS危险因素和预测指标的Meta分析[J]. 西南大学学报(自然科学版), 2025, 47(3): 168-178.

[14] JIN Y L, JIE Z Q, FAN X M. Risk factors and predictors of sepsis complicated with ARDS: A meta-analysis[J]. J Southwest Univ Nat Sci Ed, 2025, 47(3): 168-178.

[15] 尹盼盼, 许航 . CRRT介入时机对ARDS患者预后的影响[J]. 临床医药文献电子杂志, 2020, 7(4): 63-64.

[16] YIN P P, XU H. Effect of timing of CRRT intervention on prognosis of ARDS patients[J]. Electron J Clin Med Lit, 2020, 7(4): 63-64.

[17] 鲍邦龙 . 急诊多发伤患者并发急性呼吸窘迫综合征的影响因素分析及列线图模型构建[J]. 现代医学与健康研究电子杂志, 2025, 9(5): 126-129.

[18] BAO B L. Analysis of influencing factors of acute respiratory distress syndrome in emergency patients with multiple injuries and construction of nomogram model[J]. Mod Med Health Res Electron J, 2025, 9(5): 126-129.

[19] BARDAJÍ-CARRILLO M, MARTÍN-FERNÁNDEZ M, LÓPEZ-HERRERO R, et al. Post-operative sepsis-induced acute respiratory distress syndrome: Risk factors for a life-threatening complication[J]. Front Med, 2024, 11: 1338542.

[20] 急性呼吸窘迫综合征精准分型诊治专家组, 方恒, 李怿辰, 等 . 急性呼吸窘迫综合征精准分型诊治专家共识[J]. 中国临床医学, 2025, 32(4): 710-716.

[21] Expert Group for Precise Classification and Diagnosis of Acute Respiratory Distress Syndrome, FANG H, LI Y C, et al. Expert consensus on the precise classification and diagnosis of acute respiratory distress syndrome[J]. Chin J Clin Med, 2025, 32(4): 710-716.