2021, Vol. 50文章信息
- 宋薇, 张强, 郑锐, 娜合木古丽·阿依达尔汗, 栗伟, 谭明旗
- SONG Wei, ZHANG Qiang, ZHENG Rui, Nahemuguli·AYIDAERHAN, LI Wei, TAN Mingqi
- 慢性阻塞性肺疾病急性加重患者肺动脉直径与主动脉直径比值的临床意义
- Clinical significance of the pulmonary artery diameter to aorta diameter ratio in patients with acute exacerbation of chronic obstructive pulmonary disease
- 中国医科大学学报, 2021, 50(7): 621-624, 631
- Journal of China Medical University, 2021, 50(7): 621-624, 631
-
文章历史
- 收稿日期：2020-11-13
- 网络出版时间：2021-06-22 16:18
引用本文 |
宋薇, 张强, 郑锐, 娜合木古丽·阿依达尔汗, 栗伟, 谭明旗.
慢性阻塞性肺疾病急性加重患者肺动脉直径与主动脉直径比值的临床意义[J]. 中国医科大学学报, 2021, 50(7): 621-624, 631.
SONG Wei, ZHANG Qiang, ZHENG Rui, Nahemuguli·AYIDAERHAN, LI Wei, TAN Mingqi. Clinical significance of the pulmonary artery diameter to aorta diameter ratio in patients with acute exacerbation of chronic obstructive pulmonary disease[J]. Journal of China Medical University, 2021, 50(7): 621-624, 631.
慢性阻塞性肺疾病急性加重患者肺动脉直径与主动脉直径比值的临床意义
1. 中国医科大学附属盛京医院呼吸内科, 沈阳 110022;
2. 新疆塔城地区人民医院呼吸科, 新疆 塔城 834300;
3. 东北大学医学影像智能计算教育部重点实验室, 沈阳 110819
2. 新疆塔城地区人民医院呼吸科, 新疆 塔城 834300;
3. 东北大学医学影像智能计算教育部重点实验室, 沈阳 110819
摘要：目的 探讨慢性阻塞性肺疾病急性加重（AECOPD）患者肺动脉直径与主动脉直径比值（PA/A）的临床意义及其与住院风险的相关性。方法 回顾分析2014年10月至2019年10月中国医科大学附属盛京医院呼吸与重症监护病房223例AECOPD患者的临床资料，根据胸部CT测量计算PA/A，采用t检验或χ2检验对PA/A≤1组和PA/A>1组患者临床指标进行比较。根据患者住院次数分为入院前1年内1次组和入院前1年内≥2次组，采用t检验或χ2检验比较2组临床指标的差异，对有统计学意义（P < 0.05）指标进行logistic回归分析。结果 与PA/A≤1组比较，PA/A>1组吸烟史、住院时间增长，体质量指数、PaCO2、HCO3-增高，入院前1年急性加重住院次数增多，而肺功能更差，有创机械通气治疗更多，差异均有统计学意义（均P < 0.05）。与入院前1年内1次组比较，入院前1年内≥2次组患者FEV1%、FVC%、FEV1/FVC、HCO3-、肺动脉直径、住院时间、PA/A>1比例均增加（均P < 0.05）。Logistic回归分析显示PA/A>1是入院前1年内≥2次住院的独立危险因素（OR=6.150；95% CI：1.056~35.65；P=0.039）。结论 PA/A与AECOPD患者病情严重程度相关，PA/A>1可能是AECOPD患者多次住院风险的独立危险因素。
Clinical significance of the pulmonary artery diameter to aorta diameter ratio in patients with acute exacerbation of chronic obstructive pulmonary disease
1. Department of Respiratory Medicine, Shengjing Hospital of China Medical University, Shenyang 110022, China;
2. Department of Respiratory Medicine, The People's Hospital of Tacheng Area, Tacheng 834300, China;
3. Key Laboratory of Intelligent Computing in Medical Image, Ministry of Education, Northeastern University, Shenyang 110819, China
2. Department of Respiratory Medicine, The People's Hospital of Tacheng Area, Tacheng 834300, China;
3. Key Laboratory of Intelligent Computing in Medical Image, Ministry of Education, Northeastern University, Shenyang 110819, China
Abstract: Objective To investigate the clinical significance of the pulmonary artery diameter to aortic diameter ratio (PA/A) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and its correlation with hospitalization risk. Methods The clinical data of 223 patients with AECOPD in the Department of Pulmonary and Critical Care Medicine of our hospital were retrospectively analyzed from October 2014 to October 2019. PA/A was calculated based on chest CT measurement, and the clinical indicators of patients in the PA/A ≤ 1 and PA/A >1 groups were compared using the t test or χ2 test. Based on the admission status of patients within a year, they were divided either into the one time leading to hospitalization (one time) group or the over two times leading to hospitalization (over two times) group. The difference in clinical indicators between the two groups was also compared using t test or χ2 test, and logistic regression analysis was used to analyze statistically significant (P < 0.05) indicators. Results Compared to the PA/A ≤ 1 group, the PA/A >1 group had a history of smoking, increased hospitalization time, increased body mass index, increased PaCO2 and HCO3- levels, increased times leading to hospitalization one year before admission, worse lung function, and had more mechanical ventilation treatments, which were all statistically significant (P < 0.05). Compared to the one time group, the FEV1%, FVC%, FEV1/FVC, HCO3-, pulmonary artery diameter, length of hospital stay, and PA/A >1 proportion were higher in the over two group (P < 0.05). Moreover, logistic regression analysis showed that PA/A >1 was an independent risk factor for over two times admissions within the year before admission (OR=6.150;95% CI:1.056-35.65;P=0.039). Conclusion PA/A is associated with the AECOPD severity, and PA/A >1 is an independent risk factor for multiple admissions in AECOPD patients.
Keywords:
pulmonary artery diameter to aortic diameter ratio acute exacerbation of chronic obstructive pulmonary disease risk of hospitalization
近年来，由于人口老龄化，空气污染等问题日益加剧，慢性阻塞性肺疾病(chronic obstructive pulmonary disease，COPD)带来的医疗、社会、经济负担也逐渐加重。至2020年，全球总计约3.84亿COPD患者，患病率约为11.7%[1-2]。我国2014年至2015年40岁以上成年人COPD的总体患病率约为13.6%[3]。慢性阻塞性肺疾病急性加重(acute exacerbation of chronic obstructive pulmonary disease，AECOPD)是COPD自然病程中的重要事件，与死亡率及花费均相关[4]。目前，AECOPD诊断仍缺少简单特异的影像学检查或生物学标志物，肺动脉高压是COPD晚期常见并发症，通过CT检查获得的肺动脉直径与主动脉直径比值(pulmonary artery diameter to aortic diameter ratio，PA/A)与右心导管测量肺动脉压有一定相关性，可无创评估肺动脉高压，评估COPD病情严重程度[5-6]。本研究探讨AECOPD患者PA/A的临床意义及其与住院风险的相关性。
1 材料与方法 1.1 研究对象及分组收集2014年10月至2019年10月中国医科大学附属盛京医院呼吸与重症监护病房住院治疗的AECOPD患者的临床资料，包括性别、年龄、身高、体质量、病程、吸烟史、肺功能、急性生理和慢性健康估测(acute physiology and chronic health evaluation，APACHE)Ⅱ评分[7]、射血分数、动脉血气分析、血常规、入院前1年急性加重住院次数、COPD评估测试问卷(COPD assessment test，CAT)评分[8]、改良版英国医学研究委员会呼吸困难问卷评分(modified Medical Research Council dyspnoea scale，mMRC) [8]、C-反应蛋白(C-reaction protein，CRP)、住院时间、侵入性/非侵入性机械通气、PA/A (胸部CT纵隔窗肺动脉分叉层面测量肺动脉直径，在同一层面测量主动脉直径，计算获得[9-10])。纳入标准：(1)患者符合COPD全球倡议(global initiative for chronic obstructive lung disease，GOLD)指南标准执行AECOPD诊断[1]；(2) GOLDⅠ~Ⅳ期；(3)年龄 > 45岁。排除标准：(1)无法进行肺功能检查；(2)无法完成调查问卷；(3)患有精神疾病等不能配合；(4)合并支气管哮喘、肺血栓栓塞症、间质性肺疾病等其他肺部疾病。研究方案经我院伦理委员会批准，患者均知情同意并签署知情同意书。共纳入223例，根据PA/A值[11]分为PA/A > 1组(n = 93)与PA/A≤1组(n = 130)；根据住院次数[10]分为入院前1年内1次组(n = 86)和入院前1年内≥2次组(n = 137)。
1.2 统计学分析采用SPSS 24.0软件进行统计学处理。计量资料采用x±s表示，组间比较运用独立样本t检验；计数资料采用率(%)表示，组间差异比较采用χ2检验，对单因素分析有统计学意义(P < 0.05)变量行多因素logistics回归分析。P < 0.05为差异有统计学意义。
2 结果 2.1 PA/A > 1组与PA/A≤1组各项临床指标比较结果显示，2组肺动脉压、肺动脉直径、主动脉直径、体质量指数(body mass index，BMI)、吸烟史、入院前1年因急性加重住院次数、PCO2、HCO3-、住院时间、FEV1%、FVC%、FEV1/FVC和侵入性机械通气(invasive mechanical ventilation，IMV)均有统计学差异(均P < 0.05)，见表 1。
表 1 PA/A > 1组与PA/A≤1组各临床指标比较
Tab.1 Comparison of clinical data between the PA/A > 1 and PA/A ≤1 groups
| Item | PA/A≤1 group (n = 130) | PA/A > 1 group (n = 93) | P |
| Age (year) | 70.90±9.80 | 71.20±9.40 | 0.125 |
| Male [n (%)] | 72(55.38) | 50(53.76) | 0.242 |
| APACHEⅡ | 17.10±6.30 | 18.90±5.80 | 0.067 |
| PAP (mmHg) | 44.53±17.12 | 62.45±22.77 | 0.002 |
| Pulmonary artery (mm) | 29.96±4.49 | 37.64±5.74 | < 0.001 |
| Aorta (mm) | 38.95±5.93 | 32.24±4.69 | 0.001 |
| EF (%) | 56.45±12.13 | 57.42±12.35 | 0.323 |
| BMI (kg/m2) | 23.47±4.30 | 20.86±2.80 | 0.013 |
| Smoking history (year) | 23.70±20.78 | 34.00±17.85 | 0.013 |
| Course of disease (year) | 16.10±13.90 | 16.30±12.90 | 0.765 |
| Frequency of requiring hospitalization in the previous year | 1.63±0.74 | 2.08±0.80 | 0.002 |
| Duration of hospital stay (d) | 12.65±2.20 | 17.95±13.57 | 0.038 |
| CAT | 20.20±7.02 | 22.31±8.47 | 0.752 |
| mMRC | 2.30±0.97 | 2.37±0.976 | 0.634 |
| FEV1 % | 50.42±21.54 | 36.19±17.27 | 0.009 |
| FVC % | 71.98±19.43 | 60.29±19.83 | 0.024 |
| FEV1/FVC | 53.56±11.71 | 45.81±8.87 | 0.007 |
| WBC count (×109/L) | 7.74±3.41 | 8.12±3.75 | 0.857 |
| NEU% | 65.40±17.10 | 66.90±14.10 | 0.657 |
| CRP (mg/L) | 28.94±32.56 | 28.65±35.36 | 0.977 |
| pH | 7.41±0.79 | 7.38±0.39 | 0.186 |
| PCO2(mmHg) | 44.52±13.32 | 53.29±11.99 | 0.012 |
| PO2(mmHg) | 73.90±17.98 | 72.3±37.10 | 0.658 |
| IMV [n (%)] | 53(40.76) | 67(72.04) | 0.001 |
| NIMV [n (%)] | 103(79.23) | 71(76.34) | 0.078 |
| HCO3- (mmol/L) | 27.31±4.87 | 31.10±5.36 | 0.030 |
| PAP，pulmonary arterial pressure；PA/A，pulmonary artery diameter to the aorta diameter ratio；EF，ejection fraction；BMI，body mass index；CAT，COPD assessment test；mMRC，modified Medical Research Council dyspnoea scale；FEV1，forced expiratory volume in 1 s；FVC，forced vital capacity；WBC，white blood cell；NEU，neutrophil；CRP，C-reactive protein；PaO2，partial arterial oxygen pressure；PaCO2，partial arterial carbon dioxide pressure；IMV，invasive mechanical ventilation；NIMV，non-invasive mechanical ventilation. | |||
2.2 入院前1年内1次组和入院前1年内≥2次组临床指标比较
结果显示，与入院前1年内1次组比较，入院前1年内≥2次组患者FEV1 %、FVC %、FEV1/FVC、HCO3-、肺动脉直径、住院时间、PA/A > 1比例均增加(均P < 0.05)。而年龄、性别、BMI、吸烟史、病程、CAT评分、mMRC评分等均无统计学差异(均P > 0.05)，见表 2。
表 2 入院前1年内1次组和入院前1年内≥2次组临床指标比较
Tab.2 Comparison of clinical data between the one time leading to hospitalization and the over two times leading to hospitalization groups
| Item | One time leading to hospitalization group (n = 86) |
Over two times leading to hospitalization group (n = 137) |
P |
| FEV1% | 53.9±23.0 | 41.2±19.0 | 0.008 |
| FVC% | 75.2±20.0 | 64.3±19.0 | 0.019 |
| FEV1/FVC | 55.3±10.0 | 49.3±12.0 | 0.044 |
| Length of hospital stay (d) | 11.2±2.0 | 15.0±9.0 | 0.064 |
| HCO3- (mmol/L) | 26.5±3.0 | 29.2±6.0 | 0.045 |
| PA/A > 1[n (%)] | 9(10.4) | 57(41.6) | 0.004 |
| Pulmonary artery (mm) | 29.3±5.0 | 32.5±5.0 | 0.042 |
| Aorta (mm) | 37.4±5.5 | 34.9±4.4 | 0.060 |
| BMI (kg/m2) | 22.8±4.5 | 22.6±3.8 | 0.877 |
| Smoking history (year) | 30.0±20.9 | 24.3±20.7 | 0.750 |
| Course of disease (year) | 14.1±1.2 | 15.1±1.3 | 0.064 |
| CAT | 18.5±6.8 | 21.1±7.6 | 0.650 |
| mMRC | 2.4±1.1 | 2.8±1.1 | 0.093 |
| WBC count (×109/L) | 8.3±3.7 | 7.7±3.4 | 0.220 |
| NEU% | 65.5±15.0 | 66.8±13.5 | 0.580 |
| CRP (mg/L) | 30.7±27.4 | 27.7±36.5 | 0.450 |
| pH | 7.13±0.6 | 7.0±0.2 | 0.550 |
| PCO2 (mmHg) | 44.3±11.0 | 48.9±14.4 | 0.620 |
| PO2 (mmHg) | 75.3±21.4 | 76.4±27.4 | 0.090 |
| FEV1，forced expiratory volume in 1 s；FVC，forced vital capacity；PA/A，pulmonary artery diameter to the aorta diameter ratio；BMI，body mass index；CAT，COPD assessment test；mMRC，modified Medical Research Council dyspnoea scale；NEU，neutrophil；CRP，C-reactive protein；PaO2，partial arterial oxygen pressure，PaCO2，partial arterial carbon dioxide pressure. | |||
2.3 多因素logistics回归分析
结合临床[12-13]，对于单因素分析有统计学意义变量进行多因素logistics回归分析，结果显示，PA/A > 1是AECOPD患者多次住院的独立危险因素(P < 0.05)，见表 3。
表 3 AECOPD患者多次住院(≥2次)多因素logistic回归分析
Tab.3 Multivariate logistic regression analysis of multiple hospital admissions (≥2 times) in AECOPD patients
| Viable | B | OR | 95% CI | P |
| PA/A > 1 | 1.817 | 6.150 | 1.056-35.65 | 0.039 |
| FEV1/FVC | -0.008 | 0.992 | 0.941-1.057 | 0.984 |
| HCO3- | 0.047 | 1.049 | 0.926-1.199 | 0.499 |
| Constant | -0.747 | - | - | 0.798 |
| PA/A，pulmonary artery to the aorta ratio；FEV1，forced expiratory volume in 1 s；FVC，forced vital capacity. | ||||
3 讨论
本研究结果显示，与PA/A≤1组比较，PA/A > 1组肺动脉压力、肺动脉直径、主动脉直径、BMI、吸烟史、入院前1年因急性加重住院次数、PCO2、HCO3-、住院时间、FEV1 %、FVC %、FEV1/FVC和IMV均有统计学差异(均P < 0.05)，与以往研究[14-15]结果相似。另外，既往研究[15]发现性别可能与PA/A相关，但本研究未得出类似结论，可能是样本量较小所致。
已有研究[4]发现PA/A > 1指标可以更好反应AECOPD发生风险，PA/A > 1患者病情更重，住院时间更长。本研究多因素logistics回归分析结果显示，PA/A > 1是AECOPD患者多次住院的独立危险因素(P < 0.05)，与以往研究结果类似。说明患者若PA/A > 1，则需要住院的可能性明显增大。
PA/A测量可以在常规CT图像上完成，不使用血管造影剂或特殊软件；而且测量操作简单，重复性高。因此，PA/A是评估AECOPD患者病情严重程度和多次入院风险的重要指标。
综上所述，PA/A与AECOPD患者病情严重程度相关，PA/A > 1可能是AECOPD患者多次住院风险的独立危险因素。本研究样本量较小，未对患者进行出院后随访，今后应增大样本量，并对出院后患者进行随访调查后再进一步研究论证。
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