浅析B型脑钠肽对慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者机械通气的影响

发表时间:2017/6/23   来源:《健康世界》2017年第8期   作者:赵嘉宁
[导读] 慢性阻塞性肺病急性加重患者常存在心脏合并症,B型脑钠尿肽是心室在压力负荷及容量负荷增加时所释放的多肽[1]。

北安市第一人民医院  164000
  摘要:目的 研究分析BNP对慢性阻塞性肺病急性加重合并Ⅱ型呼吸衰竭患者机械通气的影响。方法 此次研究的对象是选择2013年1~12月在我院呼吸科住院的116例慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者,将其临床资料进行回顾性分析,并依据入院24 h内血BNP结果,分为对照组(BNP<300 ng/mL)67例与心衰组(BNP≥300 ng/mL)49例。收集入选者的基本情况、疗效、机械通气、气管插管情况等资料,分析两组的机械通气率、气管插管率的差异。结果 对照组与心衰组的机械通气的使用率分别为31.3%、69.4%,气管插管率分别为6.0%、28.6%,两组比较差异均有统计学意义(P<0.05);入院时动脉血气分析中对照组与心衰组PaCO2分别为(64.1±18.2)mmHg、(75.3±21.0)mmHg,pH值分别为(7.334±0.078)、(7.298±0.098),两组比较差异均有统计学意义(P<0.05)。结论 合并心衰的慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者机械通气率及气管插管发生率高,提示BNP检测有助于病情严重程度评估。
  关键词:B型脑钠肽;慢性阻塞性肺疾病;呼吸衰竭;机械通气
  [Abstract] Objective To investigate the effect of BNP on mechanical ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease complicated with type. The object of this research method is to select the 1 to 2013 December in the Department of respiration of our hospital in 116 cases of acute exacerbation of chronic obstructive pulmonary disease with type II respiratory failure patients,retrospective analysis,and according to the hospital within 24 h blood BNP results,divided into control group(BNP<300 ng /mL)in 67 patients with heart failure group(BNP = 300,ng/mL)in 49 cases. The basic situation,curative effect,mechanical ventilation and tracheal intubation were collected. The differences of mechanical ventilation rate and trachea intubation rate between the two groups were analyzed. The use of mechanical ventilation control group and heart failure group rates were 31.3% and 69.4%,the rate of endotracheal intubation were 6% and 28.6%,with significant differences between the two groups(P<0.05);admission arterial blood gas analysis in the control group and heart failure group PaCO2 respectively(64.1 + 18.2),mmHg(75.3 + 21)mmHg,pH =(7.334 + 0.078),(7.298 + 0.098),with significant differences between the two groups(P<0.05). Conclusion the rate of mechanical ventilation and the rate of tracheal intubation are higher in patients with chronic obstructive pulmonary disease with acute exacerbation of heart failure accompanied by type II respiratory failure,which suggests that BNP test can be helpful to assess the severity of the disease.
  [B] brain natriuretic peptide,chronic obstructive pulmonary disease,respiratory failure,mechanical ventilation
  慢性阻塞性肺病急性加重患者常存在心脏合并症,B型脑钠尿肽是心室在压力负荷及容量负荷增加时所释放的多肽[1]。COPD合并肺源性心脏病时血浆BNP水平可升高,并与肺动脉压力及右室舒张末压相关,肺心病及肺动脉高压是引起COPD患者不良预后的重要原因[2]。但BNP对慢性阻塞性肺病急性加重的预测意义尚完全不明确。本研究拟评估BNP与慢性阻塞性肺病急性加重合并Ⅱ型呼吸衰竭患者机械通气及气管插管关系,探讨BNP对疾病严重程度评价的意义。现报道如下。
  1 资料与方法
  1.1 一般资料
  选择2013年1~12月在我院住院并诊断为慢性阻塞性肺病急性加重Ⅱ型呼吸衰竭的患者作为研究对象,心超排除合并原发性心脏病(缺血性心肌病、扩张性心肌病、肥厚性心肌病等)患者,入院24 h内完成血BNP检测患者予入选并采集资料,根据患者甲状腺功能检测结果进行分组(本研究以300 ng/mL为临界),分为对照组(BNP<300 ng/mL)67例与慢性阻塞性肺病急性加重合并心衰组(BNP≥300 ng/mL)49例。对照组中男44例,女23例;心衰组中男28例,女21例。
  1.2 方法
  采集入组患者性别、年龄、机械通气情况、气管插管情况、BNP、血气分析、血常规等临床资料。BNP检测用免疫荧光法;血常规检测采用细胞标记法;血气分析采用床旁血气分析仪进行检测,使用水剂缓冲液作为参考试剂。
  1.3 统计学方法
  采用SPSS 17.0软件进行统计分析。计数资料采用百分率表示,组间比较采用χ2检验。计量资料以均数±标准差(x±s)表示,两组间比较采用t检验。P<0.05为差异有统计学意义。
  2 结果
  2.1 两组基本资料比较
  心衰组血BNP水平明显高于对照组,血二氧化碳分压高于对照组,pH值显著低于对照组,差异均有统计学意义(P<0.05),两组性别、年龄、血常规指标比较差异均无统计学意义(P均>0.05)。
  2.2 两组机械通气率、气管插管率及好转率比较
  与对照组比较,心衰组的好转率低(95.9% vs 100.0%),但差异无统计学意义(P>0.05);机械通气的使用率显著增高(69.4% vs 31.3%)、气管插管率高(28.6% vs 6.0%),差异均有统计学意义(P<0.05)。
  3讨论
  慢性阻塞性肺疾病是一种严重危害人类健康的常见病、多发病,慢阻肺急性加重是指患者呼吸道症状加重(咳嗽、咳痰、呼吸困难),与患者的病死率及医疗费用增加相关[3]。晚期慢性阻塞性肺病患者基础肺功能极差,常存在慢性呼吸衰竭,急性加重时可伴Ⅱ型呼吸衰竭加重,为呼吸科常见危重症,其机械通气率及死亡率均高,且导致住院费费用增加,慢性阻塞性肺病急性加重时病情评估及机械通气发生的预测对指导临床治疗有重要意义。文献报道,APACHEⅡ、CURB-65 scores、BAP-65 scores、心动过速、精神状态改变、血尿素氮高、CRP、PCT、低钠血症、膈肌功能等因素与慢性阻塞性肺病急性加重患者的疾病严重程度、死亡率及机械通气发生密切相关[4-9]。
  B型脑钠肽(BNP)是一個32个氨基酸组成的多肽,当心室过度拉伸时由心脏合成并分泌,是评价心衰及其严重程度的指标,目前广泛用于临床,Luigino Calzetta等[10]发现BNP还有利于支气管平滑肌的舒张,慢性阻塞性肺病急性加重时早期使用β受体激动剂可导致血BNP降低。慢性阻塞性肺病急性加重时常合并心力衰竭,BNP明显升高,尤其是慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者。慢性阻塞性肺病导致心力衰竭衰竭的机制与神经内分泌、右心室扩张、室间隔左移、二氧化碳升高等密切相关[11],且预后差,因此早期发现及干预对疾病预后有重要意义。


张军等[12]报道,高血浆BNP水平是COPD患者病情加重的危险因素,且增加了患者的死亡危险,提示COPD伴BNP升高患者预后不良,稳定期COPD患者BNP为(263±52)pg/mL,故本研究以300 pg/mL为界,≥300 pg/mL为BNP升高组,<300 pg/mL为对照组;发现慢性阻塞性肺病伴Ⅱ型呼吸衰竭患者BNP升高发生率高,BNP≥300 pg/mL的发生率为42.2%。Prangthip等[13]报道,慢性阻塞性肺病急性加重患者合并急性心功能不全的发生率16.2%,低于本文报道,考虑可能与本研究选择合并Ⅱ型呼吸衰竭的患者,病情重,故心功能不全发生率高。
  Dzicha JA等[14]报道COPD患者最主要的死因不是呼吸道并发症,而是心脏并发症,BNP升高提示慢性阻塞性肺病导致心脏功能不全,合并多脏器功能不全,病情重。Marcun等[15]认为BNP的异常是慢性阻塞性肺病急性加重患者重要的预后影响因素。Saraschandra等[16]发现合并同轴性左心室肥大的AECOPD患者无创机械通气的发生率增加,且机械通气时间延长,提示合并心脏疾病与慢性阻塞性肺病急性加重患者病情严重程度相关。但慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者中,血BNP水平与机械通气率、气管插管率的关系未见报道。本研究国内外首次评价了血BNP水平与慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭患者病情严重程度及机械通气发生率的关系,与对照组比较,心衰组有较高的机械通气率(69.4% vs 31.3%)、气管插管率(28.6% vs 6.0%),差异均有统计学意义(P<0.05)。
  文献报道,二氧化碳分压及pH值与慢性阻塞性肺病急性加重患者的预后及机械通气需要显著相关[17,18],本研究中发现心衰组二氧化碳分压高于对照组,pH值低于对照组,两组比较均有统计学意义(P<0.05),推测机械通气率及气管插管率增加可能与合并心力衰竭患者二氧化潴留及PH值下降明显有关。本研究发现心衰组患者好转率低于对照组(95.9% vs 100.0%),两组比较均有统计学意义(P<0.05)。Xubin Huang等[19]报道,慢性阻塞性肺病急性加重患者28 d内死亡组的NT-pro-BNP明显高于存活组,提示NT-pro-BNP能有效預测AECODP患者28 d内死亡率,与本研究结论相符。合并心力衰竭的慢性阻塞性肺病急性加重患者病情重、机械通气需要率高,BNP有助于评价慢性阻塞性肺病急性加重伴Ⅱ型呼吸衰竭的严重程度及预后[20]。Jun Zhang等[2]报道慢性阻塞性肺病急性加重时BNP明显升高,且静脉利尿剂及扩血管药可更快降低血浆BNP水平。因此,血BNP检测有助早期发现心衰,并指导治疗。
  参考文献:
  [1] Cabanes L,Richaud-Thiriez B,Fulla Y,et al. Brain natriuretic peptide blood levels in the differential diagnosis of dyspnea[J]. Chest,2001,120:2047-2050.
  [2] Zhang Jun,Zhao Guangdan,Yu Xiaoling,et al. Intravenous diuretic and vasodilator therapy reduce plasma brain natriuretic peptide levels in acute exacerbation of chronic obstructive pulmonary disease[J]. Respirology,2012,17:715-720.
  [3] 中华医学会呼吸病学分会慢性阻塞性肺疾病学组,慢性阻塞性肺疾病诊治指南(2013年修订版)[J]. 中华结核和呼吸杂志,2013,36(4):255-264.
  [4] Ying P Tabak,Xiaowu Sun,Richard S,et al. Mortality and Need for Mechanical Ventilation in Acute Exacerbations of Chronic Obstructive Pulmonary Disease[J]. Arch Intern Med,2009,169(17):1595-1602.
  [5] Nicolas Roche,Antoine Rabbat,Mahmoud Zureik,et al. Chronic obstructive pulmonary disease exacerbations in emergency departments:predictors of outcome[J]. Current Opinion in Pulmonary Medicine,2010,16(2):112-117.
  [6] Fatmeh Tofan,Mohammad Hossein Rahimi-Rad,Yosef Rasmi,et al. High sensitive C-reactive protein for prediction of adverse outcome in acute exacerbation of chronic obstructive pulmonary disease[J]. Pneumologia,2012,61(3):160-162.
  [7] Shorr Andrew F,Sun Xiaowu,Johannes Richard S,et al. Predicting the need for mechanical ventilation in acute exacerbations of chronic obstructive pulmonary disease:Comparing the CURB-65 and BAP-65 scores[J]. J Crit Care,2012,27(6):564-570.
  [8] Roberto Chalela,Jose Gregorio Gonzalez-Garc,Juan Jose Chillaron,et al. Impact of hyponatremia on mortality and morbidity in patients with COPD exacerbations[J]. Respiratory Medicine,2016,117:237-242.
  [9] Federico Antenor,Riccardo Fantini,Aaderea Iattoni,et al. Prevalence and outcomes of diaphragmatic dysfunction assessed by ultrasound technology during acute exacerbation of COPD:A pilot study[J]. Respirology,2016,1(1):1-7.
  [10] Luigino Calzetta,Augusto Orlandi,Clive Page,et al.Brain natriuretic peptide:Much more than a biomarker[J]. International Journal of Cardiology,2016,221:1031-1038.
  [11] Nikolaos Flessasa,Ioannis Alexanianb,John Parissis,et al. Plasma activity of B-type natriuretic peptide in patients with biventricular heart failure versus those with right heart failure due to chronic obstructive pulmonary disease[J]. J Cardiovasc Med,2014,15:476-480.
  [12] 張军,潘哓明,赵菲. 血浆BNP增高对COPD急性加重患者的影响[J]. 中国医学工程,2013,21(6):12-13.
  [13] Prangthip Charoenpong,Clifton Clarke. Role of BNP as a Detector of Acute Decompensated Heart Failure(ADHF)in COPD Exarcerbation(AECOPD)[J]. Chest,2014,146(4_MeetingAbstracts):127A.
  [14] Dzicha JA,Calverley PM,Seemungal TA,et al. The prevention of chronic obstructive pulmonary disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide[J]. Am J Respir Crit Care Med,2008,177:19-26.
  [15] Marcun R,Sustic A,Brguljan PM,et al. Cardiac biomarkers predict outcome after hospitalisation for an acute exacerbation of chronic obstructive pulmonary disease[J]. Int J Cardiol,2012,161:156-159.
  [16] Saraschandra Vallabhajosyulaa,Pranathi R Sundaragiric,Arun Kanmanthareddyd,et al. Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease[J]. Journal of Chronic Obstructive Pulmonary Disease,2016,1(1):1-6.
  [17] Johanna P,Van Gemert,Folkert Brijker,et al. Intubation after noninvasive ventilation failure in chronic obstructive pulmonary disease:associated factors at emergency department presentation[J]. European Journal of Emergency Medicine,2015,22(1):49-54.

  [18] Singanayagam Aran,Schembri Stuart,Chalmers James D. Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease[J]. Ann Am Thorac Soc,2013,10(2):81-89.
  [19] Xubin Huang,Jun Zhang,Xinyan Huang,et al. Nt-pro-BNP as a prognostic factor in critically illl patients with acute exacerbation of COPD[J]. Crit Care Med,2015,43(12):Suppl 710.
  [20] 尹凤先,回银娜. 慢性阻塞性肺疾病和肺心病患者利钠肽水平临床研究[J]. 中国医刊,2016,51(10):42-45.

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