ObjectiveTo investigate the efficacy of invasive-noninvasive sequential mechanical ventilation (MV) in senile patients with severe community-acquired pneumonia (CAP).Methods A prospective study was conducted. The patients with severe CAP aged≥ 75 years admitted to Department of Respiratory Intensive Care Unit (RICU) of the First Affiliated Hospital of Xinjiang Medical University from November 2012 to July 2014, with refusal to have tracheostomy, were enrolled. All patients meeting the diagnostic criteria of CAP and severe CAP were first admitted into the Department of Emergency, and they were found to need MV without absolute contraindication for noninvasive ventilation (NIV) in RICU. The patients were mechanically ventilated via endotracheal intubation (ETI), and they were randomly divided into invasive-noninvasive sequential MV group (sequential MV group) and conventional MV group. NIV was initiated immediately when patients matched the conditions for early extubation in the sequential MV group. Oxygen therapy (5 L/min) via a Venturi mask was provided when the indications of conventional extubation were met. The baseline data and clinical characteristics were recorded, the risk factors of death were analyzed by logistic regression analysis, and 60-day survival rate was analyzed by Kaplan-Meier curve. Results Ninety-one senile patients with severe CAP were enrolled, among them 28 patients died within 60 days, with a mortality rate of 30.77%. No significant difference in 60-day mortality was found between sequential MV group (n = 44) and conventional MV group [n = 47, 25.0% (11/44) vs. 36.2% (17/47),χ2 = 1.331,P = 0.249]. In the sequential MV group, the incidence of ventilator-associated pneumonia (VAP) was significantly decreased [27.3%(12/44) vs. 55.3% (26/47),χ2 = 7.350,P = 0.007], and the rate of ETI≥2 times was increased [59.1% (26/44) vs. 29.8% (14/47),χ2 = 5.095,P = 0.024] as compared with conventional MV group. Compared with survival group, the patients in non-survival group showed a higher incidence of cerebrovascular disease (60.7% vs. 25.4%,P = 0.002), higher acute physiology and chronic health evaluationⅡ (APACHEⅡ) score (26.46±2.59 vs. 24.41±2.47,P = 0.001), British Thoracic Society confusion, uremia, respiratory rate, blood pressure,≥75 years (CURB-75 score, 4.00±0.47 vs. 3.68±0.53,P = 0.013), a longer total duration of MV (days: 21.18±10.02 vs. 14.56±7.62,P = 0.002), and a higher ratio of ETI≥ 2 times (53.6% vs. 33.3%,P< 0.001). It was revealed by multivariate logistic regression analysis that ETI≥ 2 times and comorbidity of cerebrovascular infarction were independent predictors of a worse outcome in the senile patients [odds ratio (OR) = 9.677, 95% confidence interval (95%CI) = 3.075 - 30.457,P< 0.001;OR = 5.386, 95%CI = 1.781 - 6.284,P = 0.003]. It was showed by Kaplan-Meir survival analysis that ETI times and concurrent cerebrovascular infarction imparted significant effects on the 60-day survival rate (χ2 = 40.805,P= 0.000;χ2 = 4.425, P = 0.035).ConclusionInvasive-noninvasive sequential MV may not improve the outcome of senile patients with severe CAP, and ETI≥ 2 times and concurrent cerebrovascular disorders drastically lowered the survival rate.%目的：探讨有创-无创序贯性机械通气（MV）对高龄重症社区获得性肺炎（CAP）患者的疗效及预后因素。方法采用前瞻性研究方法，选择2012年11月至2014年7月入住新疆医科大学第一附属医院呼吸危重症医学科（RICU）年龄≥75岁的高龄重症CAP患者，患者符合CAP和重症CAP的诊断标准，首诊于急诊科，需要入RICU实行MV且无无创通气（NIV）绝对禁忌证。患者均拒绝气管切开计划，经气管内插管（ETI）MV后，按随机数字表法分为有创-无创序贯性通气组（序贯性通气组）和常规通气组。序贯性通气组达到早期拔管指征时拔除ETI，改为NIV；而常规通气组达到传统拔管指征时改为Venturi面罩氧疗（5 L/min）。记录两组患者基线资料与临床特征；采用多因素logistic回归分析预测死亡危险因素；Kaplan-Meier生存曲线分析患者60 d生存率。结果有91例高龄重症CAP患者纳入研究，60 d死亡28例，病死率为30.77%。序贯性通气组（44例）和常规通气组（47例）60 d病死率差异无统计学意义〔25.0%（11/44）比36.2%（17/47），χ2＝1.331，P＝0.249〕，但序贯性通气组呼吸机相关性肺炎（VAP）发生率较低〔27.3%（12/44）比55.3%（26/47），χ2＝7.350，P＝0.007〕，ETI次数≥2次的患者比例较大〔59.1%（26/44）比29.8%（14/47），χ2＝5.095， P＝0.024〕。与存活组比较，死亡组伴脑血管疾病比例大（60.7%比25.4%，P＝0.002），急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分高（分：26.46±2.59比24.41±2.47，P＝0.001），英国胸科协会改良肺炎评分（CURB-75）高（分：4.00±0.47比3.68±0.53，P＝0.013），总MV时间长（d：21.18±10.02比14.56±7.62， P＝0.002），ETI次数≥2次的患者比例大（53.6%比33.3%，P＜0.001）。多因素logistic回归分析显示， ETI次数≥2次及伴脑血管疾病是患者死亡的独立危险因素〔优势比（OR）＝9.677，95%可信区间（95%CI）＝3.075～30.457，P＜0.001；OR＝5.386，95%CI＝1.781～16.284，P＝0.003〕。Kaplan-Meier生存曲线分析表明， ETI次数和是否伴脑血管疾病对患者60 d生存率有显著影响（χ2＝40.805、P＝0.000，χ2＝4.425、P＝0.035）。结论有创-无创序贯性通气并不能改善高龄重症CAP患者的预后，ETI次数≥2次和伴脑血管疾病的患者生存率明显降低。
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