目的 探讨中性粒细胞弹性蛋白酶(NE)、纤维蛋白原(Fib)联合肿瘤坏死因子-α(TNF-α)对儿童重症肺炎预后的预测价值.方法 选择2016年7月至2018年9月在杭州市余杭区妇幼保健院接受诊治的82例重症肺炎患儿作为重症肺炎组,再按预后将重症肺炎患儿分为存活组(70例)和死亡组(12例);另选同期在本院接受诊治的90例普通肺炎患儿作为普通肺炎组;以同期于本院接受健康体检的85例健康儿童作为健康对照组.采用酶联免疫吸附试验(ELISA)检测3组受试者NE、Fib、TNF-α含量,统计重症肺炎组、普通肺炎组患儿肺炎严重指数(PSI);采用Spearman相关性分析法分析重症肺炎患儿NE、Fib、TNF-α与PSI的相关性;绘制受试者工作特征曲线(ROC)评估NE、Fib、TNF-α预测重症肺症患儿预后的价值.结果 重症肺炎组NE、Fib、TNF-α含量高于普通肺炎组及健康对照组〔NE(μg/L):127.5±12.3比75.1±6.6、24.3±5.9,Fib(g/L):6.9±1.2比5.1±0.7、2.8±0.8,TNF-α(μg/L):98.3±6.9比63.1±6.8、30.2±2.1,均P＜0.05〕.死亡组血清NE、Fib、TNF-α含量均高于存活组〔NE(μg/L):141.2±14.9比80.3±7.4,Fib(g/L):7.6±1.5比5.7±1.0,TNF-α(μg/L):105.4±7.8比68.2±4.6,均P＜0.05〕.ROC曲线分析显示:NE、Fib、TNF-α单独及联合检测对预测重症肺炎患儿的预后均有一定价值,ROC曲线下面积(AUC)分别为0.889、0.809、0.803、0.961,95%可信区间(95%CI)分别为0.817～0.968、0.706～0.909、0.702～0.891、0.908～1.000,敏感度分别为71.2%、62.7%、64.9%、92.3%,特异度分别为73.5%、68.3%、74.5%、90.9%,均P＝0.000.重症肺炎组PSI明显高于普通肺炎组(97.4±12.1比76.4±9.6),死亡组PSI明显高于存活组(100.8±13.1比87.3±10.5),差异均有统计学意义(均P＜0.01).Spearman相关性分析显示,重症肺炎患儿NE、Fib、TNF-α与PSI均呈显著正相关(r＝0.767、0.734、0.673,均P＜0.05),NE和Fib(r＝0.655,P＝0.000)、NE和TNF-α(r＝0.530,P＝0.000)、Fib和TNF-α(r＝0.522,P＝0.000)均呈正相关.结论 联合检测NE、Fib、TNF-α能帮助临床医师判定重症肺炎患儿的病情变化、评估预后,且联合检测具有高敏感度和特异度.%Objective To study the application value of neutrophil elastase (NE), fibrinogen (Fib) combined with tumor necrosis factor-α (TNF-α) in the prognosis prediction of severe pneumonia in children. Methods Eighty-two children with severe pneumonia who were admitted into the Yuhang District Maternal and Child Health Hospital of Hangzhou in Zhejiang Province from July 2016 to September 2018 were treated as a severe group, and the children with severe pneumonia were subdivided into a survival group (70 cases) and a death group (12 cases) according to the prognosis; another 90 children with common pneumonia who were treated in our hospital at the same time were selected as a general group; and 85 normal children who received physical examinations at the same time as a healthy control group. The levels of serum NE, Fib and TNF-α in the three groups were measured by enzyme-linked immunosorbent assay (ELISA), and the pneumonia severity index (PSI) was calculated in the severe group and the general group; Spearman correlation analysis was used to analyze the correlation between NE, Fib, TNF-α and PSI;the NE, Fib and TNF-α levels were evaluated to predict the prognosis of children with severe pulmonary disease;the receive operating characteristic (ROC) curve was drawn to evaluate the prognostic value of NE, Fib, TNF-α in children with severe pulmonary disease. Results The expression levels of serum NE, Fib and TNF-α in the severe group were higher than those in the general group and the healthy control group [NE (μg/L): 127.5±12.3 vs. 75.1±6.6, 24.3±5.9, Fib (g/L): 6.9±1.2 vs. 5.1±0.7, 2.8±0.8, TNF-α (μg/L): 98.3±6.9 vs. 63.1±6.8, 30.2±2.1, all P <0.05]. Serum levels of NE, Fib and TNF-α in the death group were higher than those in the survival group [NE (μg/L):141.2±14.9 vs. 80.3±7.4, Fib (g/L): 7.6±1.5 vs. 5.7±1.0, TNF-α (μg/L): 105.4±7.8 vs. 68.2±4.6, all P < 0.05]. It was shown by ROC curve analysis that NE, Fib, TNF-α have some value in predicting the prognosis of children with severe pneumonia, the area under the ROC curve (AUC) were 0.889, 0.809, 0.803, 0.961, 95% confidence internal (95%CI) were 0.817-0.968、0.706-0.909、0.702-0.891、0.908-1.000, the sensitivity were 71.2%, 62.7%, 64.9%, 92.3%, the specificity were 73.5%, 68.3%, 74.5%, 90.9%, all P = 0.000. The PSI of severe pneumonia group was significantly higher than that of the general group (97.4±12.1 vs. 76.4±9.6), the PSI of the death group was obviously higher than that of the survival group (100.8±13.1 vs. 87.3±10.5), and the differences were statistically significant (both P < 0.01). Spearman correlation analyses showed that serum NE, Fib, TNF-α and PSI were significantly positively correlated in children with severe pneumonia respectively (r = 0.767, 0.734, 0.673, all P < 0.05), and there were positive correlations between NE and Fib (r = 0.655,P = 0.000), NE and TNF-α (r = 0.530,P = 0.000), Fib and TNF-α (r = 0.522,P = 0.000). Conclusion The combined detections of NE, Fib, and TNF-α levels can help clinicians determine the changes in the condition of children with severe pneumonia and evaluate their prognoses, combined detection has high sensitivity and specificity.
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