慢性阻塞性肺疾病机械通气患者营养风险与营养治疗策略的多中心研究

摘要

目的 分析慢性阻塞性肺疾病(COPD)机械通气患者营养风险状况与营养治疗策略的关系,为探索个体化营养治疗策略提供帮助.方法 采用前瞻性多中心观察性研究方法.选择2015年1月至2016年1月入住浙江省10家县区级医院重症医学科(ICU)需要机械通气的COPD患者.依据营养风险筛查量表(NRS2002)评分将患者分为营养风险高危组(NRS2002评分3～5分)和极高危组(NRS2002评分6～7分).比较两组患者营养实施状况和住院病死率;采用多因素Cox回归分析法分析影响COPD机械通气患者预后的危险因素;采用Kaplan-Meier曲线分析患者30 d预后;绘制受试者工作特征曲线(ROC),评价回归模型的检验效能.结果 ① 共106例COPD机械通气患者纳入本研究,其中营养风险高危组患者90例,营养风险极高危组16例.两组患者性别、年龄和体质量指数(BMI)比较差异均无统计学意义(均P＞0.05);营养风险极高危组急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、NRS2002评分均较营养风险高危组明显增高〔APACHEⅡ(分):24.9±6.1比20.3±5.8,NRS2002评分(分):6.3±0.5比4.2±0.8,均P＜0.05〕.② 两组患者均在早期实施了肠内营养(EN)治疗,营养风险极高危组开始EN治疗的比例较营养风险高危组低〔12.5%(2/16)比17.7% (16/90)〕,随着住院时间延长,营养风险极高危组和营养风险高危组开始EN治疗的比例均逐渐增加,2 d后明显上升,入ICU 6 d达峰值〔分别为100.0%(16/16)、98.9%(89/90)〕;入ICU 3 d内营养风险极高危组开始EN比例较营养风险高危组明显降低,4 d起两组EN比例比较差异无统计学意义(均P＞0.05).营养风险极高危组和营养风险高危组开始肠外营养(PN)治疗的时间均较早(均为入ICU 1 d)、比例均较高〔分别为56.2%(9/16)和27.7%(25/90)〕,且PN比例未显示随着住院时间延长和EN热卡的增加而减少的趋势.营养风险极高危组开始PN治疗的比例更高,入ICU 1 d即达到了56.2%.③ 随着住院时间延长,营养风险高危组患者EN的热卡逐渐增加,入ICU 7 d达高峰为4 318(3 912,4 812)kJ/d ;但营养风险极高危组入ICU 7 d有所降低,入ICU 6 d达峰值为3 602(2 467,4 615)kJ/d ;两组1周内EN热卡比较差异均无统计学意义(均P＞0.05).营养风险高危和极高危两组患者住院期间7 d内PN所需热卡保持在相对恒定水平,入ICU 4～5 d达到目标热卡范围.④ Kaplan-Meier生存曲线分析显示,营养风险极高危组30 d病死率明显高于营养风险高危组〔62.5%(10/16)比11.1%(10/90),χ2＝15.4,P＜0.01〕.⑤ 多因素Cox回归分析显示,NRS2002评分是影响患者住院病死率的独立危险因素〔优势比(OR)＝2.08,95%可信区间(95%CI)＝1.39～3.12,P＝0.005〕.⑥ ROC曲线分析:采用ROC曲线分析多因素回归模型的效能显示,ROC曲线下面积(AUC)为0.79,敏感度为70.00%,特异度为74.42%,阳性似然比为2.74,阴性似然比为0.40,95%可信区间(95%CI)为0.702～0.864,P＝0.001.说明回归模型有较好的预测效果.结论 机械通气COPD患者存在明显营养风险,应早期实施EN治疗,极高危风险患者开始PN的比例较高.初始营养状况是COPD机械通气患者不良预后的独立危险因素.%Objective To investigate the relationship between nutritional risk status and implementation of nutrition therapy in mechanical ventilated (MV) chronic obstructive pulmonary disease (COPD) patients, so as to provide evidence for individualized nutrition therapy. Methods A prospective multicenter observational study was conducted. MV COPD patients admitted to Department of Intensive Care Units (ICU) of 10 County Hospitals in Zhejiang Province from January 2015 to January 2016 were enrolled, and according to nutrition risk screening 2002 (NRS2002) score, they were divided into nutritional high risk group (NRS2002 3-5) and nutritional extremely high risk group (NRS2002 6-7). Nutrition therapy situation and hospital mortality were compared between the two groups; multivariate Cox regression analysis was used to analyze the risk factors affecting the prognosis of patients with COPD under mechanical ventilation. Kaplan-Meier curve was used to analyze the prognosis at 30 days; receiver operating characteristic (ROC) curve was used to test the robustness of multivariable regression analysis. Results ① One hundred and six COPD patients with MV were analyzed; among them, 90 patients were in the nutritional high risk group, and 16 were in the nutritional extremely high risk group. There were no significant differences in age, gender and body mass index (BMI) between the two groups (all P > 0.05); the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) score, NRS2002 score in patients of nutrition risk extremely high group were obviously higher than that in patients with nutrition high risk group (APACHEⅡ: 24.9±6.1 vs. 20.3±5.8, NRS2002 score: 6.3±0.5 vs. 4.2±0.8, both P 0.05). The time to start parenteral nutrition (PN) treatment was relatively early admission to the ICU on day 1 and the proportion of this therapy was high in the two groups [56.2% (9/16), 27.7% (25/90), respectively], the PN proportion did not decrease with the length of hospitalization and the increase of EN. The proportion of patients in the nutrition extremely high risk group who started PN treatment was higher, which reached 56.2% admission to the ICU on day 1.③ With extension of hospital stay, the calories of EN were gradually increased in the nutritional high risk group, the highest calories in nutritional high risk groups was 4 318 (3 912, 4 812) kJ/d at day 7; while the highest calories in nutritional extremely high risk groups was 3 602 (2 167, 4 615) kJ/d at day 6 and a slight decreased at day 7; the difference of calories within the first week between the two groups had no significance (all P > 0.05). The calorific value of PN therapy remained at a constant level during hospitalization within 7 days, and after admission into ICU for 4-5 days, the target range of calories was achieved. ④ Kaplan-Meier survival curve analysis showed that the mortality at 30 days in the extremely high risk group was significantly higher than that in the high risk group [62.5% (10/16) vs. 11.1% (10/90), χ2 = 15.4, P < 0.01]. ⑤ Multiple cox-regression analysis showed that NRS2002 scoring was the independent risk factor affecting the mortality of patients in hospital [odds ratio (OR) = 2.08, 95% confidence interval (95%CI) = 1.39-3.12, P = 0.005]. ⑥ ROC curve analysis: according to ROC curve analysis of the effectiveness of multi-factor regression model, area under ROC curve (AUC) was 0.79, sensitivity was 70.00%, specificity was 74.42%, positive likelihood ratio was 2.74, negative likelihood ratio was 0.40, 95% confidence interval (95%CI) was 0.702-0.864, P = 0.001, and it showed that the regression model had a good prediction effect. Conclusions MV COPD patients have significant nutritional risk and all receive early EN therapy. The proportion of beginning to use PN treatment in patients with nutritional extremely high risk is relatively high. Initial nutritional status is the independent risk factor of poor prognosis in MV patients with COPD.