The Effect of Bronchoalveolar Lavage Combined with Low Molecular Weight Heparin on Patients with Severe Pneumonia
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摘要:
目的 分析支气管肺泡灌洗复合低分子肝素对重症肺炎俯卧位通气患者病情转归的影响。 方法 选择2021年1月至2023年1月自贡市第一人民医院102例重症肺炎患者为研究对象，按随机数表法分为对照组（n = 51，常规治疗+低分子肝素）与研究组（n = 51，常规治疗+低分子肝素+支气管肺泡灌洗）。对比2组治疗前、治疗1周时血气指标[血氧饱和度（SaO2）、动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）]、呼吸动力学指标[呼吸做功（WOB）、气道阻力（Raw）、动态顺应性（Cdyn）]、肺功能指标[用力肺活量（FVC）、第1秒最大呼气容积（FEV1）、最高呼气流速（PEF）]、炎症因子[肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）、白细胞介素-8（IL-8）]及D-二聚体水平，统计2组不良预后（死亡、入住ICU、插管+有创呼吸机）发生率。 结果 治疗1周后，研究组SaO2、PaO2水平比对照组高，PaCO2比对照组低（t = 4.649、3.774、4.792，P < 0.05）；治疗1周后，研究组WOB、Raw比对照组低，Cdyn比对照组高（t = 7.207、5.401、3.150，P < 0.05）；治疗1周后，研究组FVC、FEV1、PEF比对照组高（t = 3.834、3.960、3.908，P < 0.05）；治疗1周后，研究组TNF-α、IL-6、IL-8、D-二聚体水平比对照组低（t = 5.642、5.002、6.712、4.127，P < 0.05）；研究组不良预后发生率比对照组低（χ2=4.547，P < 0.05）。 结论 支气管肺泡灌洗复合低分子肝素可缩短重症肺炎俯卧位通气患者临床症状消失时间及住院时间，改善血气指标、呼吸动力学，提升肺功能，降低炎症因子水平，从而促进病情转归。 Abstract:Objective To analyze the effect of bronchoalveolar lavage combined with low molecular weight heparin on the prognosis with prone ventilation due severe pneumonia. Methods 102 patients with the severe pneumonia from hospitals from January 2021 to January 2023 were selected as the study subjects and randomly divided into a control group （51 cases, conventional treatment+low molecular weight heparin） and a study group （51 cases, conventional treatment+low molecular weight heparin+bronchoalveolar lavage） using a random number table method. Blood gas indexes [blood oxygen saturation （SaO2）, partial arterial oxygen pressure （PaO2）, partial arterial carbon dioxide pressure （PaCO2）], respiratory dynamics indexes [respiratory work done （WOB）, airway resistance （Raw）, dynamic compliance （Cdyn）], pulmonary function indexes [forced vital capacity （FVC）, 1 second maximum expiratory volume （FEV1）, maximum expiratory flow rate （PEF）], inflammatory factors [tumor necrosis factor-α （TNF-α）, interleukin-6 （IL-6）, interleukin-8 （IL-8）], and D-dimer levels before and the first week of treatment were compared between the two groups. And the incidence of adverse prognosis （death, ICU admission, intubation and invasive ventilator） was calculated in the two groups. Results After one week of the treatment, the levels of SaO2 and PaO2 in the study group were higher than those in the control group, while PaCO2 was lower than those in the control group （t = 4.649, 3.774, 4.792, P < 0.05）; After one week of the treatment, the WOB and Raw levels in the study group were lower than those in the control group, while the Cdyn levels were higher than those in the control group （t = 7.207, 5.401, 3.150, P < 0.05）; After one week of the treatment, the FVC, FEV1, and PEF in the study group were higher than those in the control group （t = 3.834, 3.960, 3.908, P < 0.05）; After one week of the treatment, the study group had TNF- α、 The levels of IL-6, IL-8, and D-dimer in the control group were lower than those in the control group （t = 5.642、5.002、6.712、4.127, P < 0.05）; The incidence of poor prognosis in the study group was lower than that in the control group （χ2=4.547, P < 0.05）. Conclusion Bronchoalveolar lavage, combined with low molecular weight heparin, can shorten the duration of clinical symptom disappearance and hospital stay, improve the blood gas indexes, respiratory dynamics, enhance lung function and reduce the level of inflammatory factors in patients with severe pneumonia. -
表 1 2组一般资料比较[n（%）/（$ \bar x \pm s $）]
Table 1. Comparison of two groups of general data[n（%）/（$ \bar x \pm s$）]
指标 研究组（n=51） 对照组（n=51） χ2/t P 性别 男 28（54.90） 26（50.98） 0.157 0.692 女 23（45.10） 25（49.02） 年龄（岁） 66.42±4.86 65.83±5.17 0.594 0.554 病程（d） 4.67±1.02 4.83±1.14 0.747 0.457 APACHE Ⅱ评分（分） 22.68±3.29 22.84±3.42 0.241 0.810 白细胞计数（×109/L） 12.86±2.79 13.02±2.85 0.287 0.775 血小板计数（×109/L） 191.54±31.68 188.79±34.52 0.419 0.676 呼吸衰竭类型 Ⅰ型 14（27.45） 11（21.57） 0.477 0.490 Ⅱ型 37（72.55） 40（78.43） 合并症 糖尿病 5（9.80） 7（13.73） 0.378 0.539 高血压 16（31.37） 13（25.49） 0.434 0.510 
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表 2 2组治疗前、治疗1周后血气指标比较（$ \bar x \pm s $）
Table 2. Comparison of blood gas indexes between two groups before and after treatment for 1 week（$ \bar x \pm s$）
组别 SaO2（%） PaO2（mmHg） PaCO2（mmHg） 治疗前 治疗1周后 治疗前 治疗1周后 治疗前 治疗1周后 研究组（n=51） 73.86±9.41 94.17±2.32* 51.28±8.64 87.62±6.23* 62.43±6.19 46.39±5.61* 对照组（n=51） 74.12±10.53 91.56±3.27* 50.87±9.36 83.06±5.97* 61.97±6.32 52.01±6.22* t 0.132 4.649 0.230 3.774 0.371 4.792 P 0.896 0.000# 0.819 0.000# 0.711 0.000# 与本组治疗前相比，*P < 0.05；#P < 0.05。
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表 3 2组治疗前、治疗1周后呼吸动力学指标比较（$ \bar x \pm s $）
Table 3. Comparison of respiratory dynamic indexes between two groups before and after treatment for 1 week（$ \bar x \pm s$）
组别 WOB（J/L） Raw[cmH2O/（L's）] Cdyn（mL/cmH2O） 治疗前 治疗1周后 治疗前 治疗1周后 治疗前 治疗1周后 研究组（n=51） 0.90±0.21 0.35±0.12* 15.13±3.96 9.13±2.10* 20.76±5.39 36.28±9.32* 对照组（n=51） 0.88±0.23 0.56±0.17* 14.98±4.12 12.23±3.52* 21.03±6.17 30.86±8.01* t 0.459 7.207 0.188 5.401 0.235 3.150 P 0.648 0.000# 0.852 0.000# 0.814 0.002# 与本组治疗前相比，*P < 0.05；#P < 0.05。
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表 4 2组治疗前、治疗1周时肺功能指标比较（$ \bar x \pm s $）
Table 4. Comparison of lung function indexes between the two groups before and after treatment for 1 week（$ \bar x \pm s $）
组别 FVC（L） FEV1（L） PEF（L/s） 治疗前 治疗1周后 治疗前 治疗1周后 治疗前 治疗1周后 研究组（n=51） 1.72±0.33 2.53±0.49* 1.16±0.22 1.63±0.33* 2.36±0.34 3.82±0.64* 对照组（n=51） 1.73±0.31 2.18±0.43* 1.14±0.21 1.39±0.28* 2.38±0.36 3.34±0.60* t 0.158 3.834 0.470 3.960 0.288 3.908 P 0.875 0.000# 0.640 0.000# 0.774 0.000# 与本组治疗前相比，*P < 0.05；#P < 0.05。
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表 5 2组治疗前、治疗1周时炎症因子、D-二聚体水平比较（$ \bar x \pm s$）
Table 5. 5Comparison of inflammatory factors and D- dimer levels between the two groups before and after treatment for 1 week（$ \bar x \pm s$）
组别 TNF-α（ng/L） IL-6（ng/L） IL-8（ng/L） D-二聚体（mg/L） 治疗前 治疗1周后 治疗前 治疗1周后 治疗前 治疗1周后 治疗前 治疗1周后 研究组（n=51） 31.54±6.81 16.57±4.13* 8.63±2.05 3.16±0.68* 14.27±4.38 5.28±1.24* 2.29±1.32 0.73±0.42* 对照组（n=51） 30.96±7.15 22.08±5.62* 8.71±2.14 4.12±1.19* 13.94±5.19 8.03±2.65* 2.36±1.40 1.09±0.46* t 0.420 5.642 0.193 5.002 0.347 6.712 0.260 4.127 P 0.676 0.000# 0.848 0.000# 0.729 0.000# 0.796 0.000# 与本组治疗前相比，*P < 0.05；#P < 0.05。
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表 6 2组不良预后发生率比较[n（%）]
Table 6. Comparison of incidence of adverse prognosis between two groups [n（%）]
组别 病死 入住ICU 插管+有创呼吸机 合计 研究组（n=51） 2（3.92） 3（5.88） 2（3.92） 7（13.73） 对照组（n=51） 4（7.84） 7（13.73） 5（9.80） 16（31.37） χ2 4.547 P 0.033* *P < 0.05。
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[1] Kitaya S,Baba H,Okamoto M,et al. Severe pneumonia due to legionella and SARS-CoV-2 co-infection necessitating medical evacuation from a cargo ship[J]. J Travel Med,2023,30(9):67. [2] Toniati P,Piva S,Cattalini M,et al. Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: A single center study of 100 patients in Brescia,Italy[J]. Autoimmun Rev,2020,19(7):102568. doi: 10.1016/j.autrev.2020.102568 [3] Godoy DA,Graneros N,Oyarzabal L,et al. High-flow oxygen therapy in acute hypoxemic respiratory failure secondary to COVID-19 pneumonia[J]. Med Intensiva (Engl Ed),2021,45(8):506-508. doi: 10.1016/j.medin.2021.02.003 [4] Novelli C,Borotto E,Beverina I,et al. Heparin dosage,level,and resistance in SARS-CoV2 infected patients in intensive care unit[J]. Int J Lab Hematol,2021,43(6):1284-1290. doi: 10.1111/ijlh.13543 [5] Gaitanidis A,Breen K A,Christensen M A,et al. Low-molecular weight heparin is superior to unfractionated heparin for elderly trauma patients[J]. J Surg Res,2021,61(268):432-439. [6] Reynolds D,Vazquez Guillamet C,Day A,et al. Comprehensive immunologic evaluation of bronchoalveolar lavage samples from human patients with moderate and severe seasonal influenza and severe covid-19[J]. J Immunol,2021,207(5):1229-1238. doi: 10.4049/jimmunol.2100294 [7] Gualano G,Musso M,Mosti S,et al. Usefulness of bronchoalveolar lavage in the management of patients presenting with lung infiltrates and suspect covid-19-associated pneumonia: A case report[J]. Int J Infect Dis,2020,25(97):174-176. [8] Lee J H,Hwang S Y,Kim H R,et al. Effectiveness of the sequential organ failure assessment,acute physiology and chronic health evaluation II,and simplified acute physiology score II prognostic scoring systems in paraquat-poisoned patients in the intensive care unit[J]. Hum Exp Toxicol,2017,36(5):431-437. doi: 10.1177/0960327116657602 [9] 杨欢欢,唐颖丽,眭菓,等. 盐酸氨溴索联合纤维支气管镜肺泡灌洗治疗重症肺炎患者的疗效[J]. 西部医学,2023,35(3):400-404. [10] 中国医师协会急诊医师分会. 中国急诊重症肺炎临床实践专家共识[J]. 中国急救医学,2016,36(2):97-107. [11] 张欣欣,罗源,杨庆斌,等. 纤维支气管镜吸痰联合肺泡灌洗对重症肺炎并发呼吸衰竭患者疗效、CPIS评分及血清炎性指标水平的影响[J]. 山东医药,2022,62(4):86-88. [12] Caravita S,Baratto C,Di Marco F,et al. Haemodynamic characteristics of COVID-19 patients with acute respiratory distress syndrome requiring mechanical ventilation. An invasive assessment using right heart catheterization[J]. Eur J Heart Fail,2020,22(12):2228-2237. doi: 10.1002/ejhf.2058 [13] Pavoni V,Gianesello L,Pazzi M,et al. Venous thromboembolism and bleeding in critically ill COVID-19 patients treated with higher than standard low molecular weight heparin doses and aspirin: A call to action[J]. Thromb Res,2020,49(196):313-317. [14] Stessel B,Vanvuchelen C,Bruckers L,et al. Impact of implementation of an individualised thromboprophylaxis protocol in critically ill ICU patients with COVID-19: A longitudinal controlled before-after study[J]. Thromb Res,2020,49(194):209-215. [15] 朱建凤,王红娟. 盐酸氨溴索联合纤维支气管镜肺泡灌洗在老年重症肺炎患者中的应用效果[J]. 实用临床医药杂志,2020,24(1):82-87. [16] 吴卫照,刘东成. 支气管镜肺泡灌洗治疗幼儿重症肺炎支原体肺炎的疗效观察及肺功能的变化特点[J]. 实用医学杂志,2019,35(1):132-135. [17] 廖宝林,施海燕,王亚萍,等. 广州市135例新型冠状病毒肺炎患者的免疫学特征分析[J]. 中华传染病杂志,2020,38(10):616-620. [18] Lim J U,Choi J Y,Jeong H J,et al. Comparison of clinical characteristics and inflammatory cytokines between hypoxemic and non-hypoxemic human adenovirus 55 pneumonia[J]. J Thorac Dis,2020,12(8):4044-4056. doi: 10.21037/jtd-19-4067 [19] Li H,Zhang J,Fang C,et al. The prognostic value of IL-8 for the death of severe or critical patients with COVID-19[J]. Medicine,2021,100(11):e23656. doi: 10.1097/MD.0000000000023656 [20] Xu K,Wei Y,Giunta S,et al. Do inflammaging and coagul-aging play a role as conditions contributing to the co-occurrence of the severe hyper-inflammatory state and deadly coagulopathy during COVID-19 in older people?[J]. Exp Gerontol,2021,58(151):111423. [21] 吴小利,李戴,朱静叶,等. 低分子肝素辅助治疗D-二聚体升高的儿童重症肺炎支原体肺炎的疗效观察[J]. 中国妇幼保健,2020,35(18):3412-3414. [22] Wang Z L,He Y,Luo Z X. Continuous positive airway pressure in children with severe pneumonia: a meta-analysis[J]. World J Pediatr,2020,16(6):637-641. doi: 10.1007/s12519-020-00366-0 [23] Wang C,Ye S,Wang X,et al. Clinical efficacy and safety of mechanical ventilation combined with fiberoptic bronchoalveolar lavage in patients with severe pulmonary infection[J]. Med Sci Monit,2019,21(25):5401-5407. -
