重症肺炎患儿俯卧位与仰卧位机械通气的临床效果比较及其脱机结局的影响因素分析

摘要 目的：比较重症肺炎患儿俯卧位与仰卧位机械通气的临床效果，并分析其脱机结局的影响因素。方法：选择2020年5月~2021年12月期间在我院重症监护室（ICU）住院的重症肺炎患儿120例作为研究对象。根据机械通气体位方式的不同将患儿分为仰卧组（n=52）和俯卧组（n=68），对比仰卧组、俯卧组的临床症状改善时间和血气分析指标动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）、平均动脉压（MAP）]。记录仰卧组、俯卧组的死亡例数、脱机成功和脱机失败例数，计算死亡率、脱机失败发生率。采用单因素及多因素Logistic回归分析脱机失败的影响因素。结果：俯卧组的发热消失时间、肺部啰音消失时间、呼吸改善时间短于仰卧组（P<0.05）。两组治疗5 d后 PaO₂、MAP较治疗前升高，PaCO₂较治疗前下降（P<0.05）；俯卧组的PaO₂、MAP高于仰卧组，PaCO2低于仰卧组（P<0.05）。两组患儿死亡率组间对比未见统计学差异（P>0.05）。俯卧组的脱机失败率低于仰卧组（P<0.05）。在120例患儿中，死亡7例，根据重症肺炎患儿脱机结局将剩余113例分为脱机成功组（n=72）和脱机失败组（n=41），脱机失败组、脱机成功组在年龄、急性生理与慢性健康评分系统II（APACHE II）评分、病程、先天性病史、D-二聚体（D-D）、白蛋白（ALB）、血乳酸、脑尿钠肽（BNP）方面对比有统计学差异（P<0.05）。多因素Logistic回归分析结果显示：年龄偏小、APACHE II评分偏高、D-D偏高、ALB偏低、先天性病史均是重症肺炎患儿脱机结局的影响因素（P<0.05）。结论：与仰卧位相比，俯卧位机械通气用于重症肺炎患儿可获得更好的临床效果和脱机成功率，且患儿的脱机结局受到年龄、APACHE II评分、D-D、ALB、先天性病史的影响。

Comparison of Clinical Effect of Mechanical Ventilation in Prone Position and Supine Position in Children with Severe Pneumonia and Analysis of Influencing Factors of Offline Outcome

ABSTRACT Objective: To compare the clinical effects of mechanical ventilation in prone position and supine position in children with severe pneumonia, and to analyze the influencing factors of offline outcome. Methods: 120 children with severe pneumonia who were hospitalized in the intensive care unit (ICU) of our hospital from May 2020 to December 2021 were selected as the research objects. According to the different postures of mechanical ventilation, the children were divided into supine group (n=52) and prone group (n=68). The improvement time of clinical symptoms and blood gas analysis indexes arterial oxygen partial pressure (PaO₂), arterial carbon dioxide partial pressure(PaCO₂), mean arterial pressure (MAP)] were compared between supine group and prone group. The number of deaths, offline success and offline failure in supine group and prone group were recorded, and the mortality and the incidence of offline failure were calculated. Univariate and multivariate Logistic regression were used to analyze the influencing factors of offline failure. Results: The disappearance time of fever, the disappearance time of pulmonary rales and the improvement time of respiration in the prone group were shorter than those in the supine group (P<0.05). 5 d after treatment, PaO₂ and MAP in two groups increased compared with before treatment, and PaCO₂ decreased compared with before treatment (P<0.05). PaO₂ and MAP in prone group were higher than those in supine group, and PaCO₂ was lower than that in supine group (P<0.05). There was no significant difference in mortality between the two groups (P>0.05). The offline failure rate of prone group was lower than that of supine group (P<0.05). Among the 120 children, 7 died, according to the offline outcome of children with severe pneumonia, the remaining 113 cases were divided into offline success group (n=72) and offline failure group (n=41). There were significant differences in age, acute physiology and chronic health scoring system II (APACHE II) score, course of disease, congenital disease history, D-Dimer (D-D), albumin (ALB), blood lactic acid and brain natriuretic peptide (BNP) between the offline failure group and offline success group (P<0.05). Multivariate logistic regression analysis showed that younger age, higher APACHE II score, higher D-D, lower ALB and congenital disease history were the influencing factors of offline outcome in children with severe pneumonia (P<0.05). Conclusion: Compared with supine position, prone position mechanical ventilation can obtain better clinical effect and offline success rate in children with severe pneumonia, and the offline outcome of children is affected by age, APACHE II score, D-D, ALB and congenital disease history.