ABSTRACT
Objective:To evaluate the effect of high-flow nasal cannula (HFNC) therapy on patients with moderate acute respiratory failure.Methods:This was a randomized controlled trial. The patients with moderate acute respiratory failure in the Intensive Care Unit (ICU) of Changshu Hospital Affiliated to Soochow University from March 2019 to September 2020 were included. Patients with severe asthma or acute exacerbation of chronic respiratory failure, hemodynamic instability, disturbance of consciousness, non-invasive ventilation (NIV) contraindication, urgent need for endotracheal intubation, refusal of intubation, age <18 years and pregnancy were excluded. The patients were randomized to HFNC or NIV. Treatment failure was defined as the need for intubation and invasive ventilation. The vital signs, ROX index, blood gas analysis index, ultrasound parameters and endotracheal intubation rate were recorded at 1, 6, 12, 24 and 48 h after treatment. Kaplan-Meier method was used to draw the survival curve, and multivariate logistic regression was used to analyze the risk factors of treatment failure.Results:A total of 91 patients were included in the study, including 46 patients in the HFNC group and 45 patients in the NIV group. PaO 2/FiO 2 of the two groups were significantly increased after treatment compared with baseline ( P<0.05). The respiratory rate was lower in the NIV group than in the HFNC group at 1 and 24 h ( P<0.05). There were no significant differences in other vital signs, arterial blood gas and ultrasound parameters between the two groups (all P>0.05). The intubation rate was 52.2% in the HFNC group and 48.9% in the NIV group. Kaplan-Meier survival analysis showed that there was no significant difference in intubation rate and mortality between the two groups ( P>0.05). Multivariate logistic regression analysis showed that increased end-diastolic right ventricle/left ventricle ratio ( OR=1.044, 95% CI: 1.012~1.077) and high acute physiology and chronic health evaluationⅡ score ( OR=1.082, 95% CI: 1.006~1.163) at 0 h, lung ultrasound score ( OR=1.353, 95% CI: 1.034~1.772) and end-diastolic RV/LV ratio ( OR=1.097, 95% CI: 1.038~1.159) at 1 h were independent risk factors for non-invasive respiratory strategies failure. Increased diaphragm excursion ( OR=0.341, 95% CI: 0.165~0.704) at 0 h, high PaO 2/FiO 2 ( OR=0.929, 95% CI: 0.884~0.977), increased ROX index ( OR=0.524, 95% CI: 0.332~0.826), and increased diaphragm mobility ( OR=0.119, 95% CI: 0.030~0.476) at 1 h were independent protective factor for successful treatment. Conclusions:HFNC and NIV can improve oxygenation in patients with acute hypoxemic respiratory failure. There is no significant difference in intubation rate and mortality between HFNC and NIV. Ultrasound parameters may be helpful for predicting treatment failure.
ABSTRACT
Objective:To develop a prediction model of acute gastrointestinal injury (AGI) grading combined with qSOFA score for the diagnosis of sepsis, and evaluate its value.Methods:This was a prospective observational study. The patients with infection or suspected infection in the General Ward of Changshu Hospital Affiliated to Soochow University from September 2018 to September 2019 were included. Patients younger than 18 years, pregnant, abandoned treatment and died within 3 days after admission were excluded. Clinical characteristics, laboratory test results and AGI grading from 48 h before the infection to 24 h after the onset of infection were recorded. The patients were divided into the sepsis and non-sepsis groups according to whether they were diagnosed with sepsis. The patients were allocated randomly to a modeling cohort and a validation cohort with a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to analyze the relevant risk factors for sepsis in the modeling cohort. Three types of diagnostic models were constructed in the modeling cohort: model A (qSOFA model), model B (the combined model of AGI grading and qSOFA score), and model C (the combined model of clinical parameters). The clinical usefulness of the diagnostic models was assessed by receiver operating characteristic curve (ROC), calibration curve and decision curve analysis (DCA) in the validation cohort. The nomograms were developed based on these models.Results:A total of 2 553 patients were enrolled in the study, 1 789 patients in the modeling cohort and 764 patients in the validation cohort. and 326 were diagnosed with sepsis. There was no statistical difference in the basic conditions of patients in the two groups. Univariate analysis showed that age, gender, the source of infection, temperature, heart rate, polypnea, changes in consciousness, severe edema, hyperglycemia, white blood cell, C-reactive protein and procalcitonin, hypotension, hypoxemia, acute oliguria, coagulation disorders, hyperlacticemia, capillary filling damage or piebaldskin, AGI grading and qSOFA score were significantly correlated with sepsis (all P<0.01). Multivariate logistic regression analysis showed that age ( OR=1.027, P<0.01), source of infection ( OR=2.809, P=0.03), hypotension ( OR=35.449, P<0.01), hypoxemia ( OR=57.018, P<0.01), and AGI grading ( OR=19.313, P<0.01) were significantly associated with sepsis. ROC analysis showed that the area under the curve (AUC) of model A, B and C were 0.784, 0.944 and 0.971 in the modeling cohort, and 0.832, 0.975 and 0.980 in the validation cohort, respectively. The sensitivities were 63.9%, 89.5% and 97.5% in the modeling cohort, and 72.7%, 90.9% and 96.6% in the validation cohort; and the specificities were 90.8%, 90.3% and 88.1% in the modeling cohort, and 92.2%, 94.5% and 92.8% in the validation cohort, respectively. AUC of model B and C were significantly higher than that of model A ( P<0.01). Model A in the validation cohort was poorly calibrated, with low accuracy and high risk of missed sepsis diagnosis ( P=0.044). The net benefits of model B and C were better than that of model A. Conclusions:AGI grading combined with qSOFA score has a high predictive value and accuracy in the diagnosis of sepsis.