RESUMO
Objective To study diaphragmatic strength in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) during mechanical ventilation (MV), and to explore the predictive value of maximal transdiaphragm pressure (Pdi max) for successful extubation. Methods A prospective study was conducted. Twenty-one patients with AECOPD receiving MV admitted to intensive care unit (ICU) of Shanghai East Hospital of Tongji University of School Medicine from February 2015 to May 2017 were enrolled. Pdi max value was measured by using esophageal and gastric balloon catheters within 24 hours of intubation until the day the patient underwent extubation or died. In addition, the C-reactive protein (CRP), serum albumin (Alb) and prealbumin (PA) during MV were recorded. Pearson correlation was used to analyze the correlations between Pdi max and CRP, Alb and PA. The receiver operating characteristic curve (ROC) was used to cumulate Pdi max value of the successful weaning. Results Tracheotomy was done in 2 patients, and 2 patients quit the study. The remaining 17 patients were included in the investigative protocol. Six of the 17 patients died and 11 patients were successfully extubated. ① Mean Pdi max decreased progressively over time in 17 patients of AECOPD during MV. There were no significant changes in Pdi max at 1-2 days of MV. Mean Pdi max at 7 days was significantly lower than that at 3 days [cmH2O (1 cmH2O = 0.098 kPa): 20.2±4.2 vs. 28.1±4.4, P < 0.01]. By the end of the evaluation period at 11 days of MV, mean Pdi max decreased about 38.7% to the 1 day of MV (cmH2O: 19.8±4.7 vs. 32.3±3.9, P < 0.01). During MV, CRP, Alb and PA showed a downward trend. ② Mean Pdi max and the Pdi max before extubation in patients with difficulty extubation from MV was lower than that in successful weaning [Mean Pdi max (cmH2O): 25.2±5.4 vs. 28.9±5.8, Pdi max before extubation (cmH2O): 16.9±2.8 vs. 26.8±6.6, both P < 0.01]. ③ There was significantly negative correlation between Pdi max value and CRP (r = -0.799, P = 0.000). There was significantly positive correlation between Pdi max value and serum Alb (r = 0.613, P = 0.008) and PA (r = 0.661,P = 0.004). ④ ROC curve analysis showed that the area under the ROC curve (AUC) for predicting weaning success in the patients with AECOPD was 0.902. The sensitivity of the diagnosis was 81.8% and the specificity was 100% when cut-off value of Pdi max was 23.2 cmH2O. Conclusions MV induced the reduction of diaphragmatic contractility in a time-dependent manner. The Pdi max in patients with difficult extubation from MV was lower than that in successful weaning. The Pdi max could be a parameter to predict the successful extubation in patients with AECOPD during MV.
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ObjectiveTo investigate the role of lymphocyte apoptosis and endoplasmic reticulum stress (ERS) on the development of sepsis and their association with the prognosis of sepsis patients.Methods A prospective cohort study was conducted. Seventy septic patients admitted to intensive care unit (ICU) of Shanghai East Hospital of Tongji University were enrolled. Blood samples were collected on days 1, 3 and 7 to measure percentage of circulating apoptotic lymphocyte with flow cytometry analysis. The relative expressions of endoplasmic reticulum specific glucose regulated protein 78 (GRP78) mRNA and transcription factor CHOP mRNA were measured by real-time reverse transcription-polymerase chain reaction (RT-PCR). The correlation between CHOP mRNA expression and percentage of circulating apoptotic lymphocyte was analyzed by Spearman relative analysis. The patients were divided into death (n = 23) and survival subgroups (n = 47). Twenty healthy volunteers during the same period were selected as the healthy control group.Results① Rate of lymphocyte apoptosis: compared with healthy control group [(2.86±0.66)%], septic patients, either survival or death subgroup, exhibited higher rate of lymphocyte apoptosis on days 1, 3 and 7 [survival subgroup: (12.44±4.43)%, (8.57±3.38)%, (6.78±3.35)%; death subgroup: (14.42±2.01)%, (11.32±2.53)%, (8.87±3.62)%, allP 0.05], and GRP78 mRNA expression in the death subgroup was gradually lowered, but it was still higher than that in the healthy control group [3 days: (7.27± 3.64)×10-3, 7 days: (5.23±1.94)×10-3, bothP< 0.01].④ Spearman relative analysis showed that the expression of CHOP mRNA was positively correlated with the rate of lymphocyte apoptosis (r = 0.414,P = 0.000 ).Conclusion The increase in the rate of lymphocyte apoptosis and activation of ERS play an important role in the development of sepsis, and it is associated with worse outcome in the septic patients.
