Factors Influencing Prognosis in Patients Requiring Prolonged Mechanical Ventilation: Impact of the Role of Diurnal Plasma Cortisol Measurements

影響長期機械通氣患者預後的因子之分析著重於上下午血清中cotisol觀測值之角色

陳宗銘(Tsung-Ming Chen) ； 賴俊宏(Jun-Hung Lai) ； 吳旭鎮(Hsu-Chen Wu) ； 蔡宗華(Tsung-Hua Tsai) ； 馬英媖(Ying-Ying Ma)

《胸腔醫學》 23卷4期 (2008/08) Pp. 228-238

https://doi.org/10.29806/TM.200808.0001

摘要

背景：找尋出與接受長期機械通氣病人的預後具有相關聯之因子。
方法：本研究為一迴溯性的病歷回顧，地點為一個16床的呼吸器脫離病房，在12個月的期間，共有45位長期呼吸器依賴病人納入研究。收集的數值為入院日之基本資料，動脈血氣分析、血清白蛋白、尿素氮、肌酐酸、上午八時(8:00)之cortisol值，下午四時(16:00)之cortisol值，及功能性呼吸指標。我們並且紀錄了病人的預後。
結果：20位病人在90天內成功脫離呼吸器，另外25位病人則為於90天內死亡或仍持續需要機械通氣，單因子邏輯迴歸分析呈現5種因子與呼吸器脫離失敗有關：分別為入院日的潮氣容積、呼吸率、快淺呼吸指標、最大吸氣負壓以及上下午cortisol值的斜率。多因子迴歸分析則指出只有入院日之上下午cortisol值的斜率為唯一影響呼吸器脫離預後的因子。
結論：入院日8:00及16:00的cortisol觀測值之斜率可作為嚐試呼吸器脫離患者預後的指標。一些可以改善晝夜節律的策略，可能對長期機械通氣的病人預後有所助益。

關鍵字

長期機械通氣 ； cortisol ； 晝夜節律

並列摘要

Objectives: Identify the factors, both respiratory and non-respiratory, that are associated with the outcomes of patients requiring prolonged mechanical ventilation (PMV).
Methods: A retrospective medical record review at a 16-bed weaning ward. Forty-five consecutive ventilator-dependent patients admitted to our ward for attempted weaning during a 12-month period were included. Data were obtained from patients on the day of admission.
Measurements included demographics, arterial blood gas, serum albumin, BUN, creatinine, AM (0800) cortisol, PM (1600) cortisol and functional respiratory parameters.
Results: Twenty patients were successfully weaned from mechanical ventilation (weaning success) during the 90 days of admission, whilst the remaining 25 patients failed to wean or died (weaning failure) during the 90-day limit. Univariate logistic regression analysis showed that the outcome of weaning failure was significantly associated with 5 factors: tidal volume (OR, 0.98; 95% CI, 0.97-0.99; p=0.022), respiratory frequency (OR, 1.13; 95% CI, 1.01-1.27; p=0.024), frequency/tidal volume ratio (OR, 1.04; 95% CI, 1.01-1.16; p=0.005), maximum negative inspiratory pressure (OR, 0.91; 95% CI, 0.84-0.99; p=0.036), and slope of AM-PM cortisol levels (OR, 5.84; 95% CI, 1.81-18.88; p=0.003). Multivariate analysis revealed the 1 factor associated with weaning failure for patients requiring PMV to be the slope of AM-PM cortisol levels (OR, 8.35; 95% CI, 1.62-43.07; p=0.011).
Conclusions: The slope of AM-PM cortisol levels on the day of admission was the only independent factor that influences the outcomes of patients requiring PMV. Our study provides strong support for the prognostic value of AM and PM cortiol measurements in the weaning ward. Some strategies aimed toward improving circadian rhythms may benefit the outcome of PMV patients.

並列關鍵字

prolonged mechanical ventilation PMV ； cortisol ； circadian rhythm