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北京大学学报（医学版） ›› 2022, Vol. 54 ›› Issue (1): 153-160. doi: 10.19723/j.issn.1671-167X.2022.01.024

• 论著 • 上一篇    下一篇

老年流感肺炎的临床特征及D-二聚体与疾病严重程度的相关性

李佳1,徐钰2,王优雅3,高占成3,△()   

  1. 1.北京大学人民医院急诊科,北京 100044
    2.北京积水潭医院呼吸与危重症医学科,北京 100035
    3.北京大学人民医院呼吸与危重症医学科,北京 100044
  • 收稿日期:2020-07-31 出版日期:2022-02-18 发布日期:2022-02-21
  • 通讯作者: 高占成 E-mail:zcgao@bjmu.edu.cn
  • 基金资助:
    国家科技重大专项艾滋病和病毒性肝炎等重大传染病防治专项(2017ZX10103004)

Clinical characteristics of influenza pneumonia in the elderly and relationship between D-dimer and disease severity

LI Jia1,XU Yu2,WANG You-ya3,GAO Zhan-cheng3,△()   

  1. 1. Department of Emergency, Peking University People’s Hospital, Beijing 100044, China
    2. Department of Pulmonary and Critical Care Medicine, Beijing Jishuitan Hospital, Beijing 100035, China
    3. Department of Pulmonary and Critical Care Medicine, Peking University People’s Hospital, Beijing 100044, China
  • Received:2020-07-31 Online:2022-02-18 Published:2022-02-21
  • Contact: Zhan-cheng GAO E-mail:zcgao@bjmu.edu.cn
  • Supported by:
    National Science and Technology Major Project for Control and Prevention of Major Infectious Diseases of China(2017ZX10103004)

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摘要：

目的: 研究老年流感肺炎的临床特征以及D-二聚体与流感肺炎严重程度的相关性,以期提高临床医生对此类肺炎的甄别和管理。方法: 回顾性收集2014年起连续5个流感季(当年10月1日至次年3月31日)于北京大学人民医院诊断为流感肺炎的住院患者,年龄>65岁,收集患者的一般资料、临床症状、实验室检查、治疗方式及预后,比较重症和非重症肺炎的临床特点,分析D-二聚体与肺炎严重程度的关系,并应用受试者工作特征(receiver operating characteristic, ROC)曲线评估其预测流感肺炎死亡的效能。结果: 共纳入实验室确诊的老年流感肺炎住院患者52例,男性31例(59.6%),平均年龄(77.1±7.4)岁,符合重症肺炎诊断标准者19例(36.5%),约70%病例出现不同程度发热,重症肺炎组与非重症肺炎组相比,呼吸困难的发生率差异有统计学意义(14/19例,73.7% vs. 10/33例,30.3%,P=0.004),重症肺炎组的CURB-65(confusion, urea, respiratory rate, blood pressure, and age>65)评分、肺炎严重度指数(pneumonia severity index, PSI)评分、C反应蛋白、乳酸脱氢酶、尿素氮、空腹血糖、D-二聚体均高于非重症肺炎组,两组间差异有统计学意义(P值分别为0.004、<0.001、<0.001、0.003、0.038、0.018、<0.001),重症肺炎组的白蛋白则低于非重症肺炎组[(35.8±5.6) g/L vs. (38.9±3.5) g/L, t=-2.348,P=0.018]。入院首次检测的D-二聚体与PSI评分呈显著正相关(r=0.540, 95%CI:0.302~0.714,P<0.001),与氧合指数呈显著负相关(r=-0.559, 95%CI:-0.726-~0.330,P<0.001)。以患者是否住院期间死亡绘制ROC曲线,D-二聚体曲线下面积为0.765(95%CI:0.627~0.872),PSI曲线下面积为0.843(95%CI:0.716~0.929),二者相比,检验效能差异无统计学意义(Z=2.360,P=0.174)。D-二聚体>1 225 μg/L预测流感肺炎住院期间死亡的敏感性为76.92%,特异性为74.36%。结论: 高龄老年流感肺炎患者的发热症状不典型,呼吸困难是重症肺炎的突出表现,D-二聚体升高与老年流感肺炎严重程度相关,D-二聚体>1 200 μg/L对于老年重症流感肺炎住院期间死亡具有较好的预测价值。

关键词: 老年人, 流感, 人, 肺炎, D-二聚体

Abstract:

Objective: To clarify the clinical characteristics of influenza pneumonia in the elderly patients and the relationship between D-dimer and the severity of influenza pneumonia. Methods: In the study, 52 hospitalized patients older than 65 years with confirmed influenza pneumonia diagnosed in Peking University People’s Hospital on 5 consecutive influenza seasons from 2014 were retrospectively analyzed. General information, clinical symptoms, laboratory data, treatment methods and prognosis of the patients were collected. The relationship between D-dimer and pneumonia severity was analyzed, and receiver operating characteristic (ROC) curve was used to evaluate the predictive value of D-dimer. Results: Among the 52 patients, 31 were male (31/52, 59.6%), the average age was (77.1±7.4) years, and 19 of them (36.5%) were diagnosed with severe pneumonia. About 70% patients presenting with fever. In the severe group, the patients were more likely to complain of dyspnea than in the non-severe group (14/19, 73.7% vs. 10/33, 30.3%, P=0.004), severe pneumonia group had higher level of CURB-65 (confusion, urea, respiratory rate, blood pressure, and age>65), pneumonia severity index (PSI), C-reactive protein, urea nitrogen, lactate dehydrogenase, fasting glucose, and D-dimer (P value was 0.004, <0.001, <0.001, 0.003, 0.038, 0.018, and <0.001, respectively), albumin was lower than that in the non-severe group [(35.8±5.6) g/L vs. (38.9±3.5) g/L, t=-2.348, P=0.018]. There was a significant positive correlation between the D-dimer at the first admission and PSI score (r=0.540, 95%CI: 0.302 to 0.714, P<0.001), while a significant negative correlation with PaO2/FiO2 (r=-0.559, 95%CI: -0.726 to -0.330, P<0.001). Area under the curve of D-dimer was 0.765 (95%CI: 0.627 to 0.872). Area under the curve of PSI was 0.843 (95%CI: 0.716 to 0.929). There was no statistically significant difference in test efficacy between the two (Z=2.360, P=0.174). D-dimer level over 1 225 μg/L had a positive predict value for influenza pneumonia in hospital death with a sensitivity of 76.92% and a specificity of 74.36%. Conclusion: Influenza pneumonia in the elderly always has atypical symptoms, dyspnea is a prominent feature in severe cases, D-dimer level is associated with the severity of influenza pneumonia, and greater than 1 200 μg/L has a good predictive value for in-hospital death in the elderly.

Key words: Aged, Influenza, human, Pneumonia, D-dimer

中图分类号: 

  • R563.1

表1

老年流感肺炎患者人口统计学资料和临床表现"

Items Total Severe group Non-severe group Statistical value P
Year
October 1, 2014 to March 31, 2015 7 (13.5) 2 (10.5) 5 (15.2) 1.288 0.863
October 1, 2015 to March 31, 2016 7 (13.5) 2 (10.5) 5 (15.2)
October 1, 2016 to March 31, 2017 6 (11.5) 2 (10.5) 4 (12.1)
October 1, 2017 to March 31, 2018 17 (32.7) 8 (42.1) 9 (27.3)
October 1, 2018 to March 31, 2019 15 (28.8) 5 (26.3) 10 (30.3)
Gender (male) 31 (59.6) 12 (63.2) 19 (57.6) 0.156 0.693
Age/years 77.1±7.4 76.3±7.6 77.5±7.4 -0.544 0.589
65-70 12 (23.1) 5 (26.3) 7 (21.2) 0.360 0.853
71-80 21 (40.4) 8 (42.1) 13 (39.4)
80- 19 (36.5) 6 (31.6) 13 (39.4)
Smoking history 16 (30.8) 5 (26.3) 11 (33.3) 0.279 0.598
Drinking history 6 (11.5) 4 (21.4) 2 (6.1) 2.655 0.103
Coexisting diseases
None 7 (13.5) 2 (10.5) 5 (15.2) 0.298 0.862
1-2 25 (48.1) 9 (47.4) 16 (48.5)
3 and above 20 (38.5) 8 (42.1) 12 (36.4)
Category of coexisting diseases
Coronary heart disease 14 (26.9) 6 (31.6) 8 (24.2) 0.330 0.764
Hypertension 21 (40.4) 8 (42.1) 13 (39.4) 0.037 0.538
Pulmonary diseases 19 (36.5) 7 (36.8) 12 (36.4) 0.001 0.972
Diabetes 15 (28.8) 8 (42.1) 7 (21.2) 2.564 0.126
Chronic renal diseases 5 (9.6) 2 (10.5) 3 (9.1) 0.029 0.610
Chronic liver diseases 6 (11.5) 2 (10.5) 4 (12.1) 0.030 0.620
Cerebrovascular diseases 10 (19.2) 3 (15.8) 7 (21.2) 0.228 0.633
Immune disorders 5 (9.6) 0(0) 5 (15.2) - 0.145
Hematological diseases 10 (19.2) 4 (21.1) 6 (18.2) 0.064 0.800
Cancer 11 (21.2) 4 (21.0) 7 (21.2) 0.020 0.638
Clinical characteristics
Fever 36 (69.2) 13 (68.4) 23 (69.7) 0.009 0.924
Pharyngalgia 14 (26.9) 4 (21.1) 10 (30.3) 0.524 0.543
Cough 29 (55.8) 10 (52.6) 19 (57.6) 0.119 0.730
Expectoration 16 (30.8) 6 (31.6) 10 (30.3) 0.009 0.924
Chest discomfort 16 (30.8) 4 (21.1) 12 (36.4) 0.706 0.401
Dyspnea 24 (46.2) 14 (73.7) 10 (30.3) 1.327 0.004
Hemoptysis 3 (5.8) 0(0) 3 (9.1) - 0.291
Vomiting/diarrhea 7 (13.5) 2 (10.5) 5 (15.2) 0.221 0.638
Myodynia 9 (17.3) 2 (10.5) 7 (21.2) 0.962 0.458
Rigor 4 (7.7) 1 (5.3) 3 (9.1) 0.296 0.543
Fatigue 18 (34.6) 4 (21.1) 14 (42.4) 2.443 0.142
Confusion 7 (13.5) 3 (15.8) 4 (12.1) 0.139 0.697
Vital sign on admission
Temperature/℃ 37.2 (36.5, 38.6) 37.8 (36.9, 39.3) 37.0 (36.5, 38.4) -2.294 0.022
Heart rate/(beat/min) 93.6±18.2 103.7±17.1 87.8±16.4 3.315 0.002
Respiratory rate/(time/min) 20 (18, 22) 22 (20, 24) 18 (18, 20) -1.751 0.080
Systolic blood pressure/mmHg 126 (118, 140) 125 (115, 134) 130 (120, 143) -1.201 0.230
Diastolic blood pressure/mmHg 71 (68, 80) 70 (65, 84) 74 (69, 80) -0.326 0.774
Oxygen saturation/% 93 (91, 94) 92 (90, 93) 93 (92, 95) -2.534 0.011
Score on admission
CURB-65 2.0 (1.0, 3.0) 2.0 (1.0, 2.5) 3.0 (2.0, 4.0) -2.711 0.004
PSI 118 (92, 136) 107 (92, 129) 152 (104, 184) -4.108 <0.001

表2

老年流感肺炎患者入院24 h内辅助检查"

Laboratory data Reference range Severe group Non-severe group Statistical value P
Blood routine
WBC/(×109/L) 3.5-9.5 8.30 (6.83, 14.87) 8.80 (6.50, 11.58) -0.627 0.531
LY/(×109/L) 1.1-3.2 0.60 (0.40, 1.63) 0.92 (0.60, 1.60) -1.407 0.159
Hb/(g/L) 130-175 110.3±29.9 121.2±19.5 -1.600 0.116
PLT/(×109/L) 125-350 156.0 (98.0, 259.0) 179.0 (148.0, 219.5) -1.131 0.258
Biochemistry
AST/(U/L) 9-35 35.0 (16.0, 90.0) 28.0 (17.5, 52.0) -0.875 0.382
ALT/(U/L) 15-40 32.0 (17.0, 61.0) 31.0 (20.5, 57.5) -0.257 0.797
LDH/(U/L) 109-245 285.0 (199.0, 361.0) 176.0 (90.0, 251.0) -2.936 0.003
ALB/(g/L) 40-55 35.8±5.6 38.9±3.5 -2.348 0.018
BUN/(mmol/L) 2.8-7.2 8.8 (5.6, 11.4) 6.0 (4.6, 8.7) -2.072 0.038
CRE/(μmoI/L) 59-104 75.0 (51.0, 88.0) 77.0 (60.5, 89.0) -0.542 0.588
GLU/(mmol/L) 3.3-6.1 6.8 (5.6, 10.4) 5.5 (4.6, 7.0) -2.376 0.018
Aterial blood gas analysis
pH 7.35-7.45 7.47 (7.41, 7.48) 7.44 (7.38, 7.49) -1.276 0.202
PaO2/FiO2/mmHg 400-500 252.4±84.8 333.7±60.9 -4.004 <0.001
PaCO2/mmHg 35-45 35.2±8.5 41.6±10.8 -2.208 0.032
Lac/(mmol/L) <2.5 2.4 (1.8, 3.9) 2.0 (1.0, 3.1) -1.922 0.055
Coagulation function
PT/s 9.4-12.5 11.7 (11.0, 12.8) 12.0 (11.0, 12.9) -2.331 0.200
APTT/s 25.1-36.5 31.4±7.2 30.3±4.5 0.735 0.466
D-dimer/(μg/L) 0-243 908 (627, 1 398) 300 (193, 549) -4.380 <0.001
Inflammatory markers
CRP/(mg/L) 0-10 56.0 (37.8, 78.2) 19.5 (10.5, 37.6) -3.706 <0.001
PCT/(μg/L) <0.01 0.88 (0.16, 1.83) 0.22 (0.12, 0.99) -1.730 0.084
Myocardial injury markers
TnI greater than 2 fold 3/17 (17.6) 3/28 (10.7) 0.440 0.507
BNP greater than 2 fold 4/15 (26.7) 3/28 (10.7) 1.824 0.215

表3

老年流感肺炎患者诊治经过、并发症和转归"

Items Total Severe group Non-severe group Statistical value P
Onset to admission/d 7.0 (2.3, 8.0) 7.0 (5.0, 9.0) 7.0 (2.5, 9.0) -0.459 0.646
Virus type 0.847 0.838
A/H1N1 17 (32.7) 7 (36.8) 10 (30.3)
A/H3N2 17 (32.7) 5 (26.3) 12 (36.4)
B 14 (26.9) 5 (26.3) 9 (27.3)
Mixed 4 (7.7) 2 (10.5) 2 (6.1)
Onset to antiviral treatment 0.239 0.135
≤48 h 13 (25.0) 7 (36.8) 6 (18.2)
>48 h 39 (75.0) 12 (63.3) 27 (81.8)
Antiviral drug 9.257 0.010
Oseltamivir 45 (86.5) 13 (68.4) 32 (97.0)
Oseltamivir plus Peramivir 4 (7.7) 4 (21.1) 0(0)
Unused 3 (5.8) 2 (10.5) 1 (3.0)
Co-infection
Bacterial 13 (25.0) 9 (47.4) 4 (12.1) 7.989 0.008
Fungus 3 (5.8) 2 (10.5) 1 (3.0) 0.249 0.618
Antibiotics before admission 45 (86.5) 16 (84.2) 29 (87.9) 0.139 0.709
Antibiotic during admission 0.368 0.947
Unused 3 (5.8) 1 (5.2) 2 (6.1)
1 19 (36.5) 7 (36.8) 12 (36.4)
2 26 (50.0) 9 (47.4) 17 (51.5)
≥3 4 (7.7) 2 (10.5) 2 (6.1)
Antifungal 6 (11.5) 3 (15.8) 3 (9.1) 0.530 0.467
Hormonotherapy 23 (44.2) 12 (63.2) 11 (33.3) 4.348 0.037
Respiratory support
Nasal catheter oxygen 48 (92.3) 19 (100.0) 29 (87.9) 2.495 0.114
Mask oxygen 10 (19.2) 3 (15.8) 7 (21.1) 0.228 0.633
Noninvasive ventilation 23 (44.2) 10 (52.6) 13 (39.4) 0.857 0.355
Invasive ventilation 9 (17.3) 9 (47.4) 0(0) - <0.001
Other support modes
CRRT 9 (17.3) 4 (21.1) 5 (15.2) 0.026 0.588
ECMO 3 (5.8) 3 (15.8) 0(0) - 0.044
Complications
ARDS 16 (30.8) 10 (52.6) 6 (18.2) 6.718 0.010
Pneumothorax 4 (7.7) 2 (10.5) 2 (6.1) 0.339 0.561
Shock 9 (17.3) 6 (31.6) 3 (9.1) 2.843 0.092
Acute kidney injury 12 (23.1) 6 (31.6) 6 (18.2) 1.219 0.270
Myocardial injury 6 (11.5) 3 (15.8) 3 (9.1) 0.077 0.782
Liver injury 9 (17.3) 5 (26.3) 4 (12.1) 1.697 0.193
DIC 10 (19.2) 7 (36.8) 3 (9.1) 4.325 0.038
Encephalopathy 3 (5.8) 2 (10.5) 1 (3.0) 0.249 0.618
ICU admission 20 (38.5) 12 (63.2) 8 (24.2) 7.715 0.005
Length of stay/d 13.5 (9.0, 20.0) 14.0 (11.0, 20.0) 10.0 (8.5, 20.0) -1.162 0.245
Death 13 (25.0) 9 (47.4) 4 (12.1) 7.989 0.008

图1

D-二聚体与PSI和PaO2/FiO2的关系"

图2

D-二聚体和PSI预测住院期间死亡的受试者工作特征曲线"

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