胸部创伤患者在重症监护病房内发生呼吸机相关性肺炎的危险因素

doi:10.19723/j.issn.1671-167X.2026.02.020

摘要/Abstract

摘要：

目的: 探讨胸部创伤患者在重症监护病房(intensive care unit, ICU)内发生呼吸机相关性肺炎(ventilator-associated pneumonia，VAP)的危险因素。方法: 回顾性分析2019年6月至2023年6月收住北京大学人民医院外科ICU、入院24 h内进行气管插管且机械通气>48 h的124例成人创伤患者的临床资料。根据住院期间是否发生VAP分为VAP组(46例)和非VAP组(78例)，采用Lasso回归分析进行筛选并采用Logistic进行多因素回归分析以确定胸部创伤患者在ICU内发生VAP的危险因素。结果: 多因素回归分析显示，损伤严重度评分(injury severity score，ISS)(OR=1.08，95%CI：1.02~1.14，P=0.007)和气管切开(OR=4.61，95%CI：1.74~13.11，P=0.003)是胸部创伤患者发生VAP的独立危险因素(P < 0.05)。早期VAP患者19例，晚期VAP患者27例。所有VAP病例中，最常见的病原体是肺炎克雷伯菌(Klebsiella pneumoniae)，共18次(39.1%)；早期VAP病例中肺炎克雷伯菌最多见(10次，52.6%)，晚期VAP中铜绿假单胞菌(Pseudomonas aeruginosa)和鲍曼不动杆菌(Acinetobacter baumannii)的出现频率最高，均为10次(37.0%)。结论: 胸部创伤患者在ICU内是否发生VAP与多个因素有关，ISS评分高以及气管切开是胸部创伤患者发生VAP的独立危险因素。

Abstract:

Objective: To explore the risk factors associated with ventilator-associated pneumonia (VAP) in the patients with chest trauma in the intensive care unit (ICU). Methods: A retrospective analysis was conducted on the clinical data of 124 adult trauma patients admitted to the surgical ICU of Peking University People' s Hospital between June 2019 and June 2023. These patients underwent tra-cheal intubation within 24 hours of admission and received mechanical ventilation for more than 48 hours. Based on whether VAP occurred during hospitalization, the patients were divided into a VAP group (46 cases) and a non-VAP group (78 cases). Lasso regression analysis was employed for variable selection, followed by Logistic regression analysis to determine the risk factors for VAP in these patients with chest trauma in the ICU. Results: The multivariate regression analysis indicated that the injury severity score (ISS) (OR=1.08, 95%CI: 1.02-1.14, P=0.007) and tracheostomy (OR=4.61, 95%CI: 1.74-13.11, P=0.003) were independent risk factors for VAP in the patients with chest trauma (P < 0.05). Among all VAP cases, early-onset VAP was observed in 19 patients, while late-onset VAP was observed in 27 patients. The most common pathogen in all VAP cases was Klebsiella pneumoniae, identified in 18 cases (39.1%). In early-onset VAP, Klebsiella pneumoniae was the most frequently detected pathogen, found in 10 cases (52.6%). Conversely, in late-onset VAP, Pseudomonas aeruginosa and Acinetobacter baumannii were the most prevalent pathogens, each appearing in 10 cases (37.0%). Conclusion: The occurrence of VAP in the patients with chest trauma in the ICU was influenced by multiple factors. This study identified that a higher ISS and the presence of a tracheostomy were independent risk factors for VAP in these patients. These findings suggest that in clinical practice, special attention should be given to the chest trauma patients with high ISS scores, and the timing and necessity of tracheostomy should be carefully considered to reduce the incidence of VAP and improve patient outcomes. Furthermore, the study highlights the importance of early identification and appropriate management of the patients at higher risk for developing VAP. By recognizing the significance of these risk factors, healthcare providers can implement targeted interventions and preventive measures, such as optimizing ventilation strategies and enhancing infection control practices. Future research should further explore additional factors that may influence the occurrence of VAP and verify these findings to provide stronger evidence for the prevention and treatment of VAP. Additionally, multicenter studies with larger sample sizes are recommended to validate these results and develop comprehensive guidelines for managing the chest trauma patients in the ICU.

Key words: Ventilator-associated pneumonia, Thoracic injuries, Mechanical ventilation, Intensive care units, Risk factors

中图分类号:

R563.1

赵杰, 付春, 赵秀娟, 薛海岩, 李纾, 王振洲, 朱凤雪. 胸部创伤患者在重症监护病房内发生呼吸机相关性肺炎的危险因素[J]. 北京大学学报（医学版）, 2026, 58(2): 351-358.

Jie ZHAO, Chun FU, Xiujuan ZHAO, Haiyan XUE, Shu LI, Zhenzhou WANG, Fengxue ZHU. Risk factors for ventilator-associated pneumonia in patients with chest trauma in intensive care unit[J]. Journal of Peking University (Health Sciences), 2026, 58(2): 351-358.

图/表 5

图1

表1

患者的基线资料(n=124)"

Feature	Non-VAP (n=78)	VAP (n=46)	P value
General information
Age/years, M (P₂₅, P₇₅)	58 (46, 66)	54 (43, 64)	0.660
Gender (male), n (%)	55 (70.5)	39 (84.8)	0.073
Medical history, n (%)
Diabetes	7 (9.0)	5 (10.9)	0.760
Hypertension	15 (19.2)	16 (34.8)	0.053
Chronic kidney disease	1 (1.3)	1 (2.2)	0.999
Hepatitis B	2 (2.6)	1 (2.2)	0.999
Cerebrovascular disease	5 (6.4)	5 (10.9)	0.497
Emphysema	5 (6.4)	1 (2.2)	0.411
Coronary heart disease	1 (1.3)	3 (6.5)	0.144
Smoking history	9 (11.5)	5 (10.9)	0.909
Drinking history	6 (7.7)	4 (8.7)	0.999
Type of trauma, n (%)			0.854
Traffic accident injury	50 (64.1)	32 (69.6)
Fall injury	18 (23.1)	9 (19.6)
Slip injury	6 (7.7)	2 (4.3)
Crush injury	4 (5.1)	3 (6.5)
Overall trauma condition
Shock, n (%)	26 (33.3)	20 (43.5)	0.259
Head injury, n (%)	39 (50.0)	32 (69.6)	0.033
Facial injury, n (%)	28 (35.9)	18 (39.1)	0.719
Abdominal injury, n (%)	35 (44.9)	19 (41.3)	0.699
Spinal injury, n (%)	32 (41.0)	23 (50.0)	0.331
Pelvic injury, n (%)	38 (48.7)	25 (54.3)	0.545
ISS score, M (P₂₅, P₇₅)	26 (19, 34)	29 (26, 34)	0.003
GCS score, M (P₂₅, P₇₅)	14 (11, 15)	13 (7, 15)	0.022
Chest trauma condition
Chest AIS score, ${\bar x}$±s	3.15±0.77	3.33±0.70	0.207
Number of rib fractures, M (P₂₅, P₇₅)	5 (2, 10)	4 (2, 10)	0.801
Clavicle fracture, n (%)	12 (15.4)	12 (26.1)	0.145
Sternum fracture, n (%)	7 (9.0)	3 (6.5)	0.743
Lung contusion, n (%)	53 (67.9)	33 (71.7)	0.658
Pleural effusion, n (%)	49 (62.8)	31 (67.4)	0.607
Pneumothorax, n (%)	29 (37.2)	20 (43.5)	0.488
Routine blood tests
White blood cell count/(×10⁹/L), M (P₂₅, P₇₅)	16.71 (12.58, 21.53)	18.41 (14.92, 22.57)	0.145
Neutrophil percentage/%, M (P₂₅, P₇₅)	90.6 (88.6, 92.8)	90.2 (87.7, 92.1)	0.247
Hemoglobin level/(g/L), ${\bar x}$±s	79.31±17.55	79.80±16.98	0.402
Platelet count/(×10⁹/L), M (P₂₅, P₇₅)	65 (47, 110)	75 (49, 120)	0.284
Blood product usage
Red blood cells/U, M (P₂₅, P₇₅)	6 (1, 13)	8 (4, 14)	0.327
Plasma/mL, M (P₂₅, P₇₅)	400 (0, 900)	400 (0, 1 050)	0.580
Platelets/U, ${\bar x}$±s	0.51±1.36	0.43±0.91	0.703
Complications, n (%)
VTE	4 (5.1)	2 (4.3)	0.999
AKI	6 (7.7)	3 (6.5)	0.999
ARDS	2 (2.6)	3 (6.5)	0.359
ICU procedures, n (%)
CVC	48 (61.5)	30 (65.2)	0.682
Thoracentesis	34 (43.6)	15 (32.6)	0.227
Tracheostomy	8 (10.3)	18 (39.1)	< 0.001
Multiple intubations	2 (2.6)	4 (8.7)	0.193
Surgeries, n (%)
Thoracic surgery	29 (37.2)	14 (30.4)	0.446
Cranial surgery	13 (16.7)	8 (17.4)	0.917
Pelvic surgery	17 (21.8)	12 (26.1)	0.585
Spinal surgery	9 (11.5)	6 (13.0)	0.804
Abdominal surgery	9 (11.5)	9 (19.6)	0.220
Femoral surgery	11 (14.1)	4 (8.7)	0.372
Mechanical ventilation duration/h, ${\bar x}$±s	183±116	299±290	0.012
Outcomes
ICU stay duration/d, ${\bar x}$±s	16±9	19±12	0.140
Discharge outcome (mortality), n (%)	10 (12.8)	5 (10.9)	0.748

表1

表2

图2

表3

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Pathogen	Total VAP patients (n=46), n (%)	Early-onset VAP (n=19), n (%)	Late-onset VAP (n=27), n (%)
Pseudomonas aeruginosa	12 (26.1)	2 (10.5)	10 (37.0)
Acinetobacter baumannii	13 (28.3)	3 (15.8)	10 (37.0)
Klebsiella pneumoniae	18 (39.1)	10 (52.6)	8 (29.6)
Stenotrophomonas maltophilia	7 (15.2)	0 (0)	7 (25.9)
Escherichia coli	2 (4.3)	2 (10.5)	0 (0)
Candida albicans	2 (4.3)	0 (0)	2 (7.4)
Enterobacter cloacae	2 (4.3)	0 (0)	2 (7.4)

Predictor	Estimate	SE	Z	P	Odds ratio	Lower	Upper
(Intercept)	-2.773	0.783	-3.543	0.000	0.062	0.012	0.268
ISS score	0.067	0.026	2.550	0.011	1.069	1.017	1.128
Tracheostomy	1.608	0.499	3.224	0.001	4.995	1.928	13.904

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