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The Search for Optimal Pulse Oxygen Saturation Targets in Pulmonary Embolism Patients
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摘要:
目的 探讨肺栓塞患者氧疗期间脉搏血氧饱和度(pulse oxygen saturation, SpO2)与院内全因死亡风险的关系。 方法 检索2014—2015年eICU数据库中美国多家医院以肺栓塞为主要诊断的病历资料。以院内全因死亡为因变量，氧疗期间中位SpO2为自变量构建广义相加模型(generalized additive model, GAM)，分析肺栓塞患者氧疗期间中位SpO2与院内全因死亡率的关系，并绘制曲线图，以曲线最低最平坦区域为SpO2目标区间。采用多因素Cox回归分析法验证氧疗期间SpO2水平与肺栓塞患者院内全因死亡风险的关系。 结果 共入选符合纳入和排除标准的肺栓塞患者422例，其氧疗期间中位SpO2为97%(95%, 98%)，院内存活336例(79.6%)，全因死亡86例(20.4%)。GAM分析结果显示，氧疗期间中位SpO2与肺栓塞患者院内全因死亡率呈“U”形关系，中位SpO2处于96%~98%时，院内全因死亡率最低。多因素Cox回归分析结果显示，氧疗期间SpO2水平是肺栓塞患者发生院内全因死亡的独立影响因素，以中位SpO2处于96%~98%患者为对照，中位SpO2＜96%患者院内全因死亡的风险增加129.8%(HR=2.298, 95% CI：1.268~4.163, P=0.006)，中位SpO2＞98%患者院内全因死亡风险增加77.3%(HR=1.773, 95% CI：1.068~2.942, P=0.027)。 结论 肺栓塞患者氧疗期间SpO2与院内全因死亡风险呈“U”形关系，氧疗期间SpO2处于96%~98%时，院内全因死亡风险最低，可能为氧合的目标区间。 Abstract:Objective To determine the association between pulse oximetry-derived oxygen saturation(SpO2) and all-cause in-hospital mortality of patients with pulmonary embolism during oxygen therapy. Methods Clinical data of the patients with pulmonary embolism as the primary diagnosis in different American medical institutions from the eICU database during 2014 to 2015 were retrieved. Generalized additive model (GAM) was constructed and the graph was drawn to analyze the association between median SpO2 and all-cause in-hospital mortality. The lowest and smooth area of the curve was the optimal SpO2 range. Moreover, the mult- ivariate Cox regression model was applied to verify the association between SpO2 level during oxygen therapy and all-cause in-hospital mortality of patients with pulmonary embolism. Results A total of 422 patients with pulmonary embolism that met the inclusion and exclusion criteria were enrolled. The median score of SpO2 was 97%(95%, 98%) during oxygen therapy.A total of 336 (79.6%) patients were discharged from the hospital and 86 (20.4%) patients died. The GAM indicated a U-shaped relationship between the median score of SpO2 and all-cause in-hospital mortality in patients with pulmonary embolism. In addition, the lowest mortality was observed when the SpO2 range was 96%-98%. Multivariable Cox regression analysis confirmed that the SpO2 level was independently associated with decreased mortality. Taking patients with median SpO2 rang of 96% to 98% as controls, the risk of all-cause in-hospital mortality was increased by 129.8% in patients with median SpO2 < 96% (HR=2.298, 95% CI: 1.268-4.163, P=0.006) and 77.3% in patients with median SpO2 > 98% (HR=1.773, 95% CI: 1.068-2.942, P=0.027). Conclusions The relationship between SpO2 levels and all-cause in-hospital mortality followed a U-shaped curve in patients with pulmonary embolism. The risk of all-cause in-hospital mortality was lowest when SpO2 was between 96% to 98% during oxygen therapy, which may be the target range of oxygenation. -
Key words:
- pulse oxygen saturation /
- pulmonary embolism /
- hyperoxemia /
- oxygen therapy /
- mortality
作者贡献：王洋负责数据提取与处理、统计分析、论文撰写及修改；陈豪负责研究项目设计、统计分析及论文修订。利益冲突：所有作者均声明不存在利益冲突 -
表 1 肺栓塞患者一般临床资料(n=422)
变量 存活组(n=336) 死亡组(n=86) P值 年龄[M(P25, P75), 岁] 64(51，76) 63(56，74) 0.489 男性[n(%)] 169(50.3) 48(55.8) 0.361 氧疗期间SpO2[M(P25, P75), %] 97(96，98) 97(95，99) 0.807 住院时间[M(P25, P75), d] 9.70(6.14，14.70) 8.44(5.49，13.52) 0.174 APACHE Ⅳ评分[M(P25, P75), 分] 60(44，82) 82(56，114) ＜0.001 sPESI评分[M(P25, P75), 分] 1(0，2) 1(1，2) 0.008 溶栓治疗[n(%)] 33(9.8) 3(3.5) 0.061 抗凝治疗[n(%)] 211(62.8) 40(46.5) 0.006 氧疗方式[n(%)] ＜0.001 COT 119(35.4) 12(14.0) NIV 51(15.2) 5(5.8) IMV 166(49.4) 69(80.2) SpO2：脉搏血氧饱和度；APACHE Ⅳ：急性生理学和慢性健康状况评分系统Ⅳ；sPESI：简化肺栓塞风险指数；COT：鼻导管或面罩给氧；NIV：无创机械通气；IMV：有创机械通气 
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表 2 肺栓塞患者院内全因死亡危险因素的Cox回归分析结果
变量 单因素Cox回归分析 方差膨胀因子 多因素Cox回归分析 HR(95% CI) P值 HR(95% CI) P值 中位SpO2＜96%* 1.994(1.129~3.522) 0.017 1.018 2.298(1.268~4.163) 0.006 中位SpO2＞98%* 2.131(1.291~3.517) 0.003 1.018 1.773(1.068~2.942) 0.027 APACHE Ⅳ评分 1.013(1.007~1.020) 0.000 1.234 1.012(1.005~1.019) 0.001 sPESI评分 1.410(1.134~1.754) 0.002 1.017 1.280(1.025~1.599) 0.030 抗凝治疗 0.625(0.408~0.958) 0.031 1.047 0.626(0.405~0.969) 0.035 NIV# 1.030(0.362~2.929) 0.956 1.274 0.911(0.315~2.636) 0.863 IMV# 1.927(1.035~3.585) 0.038 1.274 1.347(0.704~2.577) 0.368 SpO2、APACHE Ⅳ、sPESI、NIV、COT、IMV：同表 1；*以中位SpO296%~98%患者为对照，#以COT患者为对照
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