目的 探讨急性呼吸窘迫综合征(ARDS)高危患者的中医辨证要素与与免疫-炎症反应与预后的关系。方法?依照纳入排除标准,纳入2017年5月至2019年3月广东省中医院收治的ARDS高危患者153例,收集纳入当日的一般资料、中医临床四诊信息、炎症指标、肝肾功能、乳酸、免疫指标等,测定序贯器官衰竭评估(SOFA)评分、急性生理学与慢性健康状况评分系统II (APACHEⅡ)评分,并跟踪随访采集卫生经济学指标和28天死亡率。结果?证候分型方面,虚症证候要素中,气虚占比73.9%,阴虚11.1%、阳虚3.3%、血虚1.3%,不同虚证要素占比之间差别具有统计学意义(c2=315.795,P＜0.05)；实证证候要素中,痰邪、血瘀、火(热)邪、水湿占比分别为77.8%、44.4%、36.6%、2.0%,不同实证要素占比之间差别具有统计学意义(c2=184.913,P＜0.05)。发生ARDS的患者与未发生ARDS患者,在心率(HR)、呼吸频率、淋巴细胞百分比、CD3+/LYM、血IgG存在统计学差异(均P <0.05)。在不同的证候要素的指标中,阳虚患者与非阳虚患者相比,平均动脉压、淋巴细胞百分比、CD3+CD4+/CD3+CD8+比例显著降低,28天死亡率、ICU住院天数及费用显著升高(均P <0.05)。采用Cox比例风险模型进行生存分析,最终选取HR、APACHE II评分、SOFA评分、是否发生ARDS,是否阳虚证5项自变量纳入Cox回归分析,获得的回归方程具有统计学意义(c2=68.185,P<0.0001),其中HR(OR=1.027, 95% CI：1.006-1.049)、SOFA评分 (OR=1.432, 95%CI：1.216-1.686)、合并ARDS(OR=0.044, 95% CI：0.010-0.191)、阳虚证(OR=0.057, 95% CI：0.010-0.340)与28天死亡率独立相关。结论?ARDS炎症反应迟于免疫应答的抑制,免疫功能的下降更为敏感。ARDS高危患者,中医证候因素以气虚痰热瘀阻最为多见；治疗上,虚证患者,尤其是阳虚证患者,需实施免疫增强的调节。
Objective To investigate the distribution, characteristics, and the correlation between the Chinese Medicine syndrome differentiation factors and prognosis of patients with a high risk of acute respiratory distress syndrome (ARDS).Methods 153 patients with a high risk of ARDS admitted in Guangdong Provincial Hospital of Chinese Medicine from May 2017 to March 2019 were enrolled, according to the inclusion and exclusion criteria. General data, Chinese Medicine clinical diagnosis information, inflammation indicators, liver and kidney function, lactic acid, immune indicators, Sequential Organ Failure Assessment (SOFA) scores, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were collected in the day of admission, and 28-day mortality and health economics indicators were followed up. Results In terms of syndrome differentiation, among the deficiency pattern, qi deficiency accounted for 73.9%, yin deficiency 11.1%, yang deficiency 3.3%, blood deficiency 1.3%, and the difference between different deficiency pattern factors was statistically significant (c2== 315.795, P<0.05); among the excess pattern, phlegm, blood stasis, fire (heat), and water-dampness were 77.8%, 44.4%, 36.6%, and 2.0% respectively, while the difference was statistically significant (c2=184.913, P<0.05). There was a statistically significant difference in heart rate(HR), respiratory rate, percentage of lymphocytes, CD3+/LYM, and serum IgG between patients with ARDS and those without ARDS (all P<0.05). The mean arterial pressure, rate of lymphocytes, and CD3+CD4+/CD3+CD8+ ratio were significantly lower in patients with yang deficiency and non-yang deficiency patients, while 28-day mortality, ICU hospitalization days and expenses significantly elevated (all P<0.05).Survival analysis was performed using the Cox proportional-hazards model. The five independent variables,which combined with heart rate, APACHE II score, SOFA score, whether ARDS occurred, and Yang deficiency syndrome,included in the Cox regression analysis that was statistically significant (c2=68.185, P<0.0001). HR (OR=1.027, 95% CI: 1.006-1.049), SOFA score (OR=1.432, 95% CI: 1.216-1.686), ARDS occurred (OR=0.044, 95% CI: 0.010) -0.191), Yang deficiency syndrome (OR=0.057, 95% CI: 0.010-0.340) was independently associated with 28-day mortality. Conclusion Inflammation of ARDS is later than immunosuppressive, while the Immune function downregulation is more sensitive than inflammation. In high risk of ARDS, qi deficiency with phlegm-heat and blood stasis is the syndrome in Chinese Medicine of the most. Patients with the deficiency pattern, especially those with yang deficiency, need for immune upregulation.