急性呼吸窘迫综合征不同病因对驱动压预后评估价值的影响：一项前瞻性队列研究

doi:10.12114/j.issn.1007-9572.2025.0365

中国全科医学 ›› 2026, Vol. 29 ›› Issue (19): 2638-2647.DOI: 10.12114/j.issn.1007-9572.2025.0365

急性呼吸窘迫综合征不同病因对驱动压预后评估价值的影响：一项前瞻性队列研究

刘阳¹^,²^,^*(), 周国平¹, 李小石¹, 李萍¹, 张鑫¹

1．211300　江苏省南京市高淳人民医院重症医学科
2．300100　天津市，天津医科大学附属南开医院感染科（呼吸二科）

收稿日期:2025-06-15 修回日期:2026-02-28 出版日期:2026-07-05 发布日期:2026-06-05
通讯作者: 刘阳
作者贡献：
刘阳提出研究理念，负责研究的构思与设计，数据整理、统计分析、论文撰写，负责文章的质量控制与审查，对文章整体负责，监督管理；周国平、李小石负责进行试验，研究过程的实施，数据收集、数据整理、统计分析、图表绘制；李萍负责进行试验，研究过程的实施，提供统计学方法和思路、协助编辑与修改论文；张鑫负责数据整理、论文的修订。
基金资助:
江苏省卫生健康委2022年度医学科研立项项目(重点项目ZD2022031); 江苏大学2021年度临床医学科技发展基金项目(JLY2021170); 南京市卫生科技发展专项资金项目(YKK20175)

Impact of Acute Respiratory Distress Syndrome Etiology on the Prognostic Value of Driving Pressure: a Prospective Cohort Study

LIU Yang¹^,²^,^*(), ZHOU Guoping¹, LI Xiaoshi¹, LI Ping¹, ZHANG Xin¹

1. Department of Critical Care Medicine, Nanjing Gaochun People's Hospital, Nanjing 211300, China
2. Department of Infectious Diseases, Tianjin NanKai Hospital, Tianjin Medical University, Tianjin 300100, China

Received:2025-06-15 Revised:2026-02-28 Published:2026-07-05 Online:2026-06-05
Contact: LIU Yang

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摘要/Abstract

摘要： 背景在接受机械通气急性呼吸窘迫综合征（ARDS）患者中，过高的气道驱动压（DP）是全因死亡风险的独立危险因素。尽管不同病因（肺内源性和肺外源性）ARDS在病理生理学方面具有较大的差异已得到充分证实，但是不同病因是否影响DP在ARDS中的预后价值，目前尚不清楚。目的本研究旨在确定在ARDS中，DP与90 d全因死亡风险的关联是否受不同病因的影响。方法选取2021年12月—2023年10月南京市高淳人民医院重症监护室收治的>18岁、符合柏林共识诊断标准的ARDS患者172例。根据临床资料将患者分为肺内源性ARDS（n=82）或肺外源性ARDS（n=90），入选首日，记录年龄、性别、序贯性器官功能衰竭评分（SOFA评分）、急性生理与慢性健康状况评分（APACHE Ⅱ评分）、氧合指数（PaO2/FiO2）以及呼吸力学参数包括DP、气道平台压（Pplat）、呼吸系统顺应性（Crs），研究终点为90 d全因死亡，随访结束时根据患者结局分为死亡组和存活组。采用Cox比例风险回归模型评估DP与病因在90 d死亡风险中的交互作用。敏感性分析包括使用基于倾向评分的逆概率加权（IPTW）方法，以控制潜在混杂因素的影响。结果纳入172例ARDS患者，年龄（57±18）岁，随访结束死亡63例，病死率为36.3%。死亡组SOFA评分、APACHE Ⅱ评分、DP和Pplat高于存活组，PaO2/FiO2、Crs低于存活组（P<0.05）。调整年龄、SOFA评分、PaO2/FiO2后，过高的DP（HR=1.134，95%CI=1.067~1.206，P<0.001）与90 d全因死亡风险独立相关。交互作用分析显示：DP与90 d全因死亡风险的关联在不同ARDS病因人群中的差异有统计学意义（P=0.04）；在肺内源性ARDS患者（n=82）中，PaO2/FiO2降低（HR=0.990，95%CI=0.980~1.000，P=0.04）和过高的DP（HR=1.253，95%CI=1.146~1.370，P<0.01）均为90 d全因死亡风险的独立危险因素；而在肺外源性ARDS患者中（n=90），高SOFA评分（HR=1.277，95%CI=1.067~1.528，P<0.01）是全因死亡风险唯一的独立危险因素，DP（HR=1.083，95%CI= 0.957~1.227，P=0.21）不再是90 d全因死亡风险的危险因素。IPTW后加权Cox分析的结果与主分析结果高度一致（不同ARDS病因与过高的DP对死亡风险影响存在显著交互作用，P=0.009）。结论虽然DP是ARDS全因死亡风险的强预测因子，但受不同病因的影响，肺外源性ARDS与不良预后并不显著相关。提示在机械通气策略的制订中应结合ARDS的病因特征，实施个体化通气管理。

关键词: 呼吸窘迫综合征, 气道驱动压, 精准治疗, 预后, 前瞻性研究

Abstract:

Background

Airway driving pressure (DP) is a recognized independent predictor of mortality in mechanically ventilated patients with acute respiratory distress syndrome (ARDS). Although pathophysiological differences between pulmonary and extrapulmonary ARDS are well-established, it remains unclear whether the prognostic value of DP varies by ARDS etiology.

Objective

This prospective cohort study evaluated whether ARDS etiology modifies the association between DP and 90-day all-cause mortality.

Methods

We enrolled 172 mechanically ventilated ARDS patients aged>18 years who met the Berlin definition at Nanjing Gaochun People's Hospital from December 2021 to October 2023. Patients were classified as having pulmonary ARDS (n=82) or extrapulmonary ARDS (n=90) based on clinical features. We collected data on Day 1, including Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) score, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO₂/FiO₂), and respiratory mechanics including DP, plateau pressures (Pplat), and respiratory system compliance (Crs). The primary outcome was 90-day all-cause mortality. Cox proportional hazards regression models were employed to assess the interaction between DP and ARDS etiology (pulmonary versus extrapulmonary) on 90-day mortality. Sensitivity analyses using inverse probability of treatment weighting (IPTW) based on propensity scores were conducted to account for potential confounders.

Results

Among the 172 ARDS patients mean age (57±18) years, 63 (36.3%)died during follow-up. Non-survivors had higher SOFA scores, APACHE Ⅱ scores, DP, Pplat, and lower PaO₂/FiO₂ ratios and Crs than survivors (all P<0.05). The association between DP and 90-day mortality (HR=1.134, 95%CI =1.067-1.206, P<0.001) varied by ARDS etiology (P=0.04 for interaction) after adjustment for age, PaO₂/FiO₂ ratio, and SOFA score. In pulmonary ARDS (n=82), both PaO₂/FiO₂ (HR=0.990, 95%CI=0.980-1.000, P=0.04) and DP (HR=1.253, 95%CI =1.146-1.370, P<0.01) were associated with 90-day mortality. Conversely, in extrapulmonary ARDS (n=90), DP (HR=1.083, 95%CI=0.957-1.227, P=0.21) was not associated with mortality, while only the SOFA score remained an independent risk factor(HR=1.277, 95%CI=1.067-1.528, P<0.01). These findings were consistent in the IPTW analysis (P=0.009 for interaction between ARDS etiology and DP on mortality).

Conclusion

While DP is a strong predictor of mortality in ARDS overall, its prognostic significance differs by etiology. Specifically, in extrapulmonary ARDS, elevated DP is not significantly associated with poor prognosis, suggesting that ventilation strategies should be aligned with the underlying ARDS etiology.

Key words: Respiratory distress syndrome, Airway driving pressure, Precision therapy, Prognosis, Prospective studies

中图分类号:

R 563.8

刘阳,周国平,李小石,等. 急性呼吸窘迫综合征不同病因对驱动压预后评估价值的影响：一项前瞻性队列研究[J]. 中国全科医学, 2026, 29(19): 2638-2647. DOI: 10.12114/j.issn.1007-9572.2025.0365.
LIU Yang,ZHOU Guoping,LI Xiaoshi, et al. Impact of Acute Respiratory Distress Syndrome Etiology on the Prognostic Value of Driving Pressure: a Prospective Cohort Study[J]. Chinese General Practice, 2026, 29(19): 2638-2647. DOI: 10.12114/j.issn.1007-9572.2025.0365.

图/表 11

表1 存活者和非存活者基线资料比较

Table 1 Baseline characteristics of survivors versus nonsurvivors

组别	例数	性别[例（%）]		年龄（±s，岁）	SOFA评分（±s，分）	PaO₂/FiO₂ （±s，mmHg）	PaCO₂ （±s，mmHg）	Crs（±s，mL/cmH₂O）
组别	例数	男	女	年龄（±s，岁）	SOFA评分（±s，分）	PaO₂/FiO₂ （±s，mmHg）	PaCO₂ （±s，mmHg）	Crs（±s，mL/cmH₂O）
存活组	109	83（76.15）	26（23.85）	54±16	11.28±2.32	144±48	46±7	30±6
死亡组	63	51（80.95）	12（19.05）	60±20	12.32±2.25	128±34	46±5	28±6
t（χ²）值		0.29^a		-1.94	-2.84	2.32	-0.36	2.26
P值		0.58		0.05	<0.01	0.02	0.72	0.03
组别	ARDS病因[例（%）]		Vt（±s，mL/kg理想体质量)	PEEPtot（±s，cmH₂O）	DP（±s，cmH₂O）	Pplat（±s，cmH₂O）	APACHE Ⅱ评分（±s，分）
组别	肺内源性	肺外源性	Vt（±s，mL/kg理想体质量)	PEEPtot（±s，cmH₂O）	DP（±s，cmH₂O）	Pplat（±s，cmH₂O）	APACHE Ⅱ评分（±s，分）
存活组	46（42.20）	63（57.80）	6.54±0.97	13±3	15±3	29±4	22±4
死亡组	36（57.14）	27（42.86）	6.67±0.70	13±3	17±4	31±3	25±5
t（χ²）值	2.99^a		-0.91	-0.32	-3.27	-3.42	-3.80
P值	0.08		0.36	0.74	<0.01	<0.01	<0.01

表2 急性呼吸窘迫综合征（ARDS）患者90 d全因死亡风险的单因素Cox比例风险回归分析

Table 2 Univariable Cox proportional hazards regression analysis of 90-day all-cause mortality in patients with acute respiratory distress syndrome

变量	B	SE	Z值	P值	HR（95%CI）	与ARDS病因交互作用的P值
年龄	0.016	0.008	2.048	0.04	1.016（1.001~1.031）	0.77
SOFA评分	0.164	0.056	2.917	<0.01	1.178（1.055~1.315）	0.59
PaO₂/FiO₂	-0.007	0.003	-2.244	0.02	0.993（0.987~0.999）	0.95
Crs	-0.056	0.022	-2.509	0.01	0.945（0.905~0.988）	0.46
DP	0.126	0.034	3.693	<0.01	1.127（1.055~1.205）	0.03
Pplat	0.130	0.036	3.603	<0.01	1.134（1.051~1.226）	<0.01

图1 模型1各变量的标准化Schoenfeld残差随时间变化的散点图注：A为气道驱动压的Schoenfeld残差图，B为急性呼吸窘迫综合征（ARDS）病因的Schoenfeld残差图，C为年龄的Schoenfeld残差图，D为序贯性器官功能衰竭（SOFA）评分的Schoenfeld残差图，E为氧合指数（PaO2/FiO2）的Schoenfeld残差图，F为气道驱动压与ARDS病因交互项的Schoenfeld残差图。红色散点表示各事件时间点对应的标准化Schoenfeld残差，黑色实线为局部加权回归（LOESS）平滑曲线。虚线代表拟合周围的+/-2倍标准误差范围。可见平滑曲线在随访期间围绕0刻度线平稳波动，各变量的比例风险假设检验均无统计学意义（P>0.05）；提示变量均满足比例风险假设。

Figure 1 Scaled Schoenfeld residuals versus time for each variable in model 1

表3 急性呼吸窘迫综合征患者90 d全因死亡风险的多因素Cox比例风险回归分析

Table 3 Multivariate Cox proportional hazards regression analysis of 90-day all-cause mortality in patients with acute respiratory distress syndrome

变量	模型1（包含DP）			模型2（DP作为二分变量）			模型3（包含Pplat）
变量	HR（95%CI）	P值	P_交互值^a	HR（95%CI）	P值	P_交互值^a	HR（95%CI）	P值	P_交互值^a
年龄	1.021（1.004~1.038）	0.014	0.55	1.020（1.004~1.037）	0.02	0.46	1.018（1.001~1.034）	0.03	0.26
SOFA评分	1.202（1.075~1.343）	0.001	0.27	1.205（1.078~1.346）	<0.01	0.31	1.232（1.101，1.378）	<0.01	0.37
PaO₂/FiO₂	0.992（0.985~0.998）	0.009	0.42	0.992（0.986~0.998）	0.01	0.34	0.997（0.990~1.003）	0.31	0.48
DP/Pplat	1.134（1.067~1.206）	<0.001	0.04				1.123（1.043~1.210）	<0.01	<0.01
高DP				1.724（1.007~2.950）	0.04	<0.01

图2 不同ARDS病因，气道驱动压与校正后90 d全因死亡对数风险比(Log AHR)的关联注：DP =气道驱动压；Log AHR=校正后的90 d死亡对数风险比，风险比调整了年龄、序贯性器官功能衰竭评分以及氧合指数；a多因素Cox回归的交互作用分析显示，DP与90 d全因死亡风险的关联在不同ARDS病因（肺内源性ARDS、肺外源性ARDS）中的差异具有统计学意义（P=0.04）；1 cmH2O=0.098 kPa。

Figure 2 Association between airway driving pressure and adjusted log hazard ratio for 90-day all-cause mortality, stratified by ARDS etiology

表4 DP与校正后90 d全因死亡风险的亚组分析

Table 4 Adjusted 90-day all-cause mortality risk associated with airway driving pressure: a subgroup analysis

组别	HR（95%CI）	P值
肺内源性ARDS（n=82）
年龄	1.014（0.996~1.033）	0.12
SOFA评分	1.115（0.973~1.278）	0.11
PaO₂/FiO₂	0.990（0.980~1.000）	0.04
DP	1.253（1.146~1.370）	<0.01
肺外源性ARDS（n=90）
年龄	1.027（0.996~1.059）	0.08
SOFA评分	1.277（1.067~1.528）	<0.01
PaO₂/FiO₂	0.995（0.986~1.004）	0.27
DP	1.083（0.957~1.227）	0.21

图3 在肺内源性ARDS（A）及肺外源性（B）ARDS患者中，调整后高DP（≥15 cmH2O）与90 d全因死亡风险关联的森林图

Figure 3 Forest plot of the adjusted association between higher airway driving pressure (≥15 cmH2O) and 90-day all-cause mortality in Pulmonary (A) and extrapulmonary (B) ARDS

图4 不同病因ARDS患者（A肺内源性ARDS，B肺外源性ARDS）中，高DP组（DP≥15 cmH2O）与低DP组（DP<15 cmH2O）的Kaplan-Meier生存曲线

Figure 4 Kaplan-Meier survival curves for patients with higher (≥15 cmH2O) vs. lower (<15 cmH2O) airway driving pressure, stratified by etiology: (A) pulmonary ARDS, (B)Extrapulmonary ARDS

图5 暴露组（气道驱动压≥15 cmH2O）与未暴露组（气道驱动压<15 cmH2O）在应用基于倾向评分的逆概率加权（PS-IPTW）前后各协变量的标准化均差注：PaCO2=动脉血二氧化碳分压，APACHE II=急性生理与慢性健康评分。

Figure 5 Absolute standardized differences in covariates between the exposed and unexposed groups before and after application of propensity score–based inverse probability of treatment weighting (PS-IPTW)

图6 气道驱动压与90 d全因死亡风险关联的敏感性分析注：aHR=调整的风险比（HR），四个人群中均使用Cox比例风险模型调整序贯性器官功能衰竭评分、PaO2/FiO2和年龄后，分析气道驱动压和ARDS病因与全因死亡风险的关系；ARDS=急性呼吸窘迫综合征；IPTW =逆概率加权；PaO2/FiO2=氧合指数；P交互=气道驱动压与ARDS病因交互作用的P值。

Figure 6 Sensitivity analyses for the association of baseline airway driving pressure with 90-Day all-cause Mortality

图7 倾向性评分IPTW加权后不同病因ARDS患者（A肺内源性ARDS，B肺外源性ARDS）高DP组（DP≥15 cmH2O）与低DP组（DP <15 cmH2O）的Kaplan-Meier生存曲线

Figure 7 Kaplan-Meier survival curves for higher (≥15 cmH2O) vs. lower(<15 cmH2O) airway driving pressure, adjusted using inverse probability of treatment weighting and stratified by ARDS etiology (A Pulmonary ARDS, B extrapulmonary ARDS)

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急性呼吸窘迫综合征不同病因对驱动压预后评估价值的影响：一项前瞻性队列研究

Impact of Acute Respiratory Distress Syndrome Etiology on the Prognostic Value of Driving Pressure: a Prospective Cohort Study

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