Research progress of serum biomarkers in acute respiratory distress syndrome
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摘要:
急性呼吸窘迫综合征（ARDS）是由肺内外原因引起的以顽固性低氧血症为显著特征的临床综合征，病死率较高，其诊断主要依靠临床表现，缺乏特异性检验方法，易被忽视。生物标志物的应用可以为ARDS的病理生理机制研究提供重要依据，并且有助于诊断、风险分层和确定候选治疗靶标。本文对近年来ARDS生物标记物的临床应用进展进行综述，并探讨未来的研究方向及前景，以期为精准医学在ARDS管理中的应用提供理论支持。
Abstract:Acute respiratory distress syndrome (ARDS),with high mortality,is a clinical syndrome characterized by intractable hypoxemia induced by internal and external causes.However,the diagnosis mainly depends on clinical diagnosis and lacks specific test,which is often ignored.The use of biomarkers can provide important insights into the pathophysiological mechanism of ARDS and contribute to diagnosis,risk stratification and identification of candidate treatment targets.This study summarized the research progress of biomarkers in the clinical application of ARDS in recent years,and discussed its future research direction and prospects,in order to provide theoretical support for precision medicine in ARDS management.
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Keywords:
- biomarkers /
- acute respiratory distress syndrome /
- diagnosis /
- precision medicine /
- treatment /
- phenotype
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出血性脑卒中是临床上常见急性脑血管疾病，具有较高致死率与致残率。绝大多数患者需要进行术后康复锻炼，而术后康复护理途径是保证患者神经功能恢复的关键步骤[1-2]。传统院内护理具有一定局限性，临床上需要一套更为科学、完整的护理模式。本研究为探讨综合护理干预对脑出血术后患者神经功能康复的应用效果，将本院80例患者进行研究观察，现将结果报告如下。
1. 资料与方法
1.1 一般资料
将2017年1月—2018年12月入院的80例脑出血手术患者随机分为2组，每组40例。纳入标准[3-4]:符合全国第四届脑血管病学术会议诊断标准且经头颅影像学检查确诊患者; 满足手术指征患者; 家属签署知情同意书患者。排除标准[5-6]:合并其他神经系统疾病或精神疾病患者; 合并其他严重躯体疾病患者; 存在失访风险患者。综合护理组患者男24例，女16例; 年龄51~70岁，平均(60.40±7.20)岁; 格拉斯哥昏迷(GCS)评分为(9.10±0.80)分; 术前出血量(38.20±5.60) mL。常规组患者男21例，女19例; 年龄54~68岁，平均(60.90±6.30)岁; GCS评分(9.00±0.60)分; 术前出血量(38.00±6.20) mL。2组患者性别、年龄、GCS评分与术前出血量等一般资料比较差异无统计学意义(P>0.05), 具有可比性。
1.2 方法
常规组患者给予常规康复护理，包括健康教育、康复训练、饮食指导、技能培训与家属康复指导等。综合护理组在常规护理基础上给予综合护理干预，具体步骤如下。①出院前3 d护理:采用群体健康教育模式，由护士组织讲课，以PPT播放相关知识，讲解脑出血诱因、并发症与饮食结构等问题，告知患者建立良好生活习惯的必要性，并详细指导康复训练细节。②出院前1 d护理:进行床边肢体康复指导，上肢训练包括够物、转换物品、拧毛巾等动作，并向上活动肩胛部，屈曲外展肩关节，按摩肘关节并屈曲伸展，按摩手腕部后活动指关节，每个动作20次; 下肢运动则分别屈曲伸展髋关节、膝关节与踝关节，并按摩小腿与脚趾。③强化指导:由病房护士与康复师共同指导患者及照顾者，包括生活指导、情绪调整方式、生活作息更改与答疑解惑等，使照顾者完全掌握康复技能，必要时现场指导并检验其技能掌握情况，并重点阐述需要格外注意的问题。④出院后护理:出院后干预3个月，随访5次，评估居住环境，提出整改建议，指导日常起居; 注意保暖与呼吸道清洁，保证大便通畅; 再次随访时检查上次随访遗留问题是否改进，对患者康复依从性进行检查，记录每次康复过程，并安抚患者情绪，鼓励其保持康复进度与耐性，告知以往康复成功案例，提高其信心等。
1.3 观察指标
神经功能缺损采用美国国立卫生研究院制定的神经缺损量表(NIHSS)[7]进行评价; 四肢功能参考Fugl-Meyer量表[8]; 康复依从性情况根据患者依从性问卷进行分析; 神经认知功能采用蒙特利尔认知评估量表(MoCA)[9]进行评价; 日常生活能力采用日常生活活动能力评估量表(ADL)[10]评价。以上指标分数越高分别代表神经缺损越严重、四肢功能越强、依从性越高、认知水平越高或生活能力越强。
1.4 统计学分析
采用IBM公司SPSS 19.0分析本试验数据并评估差异性。干预前后神经缺损、四肢功能、康复依从性、认知水平与远期随访生活能力等计量资料比较采用重复测量配对t检验，以P < 0.05为差异有统计学意义。
2. 结果
2.1 2组患者干预前后神经缺损与四肢功能比较
干预后，综合护理组NIHSS评分显著低于常规组，上下肢Fugl-Meyer评分均显著高于常规组(P < 0.05)。见表 1。
表 1 2组患者干预前后神经缺损与四肢功能比较分 指标 综合护理组(n=40) 常规组(n=40) 干预前 干预后 干预前 干预后 NIHSS评分 64.17±7.55 15.12±4.72*# 65.31±8.31 25.37±6.25* 上肢Fugl-Meyer评分 11.36±2.72 42.41±6.68*# 11.45±2.63 29.41±7.14* 下肢Fugl-Meyer评分 16.52±3.60 55.04±9.27*# 16.87±3.54 35.69±8.44* NIHSS:美国国立卫生研究院制定的神经缺损量表。与干预前比较, *P < 0.05;与常规组比较, #P < 0.05。 2.2 2组患者康复依从性比较
综合护理组干预后康复依从性总分显著高于常规组(P < 0.05)。见表 2。
表 2 2组患者康复依从性比较分 项目 综合护理组(n=40) 常规组(n=40) 干预前 干预后 干预前 干预后 康复训练 0.60±0.10 1.82±0.33*# 0.62±0.11 1.20±0.38* 均衡饮食 2.10±0.47 2.25±0.46 2.14±0.45 2.20±0.44 生活作息 1.75±0.38 2.46±0.49*# 1.69±0.39 2.04±0.40* 正规服药 1.35±0.40 2.20±0.45*# 1.36±0.42 1.83±0.45* 复诊随访 1.21±0.36 2.50±0.43*# 1.18±0.33 1.98±0.50* 总分 7.01±1.31 11.54±1.90*# 7.12±1.35 9.14±1.63* 与干预前比较, *P < 0.05;与常规组比较, #P < 0.05。 2.3 2组患者干预前后认知水平比较
综合护理组患者干预后认知水平总分显著高于常规组(P < 0.05)。见表 3。
表 3 2组患者干预前后认知水平比较分 项目 综合护理组(n=40) 常规组(n=40) 干预前 干预后 干预前 干预后 视空间与执行功能 2.01±0.42 3.90±0.66*# 2.04±0.44 2.77±0.59* 命名 2.54±0.38 2.71±0.41 2.48±0.39 2.50±0.41 注意 2.31±0.40 4.85±0.62*# 2.40±0.42 3.28±0.57* 语言 1.72±0.43 2.83±0.66*# 1.75±0.50 2.20±0.52* 抽象 1.07±0.30 2.42±0.50*# 1.12±0.34 1.72±0.40* 延迟回忆 1.90±0.32 3.72±0.52*# 1.92±0.38 2.74±0.55* 定向 3.55±0.50 5.65±0.59*# 3.60±0.53 4.39±0.57* 总分 18.01±2.54 26.31±3.71*# 18.20±2.66 20.10±3.01* 与干预前比较, *P < 0.05;与常规组比较, #P < 0.05。 2.4 2组患者远期随访生活能力比较
综合护理组患者末期随访生活能力总分显著高于常规组(P < 0.05)。见表 4。
表 4 2组患者远期随访生活能力比较分 项目 综合护理组(n=40) 常规组(n=40) 干预前 末期随访 干预前 末期随访 进食 5.20±0.54 7.81±0.62*# 5.12±0.54 6.22±0.60* 洗澡 2.50±0.40 3.97±0.59*# 2.44±0.42 2.50±0.50* 个人卫生 2.24±0.51 4.62±0.64*# 2.30±0.54 3.08±0.62* 穿衣 3.18±0.55 5.80±0.77*# 3.23±0.60 4.33±0.76* 肛门控制 7.70±0.72 9.04±0.80*# 7.55±0.81 8.30±0.51* 膀胱控制 7.17±0.62 9.29±0.76*# 7.28±0.64 8.50±0.66* 用厕 3.30±0.50 5.90±0.80*# 3.35±0.51 4.10±0.65* 床椅转移 5.17±0.68 9.54±0.91*# 5.01±0.70 7.60±0.84* 行走/轮椅 5.60±0.81 10.85±1.42*# 5.53±0.80 8.22±0.97* 上下楼梯 2.90±0.60 6.29±0.71*# 2.81±0.59 4.50±0.71* 总分 45.31±7.31 73.19±12.80*# 46.50±9.45 54.80±11.31* 与干预前比较, *P < 0.05;与常规组比较, #P < 0.05。 3. 讨论
流行病学研究[11-12]显示，脑出血是目前临床上公认的最具威胁性的脑血管疾病之一, 50%~70%的脑出血存活患者均存在不同程度的神经功能缺损，导致患者不同程度地丧失了劳动能力与生活能力，为家庭与社会带来沉重经济负担[13-14]。手术治疗是针对脑出血急性期最有效的方式，术后康复训练则是保证患者神经功能恢复的最重要步骤，但有学者提出，中国脑出血患者及家属对于该病的认知程度普遍偏低，康复依从性较差，远期预后不良，是造成中国脑出血预后较差的根本原因之一[15-16]。患者及其家属认知水平不高使其不具备长期康复锻炼的理论基础，在依从性无法保证的前提下无法完成康复进度，因此有效的护理模式显得尤为重要[17-18]。
综合护理模式下的脑出血康复训练是在院内护理与延续护理理论基础上衍生出的护理模式[19-22], 在常规护理基础上强化的健康教育模式，重点指导患者家属照顾技能，提高院外康复依从性与有效性，摒弃传统院内护理理念，在患者出院后患者依然保持与医院的联系，有效应对患者从医院转到家庭康复期间的自我护理能力缺失问题[23-25]。
本研究结果显示，综合护理组干预后NIHSS评分显著低于常规组，上下肢Fugl-Meyer评分、康复依从性总分、认知水平总分、末期随访生活能力总分显著高于常规组。可见，综合护理干预可显著改善神经缺损，增强患者肢体功能，提高依从性与认知水平，从而保证远期生活能力的恢复。
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