多脏器功能障碍评分系统：一种适应于中度高原地区ARDS/MODS的诊断标准
张世范 张德海 刘惠萍 高炜 罗晓红 武建英 林树新 刘传兰 张鲜英 陈天铎【摘要】 目的: 判别高原急性呼吸窘迫综合征和多器官功能障碍综合征(H-ARDS/MODS)各项诊断指标参数界值与平原地区的差异，修改建立更合理的H-ARDS/MODS诊断标准。方法 :按统一标准将总数为505例ARDS/MODS患者根据海拔高度分为平原(<430 m)对照组(CG,n=113)、中度高原(1 517 m)1组(H1G,n=314)和中度高原(2 261～2 400 m)2组(H2G,n=78)。3组分别用平原常用的ARDS/MODS评分诊断标准(庐山及Marshall标准)和兰州H-ARDS/MODS评分，建立3个数据统计模型，绘制受试者运行特征性曲线(ROC曲线)，计算约登指数(Yoden)和最佳界值，验证3个标准在高原和平原预测ARDS/MODS结局的准确性、敏感性和特异性。结果: 用庐山、Marshall和兰州3个标准检验CG时，其ROC曲线下面积、最大Yoden、各指标总分的最佳界值、敏感性、特异性。多脏器单一指标的ROC曲线分析进一步发现，肺、脑、心、肾等项指标的ROC值在兰州标准中的总体水平明显优于庐山和Marshall标准(P<0.05和P<0.01)。结论:①平原常用的ARDS/MODS诊断标准参数不适合中度高原以上地区，修订重建H-ARDS/MODS标准是必要的；②海拔高度>1 500 m以上地区可能是区分平原和高原ARDS/MODS诊断标准的一个有意义
的分界线。
【关键词】 急性呼吸窘迫综合征; 多器官功能障碍综合征; 诊断标准; 评分分期; 高原; 平原
Criteria suitable for diagnosis of acute respiratory distress syndrome/multiple organ dysfunction syndrome at moderately high altitude area
ZHANG Shi-fan, ZHANG De-hai, LIU Hui-ping, GAO Wei, LUO Xiao-hong, WU Jian-ying, LIN Shu-xin, LIU Chuan-lan, ZHANG Xian-ying, CHEN Tian-duo.
Lanzhou General Hospital of Lanzhou Command, Lanzhou 730050, Gansu, China[STBZ]【Abstract】 OBJECTIVE:： To compare the diagnostic parameters of acute respiratory distress syndrome/multiple organ dysfunction syndrome (ARDS/MODS) at high altitude (H-ARDS/MODS) with that on plain, and to establish a more practical diagnostic criterion of H-ARDS/MODS. METHODS:：Five hundred and five cases fulfilled the criteria for the diagnosis of ARDS/MODS were divided into three groups according to the altitude of their habitation: control group including habitants (<430 m) on plain (CG, n=113), moderate high altitude group 1 habitants at the altitude of 1 517 m(H1G, n=314), moderate high altitude group 2 habitants at the altitude of 2 261 m to 2 400 m (H2G, n=78). The ARDS/MODS scores of the three groups were made according to the diagnostic criteria of Lushan conference, Marshall(1995) and Lanzhou criteria drafted by the authors respectively to set up three data analyzing models, followed by plotting of receiver operating characteristic curves (ROC curve) and calculation of the Yordon Index and the optimum cutoff points of the parameters,in order to study the accuracy of the three diagnostic criteria in predicting the outcome of the patients suffering from ARDS/MODS. RESULTS:In CG group, the differences were not significant in area of ROC, the maximal Yordon Index, the optimum cutoff points and the sensitivity and the specificity for three criteria; but the differences were significant for the three criteria in H1G group. Further investigation in comparing the ROC values of lung, brain, heart and kidney, the Lanzhou criteria were more advantageous in the high altitude than the other criteria. CONCLUSION:： ①The current diagnostic criteria of ARDS/MODS are not suitable for the diagnosis of these syndromes in moderately high or high altitude areas. It is necessary to revise the diagnostic criteria of H-ARDS/MODS. ②One thousand five hunded and seventeen meters in altitude might be considered to be an important borderline, above with the diagnostic criteria of ARDS/MODS for patients inhabiting on plain could not be suitably applied to those living above this level. ......
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