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中华妇幼临床医学杂志(电子版) ›› 2025, Vol. 21 ›› Issue (05) : 534 -543. doi: 10.3877/cma.j.issn.1673-5250.2025.05.006

论著

肺炎支原体肺炎患儿发生塑型性支气管炎的危险因素分析及列线图预测模型的建立
郑佳1,2, 李蕾2, 管仁政2, 曲政海2,†()   
  1. 1青岛大学医学部，青岛　266021
    2青岛大学附属医院儿科，青岛　266555
  • 收稿日期:2024-05-07 修回日期:2025-09-08 出版日期:2025-10-01
  • 通信作者: 曲政海

Risk factors analysis and nomogram development for predicting plastic bronchitis in children with Mycoplasma pneumoniae pneumonia

Jia Zheng1,2, Lei Li2, Renzheng Guan2, Zhenghai Qu2,†()   

  1. 1Medical College, Qingdao University, Qingdao 266021, Shandong Province, China
    2Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao 266555, Shandong Province, China
  • Received:2024-05-07 Revised:2025-09-08 Published:2025-10-01
  • Corresponding author: Zhenghai Qu
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引用本文：

郑佳, 李蕾, 管仁政, 曲政海. 肺炎支原体肺炎患儿发生塑型性支气管炎的危险因素分析及列线图预测模型的建立[J/OL]. 中华妇幼临床医学杂志(电子版), 2025, 21(05): 534-543.

Jia Zheng, Lei Li, Renzheng Guan, Zhenghai Qu. Risk factors analysis and nomogram development for predicting plastic bronchitis in children with Mycoplasma pneumoniae pneumonia[J/OL]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2025, 21(05): 534-543.

目的

探讨肺炎支原体肺炎(MPP)患儿发生塑型性支气管炎(PB)的危险因素，并建立列线图预测模型。

方法

选择2021年9月至2022年2月在青岛大学附属医院住院并进行纤维支气管镜治疗的233例MPP患儿为研究对象，其中PB患儿为88例，无PB为145例。按照收治时间，将其分别纳入训练组(n＝172，2021年9月至12月收治的患儿)与验证组(n＝61，2022年1月至2月收治的患儿)。采用回顾性分析方法，收集2组患儿的一般临床资料、临床表现、实验室及影像学检查结果。采用单因素与多因素非条件logistic回归分析，筛选MPP患儿发生PB的独立影响因素，并将筛选出的独立影响因素作为预测因子，采用R-4.3.0-win软件构建预测MPP患儿发生PB风险的列线图模型，利用受试者工作特征(ROC)曲线与曲线下面积(AUC)、校准曲线、Hosmer-Lemeshow检验及临床决策曲线分析(DCA)等方法，评价该列线图模型的区分度、校准度、拟合度及临床实用性。2组患儿年龄、性别构成比等一般临床资料比较，差异均无统计学意义(P>0.05)。本研究遵循的程序经过青岛大学附属医院伦理委员会审批(审批文号：QYFY WZLL 28344)。

结果

①在训练组患儿中，单因素非条件logistic回归分析结果显示，MPP患儿年龄、热程、呼吸音低、肺实变、胸腔积液、肺不张、血小板计数(PLT)、C反应蛋白(CRP)水平、天冬氨酸氨基转移酶(AST)水平、乳酸脱氢酶(LDH)水平、D-二聚体水平、凝血酶原时间(PT)可能为影响其发生PB的因素，差异均有统计学意义(P<0.05)；多因素非条件logistic回归分析结果显示，MPP患儿年龄大(OR＝1.369，95%CI：1.110~1.688，P＝0.003)、发生肺实变(OR＝4.429，95%CI：2.002~9.795，P<0.001)，CRP水平高(OR＝1.037，95%CI：1.003~1.072，P＝0.035)，LDH水平高(OR＝1.006，95%CI：1.000~1.012，P＝0.030)，以及D-二聚体水平≥500 ng/mL(OR＝3.184，95%CI：1.360~7.455，P＝0.008)，均为导致MPP患儿发生PB的独立危险因素。②基于上述5个独立危险因素构建预测MPP患儿发生PB风险的列线图模型，Hosmer-Lemeshow检验结果显示，在训练组中P＝0.456，在验证组中P＝0.309。ROC曲线分析结果显示，该列线图模型在训练组患儿中预测MPP患儿发生PB的敏感度为83.1%，特异度为78.8%，AUC为0.854(95%CI：0.793~0.915)；在验证组中，预测MPP患儿发生PB的敏感度为93.1%，特异度为65.6%，AUC为0.837(95%CI：0.739~0.936)。校准曲线显示，该列线图模型在训练组与验证组患儿中预测MPP发生PB的风险与实际发生风险均较为一致。DCA结果显示，该列线图模型具有较好的临床实用价值。

结论

MPP患儿年龄大、发生肺实变、CRP水平高、LDH水平高、D-二聚体水平≥500 ng/mL，均为导致MPP患儿发生PB的独立危险因素，基于这些因素构建的预测MPP患儿发生PB风险的列线图模型，可以较为准确预测MPP患儿发生PB的风险。

关键词: 肺炎支原体, 肺炎，支原体, 支气管炎, 危险因素, 列线图, 儿童
Objective

To investigate the risk factors of plastic bronchitis (PB) in children with Mycoplasma pneumoniae pneumonia (MPP) and establish a nomogram prediction model.

Methods

A total of 233 cases of MPP children who underwent flexible bronchoscopy at the Affiliated Hospital of Qingdao University between September 2021 and February 2022 were enrolled into this study. Among them, 88 cases developed PB and 145 cases did not. Patients admitted from September to December 2021 were assigned to the training set group (n=172), and those admitted from January to February 2022 were assigned to the validation set group (n=61). General clinical data, clinical manifestations, laboratory results, and imaging findings were collected by retrospective method. Univariate and multivariate unconditional logistic regression analyses were performed to identify independent risk factors for PB in MPP children. A nomogram model for predicting PB risk in MPP children was constructed using R-4.3.0-win software based on the identified risk factors. The discriminative ability, calibration, goodness-of-fit, and clinical utility of the nomogram model were evaluated using the receiver operating characteristic (ROC) curve and area under the curve (AUC), calibration curves, Hosmer-Lemeshow test, and decision curve analysis (DCA), respectively. There were no statistically significant differences in general clinical data, such as age and gender ratio between two groups (P>0.05). This study was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University (Approval No. QYFY WZLL 28344).

Results

① In the training set group, univariate logistic regression analysis showed that age, duration of fever, decreased breath sounds, lung consolidation, pleural effusion, atelectasis, platelet count (PLT), C-reactive protein (CRP) level, aspartate aminotransferase (AST) level, lactate dehydrogenase (LDH) level, D-dimer level, and prothrombin time (PT) were potential risk factors for PB in MPP children (all P<0.05). Multivariate logistic regression analysis revealed that older age (OR=1.369, 95%CI: 1.110-1.688, P=0.003), pulmonary consolidation on imaging (OR=4.429, 95%CI: 2.002-9.795, P<0.001), elevated CRP level (OR=1.037, 95%CI: 1.003-1.072, P=0.035), elevated LDH level (OR=1.006, 95%CI: 1.000-1.012, P=0.030), and D-dimer ≥500 ng/mL (OR=3.184, 95%CI: 1.360-7.455, P=0.008) were independent risk factors for PB in MPP children. ② A nomogram model was constructed based on these five independent risk factors. The Hosmer-Lemeshow test showed P=0.456 in the training set group and P=0.309 in the validation set group, indicating good model fit. ROC curve analysis demonstrated that the nomogram model had a sensitivity of 83.1%, specificity of 78.8%, and AUC of 0.854 (95%CI: 0.793-0.915) in predicting the risk of PB in MPP children in the training set group, and a sensitivity of 93.1%, specificity of 65.6%, and AUC of 0.837 (95%CI: 0.739-0.936) in the validation set group. Calibration curves showed good agreement between predicted and actual PB risks in both the training and validation set groups. DCA curves confirmed the favorable clinical utility of the nomogram model.

Conclusions

Older age, pulmonary consolidation, elevated CRP level, elevated LDH level, and D-dimer ≥500 ng/mL are independent risk factors for PB in MPP children. The nomogram model constructed based on these factors can accurately predict the risk of PB in MPP children.

Key words: Mycoplasma pneumoniae, Pneumonia, Mycoplasma, Bronchitis, Risk factors, Nomograms, Child
表1 训练组与验证组MPP患儿的临床资料比较
组别 例数 PB[例数(%)] 性别[例数(%)] 热程[例数(%)] 有变态反应史[例数(%)] BMI[(kg/m2，M(Q1，Q3)] 呼吸音低[例数(%)]
男 女 ≥7 d <7 d
训练组 172 59(34.3) 90(52.3) 82(47.7) 123(71.5) 49(28.5) 33(19.2) 15.1(14.1，16.5) 80(47.1)
验证组 61 29(47.5) 27(44.3) 34(55.7) 46(75.4) 15(24.6) 10(16.4) 15.1(14.2，16.7) 28(45.9)
统计量   χ2＝3.36 χ2＝1.17 χ2＝0.34 χ2＝0.61 Z＝－0.23 χ2＝0.01
P值   0.067 0.279 0.558 0.738 0.821 0.935
组别 例数 喘息[例数(%)] 肺实变[例数(%)] 胸腔积液[例数(%)] 肺不张[例数(%)] D-二聚体≥500 ng/mL[例数(%)] 年龄(岁，±s) WBC[×109/L，M(Q1，Q3)] N%[%，M(Q1，Q3)]
训练组 172 14(8.1) 75(43.6) 38(22.1) 20(11.6) 93(54.1) 7.3±2.1 7.2(5.5，9.1) 28.5(19.8，37.9)
验证组 61 3(4.9) 34(55.7) 17(27.9) 5(8.2) 31(50.8) 7.6±2.1 6.4(5.0，9.1) 27.0(19.0，38.9)
统计量   χ2＝0.30a χ2＝2.66 χ2＝0.83 χ2＝0.55 χ2＝0.19 t＝－1.16 Z＝－1.10 Z＝－0.55
P值   0.586 0.103 0.361 0.457 0.662 0.246 0.269 0.583
组别 例数 RBC(×1012/L，±s) L%(%，±s) Hb(g/L，±s) PLT[×109/L，M(Q1，Q3)] 白蛋白(g/L，±s) 纤维蛋白原(g/L，±s) PT(s，±s) APTT(s，±s)
训练组 172 4.4±0.5 60.0±14.5 125.3±9.5 301(243，366) 38.0±3.7 4.0±0.9 12.3±1.0 33.0±5.5
验证组 61 4.4±0.5 60.7±17.4 128.1±8.9 274(228，352) 37.0±3.8 3.8±0.9 12.7±0.7 33.2±5.2
统计量   t＝0.04 t＝－0.30 t＝－2.01 Z＝－1.41 t＝1.72 t＝1.68 t＝－3.00 t＝－0.30
P值   0.972 0.763 0.045 0.16 0.088 0.094 0.003 0.768
组别 例数 CRP[mg/L，M(Q1，Q3)] ALT[U/L，M(Q1，Q3)] AST[U/L，M(Q1，Q3)] LDH[U/L，M(Q1，Q3)] CK-MB[U/L，M(Q1，Q3)] TT[s，M(Q1，Q3)]
训练组 172 14.4(5.7，26.7) 15.1(10.7，25.4) 24.5(20.3，30.5) 297.5(253.0，363.8) 20.9(17.0，25.0) 17.7(16.9，18.3)
验证组 61 16.4(10.9，22.7) 20.4(13.0，29.8) 27.0(20.9，35.0) 292.0(241.5，350.3) 21.3(16.8，26.9) 17.7(17.3，18.8)
统计量   Z＝－0.66 Z＝－1.88 Z＝－1.59 Z＝－0.63 Z＝－0.27 Z＝－1.55
P值   0.511 0.06 0.112 0.526 0.787 0.121
表2 训练组MPP患儿发生PB影响因素的单因素非条件logistic回归分析
影响因素 B SE Wald值 P值 OR值 OR值95%CI
年龄 0.168 0.078 4.632 0.031 1.183 1.015~1.378
性别 －0.194 0.322 0.363 0.547 0.824 0.438~1.549
BMI －0.098 0.069 2.047 0.155 0.907 0.792~1.038
热程 0.949 0.399 5.638 0.018 2.582 1.181~5.645
变态反应史 －0.323 0.386 0.701 0.402 0.724 0.340~1.542
喘息 0.396 0.566 0.489 0.484 1.486 0.490~4.506
呼吸音低 0.790 0.327 5.874 0.016 2.204 1.161~4.183
肺实变 1.790 0.354 25.647 <0.001 5.989 2.993~1.987
胸腔积液 1.282 0.381 11.493 0.001 3.605 1.708~7.607
肺不张 0.974 0.482 4.085 0.043 2.648 1.030~6.811
RBC －0.007 0.326 0.000 0.983 0.993 0.524~1.881
WBC －0.017 0.058 0.085 0.768 0.983 0.877~1.101
N% 0.013 0.011 1.350 0.259 1.013 0.991~1.035
L% －0.017 0.013 1.705 0.192 0.984 0.959~1.009
Hb －0.017 0.017 0.970 0.326 0.983 0.951~1.016
PLT －0.005 0.002 6.761 0.010 0.995 0.991~0.999
CRP 0.062 0.014 19.612 <0.001 1.064 1.035~1.094
白蛋白 －0.060 0.045 1.806 0.179 0.942 0.862~1.029
ALT 0.006 0.005 1.503 0.225 1.006 0.996~1.016
AST 0.029 0.014 4.102 0.043 1.029 1.001~1.058
LDH 0.009 0.002 20.250 <0.001 1.009 1.005~1.013
CK-MB －0.002 0.008 0.034 0.830 0.998 0.983~1.014
D-二聚体 1.471 0.360 16.713 <0.001 4.353 2.149~8.814
FIB 0.214 0.192 1.267 0.263 1.239 0.851~1.805
PT 0.399 0.173 5.338 0.021 1.490 1.061~2.091
APTT －0.049 0.031 0.106 0.106 0.952 0.896~1.012
TT －0.214 0.115 0.062 0.062 0.807 0.644~1.012
表3 训练组MPP患儿发生PB影响因素的多因素非条件logistic回归分析
影响因素 B SE Wald值 P值 OR值 OR值95%CI VIF
年龄(连续变量) 0.314 0.107 8.673 0.003 1.369 1.110~1.688 1.031
肺实变(vs未发生肺突变) 1.488 0.405 13.547 <0.001 4.429 2.002~9.795 1.111
CRP(连续变量) 0.036 0.017 4.528 0.035 1.037 1.003~1.072 1.669
LDH(连续变量) 0.006 0.003 4.640 0.030 1.006 1.000~1.012 1.681
D-二聚体≥500 ng/mL(vs <500 ng/mL) 1.158 0.434 7.129 0.008 3.184 1.360~7.455 1.154
常数项 －6.990 1.373 8.673 <0.001 — — —
图1 预测MPP患儿发生PB风险的列线图模型注：MPP为肺炎支原体肺炎，PB为塑型性支气管炎，CRP为C反应蛋白，LDH为乳酸脱氢酶
图2 预测2组MPP患儿发生PB风险的列线图模型预测MPP患儿发生PB的ROC曲线(图2A：训练组；图2B：验证组)注：MPP为肺炎支原体肺炎，PB为塑型性支气管炎，ROC曲线为受试者工作特征曲线
图3 预测2组MPP患儿发生PB风险的列线图模型的校准曲线图(图3A：训练组；图3B：验证组)注：MPP为肺炎支原体肺炎，PB为塑型性支气管炎
图4 预测2组MPP患儿发生PB风险的列线图模型的DCA曲线注：MPP为肺炎支原体肺炎，PB为塑型性支气管炎，DCA为决策曲线分析
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