Analysis of risk factors and construction of predictive model for severe Mycoplasma pneumoniae pneumonia complicated with plastic bronchitis in children

doi:10.3877/cma.j.issn.1673-5250.2026.01.005

Objective

To explore the risk factors for the development of plastic bronchitis (PB) in children with severe Mycoplasma pneumoniae pneumonia (SMPP), and to construct a predictive model for the risk of PB onset.

Methods

A total of 96 children with SMPP hospitalized at Jining No.1 People′s Hospital from July 1, 2023, to December 31, 2024, who underwent electronic bronchoscopy and treatment were enrolled. A retrospective analysis was conducted, the subjects were divided into PB group (n=29, complicated with PB) and non-PB group (n=67, not complicated with PB) based on whether PB was found through bronchoscopy. Multivariate unconditional logistic regression analysis was used to determine the independent risk factors for children with SMPP complicated with PB, and a Nomogram risk prediction model for children with SMPP complicated with PB was constructed based on these risk factors. This study was approved by the Medical Ethics Committee of Jining No.1 People′s Hospital (Approval No. 2025-IIT-quick 076). Written informed consents were obtained from all children′s guardians.

Results

① The results of multivariate unconditional logistic regression analysis showed that SMPP children′s elevated serum LDH levels (OR=1.005, 95%CI: 1.001-1.009, P=0.010), elevated serum D-dimer levels (OR=1.000, 95%CI: 1.000-1.001, P=0.039), the occurrence of pleural effusion (OR=3.367, 95%CI: 1.049-10.805, P=0.041), and occurrence of pulmonary consolidation ≥2/3 of a single lobe (OR=4.872, 95%CI: 1.369-17.332, P=0.014) were all independent risk factors for children with SMPP complicated with PB. ② The area under the curve (AUC) of receiver operating characteristic (ROC) curve of the predictive model for children with SMPP complicated with PB based on the above independent risk factors was 0.866 (95%CI: 0.785-0.947), and the sensitivity, specificity and accuracy of the predictive model for predicting children with SMPP complicated with PB were 75.9%, 86.6% and 80.2%, respectively. The Hosmer-Lemeshow goodness-of-fit test indicated that the predictive model fitted well with the actual situation (χ²=13.92, P>0.05). The calibration and decision curve analysis of the Nomogram indicated that the predictive model possessed high predictive efficacy and clinical applicability. ③ Comparison of treatment outcomes between the two groups of children with SMPP showed that the PB group exhibited significantly higher proportions of children underwent bronchoscopic examinations and treatment at least 2 times, receiving glucocorticoid therapy, and treated with doxycycline or levofloxacin compared to the non-PB group (93.1% vs 4.5%, 72.4% vs 22.4%, 48.3% vs 22.4%), and the differences were statistically significant (χ²=74.00, P<0.001; χ²=21.61, P<0.001; χ²=6.43, P=0.011).

Conclusions

The predictive model incorporating serum D-dimer levels, serum LDH levels, pleural effusion, and pulmonary consolidation ≥2/3 of a single lobe of SMPP children demonstrates high clinical value for predicting the risk of children with SMPP complicated with PB.

Key words: Mycoplasma pneumoniae, Pneumonia, Mycoplasma, Bronchitis, plastics, Risk factors, Forecasting, Nomograms, Child

图1 1例SMPP并发PB患儿(男性，6岁)电子支气管镜检查及结果图[图1A：术中见左肺下叶内前、外后基底段黏膜糜烂，胶冻样塑型黏液栓嵌塞段以下的各级支气管；图1B：支气管镜下取出的塑型(管形)黏液栓大体标本(置于10%福尔马林中性缓冲液中)呈树枝状；图1C：塑型黏液栓于显微镜下可见大量中性粒细胞浸润、坏死脱落的上皮细胞和周围纤维蛋白样结构(HE染色)]注：SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎。HE为苏木精-伊红

表1 2组SMPP患儿临床资料比较

组别	例数	年龄(岁，±s)	男性[例数(%)]	体温峰值[℃，M(Q₁，Q₃)]	WBC[×10⁹/L，M(Q₁，Q₃)]	NEUT[×10⁹/L，M(Q₁，Q₃)]	LY[×10⁹/L，M(Q₁，Q₃)]
PB组	29	7.3±1.8	15(51.7)	39.7(39.3，40.0)	8.7(7.5，10.4)	5.5(4.4，7.3)	1.9(1.2，2.7)
非PB组	67	7.6±2.4	41(61.2)	39.3(39.0，39.7)	8.8(7.2，12.2)	5.6(4.0，7.3)	2.4(1.7，3.0)
统计量		t＝－0.54	χ²＝0.75	Z＝－3.01	Z＝－0.41	Z＝－0.43	Z＝－1.95
P值		0.590	0.388	0.003	0.684	0.043	0.052
组别	例数	热程(d，±s)	既往变态反应[例数(%)]	PCT[ng/mL，M(Q₁，Q₃)]	NLR[M(Q₁，Q₃)]	MPV[fL，M(Q₁，Q₃)]	PLT[×10⁹/L，M(Q₁，Q₃)]
PB组	29	10.2±2.4	7(14.6)	0.12(0.06，0.23)	2.9(2.1，5.6)	9.4(8.7，10.2)	280(221，350)
非PB组	67	8.4±3.4	2(3.8)	0.07(0.05，0.14)	2.5(1.6，4.0)	9.2(8.7，9.7)	287(239，376)
统计量		t＝－3.10	χ²＝4.16^a	Z＝－2.00	Z＝－2.02	Z＝－0.64	Z＝－1.21
P值		0.003	0.041	0.046	0.043	0.525	0.225
组别	例数	MPV/PLT(±s)	D-二聚体[ng/mL，M(Q₁，Q₃)]	LDH[U/L，M(Q₁，Q₃)]	CRP[mg/L，M(Q₁，Q₃)]	白蛋白[g/L，M(Q₁，Q₃)]
PB组	29	0.03±0.01	1 670(1 200，3 717)	409(331，519)	12.2(6.3，26.6)	41.4(38.4，43.2)
非PB组	67	0.03±0.01	850(441，1 333)	312(264，355)	6.4(2.9，16.1)	42.4(40.5，45.0)
统计量		t＝0.61	Z＝－4.66	Z＝－4.40	Z＝－2.45	Z＝－2.16
P值		0.542	<0.001	<0.001	0.014	0.031
组别	例数	胸腔积液[例数(%)]	肺实变≥2/3单肺叶[例数(%)]	PA[mg/dL，M(Q₁，Q₃)]	ALT[U/L，M(Q₁，Q₃)]	CK[U/L，M(Q₁，Q₃)]	CK-MB[ng/mL，M(Q₁，Q₃)]
PB组	29	13(44.8)	23(79.3)	10.1(8.6，11.5)	21.3(15.7，36.1)	67.0(44.0，125.5)	1.8(1.4，3.0)
非PB组	67	10(14.9)	31(46.3)	12.9(10.8，15.0)	15.0(11.4，21.6)	58.0(43.0，90.0)	1.8(1.5，2.6)
统计量		χ²＝9.93	χ²＝8.98	Z＝－4.25	Z＝－3.04	Z＝－0.66	Z＝－0.12
P值		0.002	0.003	<0.001	0.002	0.510	0.908

表1 2组SMPP患儿临床资料比较

组别	例数	年龄(岁，±s)	男性[例数(%)]	体温峰值[℃，M(Q₁，Q₃)]	WBC[×10⁹/L，M(Q₁，Q₃)]	NEUT[×10⁹/L，M(Q₁，Q₃)]	LY[×10⁹/L，M(Q₁，Q₃)]
PB组	29	7.3±1.8	15(51.7)	39.7(39.3，40.0)	8.7(7.5，10.4)	5.5(4.4，7.3)	1.9(1.2，2.7)
非PB组	67	7.6±2.4	41(61.2)	39.3(39.0，39.7)	8.8(7.2，12.2)	5.6(4.0，7.3)	2.4(1.7，3.0)
统计量		t＝－0.54	χ²＝0.75	Z＝－3.01	Z＝－0.41	Z＝－0.43	Z＝－1.95
P值		0.590	0.388	0.003	0.684	0.043	0.052
组别	例数	热程(d，±s)	既往变态反应[例数(%)]	PCT[ng/mL，M(Q₁，Q₃)]	NLR[M(Q₁，Q₃)]	MPV[fL，M(Q₁，Q₃)]	PLT[×10⁹/L，M(Q₁，Q₃)]
PB组	29	10.2±2.4	7(14.6)	0.12(0.06，0.23)	2.9(2.1，5.6)	9.4(8.7，10.2)	280(221，350)
非PB组	67	8.4±3.4	2(3.8)	0.07(0.05，0.14)	2.5(1.6，4.0)	9.2(8.7，9.7)	287(239，376)
统计量		t＝－3.10	χ²＝4.16^a	Z＝－2.00	Z＝－2.02	Z＝－0.64	Z＝－1.21
P值		0.003	0.041	0.046	0.043	0.525	0.225
组别	例数	MPV/PLT(±s)	D-二聚体[ng/mL，M(Q₁，Q₃)]	LDH[U/L，M(Q₁，Q₃)]	CRP[mg/L，M(Q₁，Q₃)]	白蛋白[g/L，M(Q₁，Q₃)]
PB组	29	0.03±0.01	1 670(1 200，3 717)	409(331，519)	12.2(6.3，26.6)	41.4(38.4，43.2)
非PB组	67	0.03±0.01	850(441，1 333)	312(264，355)	6.4(2.9，16.1)	42.4(40.5，45.0)
统计量		t＝0.61	Z＝－4.66	Z＝－4.40	Z＝－2.45	Z＝－2.16
P值		0.542	<0.001	<0.001	0.014	0.031
组别	例数	胸腔积液[例数(%)]	肺实变≥2/3单肺叶[例数(%)]	PA[mg/dL，M(Q₁，Q₃)]	ALT[U/L，M(Q₁，Q₃)]	CK[U/L，M(Q₁，Q₃)]	CK-MB[ng/mL，M(Q₁，Q₃)]
PB组	29	13(44.8)	23(79.3)	10.1(8.6，11.5)	21.3(15.7，36.1)	67.0(44.0，125.5)	1.8(1.4，3.0)
非PB组	67	10(14.9)	31(46.3)	12.9(10.8，15.0)	15.0(11.4，21.6)	58.0(43.0，90.0)	1.8(1.5，2.6)
统计量		χ²＝9.93	χ²＝8.98	Z＝－4.25	Z＝－3.04	Z＝－0.66	Z＝－0.12
P值		0.002	0.003	<0.001	0.002	0.510	0.908

表2 SMPP患儿并发PB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
血清LDH水平(连续变量)	0.005	0.002	6.641	0.010	1.005	1.001~1.009
血清D-二聚体水平(连续变量)	3.130×10^－4	1.520×10^－4	4.269	0.039	1.000	1.000~1.001
胸腔积液(vs未发生胸腔积液)	1.214	0.595	4.164	0.041	3.367	1.049~10.805
肺实变≥2/3单肺叶(vs未发生肺实变≥2/3单肺叶)	1.583	0.648	5.980	0.014	4.872	1.369~17.332
常数项	－4.817	1.074	20.108	<0.001	—	—

表2 SMPP患儿并发PB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
血清LDH水平(连续变量)	0.005	0.002	6.641	0.010	1.005	1.001~1.009
血清D-二聚体水平(连续变量)	3.130×10^－4	1.520×10^－4	4.269	0.039	1.000	1.000~1.001
胸腔积液(vs未发生胸腔积液)	1.214	0.595	4.164	0.041	3.367	1.049~10.805
肺实变≥2/3单肺叶(vs未发生肺实变≥2/3单肺叶)	1.583	0.648	5.980	0.014	4.872	1.369~17.332
常数项	－4.817	1.074	20.108	<0.001	—	—

图2 4个独立影响因素预测SMPP患儿并发PB的ROC曲线比较注：4个独立影响因素分别为血清LDH水平、血清D-二聚体水平、胸腔积液、肺实变≥2/3单肺叶。SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎。ROC曲线为受试者工作特征曲线，LDH为乳酸脱氢酶

表3 4个独立影响因素预测SMPP患儿并发PB的ROC曲线分析结果

独立影响因素	ROC曲线			最佳临界值	敏感度(%)	特异度(%)	约登指数
独立影响因素	AUC	AUC 95%CI	P值	最佳临界值	敏感度(%)	特异度(%)	约登指数
血清LDH水平	0.784	0.688~0.879	<0.001	357.5 U/L	69.0	76.1	0.451
血清D-二聚体水平	0.801	0.710~0.891	<0.001	1 356 ng/mL	65.5	76.1	0.416
胸腔积液	0.650	0.523~0.776	0.020	－	44.8	85.1	0.299
肺实变≥2/3单肺叶	0.665	0.550~0.780	0.010	－	79.3	53.7	0.330

表3 4个独立影响因素预测SMPP患儿并发PB的ROC曲线分析结果

独立影响因素	ROC曲线			最佳临界值	敏感度(%)	特异度(%)	约登指数
独立影响因素	AUC	AUC 95%CI	P值	最佳临界值	敏感度(%)	特异度(%)	约登指数
血清LDH水平	0.784	0.688~0.879	<0.001	357.5 U/L	69.0	76.1	0.451
血清D-二聚体水平	0.801	0.710~0.891	<0.001	1 356 ng/mL	65.5	76.1	0.416
胸腔积液	0.650	0.523~0.776	0.020	－	44.8	85.1	0.299
肺实变≥2/3单肺叶	0.665	0.550~0.780	0.010	－	79.3	53.7	0.330

图3 根据4个独立影响因素构建SMPP患儿并发PB风险预测模型预测效能的ROC曲线注：4个独立影响因素分别为血清LDH水平、血清D-二聚体水平、胸腔积液、肺实变≥2/3单肺叶。SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎。ROC曲线为受试者工作特征曲线，LDH为乳酸脱氢酶

图4 根据4个独立影响因素应用R软件绘制的SMPP患儿并发PB风险列线图注：4个独立影响因素分别为血清LDH水平、血清D-二聚体水平、胸腔积液、肺实变≥2/3单肺叶。SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎。LDH为乳酸脱氢酶

图5 采用100次重复抽样法绘制的SMPP患儿并发PB风险的列线图预测模型校准曲线图注：SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎

图6 SMPP患儿并发PB风险列线图预测模型的决策曲线注：SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎

图7 2组SMPP患儿Kaplan-Meier肺实变吸收率曲线注：SMPP为重症肺炎支原体肺炎，PB为塑型性支气管炎

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