An early scoring system to predict mechanical ventilation for botulism: a single-center-based study

doi:10.5847/wjem.j.1920-8642.2024.067

Abstract

Abstract:

BACKGROUND Early identification of patients requiring ventilator support will be beneficial for the outcomes of botulism. The present study aimed to establish a new scoring system to predict mechanical ventilation (MV) for botulism patients.

METHODS: A single-center retrospective study was conducted to identify risk factors associated with MV in botulism patients from 2007 to 2022. Univariate analysis and multivariate logistic regression analysis were used to screen out risk factors for constructing a prognostic scoring system. The area under the receiver operating characteristic (ROC) curve was calculated.

RESULTS: A total of 153 patients with botulism (66 males and 87 females, with an average age of 43 years) were included. Of these, 49 patients (32.0%) required MV, including 21 (13.7%) with invasive ventilation and 28 (18.3%) with non-invasive ventilation. Multivariate analysis revealed that botulinum toxin type, pneumonia, incubation period, degree of hypoxia, and severity of muscle involvement were independent risk factors for MV. These risk factors were incorporated into a multivariate logistic regression analysis to establish a prognostic scoring system. Each risk factor was scored by allocating a weight based on its regression coefficient and rounded to whole numbers for practical utilization ([botulinum toxin type A: 1], [pneumonia: 2], [incubation period ≤1 day: 2], [hypoxia <90%: 2], [severity of muscle involvement: grade II, 3; grade III, 7; grade IV, 11]). The scoring system achieved an area under the ROC curve of 0.82 (95% CI 0.75-0.89, P<0.001). At the optimal threshold of 9, the scoring system achieved a sensitivity of 83.7% and a specificity of 70.2%.

CONCLUSION: Our study identified botulinum toxin type, pneumonia, incubation period, degree of hypoxia, and severity of muscle involvement as independent risk factors for MV in botulism patients. A score ≥9 in our scoring system is associated with a higher likelihood of requiring MV in botulism patients. This scoring system needs to be validated externally before it can be applied in clinical settings.

Key words: Botulism, Scoring system, Botulinum toxin type, Incubation period, Hypoxia, Pneumonia, Severity of muscle involvement

Yaqing An, Tuokang Zheng, Yanling Dong, Yang Wu, Yu Gong, Yu Ma, Hao Xiao, Hengbo Gao, Yingping Tian, Dongqi Yao. An early scoring system to predict mechanical ventilation for botulism: a single-center-based study[J]. World Journal of Emergency Medicine, 2024, 15(5): 365-371.

Figures/Tables 4

Table 1.

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Table 3.

Figure 1.

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Variables	Value
Sex, n (%)
Male	66 (43.1)
Female	87 (56.9)
Age
Total, years, mean±SD	43±14
<60 years, n (%)	134 (87.6)
≥60 years, n (%)	19 (12.4)
Types of botulinum toxin, n (%)
A	64 (41.8)
B	89 (58.2)
Incubation period, n (%)
≤1 d	106 (69.3)
>1 d	47 (30.7)
Headache and/or dizziness, n (%)
No	81 (52.9)
Yes	72 (47.1)
Abdominal pain, n (%)
No	119 (77.8)
Yes	34 (22.2)
Nausea and/or vomiting, n (%)
No	88 (57.5)
Yes	65 (42.5)
Diarrhea, n (%)
No	92 (60.1)
Yes	61 (39.9)
Severity of muscle involvement, n (%)
I	36 (23.5)
II	29 (19.0)
III	51 (33.3)
IV	37 (24.2)
Number of comorbidities, n (%)
0	126 (82.4)
1	17 (11.1)
2	10 (6.5)
Severity of hypoxia, n (%)
SpO₂<90%	80 (52.3)
SpO₂≥90%	73 (47.7)
Body mass index, n (%)
<24 kg/m²	71 (46.4)
≥24 kg/m²	82 (53.6)
Pneumonia, n (%)
No	125 (81.7)
Yes	28 (18.3)
Ventilator support, n (%)
Total number requiring ventilation	49 (32.0)
Invasive ventilation	21 (13.7)
Non-invasive ventilation	28 (18.3)
No, n (%)	104 (68.0)

Variables	Overall (n=153)	Without ventilatory support (n=104)	Ventilatory support (n=49)	P-value
Sex, n (%)				0.691
Male	66 (43.1)	46 (44.2)	20 (40.8)
Female	87 (56.9)	58 (55.8)	29 (59.2)
Age, n (%)				0.126
<60 years	134 (87.6)	94 (90.4)	40 (81.6)
≥60 years	19 (12.4)	10 (9.6)	9 (18.4)
Types of botulism, n (%)				0.003
A	64 (41.8)	35 (33.7)	29 (59.2)
B	89 (58.2)	69 (66.3)	20 (40.8)
Incubation period, n (%)				<0.001
≤1 d	106 (69.3)	62 (59.6)	44 (89.8)
>1 d	47 (30.7)	42 (40.4)	5 (10.2)
Headache and/or dizziness, n (%)				0.171
No	81 (52.9)	59 (56.7)	22 (44.9)
Yes	72 (47.1)	45 (43.3)	27 (55.1)
Abdominal pain, n (%)				0.229
No	119 (77.8)	78 (75.0)	41 (83.7)
Yes	34 (22.2)	26 (25.0)	8 (16.3)
Nausea and/or vomiting, n (%)				0.444
No	88 (57.5)	62 (59.6)	26 (53.1)
Yes	65 (42.5)	42 (40.4)	23 (46.9)
Diarrhea, n (%)				0.870
No	92 (60.1)	63 (60.6)	29 (59.2)
Yes	61 (39.9)	41 (39.4)	20 (40.8)
Severity of muscle involvement, n (%)				<0.001
I	36 (23.5)	35 (33.7)	1 (2.0)
II	29 (19.0)	21 (20.2)	8 (16.3)
III	51 (33.3)	29 (27.9)	22 (44.9)
IV	37 (24.2)	19 (18.3)	18 (36.7)
Number of comorbidities, n (%)				0.113
0	126 (82.4)	83 (79.8)	43 (87.8)
1	17 (11.1)	15 (14.4)	2 (4.1)
2	10 (6.5)	6 (5.8)	4 (8.2)
Severity of hypoxia, n (%)				0.004
SpO₂<90%	80 (52.3)	46 (44.2)	34 (69.4)
SpO₂≥90%	73 (47.7)	58 (55.8)	15 (30.6)
Body mass index, n (%)				0.432
<24 kg/m²	71 (46.4)	46 (44.2)	25 (51.0)
≥24 kg/m²	82 (53.6)	58 (55.8)	24 (49.0)
Pneumonia, n (%)				<0.001
No	125 (81.7)	96 (92.3)	29 (59.2)
Yes	28 (18.3)	8 (7.7)	20 (40.8)
Vital signs, mean±SD
Systolic BP, mmHg	114.00±17.86	115.42±17.86	110.96±19.51	0.166
Diastolic BP, mmHg	76.44±15.65	77.76±16.46	73.61±13.53	0.126
Pulse rate, beats/min	84.36±18.91	85.89±18.01	81.10±20.51	0.144

Variables	Univariable analysis		Multivariable analysis
Variables	P-value	Odds ratio (95% CI)	β	Standard error	P-value	Odds ratio (95% CI)
Pneumonia (reference “no pneumonia”)	<0.001	8.28 (3.30, 20.75)	2.30	0.63	<0.001	10.02 (2.90, 34.56)
Types of botulism (reference “B”)	0.003	2.86 (1.42, 5.76)	1.05	0.48	0.030	2.84 (1.11, 7.32)
Incubation period (reference “>1 d”)	<0.001	5.96 (2.18, 16.28)	1.97	0.64	0.002	7.17 (2.03, 25.26)
Hypoxia (reference “≥90%”)	0.004	2.86 (1.39, 5.87)	1.58	0.50	0.002	4.84 (1.82, 12.86)
Severity of muscle involvement
II (reference “I”)	0.018	13.33 (1.56, 114.25)	2.91	1.25	0.020	18.30 (1.57, 212.71)
III (reference “II”)	0.002	26.55 (3.37, 209.07)	3.81	1.21	0.002	44.95 (4.18, 483.34)
IV (reference “III”)	0.001	33.16 (4.10, 267.00)	4.06	1.22	0.001	58.13 (5.30, 638.04)

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