重症肺超改良BLUE方案在ICU急性呼吸困难患者中的临床应用
2022-07-15刘庆益林燕陈虎
刘庆益 林燕 陈虎
[摘要] 目的 探讨改良急诊床旁肺部超声评估(BLUE)在ICU急性呼吸困难患者肺实变、肺不张诊断中的应用。 方法 选取2018年10月~2021年6月江西省萍乡市第二人民医院ICU收住的疑似急性呼吸困难肺实变、肺不张患者56例作为观察对象,入住ICU后完成传统BLUE方案、改良BLUE方案检查,传统BLUE方案由彩超室医生独立完成及诊断,传统BLUE方案包括上蓝点、下蓝点、膈肌线、PLAPS点;改良BLUE方案由笔者医院ICU医生独立完成并诊断,改良BLUE方案检查:在传统BLUE方案基础上增加了后蓝点。上述检查完成24 h内行胸部CT和X线胸片检查,以胸部CT检查结果为金标准,将重症肺改良BLUE方案和傳统BLUE方案检查结果、X线胸片结果与“金标准”进行比较,分析不同检查方法诊断效能。 结果 56例患者112侧肺部中,经胸部CT检查诊断肺实变及肺不张85侧(75.89%),改良BLUE方案检查诊断有81侧(72.30%),传统BLUE方案检查诊断有63侧(56.25%),X线胸片诊断35侧(44.64%);经Kappa一致性检验分析,改良BLUE方案与胸部CT检查的一致性较好(Kappa=0.89),传统BLUE方案与胸部CT检查的一致性较差(Kappa=0.34),X线胸片与胸部CT检查的一致性最差(Kappa=0.21)。改良BLUE方案诊断肺实变及肺不张的敏感度为94.11%,特异性为96.29%,诊断准确率为94.64%,阳性预测值为98.76%,阴性预测值为83.87%;BLUE方案诊断肺实变及肺不张的敏感度为65.88%,特异性为74.07%,诊断准确率为67.85%,阳性预测值为88.89%,阴性预测值为40.81%,与胸部CT比较,差异有统计学意义(P<0.05);X线胸片诊断肺实变及肺不张的敏感度为41.18%,特异性为44.44%,诊断准确率为41.96%,阳性预测值为70.00%,阴性预测值为19.35%,与胸部CT比较,差异有统计学意义(P<0.05)。重症肺超改良BLUE方案用于ICU急性呼吸困难的肺实变患者中诊断敏感度、特异性、阳性预测值和阴性预测值和诊断符合率均高于传统BLUE方案检查和X线胸片检查(P<0.05)。 结论 改良BLUE方案用于ICU急性呼吸困难患者肺实变、肺不张中,能获得较高的诊断准确度、敏感度及特异性,能为临床诊疗提供参考依据。
[关键词] 重症肺改良床旁肺部超声评估方案;急性呼吸困难;肺实变;诊断效能
[中图分类号] R563 [文献标识码] B [文章编号] 1673-9701(2022)16-0097-04
Clinical application of modified BLUE lung ultrasound program for severe lung disease in ICU patients with acute dyspnea
LIU Qingyi1 LIN Yan2 CHEN Hu1
1.Department of Critical Care Medicine,Pingxiang No.2 People′s Hospital, Pingxiang 337000,China;2.Department of Respiratory Medicine,Pingxiang No.2 People′s Hospital,Pingxiang 337000,China
[Abstract] Objective To investigate the clinical application of modified bedside lung ultrasound in emergency (BLUE) program in diagnosing pulmonary consolidation and atelectasis in ICU patients with acute dyspnea. Methods Fifty-six suspected acute dyspnea patients with pulmonary consolidation and atelectasis admitted to Pingxiang No.2 People′s Hospital ICU from October 2018 to June 2021 were selected as the observation subjects. After admission to the ICU, the traditional BLUE program and modified BLUE program were examined. The traditional BLUE program was independently completed and diagnosed molependently by the doctors in the color Doppler ultrasound room. The traditional BLUE program included the upper blue spot, lower blue spot, diaphragmatic line, and PLAPS point.The modified BLUE program was independently completed and diagnosed by the ICU doctors who obtained the special training certificate of severe ultrasound.The modified BLUE program examination: the posterior blue point was added based on the traditional BLUE. Chest CT and chest X-ray examinations were performed within 24 hours after completing the above examinations. The results of chest CT examinations were set as the gold standard. The modified BLUE program and traditional BLUE examinations for severe lung disease and lung X-ray findings were compared with the "gold standard". The diagnostic efficacy of different examination methods was analyzed. Results Of the 112 lungs in 56 patients,85(75.89%) were diagnosed with pulmonary consolidation and atelectasis by chest CT, 81(72.30%) by modified BLUE program, 63(56.25%) by traditional BLUE program, and 35(44.64%) by chest X-ray. By kappa consistency test analysis, the consistency between the modified BLUE program and chest CT was good (Kappa=0.89), the consistency between the traditional BLUE program and chest CT was poor(Kappa=0.34), and the consistency between chest X-ray and chest CT was the worst(Kappa =0.21). The sensitivity,specificity, diagnostic accuracy, positive predictive value,and negative predictive value of modified BLUE program in pulmonary consolidation and atelectasis diagnosis were 94.11%,96.29%,94.64%,98.76%, and 83.87%, respectively. The sensitivity,specificity,diagnostic accuracy, positive predictive value, and negative predictive value of the BLUE program in the diagnosis of pulmonary consolidation and atelectasis were 65.88%,74.07%,67.85%,88.89% and 40.81%, respectively,which were significantly different from those of chest CT(P<0.05). The sensitivity,specificity,diagnostic accuracy,positive predictive value, and negative predictive value of chest X-ray in the diagnosis of pulmonary consolidation and atelectasis were 41.18%,44.44%,41.96%,70.00%,and 19.35%,respectively,which were significantly different from those of chest CT(P<0.05). The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic coincidence rate of severe lung ultrasound modified BLUE examination in pulmonary consolidation patients with acute dyspnea in the ICU were higher than traditional BLUE examination and chest X-ray examination(P<0.05). Conclusion The modified BLUE program has high sensitivity, specificity, and accuracy in diagnosing pulmonary consolidation and atelectasis in ICU patients with acute dyspnea, which is worthy of clinical application.
[Key words] Modified bedside severe ultrasound evaluation program for severe lung disease; Acute dyspnea; Pulmonary consolidation; Diagnostic efficacy
重癥监护室(intensive care unit,ICU)患者由于病情变化较快,常伴有多种基础疾病等,导致需给予机械通气治疗干预,再加上持续的镇痛及镇静等,均会增加肺不张、肺部炎症发生率,延长撤机时间,亦增加抢救风险。目前临床上对于急性呼吸困难患者肺部实变诊断以胸部CT检查为主,并将其视为“金标准”[1]。但是,由于患者病情较重,患者需转运到影像科,风险相对较大,尤其是对于血流动力学不稳定的危重症患者,增加反复动态检查难度[2]。床旁X线检查虽然能避免检查转运,但是该方法诊断效能较低;传统床旁肺部超声评估(BLUE)方案具有无创性、可重复性等特点[3,4]。但是,重症患者生理学特点决定患者容易出现重力依赖区的肺不张与肺实变,且病灶部位主要集中在双肺下叶背段、基底段,仰卧位姿势下该区域不易探及,导致临床诊断敏感度、准确性相对偏低[5,6]。改良BLUE方案是在BLUE方案基础上增加后蓝点,能明确患者重力依赖区,能提高两肺下叶背段与基底段的诊断,可获得较高的诊断价值[7,8]。因此,本研究以疑似急性呼吸困难的肺实变、肺不张患者为对象,探讨改良急诊床旁肺部超声评估(BLUE)方案在ICU急性呼吸困难患者肺实变及肺不张诊断中的临床应用,现报道如下。
1 资料与方法
1.1 一般资料
选择2018年10月~2021年6月江西省萍乡市第二人民医院疑似急性呼吸困难的肺实变、肺不张患者56例作为对象。其中男34例,女22例,年龄39~82岁,平均(64.48±15.42)岁;病程3~60 d,体质量指数(BMI)18~29 kg/m2,平均(23.23±3.51)kg/m2;合并症:高血压4例、糖尿病3例、冠心病5例。本研究已通过笔者医院医学伦理委员会批准;患者或患者委托人对本次研究知情,并签署知情同意书。
1.2 纳入及排除标准
纳入标准:①参考急性呼吸困难的肺实变有关诊断标准[9,10],且患者具有完整的CT报告结果;②均可耐受完成重症肺超改良BLUE方案与传统BLUE方案检查;③入住ICU使用机械通气的患者,入住ICU有急性呼吸困难、呼吸衰竭的患者。排除标准:①原发于心排出量降低、心内解剖分流者;②严重肝肾功能异常或合并胸廓严重疾病者;③皮下气肿难以进行超声检查或严重血流动力学不稳定者。
1.3 方法
(1)临床资料采集。所有患者入院后查阅其病历资料,检索患者的年龄、性别及病史资料。(2)入住ICU后均采用GE vivid便携式超声诊断仪进行改良BLUE方案、传统BLUE方案检查;传统BLUE方案检查由超声室医生独立完成并诊断,传统BLUE方案:包括上蓝点、下蓝点、膈肌线、PLAPS点(posterolateral alveolar and/or pleural syndrome,即下蓝点垂直向后与同侧腋后线的交点);改良BLUE方案检查结果由医院医生独立完成并诊断:在传统BLUE方案基础上增加后蓝点。即包括:上蓝点:左手第3、4掌指关节部位;下蓝点:右手掌中心;膈肌线:右手小指横线;PLAPS:下蓝点垂直向后,并与同侧腋后线交点部位;后蓝点:肩胛下线与脊柱间区域。借助超声完成上述各个区域检查,确定并对比两侧的超声征象[11,12]。判断标准,根据超声征象判断患者肺部实变情况:①组织样征:肺部超声下出现类似于肝组织样结构;②碎片征、块状组织样结构,并位于胸膜下产生的征象;③支气管充气征[13,14]。上述检查完成24 h内行胸部CT和X线胸片检查,分别由两位放射科医师独立作出报告,且医生对改良BLUE检查结果不知情。以肺部CT检查作为“金标准”,将重症肺改良BLUE方案和传统BLUE方案检查、X线胸片结果与“金标准”进行比较,分析不同检查方法诊断效能(敏感度、特异性、诊断准确率、预测值)。
1.4 统计学方法
采用SPSS 21.0统计学软件进行分析数据,计量资料以均数±标准差(x±s)表示,满足正态分布和方差齐性,应用t检验,否则应用秩和检验。将CT诊断结果为“金标准”,将肺部超声、X线胸片结果与金标准进行比较,进行Kappa一致性检验,Kappa值为0~1,Kappa≥0.75表明两者有较好一致性,0.4≤Kappa<0.75表明两者一致性一般,Kappa<0.4表明两者一致性较差;采用χ2检验计算并比较超声与X线胸片诊断肺实变及肺不张的敏感度、特异性、阳性预测值、阴性预测值和准确率。P<0.05为差异有统计学意义。
2 结果
2.1 不同检查方法检查结果符合情况分析
56 例患者112侧肺部中,CT检查确诊肺实变及肺不张85侧(75.89%),改良BLUE方案检查诊断81侧(72.3%),传统BLUE方案确诊63侧(56.25%),X线胸片确诊35侧(44.64%);改良BLUE方案诊断肺实变及肺不张的敏感度为94.11%,特异性为96.29%,诊断准确率为94.64%;传统BLUE方案诊断肺实变及肺不张的敏感度为65.88%,特异性为74.07%,诊断准确率为67.85%;X线胸片诊断肺实变及肺不张的敏感度为41.18%,特异性为44.44%,诊断准确率为41.96%。配对资料McNemar检验提示,改良BLUE方案与CT诊断有较好的一致性(Kappa=0.89)。见表1。
2.2 不同检查方法诊断效能比较
重症肺超改良BLUE方案检查在ICU急性呼吸困难的肺实变、肺不张患者中诊断敏感度、特异性、阳性预测值、阴性预测值和诊断准确率均高于传统方案BLUE检查和X线胸片检查(P<0.05)。见表2、图1。
3 讨论
呼吸衰竭患者常通过呼吸机辅助通气治疗干预,借助该方法能改善患者症状,延缓病情发展。但是,机械通气属于一种创伤性操作,患者治疗后并发症发生率较高,远期预后较差[15]。因此,加强急性呼吸困难患者肺部实变诊断,对指导临床治疗具有重要意义。
胸部CT是急性困難肺部实变患者常用的诊断方法,但是该方法难以实现床旁检查,检查时常需要转运到影像科,风险较高,尤其是对于血流动力学不稳定患者,增加患者转运风险,使得该检查方法受到限制[16];床旁X线胸片则能弥补CT检查存在的弊端与不足,能实现床旁检查,避免对患者的转运,但是该方法诊断效能较低[17]。本研究显示,X线检查肺实变及肺不张的敏感度为41.18%,特异性为44.44%,诊断准确率为41.96%。因此还需寻找床旁准确性高、重复性好且快速的检查手段。
床旁超声则能弥补胸部CT和X线胸片检查的弊端,具有操作简单、无辐射、无创等优点,能对各种原因引起的患者通气变化进行快速评估,近年来,BLUE在急性呼吸困难患者肺实变中得到应用,且效果理想[18]。本研究中,传统BLUE方案诊断肺实变及肺不张的敏感度为65.88%,特异性为74.07%,诊断准确率为67.85%,本研究显示,传统的BLUE用于急性呼吸困难患者中诊断符合率相对较低。原因主要是ICU患者长期卧床,患者肺实变及肺不张主要分布于双肺下叶背段、后外侧基底段和后基底段,当患者仰卧时,此区域不易探查,导致临床漏诊率及误诊率较高[19]。因ICU患者在治疗期间以卧床为主,肺实变及肺不张发生部位常在重力作用下主要集中于肺下叶背段,故传统BLUE方案对肺实变及肺不张的诊断依然存在不足。
重症肺超改良BLUE方案则是在传统BLUE方案基础上增加后蓝点,具有安全性高、无创、方便快捷、经济有效及准确等优点,且该检查方法更加容易获得结果,避免对患者产生辐射。既往研究表明[20]:重症肺超改良BLUE对于右肺下叶后外侧基底段、后侧基底段、左肺下叶段等诊断符合率较高,对于早期发现重症急性呼吸困难患者肺部实变提供客观依据,能实现肺部实变的早期识别,能及时干预、改善预后、降低病死率、缩短住院时间。本研究中,改良BLUE方案诊断肺实变及肺不张的敏感度为94.11%,特异性为96.29%,诊断准确率为94.64%,与胸部CT检查具有较好一致性,重症肺超改良BLUE方案检查在ICU急性呼吸困难的肺实变患者中诊断敏感度、特异性、阳性预测值、阴性预测值和诊断准确率均高于传统BLUE方案检查和X线胸片检查(P<0.05),因此,临床上对于疑似ICU急性呼吸困难的肺实变、肺不张患者,应加强其重症肺超改良BLUE方案检查,帮助其早期确诊。
综上所述,改良BLUE方案对ICU急性呼吸困难患者肺实变及肺不张的诊断有较高敏感度、特异性及诊断准确率,值得推广应用为重症急性呼吸困难患者肺实变及肺不张首选检查手段。
[参考文献]
[1] 米婷,毛静,秦妮.咪达唑仑与右美托咪定对ICU慢性阻塞性肺疾病急性加重期机械通气患者的临床应用分析[J].解放军医药杂志,2019,31(5):105-108.
[2] 任迪,李颖,曾晶晶,等.高通量测序在重症肺部感染患者中的应用效果[J].中国医药导报,2020,17(7):94-97.
[3] 李艳花,苏锐,王娟娟,等.雾化吸入在慢性阻塞性肺疾病急性加重有创机械通气患者中的临床应用[J].中国药物与临床,2019,19(13):3.
[4] TuinmanPR,Jonkman AH,Dres M,et al. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients—a narrative review[J].Intensive Care Medicine,2020, 46(4):594-605.
[5] 朱海云,段军,孙艳文,等.急诊床旁肺部超声在诊断ICU术后低氧血症中的价值[J].中国中西医结合急救杂志,2019,26(3):293-295.
[6] 欧艳,李芳,刘利.M-BLUE对于急性呼吸衰竭鉴别及病因诊断中的价值[J].临床肺科杂志,2020,25(6):54-58.
[7] 侯晓红,刘伟明,段飞,等.改良床旁肺部超声评估方案在重症肺炎机械通气患者胸部物理治疗中的应用[J].中国实用护理杂志,2020,36(2):146-149.
[8] 陈卫挺,陈英姿,陈仁辉,等.改良BLUE方案在ICU患者肺实变评估中的应用[J].浙江医学,2019,41(8):826-828.
[9] 夏宇,黄雪培,姜玉新.经胸壁肺部超声在急性呼吸困难患者中的应用研究[J].医学研究杂志,2019,48(3):1-4.
[10] Peafiel FS,Tapia AP,Nesvadba DF,et al. Manifestaciones clínicas y predictores de gravedad en pacientes adultos con infección respiratoria aguda por coronavirus SARS-CoV-2[J].Revista medica de Chile,2020,148(10):1387-1397.
[11] 张亮,王波,范志强,等.保护性肺通气在重症胸部创伤合并急性呼吸窘迫综合征中的临床应用效果[J].中国医药导刊,2019,21(12):19-23.
[12] 劉奇,陆欢,单梦田,等.头罩无创通气在慢性阻塞性肺疾病急性加重合并呼吸衰竭患者中的应用[J].中华危重病急救医学,2020,32(1):14-19.
[13] Liu Y,Xie W,Meng Y,et al.The clinical course of critically ill COVID-19 patients receiving invasive mechanical ventilation with subsequent terminal weaning: Primary data from 11 cases[J].Medicine,2021,100(16):e25619.
[14] 魏霞,曹秀廷.风险预警制度指导的预见性护理在ICU急性呼吸衰竭患者中的应用效果[J].中国医药导报,2019, 16(32):4.
[15] Neto AS, Hemmes SN, Barbas CS, et al.Association between driving pressure and vdevelopment of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: A meta-analysis of individual patient data[J].Lancet Respiratory Medicine,2016,4(4):272-280.
[16] 马伟峰.浅谈X线床旁胸片对新生儿呼吸困难的诊断价值[J].世界最新医学信息文摘,2019,19(3):158.
[17] Cai Q,Wu C,Xu W,et al.Stiff-person syndrome coexisting with critical illness polyneuropathy: A case report[J].Medicine,2020,99(50):e23 607.
[18] 赵浩天,龙玲,任珊,等.肺超声胸部X线和CPIS评分对ICU重症肺炎患者肺实变的诊断价值分析[J].河北医学,2020,26(12):124-129.
[19] 刘路,梅清,潘爱军.电子支气管镜肺泡灌洗术在重症监护室机械通气伴有肺不张病人中的应用[J].安徽医药,2019,23(12):2386-2389.
[20] 王灵,杨勇灵,张郑平,等.ICU重症肺炎并休克患者发生急性呼吸窘迫综合征预警指标研究[J].海南医学,2019, 30(19):2449-2452.
(收稿日期:2021-11-22)