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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2019, Vol. 16 ›› Issue (11) : 832 -837. doi: 10.3877/cma.j.issn.1672-6448.2019.11.007

所属专题： 文献；

肌肉骨骼超声影像学

膈肌超声对脑卒中后机械通气患者脱机的评估研究
张成1, 黄怀1,†(), 沈丹彤1, 古菁1, 叶水林1, 邢然然1, 钱绮雯1, 李新亚1, 叶云霞1   
  1. 1. 510010　广州，南部战区总医院　神经医学专科医院神经康复二科
  • 收稿日期:2019-06-30 出版日期:2019-11-01
  • 通信作者: 黄怀
  • 基金资助:
    广东省医学科学技术研究基金项目(A2018327); 军队后勤科研项目(CWH17J022)

Prediction of weaning from mechanical ventilation in patients after cerebral apoplexy by diaphragm ultrasound

Cheng Zhang1, Huai Huang1,†(), Dantong Shen1, Jing Gu1, Shuilin Ye1, Ranran Xing1, Qiwen Qian1, Xinya Li1, Yunxia Ye1   

  1. 1. The Second Department of Neurologic Rehabilitation of Neurologic Specialized Hospital, General Hospital of Southern Theatre Command of PLA, Guangzhou 510010, China
  • Received:2019-06-30 Published:2019-11-01
  • Corresponding author: Huai Huang
  • About author:
    Corresponding author: Huanghuai, Email:
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引用本文：

张成, 黄怀, 沈丹彤, 古菁, 叶水林, 邢然然, 钱绮雯, 李新亚, 叶云霞. 膈肌超声对脑卒中后机械通气患者脱机的评估研究[J/OL]. 中华医学超声杂志（电子版）, 2019, 16(11): 832-837.

Cheng Zhang, Huai Huang, Dantong Shen, Jing Gu, Shuilin Ye, Ranran Xing, Qiwen Qian, Xinya Li, Yunxia Ye. Prediction of weaning from mechanical ventilation in patients after cerebral apoplexy by diaphragm ultrasound[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2019, 16(11): 832-837.

目的

探讨膈肌超声在脑卒中后机械通气患者脱机中的评估价值。

方法

选取2017年8月至2018年12月入住南部战区总医院神经外科重症监护室、内科重症监护室脑卒中并机械通气患者机械通气时间大于48 h、符合自主呼吸试验（SBT）脱机标准患者80例，SBT 30 min时记录气道闭合压（P0.1）、最大吸气压（MIP）、计算P0.1/MIP、浅快呼吸指数（RSBI），测量左侧、右侧及双侧平均的膈肌移动度（DE），采用受试者工作特征曲线（ROC）评估各项指标预测价值，计量资料采用t检验、Mann-whitney U检验，计数资料采用χ2检验。

结果

脱机成功组59例，脱机失败组21例，脱机成功组与脱机失败组比较，机械通气时间、监护室住院时间、Paco2、潮气量、P0.1/MIP、RSBI、左侧DE，差异均有统计学意义（U=2.484、2.629，t=-2.903、2.049、4.368、2.127、3.030，P均<0.05），右侧DE、双侧平均DE，差异均有统计学意义（t=-6.430、-4.625，P均<0.01）；双侧平均DE预测脱机效果最为理想，敏感度为93.8%，特异度为82.3%，ROC曲线下面积（AUC）为0.859；右侧DE，敏感度为85.5%，特异度为75.7%，AUC为0.786；左侧DE，敏感度为81.7%，特异度为78.9%，AUC为0.763；浅快呼吸指数敏感度为78.6%，特异度为61.3%，AUC为0.706；P0.1/MIP敏感度为73.9%，特异度为59.7%，AUC为0.685。

结论

膈肌超声可有效评估脑卒中后机械通气患者的脱机结果，结合SBT，其有效性优于传统脱机指标。

关键词: 脑卒中, 膈肌超声, 机械通气, 预判
Objective

To evaluate the value of diaphragm ultrasound in predicting weaning from mechanical ventilation in patients after stroke.

Methods

From August 2017 to December 2018, 80 patients with stroke who were admitted to the neurological intensive care unit (NICU) and medical ICU (MICU) of General Hospital of Southern Theatre Command of PLA for mechanical ventilation for more than 48 hours and met the standard of spontaneous breathing test (SBT) were selected. At 30 minutes after SBT, airway closing pressure (P0.1) and maximum inspiratory pressure (MIP) were recorded, P0.1/MIP and shallow rapid breathing index (RSBI) were calculated, and left diaphragm mobility, right diaphragm mobility, and bilateral average diaphragm mobility (DE) were measured by ultrasound. The predictive value of each index was evaluated by receiver operating characteristic (ROC) curve analysis. The t-test and Mann-Whitney U test were used for comparing measurement data, and the Chi-square test was used for comparing count data.

Results

There were 59 patients who had successful ventilator weaning and 21 who had ventilator weaning failure. Mechanical ventilation time, hospital stay in the ICU, PaCO2, tidal volume, P0.1/MIP, RSBI, and left DE differed significantly between the two groups (U=2.484 and 2.629, and t=-2.903, 2.049, 4.368, 2.127, and 3.030, respectively, P<0.05). Right DE and bilateral mean DE were also significantly different between the two groups (t=-6.430 and -4.625, respectively, P<0.01). Bilateral average DE was the best indictor to predict the weaning results, with a sensitivity of 93.8%, specificity of 82.3%, and area under the ROC curve (AUC) of 0.859. The sensitivity, specificity, and specificity of right DE, left DE, shallow fast respiration index, and P0.1/MIP were 85.5%, 75.7%, and 0.786, 81.7%, 78.9%, and 0.763, 78.6%, 61.3%, and 0.706, and 73.9%, 59.7%, and 0.685, respectively.

Conclusion

Diaphragmatic ultrasound can effectively predict the weaning results in patients with mechanical ventilation after stroke. When combined with SBT, diaphragmatic ultrasound has better effectiveness than traditional weaning indicators.

Key words: Stroke, Diaphragm ultrasound, Mechanical ventilation, Prediction
图1 M型超声下膈肌活动
表1 脑卒中机械通气患者基本资料
参数 脱机成功组（59例） 脱机失败组（21例） 统计值 P值
年龄（岁，±s） 57.35±13.66 59.26±14.82 t=0.531 0.598
性别（男/女） 40/19 14/7 χ2=0.594 0.441
身高（cm，±s） 167.16±8.56 165.00±7.07 t=0.597 0.553
体重（kg，±s） 63.00±9.27 65.83±10.33 t=0.472 0.669
脑卒中类型（出血/梗死） 42/17 13/8 χ2=0.262 0.610
机械通气时间［d，M（p25，p75）］ 3.5（3，5） 7（5，8） U=2.484 0.013
监护室住院时间［d，M（p25，p75）］ 5（3，7.5） 9（6，10） U=2.629 0.012
PaO2（mmHg） 92.39±25.39 86.92±22.85 t=0.580 0.563
PaCO2（mmHg） 35.22±6.41 40.26±10.28 t=-2.903 0.007
潮气量（ml） 510.96±128.45 483.52±112.61 t=2.049 0.048
表2 脱机成功组与脱机失败组机械通气患者脱机时参数比较（±s）
组别 例数 浅快呼吸指数 P0.1/MIP 左侧DE（mm） 右侧DE（mm） 双侧平均DE（mm）
脱机成功组 59 42.59±15.77 0.18±0.11 14±7 18±4 17±6
脱机失败组 21 58.29±22.51 0.21±0.15 10±2 11±3 10±4
t值 ? 2.127 4.368 3.030 -6.430 -4.625
P值 ? 0.039 0.022 0.010 <0.001 <0.001
表3 观察指标对脑卒中机械通气患者脱机预测能力
参数 最佳临界值 曲线下面积（95%CI） 敏感度（%） 特异度（%） P值
浅快呼吸指数 51 0.706（0.513~0.899） 78.6 61.3 <0.001
P0.1/MIP 0.31 0.685（0.552~0.818） 73.9 59.7 <0.001
左侧DE（mm） 9.6 0.763（0.641~0.885） 81.7 78.9 <0.001
右侧DE（mm） 12.1 0.786（0.656~0.916） 85.5 75.7 <0.001
双侧平均DE（mm） 13.5 0.859（0.758~0.960） 93.8 82.3 <0.001
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