切换至 "中华医学电子期刊资源库"
高级检索
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:
全文 ( ) 下载PDF ( ) 导出引用
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]. 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]. 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
1
Demoule A, Jung B, Prodanovic H, et al. Diaphragm dysfunction on admission to the intensive care unit. Prevalence, risk factors, and prognostic impact-a prospective study [J]. Am J Respir Crit Care Med, 2013, 188(2): 213-219.
2
Umbrello M, Formenti P, Longhi D, et al. Diaphragm ultrasound as indicator of respiratory effort in critically ill patients undergoing assisted mechanical ventilation: a pilot clinical study [J]. Crit Care, 2015, 19(1): 161.
3
Cox CE, Carson SS. Medical and economic implications of prolonged mechanical ventilation and expedited post-acute care [J]. Semin Respir Crit Care Med, 2012, 33(4): 357-361.
4
Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation [J]. Crit Care Clin, 2018, 34(3): 357-381.
5
Zorowitz RD. ICU-Acquired Weakness: A Rehabilitation Perspective of Diagnosis, Treatment, and Functional Management [J]. Chest, 2016, 150(4): 966-971.
6
Matamis D, Soilemezi E, Tsagoufias M, et al. Sonographic evaluation of the diaphragm in criti callv ill patients. Technique and clinical applications [J]. Intensive Care Med, 2013, 39(5): 801-810.
8
Richard P. Exploring the diaphragm: Ultrasound is essential [J]. Rev Mal Respir, 2017, 34(6): 645-660.
9
Lieber RL, Steinman S, Barash IA, et al. Structural and functional changes in spastic skeletal muscle [J]. Muscle Nerve, 2004, 29(5): 615-276.
10
Pinheiro MB, Polese JC, Faria CD, et al. Inspiratory muscular weakness is most evident in chronic stroke survivors with lower walking speeds [J]. Eur J Phys Rehabil Med, 2014, 50(3): 301-307.
11
Jung KJ, Park JY, Hwang DW, et al. Ultrasonographic Diaphragmatic Motion Analysis and Its Correlation With Pulmonary Function in Hemiplegic Stroke Patients [J]. Ann Rehabil Med, 2014, 38(1): 29-37.
12
Kim M, Lee K, Cho J, et al. Diaphragm Thickness and Inspiratory Muscle Functions in Chronic Stroke Patients [J]. Med Sci Monit, 2017, 23: 1247-1253.
13
Boon AJ, Harper CJ, Ghahfarokhi LS, et al. Two-dimensional ultrasound imaging of the diaphragm: Quantitative values in normal subjects [J]. Muscle Nerve, 2013, 47(6): 884-889.
14
Jung B, Nougaret S, Conseil M, et al. Sepsis Is Associated with a Preferential Diaphragmatic Atrophy A Critically Ill Patient Study Using Tridimensional Computed Tomography [J]. Anesthesiology, 2014, 120(5): 1182-1191.
15
Boussuges A, Gole Y, Blanc P. Diaphragmatic Motion Studied by M-Mode Ultrasonography [J]. Chest, 2009, 135(2): 391-400.
16
Llamas-Álvarez AM, Tenza-Lozano EM, Latour-Pérez J. Diaphragm and Lung Ultrasound to Predict Weaning Outcome [J]. Chest, 2017, 152(6): 1140-1150.
17
Orde SR, Boon AJ, Firth DG, et al. Use of Angle-Independent M-Mode Sonography for Assessment of Diaphragm Displacement [J]. J Ultrasound Med, 2016, 35(12): 2615-2621.
18
Ayoub J, Cohendy R, Prioux J, et al. Diaphragm Movement Before and After Cholecystectomy: A Sonographic Study [J]. Anesth Analg, 2001, 92(3): 755-761.
19
Zambon M, Greco M, Bocchino S, et al. Assessment of diaphragmatic dysfunction in the critically ill patient with ultrasound:a systematic review [J]. Intensive Care Med, 2016, 43(1): 29-38.
20
de Souza LC, da Silva CT Jr, Almeida JR, et al. Comparison of Maximal Inspiratory Pressure, Tracheal Airway Occlusion Pressure, and Its Ratio in the Prediction of Weaning Outcome: Impact of the Use of a Digital Vacuometer and the Unidirectional Valve [J]. Respir Care, 2012, 57(8): 1285-1290.
21
王飞飞，朱晓萍，张常晶，等. 机械通气对AECOPD患者膈肌收缩功能的影响 [J]. 中华危重病急救医学, 2017, 29(11): 988-993.
[1] 徐娟, 孙汝贤, 赵东亚, 张清艳, 金兆辰, 蔡燕. 右美托咪定序贯镇静模式对中深度镇静的机械通气患者预后和谵妄的影响[J]. 中华危重症医学杂志(电子版), 2023, 16(05): 363-369.
[2] 豆艺璇, 黄怀, 钱绮雯, 邢然然, 林丽, 白建芳. 低强度吸气肌训练对机械通气患者肺康复的影响[J]. 中华危重症医学杂志(电子版), 2023, 16(05): 370-375.
[3] 许振琦, 易伟, 范闻轩, 王金锋. 经鼻高流量氧疗与无创机械通气在严重创伤术后轻中度低氧血症患者中的临床应用[J]. 中华危重症医学杂志(电子版), 2023, 16(04): 306-309.
[4] 钱晓英, 吴新, 徐婷婷. 颅脑损伤并发呼吸衰竭患者早期机械通气的效果分析[J]. 中华肺部疾病杂志(电子版), 2023, 16(04): 526-528.
[5] 代芬, 卞士柱. 无创机械通气联合肺康复在肺动脉高压呼吸衰竭治疗中的临床应用[J]. 中华肺部疾病杂志(电子版), 2023, 16(04): 560-562.
[6] 尚慧娟, 袁晓冬. 机械取栓术后应用依达拉奉右崁醇对急性缺血性脑卒中预后的改善[J]. 中华神经创伤外科电子杂志, 2023, 09(05): 295-301.
[7] 廖家权, 吴波, 唐昌敏. 体外冲击波联合肌电生物反馈对脑卒中后足下垂的影响[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(05): 286-292.
[8] 许方军, 曹晓光, 王修敏, 董学超, 刘云卫, 彭云飞, 周康. 虚拟情景互动技术联合肩胛骨运动控制强化训练对偏瘫患者上肢功能及日常生活活动能力的影响[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(04): 222-228.
[9] 侯牧韶, 刘子渤, 李红玲. 局部振动疗法治疗脑卒中后运动障碍的研究进展[J]. 中华脑科疾病与康复杂志(电子版), 2023, 13(04): 246-250.
[10] 孙畅, 赵世刚, 白文婷. 脑卒中后认知障碍与内分泌激素变化的关系[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 471-476.
[11] 张许平, 刘佳成, 张舸, 杜艳姣, 李韶, 商丹丹, 王浩, 李艳, 段智慧. CYP2C19基因多态性联合血栓弹力图指导大动脉粥样硬化型非致残性缺血性脑血管事件患者抗血小板治疗的效果[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 477-481.
[12] 杨海华, 袁景林, 周晓梅, 牛军伟. RNF213基因突变所致烟雾病一家系病例临床分析并文献复习[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 495-498.
[13] 李昕, 李永凯, 江树青, 夏来百提姑·赛买提, 杨建中. 急性缺血性脑卒中静脉溶栓后出血转化相关危险因素分析[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 331-336.
[14] 邓颖, 黄山, 胡慧秀, 孙超. 老年缺血性脑卒中患者危险因素聚集情况分析[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 344-349.
[15] 祁研, 张岩, 陈雪, 刘颖, 史楠. 探讨高低频交互rTMS对老年脑卒中偏瘫患者肢体功能、吞咽功能及日常生活活动能力的影响[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 359-363.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号