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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） ›› 2021, Vol. 18 ›› Issue (09) : 875 -879. doi: 10.3877/cma.j.issn.1672-6448.2021.09.011

重症超声影像学

超声评估右心功能预测机械通气患者撤机效果
谈媛媛1, 丁振兴1, 张丹1, 俞凤1,†()   
  1. 1. 230022　合肥，安徽医科大学第一附属医院急诊科
  • 收稿日期:2020-11-23 出版日期:2021-09-01
  • 通信作者: 俞凤

Right heart function measured by ultrasonography for predication of withdrawal result in patients on mechanical ventilation

Yuanyuan Tan1, Zhenxing Ding1, Dan Zhang1, Feng Yu1,†()   

  1. 1. Department of Emergency Medicine, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
  • Received:2020-11-23 Published:2021-09-01
  • Corresponding author: Feng Yu
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谈媛媛, 丁振兴, 张丹, 俞凤. 超声评估右心功能预测机械通气患者撤机效果[J]. 中华医学超声杂志（电子版）, 2021, 18(09): 875-879.

Yuanyuan Tan, Zhenxing Ding, Dan Zhang, Feng Yu. Right heart function measured by ultrasonography for predication of withdrawal result in patients on mechanical ventilation[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2021, 18(09): 875-879.

目的

探讨超声评估右心功能预测机械通气患者撤机的效果。

方法

选择2018年1月至2020年11月在安徽医科大学第一附属医院收治的机械通气患者，通过撤机筛查后采用T管模式进行自主呼吸试验的患者100例，观察其撤机效果，并采用超声检测撤机成功与撤机失败组患者的右心功能指标。采用t检验比较2组患者基本临床特征、生命体征及右心功能指标的差异，通过受试者操作特征（ROC）曲线下面积（AUC）评价各心功能指标对撤机结果的预测价值。

结果

本研究中撤机成功者78例，失败者22例，撤机成功率为78.0%（78/100）。2组患者撤机前各项指标比较，撤机失败组患者中心静脉压水平明显高于撤机成功组［（10.1±2.9）mmHg vs（7.3±2.8）mmHg；1 mmHg=0.133 kPa］，差异具有统计学意义（t=7.871，P=0.002）；性别、年龄、急性生理学与慢性健康状况评分系统Ⅱ评分、心率、呼吸频率、平均动脉压、动脉血氧分压/吸入氧浓度、乳酸浓度比较，差异均无统计学意义（P均＞0.05）。与撤机成功组比较，撤机失败组的三尖瓣环根部侧壁收缩期位移（TAPSE）、三尖瓣舒张早期血流峰速度/舒张晚期血流峰速度（E/A）均较低［（13.3±6.8）mm vs（25.2±6.4）mm；（1.0±0.4）vs（1.6±0.6）］，右心室舒张末期面积/左心室舒张末期面积、呼气末下腔静脉内径则升高明显［（0.9±0.1）vs（0.5±0.2）；（19.0±4.8）mm vs（14.3±4.5）mm］，差异具有统计学意义（t=18.825、8.733，-9.221、-17.955，P=0.001、=0.024、＜0.001、=0.001）。心脏超声检查各指标对患者撤机结果均有预测价值，其中TAPSE和三尖瓣E/A预测撤机结果的AUC较大（0.87和0.75）。

结论

机械通气患者的右心功能可预测撤机结果，并指导液体管理，可通过床旁自主呼吸试验前超声对其进行评估。

关键词: 机械通气, 超声, 撤机结果, 右心功能, 预测
Objective

To assess the clinical value of right heart function measured by ultrasonography in predicting the withdrawal result in patients on mechanical ventilation.

Methods

One hundred patients on mechanical ventilation who were treated at the First Affiliated Hospital of Anhui Medical University from January 2018 to November 2020 were enrolled. T tube model was used to perform spontaneous breathing trial in these patients after machine withdrawal screening. The withdrawal result was observed, and ultrasonography was used to compare the right heart function indexes between withdrawal success and withdrawal failure groups. The area under the curve of each heart function index in predicting the withdrawal result was assessed.

Results

Of the 100 patients included, 78 had successful withdrawal and 22 had failed withdrawal, with a success rate of 78.0% (78/100). Before withdrawal, the central venous pressure was significantly higher in the failure group than in the success group [(10.1±2.9) mmHg vs (7.3±2.8) mmHg; t=7.871, P=0.002], while sex, age, acute physiology and chronic health evaluation Ⅱ score, heart rate, respiratory frequency, mean arterial pressure, central venous pressure, pressure of oxygen in arterial blood/fraction of inspired oxygen, and lactate concentration were comparable between the two groups (P＞0.05). Compared with the successful withdrawal group, systolic displacement of the tricuspid annulus and the ratio of the blood flow peak velocity in the early diastole to the blood flow peak velocity in the late diastole were significantly lower [(13.3±6.8) mm vs (25.2±6.4) mm, t=18.825, P=0.001; (1.0±0.4) vs (1.6±0.6), t=8.733, P=0.024], and right ventricular end diastolic area/left ventricular end diastolic area ratio and end expiratory inferior vena cava diameter were significantly higher [(0.9±0.1) vs (0.5±0.2), t=-9.221, P＜0.001; (19.0±4.8) mm vs (14.3±4.5) mm, t=-17.955, P=0.001 in the failure group. The cardiac ultrasound index TAPSE, mitral E/A, RVarea/LVarea, dIVC has predictive value for patient withdrawal results, with TAPSE (0.87) and mitral E/A (0.75) predicting large AUC of withdrawal results.

Conclusion

Right heart function assessed by ultrasonography can predict the withdrawal result and guide fluid management in patients on mechanical ventilation.

Key words: Mechanical ventilation, Ultrasonography, Withdrawal result, Right heart function, Prediction
图1 超声检查机械通气患者三尖瓣环根部侧壁收缩期位移提示右心室收缩功能障碍
图2 超声检查机械通气患者聚焦于右心室的心尖四腔心切面
表1 2组机械通气患者基本临床特征及生命体征比较
组别 例数 年龄（岁，
x¯
±s）		 男/女（例） APACHE Ⅱ评分（分，
x¯
±s）		 心率（次/min，
x¯
±s）		 呼吸频率（次/min，
x¯
±s）		 MAP（mmHg，
x¯
±s）		 CVP（mmHg，
x¯
±s）		 PaO2/FiO2（mmHg，
x¯
±s）		 乳酸浓度（mmol/L，
x¯
±s）
撤机成功组 78 59.2±14.8 49/29 10.2±4.1 83.0±14.0 14.0±5.0 81.3±11.6 7.3±2.8 283.2±74.8 2.0±0.5
撤机失败组 22 60.1±14.9 14/8 11.1±4.9 87.0±15.0 16.0±6.0 80.7±11.0 10.1±2.9 279.1±75.2 2.0±0.6
统计值 t=0.558 χ2=0.063 t=0.282 t=0.313 t=0.378 t=0.118 t=7.871 t=1.167 t=1.003
P值 0.455 0.962 0.784 0.764 0.717 0.925 0.002 0.255 0.327
表2 2组机械通气患者心脏超声检查指标比较（
xˉ
±s）
组别 例数 TAPSE（mm）

三尖瓣

E/A

 RVarea/LVarea dIVC（mm）
撤机成功组 78 25.2±6.4 1.6±0.6 0.5±0.2 14.3±4.5
撤机失败组 22 13.3±6.8 1.0±0.4 0.9±0.1 19.0±4.8
t值 18.825 8.733 -9.221 -17.955
P值 0.001 0.024 ＜0.001 0.001
表3 不同心脏超声检查指标对机械通气患者撤机结果的预测价值
超声检查指标 AUC 95%CI P值 截断值 敏感度（%） 特异度（%）
TAPSE 0.87 0.81~0.96 0.01 15.0 94 78
三尖瓣E/A 0.75 0.67~0.89 0.01 1.0 82 78
RVarea/LVarea 0.73 0.63~0.88 0.01 0.7 75 80
dIVC 0.70 0.60~0.87 0.01 18.0 66 79
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