不同检查方法评估COPD患者膈肌运动状态的比较

Comparison of different examination methods in evaluating diaphragmatic motion in patients with COPD

目的:通过比较不同膈肌测量方法评估不同严重程度慢性阻塞性肺疾病(COPD)的准确性以探索最优的膈肌检查方法。方法:选择我院COPD患者120例,并根据COPD全球倡议(GOLD)分为4级,每一级患者30例。对所有GOLD 1~4级患者分别行膈肌的M型超声法和B超直接法检查。记录患者用力呼气时的膈肌运动幅度(DMA)以及开始呼气到呼气第一秒内膈肌的运动幅度(DMA1)。采用同样方法对所有患者行X线膈肌运动角度测量,记录右侧膈肌呼气末顶点和右肋膈角顶点连线与水平线所成角度(DMAG),以及开始呼气到呼气第一秒时膈肌的运动角度(DMAG1)。采用Kappa一致性分析法评估超声、X线测量膈肌运动与肺功能检测结果的一致性。利用ROC曲线分析超声及X线鉴别COPD不同严重程度的准确性。结果:三种膈肌测量方法获得的结果均随着GOLD分级的逐渐升高而逐渐降低,差异均有统计学意义(均P<0.05)。M型超声法与GOLD分级的一致性最好(Kappa=0.911,P=0.000),X线测量法次之(Kappa=0.700,P=0.000)。M型超声法和X线测量法在鉴别GOLD 1级vs. GOLD 2级方面AUC均较低(0.711,0.750)。在鉴别GOLD 2级vs. GOLD 3级方面,M型超声法和X线测量法均获得最好的AUC(0.928,0.938)。在鉴别GOLD 3级vs. GOLD 4级方面,M型超声法的AUC(0.916)大于X线测量法(0.764),差异有统计学意义(z=2.101,P=0.036)。M型超声法的最佳诊断点为4.58 cm,此时敏感性为100%,特异性为73.33%。结论:M型超声法相比X线测量法和B超直接法能够更准确的区分不同严重程度的COPD。

Objective: To evaluate the optimal diaphragmatic examination methods by comparing the accuracy of different diaphragm measurements in chronic obstructive pulmonary disease(COPD) patients of different severity. Methods: A total of 120 patients with COPD were enrolled in our hospital. According to the global initiative for chronic obstructive pulmonary disease(GOLD), patients were divided into 4 groups with 30 patients in each group. M-mode ultrasound and B-ultrasound direct examination of the diaphragm were performed in all patients with GOLD 1~4. The diaphragm movement amplitude(DMA) when the patient was forced to exhale and the diaphragm movement amplitude in one second(DMA1) were recorded. All patients underwent X-ray diaphragm movement angle measurement in the same way, and the right diaphragm movement angle(DMAG)and diaphragm movement angle in one second(DMAG1) were recorded. Kappa consistency analysis was used to evaluate the consistency of ultrasound and X-ray measurements of diaphragm movement and lung function tests. ROC curves of ultrasound and X-ray were used to identify the accuracy of different severity of COPD. Results: The data obtained by the three diaphragm measurements were gradually decreased with the increase of GOLD grade, and the differences were statistically significant(P<0.05). M-mode ultrasound had the best agreement with GOLD classification(Kappa=0.911, P=0.000), followed by X-ray measurement(Kappa=0.700, P=0.000). M-mode ultrasound and X-ray measurements had lower AUC(0.711, 0.750) in the identification of GOLD 1 vs. GOLD 2. In the identification of GOLD 2 vs. GOLD 3, the best AUC(0.928, 0.938) were obtained for both M-mode ultrasound and X-ray measurements. In the identification of GOLD 3 vs. GOLD 4, the AUC(0.916) of the Mmode ultrasound method was greater than the X-ray measurement(0.764), and the difference was statistically significant(z=2.101, P =0.036). The best diagnostic point for M-mode ultrasound was 4.58 cm, where the sensitivity was 100% and the specificity was 73.33%. Conclusion: M-mode ultrasound method can identify COPD of different severity more accurately compared with X-ray measurement and B-ultrasound direct examination.