床旁超声监测小儿先心病术后反向膈肌运动与膈肌移动度减低对评估神经麻痹的临床价值

Clinical values of the monitor with bedside ultrasound for the movement of reverse diaphragm and the reduction of diaphragmatic mobility after CHD surgery in assessing neural paralysis

目的:研究床旁超声监测小儿先天性心脏病术后反向膈肌运动与膈肌移动度减低评估神经麻痹的应用价值。方法:选取于医院进行先天性心脏病手术后出现自主呼吸困难的53例患儿,均采用床旁超声监测膈肌运动,以反映膈神经情况,评估反向膈肌运动与膈肌移动度减低进行联合诊断膈肌麻痹的临床价值;统计术后及胸片确诊膈神经麻痹患儿超声下不同表现情况及所占比例。结果:在53例患儿中经手术确诊16例反向膈肌运动患儿为膈神经麻痹;25例膈肌移动度减低患儿中7例经手术确诊为膈神经麻痹、2例经胸片复查确诊为膈神经麻痹、16例经观察排除为膈神经麻痹;12例正常运动膈肌经观察期与复查胸片均排除为膈神经麻痹。床旁超声监测反向膈肌运动与膈肌移动度减低联合诊断膈肌麻痹的灵敏度为100%、特异度为42.86%,准确率为69.81%,阳性预测值为60.98%,阴性预测值为100%。25例膈神经麻痹患儿中,16例反向膈肌运动患儿均确诊,25例膈肌移动度减低患儿中9例确诊,两种确诊方法比例比较差异有统计学意义(x^(2)=16.794,P<0.05);床旁超声监测可重复性较好(Kappa=0.904)。结论:床旁超声监测小儿先天性心脏病术后膈肌麻痹的灵敏度、可重复性均较高,可将反向膈肌运动作为诊断标准应用于临床诊断,辅以动态观察膈肌移动度减低,以缩短膈肌麻痹患儿确诊时间。

Objective:To explore the application value of the monitor with bedside ultrasound for the movement of reverse diaphragm and the reduction of diaphragmatic mobility after the surgery of congenital heart disease(CHD)of children in assessing neural paralysis.Methods:53 child patients who occurred autonomous respiration dyspnea after underwent CHD surgery.All of them adopted bedside ultrasound to monitor the movement of diaphragm for reflecting the condition of phrenic nerve and assessing the clinical value of the combined diagnosis of the movement of reverse diaphragm and the reduction of diaphragmatic mobility.The different appearance and the proportion of these appearance of these child patients with neural paralysis on phrenic nerve who were confirmed by surgery and chest radiography were further analyzed as statistic method.Results:In 53 child patients,16 cases with the movement of reverse diaphragm were confirmed as neural paralysis on phrenic nerve and 7 cases of 25 child patients with the reduction of diaphragmatic mobility were confirmed as neural paralysis on phrenic nerve by surgery,and 2 cases of them were confirmed as neural paralysis on phrenic nerve by chest radiography,and 16 cases of them were excluded by observation,12 cases with normal motion diaphragm of them were excluded by observation stage and reexamination on chest radiography.The sensitivity,specificity,accuracy,positive predictive value and negative predictive value of the combined diagnosis of"the movement of reverse diaphragm and the reduction of diaphragmatic mobility"by the monitor with bedside ultrasound were 100%,42.86%,69.81%,60.98%and 100%,respectively,on diaphragmatic paralysis.In the 25 child patients with phrenic nerve palsy,16 cases with the movement of reverse diaphragm were confirmed,and 9 cases of 25 child patients with the reduction of diaphragmatic mobility were confirmed.The difference of the ratio between the two methods was significant(x^(2)=16.794,P<0.05).And the repeatability of the monitor with bedside ultrasound was favorable(Kappa=0.904).Conclusion:The sensitivity and repeatability of the monitor with bedside ultrasound on the postoperative diaphragmatic paralysis of child patients with CHD are higher,and the movement of reverse diaphragm can be used as diagnostic standard in clinical diagnosis to assist the dynamic observation on the reduction of diaphragmatic mobility so as to shorten the confirmed time of child patients with diaphragmatic paralysis.