膈肌电活动监测在神经重症患者呼吸机撤机中的应用价值

Study on the application value of diaphragm electrical activity monitoring in the weaning of neurosurgery patients

目的:目的:探讨通过膈肌电活动(electrical activity of the diaphragm,EAdi)监测技术评价膈肌功能指标,明确膈肌电活动监测技术在神经危重症患者呼吸机撤机中的指导价值。方法:选取2019年3月—2021年7月收治的皖南医学院第一附属医院神经外科ICU行机械通气时间大于24h并且符合撤机条件的患者共52例。所有患者撤机前均经鼻植入膈肌电活动(EAdi)监测导管并采用低水平压力支持通气(PSV)进行自主呼吸实验(spontaneous breathing trial,SBT)30min,记录SBT结束时的生命体征、动脉血气、机械通气参数及膈肌功能指标[主要包括膈肌电活动峰值(EAdimax)、膈肌电活动低值(EAdimin)、神经通气耦联指数(NVE)、神经机械耦联指数(NME)]。根据撤机结果将患者分为撤机成功组和撤机失败组,采用受试者工作特征曲线(ROC)评价各膈肌指标预测撤机成功的价值。结果:52例患者中撤机成功(成功组)38例,撤机失败(失败组)14例。两组患者SBT结束时,在生命体征方面:成功组心率(HR)、呼吸频率(RR)均显著低于失败组[HR:74(66.5~83)vs 92(72.75~102)次/min,RR:19(14.75~25.25)vs 27.5(18.5~31)次/min,P<0.05]。在动脉血气方面:成功组的PaCO_(2),显著高于失败组[33.8(32~35)vs 30.55(29.5~33.8)mmHg,P<0.05]。在机械通气参数监测方面均无显著差异(P>0.05)。在膈肌功能方面:成功组的NVE、NME、NVE×NME均显著高于失败组[NVE:99.5(92~142)vs 91.5(25.5~96.5)mL/μV、NME:2.25(1.9~3.3)vs 1.85(0.88~2.3)cmH_(2)O/μV、NVE×NME:265.05(199.48~303.6)vs182.9(20.33~242.64)mL×cmH_(2)O/μV^(2),P<0.05]。当NVE的最佳临界值为59.15 mL/μV时,预测撤机成功的敏感度为100%,特异度为42.9%,ROC曲线下面积(AUC)为0.727(95%CI:0.567~0.888);当NME的最佳临界值为1.83 cmH_(2)O/μV时,预测撤机成功的敏感度为86.80%,特异度为50%,ROC曲线下面积(AUC)为0.736(95%CI:0.581~0.891);当NVE×NME的最佳临界值为76.4 mL×cmH_(2)O/μV^(2)时,预测撤机成功的敏感度为100%,特异度为42.9%,ROC曲线下面积(AUC)为0.757(95%CI:0.607~0.906)。结论:通过膈肌电活动监测技术量化评价患者膈肌功能指标对指导临床撤机具有一定的意义,同时今后也有望作为新的撤机参照指标。

Objective:To explore the use of electrical activity of the diaphragm(EAdi)monitoring technology to evaluate diaphragm function indicators,and to clarify the guiding value of diaphragm electrical activity monitoring technology in the weaning of neurocritical patients.Methods:A total of 52 patients who were admitted to the neurosurgery ICU of the First Affiliated Hospital of Wannan Medical College from March 2019 to July 2021 underwent mechanical ventilation for more than 24 hours and met the conditions for weaning.Before weaning,all patients were implanted nasally with a diaphragmatic muscle electrical activity monitoring(EAdi)catheter and used low-level pressure support ventilation(PSV)for spontaneous breathing trial(SBT)for 30 minutes.Record the vital signs,arterial blood gas,mechanical ventilation parameters and diaphragm function indexes at the end of SBT,including diaphragm electrical activity peak(EAdimax),diaphragm electrical activity low(EAdimin),neural ventilation coupling index(NVE),neuromechanical coupling Index(NME).According to the results of weaning,patients were divided into successful weaning group and failed weaning group.The receiver operating characteristic curve(ROC)was used to evaluate the value of each diaphragm index in predicting the success of weaning.Results:All 52 patients were included in the final analysis,including 38 cases in the successful weaning group and 14 cases in the weaning failure group.At the end of SBT of the two groups of patients,in terms of vital signs:the heart rate(HR)and respiratory rate(RR)of the success group were significantly lower than those of the failure group[HR:74(66.5~83)vs 92(72.75~102)beats/min,R:19(14.75~25.25)vs 27.5(18.5~31)times/min,all P<0.05].In terms of arterial blood gas:the PaCO_(2) of the success group was significantly higher than that of the failure group by 33.8(32~35)vs30.55(29.5~33.8)mmHg,(P<0.05).There was no significant difference in the monitoring of mechanical ventilation parameters(P>0.05).In terms of diaphragm function:NVE,NME,and NVE×NME in the success group were significantly higher than those in the failure group[NVE:99.5(92~142)vs 91.5(25.5~96.5)mL/μV,NME:2.25(1.9~3.3)vs1.85(0.88~2.3)cmH_(2)O/μV,NVE×NME:265.05(199.48~303.6)vs182.9(20.33~242.64)mL×cmH_(2)O/μV^(2),both P<0.05].When the optimal critical value of NVE is 59.15mL/μV,the sensitivity to predict the success of weaning is 100%,the specificity is 42.9%,and the area under the ROC curve(AUC)is 0.727(95%CI:0.567~0.888);When the optimal critical value of NME is 1.83cmH_(2)O/μV,the sensitivity to predict the success of weaning is 86.80%,the specificity is 50%,and the area under the ROC curve(AUC)is 0.736(95%CI:0.581~0.891);When the optimal cutoff value of NME and NVE×NME is 76.4mL×cmH_(2)O/μV^(2),the sensitivity to predict the success of weaning is 100%,the specificity is 42.9%,and the area under the ROC curve(AUC)is 0.757(95%CI):0.607~0.906).Conclusion:Quantitative evaluation of patients’diaphragm function indicators through diaphragm electrical activity monitoring technology has certain significance in guiding clinical weaning,and it can also be used in the future.As a new reference index for weaning.