床旁超声评估膈肌功能在神经重症患者机械通气撤离时机中的应用

Bedside ultrasound for diaphragm function:improving mechanical ventilation outcomes in neurocritically patients

目的本文旨在探究床旁超声评估膈肌功能对神经重症患者机械通气撤离的预测价值。方法回顾性分析福建省立医院重症医学三科2021年1月至2022年6月接诊的48例神经重症患者的临床资料,记录自主呼吸试验(spontaneous breathing trail,SBT)前的器官功能衰竭评分(sequential organ failure assessment,SOFA)、急性生理学和慢性健康状况评价Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分、氧合指数、二氧化碳分压以及一般资料。SBT 30min时,记录呼吸机相关参数,使用超声测量膈肌移动度及膈肌增厚分数。尝试撤机后,根据撤机成功与否分为两组,其中撤机成功组30例,撤机失败组18例,对比两组基本资料及膈肌指标。运用受试者操作特征曲线(receiver operating characteristic curve,ROC curve,简称ROC曲线)确定最佳阈值并进行敏感度及特异度测算。结果撤机失败组SOFA评分、APACHEⅡ评分为(7.92±3.21)分、(19.66±7.01)分,均高于撤机成功组,差异有统计学意义(P<0.05)。撤机失败组膈肌移动度、膈肌增厚分数分别为[1.02(0.91,2.51)]cm、(27.00±7.12)%,均低于撤机成功组,差异有统计学意义(P<0.05)。以膈肌移动度1.08cm作为截断值,预测撤机成功的的敏感度为83.33%,特异度为93.33%,曲线下面积0.750(95%CI:0.570~0.931);以膈肌增厚分数32%为截断值,预测撤机成功的敏感度为66.67%,特异度为90.00%,曲线下面积0.667(95%CI:0.483~0.851)。两项指标联合应用,预测撤机成功的敏感度为94.44%,特异度为96.67%,曲线下面积为0.851(95%CI:0.715~0.905)。结论超声评估膈肌移动度(≥1.08cm),膈肌增厚分数(≥32%)均可预测神经重症患者机械通气撤离的时机,二者联合可以显著提高撤机成功率。

Objective To investigate the predictive value of point of care ultrasound assessment of diaphragm function for mechanical ventilation weaning in neurocritical care patients.Method The clinical data of 48 neurocritical care patients who underwent spontaneous breathing test(SBT)in the Department of Critical Care Medicine from January 2021 to June 2022 were retrospectively analyzed.Sequential organ failure score(SOFA),acute physiological and chronic health scoreⅡ(APACHEⅡ),PaO_(2)/FiO_(2) ratio,partial pressure of carbon dioxide and general information were collected before SBT.After 30 min of SBT,the relevant parameters of the ventilator were recorded.Diaphragm excursion and diaphragm thickening fraction were measured using ultrasound.According to the outcome of extubation,the patients were divided into two groups:successful group(n=30)and failed group(n=18).Basic information and diaphragmatic indexes were compared between the two groups.Receiver operating characteristic curve(ROC)was used to determine the optimal threshold and to perform sensitivity and specificity measurements.Result SOFA score and APACHEⅡscore in the failed group were(7.92±3.21)and(19.66±7.01),respectively,which were significantly higher than those in the successful group(P<0.05).Diaphragm excursion and diaphragm thickening fraction in the failed group were[1.02(0.91,2.51)]cm and(27.00±7.12)%,respectively,which were lower than those in the successful group(P<0.05).Using diaphragm excursion of 1.08 cm as the cut-off value,the sensitivity of predicting successful extubation was 83.33%,the specificity was 93.33%,and the area under the curve was 0.750(95%CI:0.570-0.931);using diaphragm thickening fraction of 32%as the cut-off value,the sensitivity of predicting successful extubation was 66.67%,the specificity was 90.00%,and the area under the curve was 0.667(95%CI:0.483-0.851).The combined use of two indicators had a sensitivity of 94.44%,specificity of 96.67%,and area under the curve of 0.851(95%CI:0.715-0.905).Conclusion Ultrasound assessment of diaphragm mobility(≥1.08 cm)and diaphragm thickening fraction(≥32%)both predicted the timing of weaning in neurocritically ill patients,and their combination contributes to improving weaning success rate.