肌萎缩侧索硬化患者隐性误吸的危险因素及ALSFRS-R对其预测价值

Risk factors of silent aspiration in patients with amyotrophic lateral sclerosis and the predictive value of ALSFRS-R scale

目的探索肌萎缩侧索硬化(ALS)患者隐性误吸的危险因素及修订版ALS功能评定量表(ALSFRS-R)对其诊断价值。方法纳入68例ALS患者,根据电视透视吞咽功能检查(VFSS)结果分为隐性误吸组(9例)和无隐性误吸组(59例)。使用医学研究理事会(MRC)评分评估颈部和四肢肌力,使用Logistic回归分析评估隐性误吸的独立影响因素。以VFSS结果为金标准,使用受试者工作特征(ROC)曲线分析ALSFRS-R球部亚评分及吞咽亚评分对隐性误吸的诊断价值。结果单因素分析结果显示,与无隐性误吸组相比,隐性误吸组患者颈屈肌肌力和右上肢近端肌力降低(P<0.05),球部起病患者比例升高(P<0.05);多因素Logistic回归分析显示,肢体起病的患者发生隐性误吸的风险较球部起病者降低(OR=0.001,95%CI:0.000~0.222,P=0.014);颈屈肌肌力越高,隐性误吸风险越小(OR=0.089,95%CI:0.010~0.814,P=0.032)。ROC曲线结果显示,ALSFRS-R球部亚评分及吞咽亚评分对ALS患者的隐性误吸的临床诊断价值有限,曲线下面积(AUC)分别为0.774(95%CI:0.741~0.924)和0.781(95%CI:0.757~0.934)。ALSFRS-R球部亚评分最佳分界值为11分,诊断隐性误吸的敏感度和特异度分别为88.89%和57.63%;ALSFRS-R吞咽亚评分的最佳分界值为3分,诊断隐性误吸的敏感度和特异度分别为77.78%和67.80%。结论对于球部起病及颈屈肌肌力差的ALS患者,应重视吞咽障碍的筛查,及早进行临床干预。ALSFRS-R球部亚评分及吞咽亚评分对隐性误吸的诊断价值有限,需要开发新的量表评估ALS患者隐性误吸的风险。

Objective To detect risk factors of silent aspiration in patients with amyotrophic lateral sclerosis(ALS)and the diagnostic value of ALSFRS-R scale.Methods A total of 68 patients with ALS were recruited in our study.According to the results of Videofluoroscopic Swallowing Study(VFSS),patients were divided into the silent aspiration group(9 cases)and the non-silent aspiration group(59 cases).The muscle strength of neck and limb was assessed using the Medical Research Council score(MRC)scale,and the independent influencing factors of silent aspiration were assessed using Logistic regression analysis.Receiver operating characteristic(ROC)curve was used to analyze the diagnostic value of ALSFRS-R bulbar subscales and swallowing items for silent aspiration.Results The results of univariate analysis showed that compared with the non-silent aspiration group,cervical flexor muscle strength and right proximal upper limb muscle strength were decreased in the silent aspiration group(P<0.05),and the proportion of patients with bulbar onset was higher in the silent aspiration group(P<0.05).Multivariate Logistic regression analysis showed that patients with limb onset were less likely to have occult aspiration than those of bulbar onset(OR=0.001,95%CI:0.000-0.222,P=0.014).The higher the cervical flexor muscle strength was,the less the risk of occult aspiration was(OR=0.089,95%CI:0.010-0.814,P=0.032).The results of ROC curve showed that the ALSFRS-R bulbar subscales and swallowing items had limit clinical diagnostic value for ALS patients with silent aspiration,and the areas under the curve(AUC)were 0.774(95%CI:0.741-0.924)and 0.781(95%CI:0.757-0.934),respectively(P<0.05).When the Youden index was the maximum,the optimal cut-off value of ALSFRS-R bulbar subscales was 11,and the sensitivity and specificity for the diagnosis of silent aspiration were 88.89% and 57.63%,respectively.The optimal cut-off value of ALSFRS-R swallowing items was 3,and the sensitivity and specificity for the diagnosis of silent aspiration were 77.78% and 67.80%,respectively.Conclusion For ALS patients with bulbar onset and poor cervical flexor muscle strength,attention should be paid to the screening of dysphagia and early clinical intervention.ALSFRS-R bulbar subscales and swallowing items have limited diagnostic value for silent aspiration,and new scales need to be developed to assess the risk of silent aspiration in ALS patients.