心肺超声在鉴别ICU机械通气患者心源性撤机失败中的应用价值

The application value of cardiopulmonary ultrasound in distinguishing cardiogenic weaning failure in ICU mechanically ventilated patients

目的探究心肺超声指标及撤机心肺超声评分在鉴别重症机械通气患者心源性因素撤机失败中的应用价值。方法选取2019年7月—2021年5月于河北省人民医院重症医学科(ICU)接受机械通气且发生撤机失败患者48例,根据N末端B型利钠肽前体(NT-proBNP)年龄分层阈值将撤机失败患者分为心源性因素撤机失败组(心源性组)22例和非心源性因素撤机失败组(非心源性组)26例。于撤机试验开始时(0 min)使用床旁超声测量患者右心室舒张末期内径(RVEDD)、左心室舒张末期内径(LVEDD)、左心室射血分数(LVEF)、下腔静脉内径(IVCD)、二尖瓣舒张早期血流峰速度(E)、二尖瓣环/左心室侧壁舒张早期组织运动速度(e’),计算E/e’。于撤机试验第0 min和第15 min分别使用肺超声观察双肺前胸壁B线数目变化,将各指标转化为二分类变量。采用二元Logistic回归模型筛选独立影响因素,并根据偏回归系数β值作为权重进行赋值评分,以总分作为撤机心肺超声评分。采用ROC曲线评价各参数预测价值。结果心源性组LVEF<50%、E/e’>14、IVCD≥20 mm、肺超声B线数目增加≥6条比例均高于非心源性组(χ^(2)/P=11.679/0.001、16.121/<0.001、11.679/0.001、13.890/<0.001);Logistic回归分析显示,LVEF<50%、E/e’>14、肺超声B线数目增加≥6条是心源性因素撤机失败的独立危险因素[OR(95%CI)=21.119(1.411~316.056)、18.119(1.089~46.615)、7.126(2.839~115.642)];ROC曲线分析显示,撤机心肺超声评分预测心源性因素撤机失败的曲线下面积(AUC)为0.913,高于LVEF和IVCD单独预测(Z/P=2.015/0.044、2.352/0.019),与E/e和肺超声B线数目变化预测差异无统计学意义(Z/P=0.928/0.353、1.558/0.119)。结论心肺超声技术对鉴别心源性因素导致的撤机失败有较高的应用价值,其中撤机心肺超声评分的预测价值最高。

Objective To explore the application value of cardiopulmonary ultrasound indicators and weaning cardiopulmonary ultrasound scores in distinguishing cardiogenic factors of weaning failure in severe mechanical ventilation patients.Method Four-eight patients who underwent mechanical ventilation at the Intensive Care Unit(ICU)of Hebei Provincial People's Hospital from July 2019 to May 2021 and experienced weaning failure were selected.According to the age stratification threshold of N-terminal B-type natriuretic peptide precursor(NT proBNP),weaning failure patients were divided into a cardiogenic weaning failure group(cardiogenic group)of 22 cases and a non cardiogenic weaning failure group(non cardiogenic group)of 26 cases.At the beginning of the weaning trial(0 min),bedside ultrasound was used to measure the patient's right ventricular end diastolic diameter(RVEDD),left ventricular end diastolic diameter(LVEDD),left ventricular ejection fraction(LVEF),inferior vena cava diameter(IVCD),early diastolic blood flow peak velocity(E)of the mitral valve,and early diastolic tissue velocity(e')of the mitral annulus/left ventricular sidewall,and E/e'was calculated.At the 0th and 15th minutes of the withdrawal test,lung ultrasound was used to observe the changes in the number of B-lines in the anterior chest wall of both lungs,and each indicator was converted into a binary variable.Using a binary logistic regression model to screen for independent influencing factors.According to partial regression coefficientsβValue is used as a weight to assign a score.Use the total score as the withdrawal cardiopulmonary ultrasound score.Use ROC curves to evaluate the predictive value of each parameter.Results The proportion of LVEF<50%,E/e'>14,IVCD≥20 mm,and an increase of≥6 B-lines in pulmonary ultrasound in the cardiogenic group were higher than those in the non cardiogenic group(χ^(2)/P=11.679/0.001,16.121/<0.001,11.679/0.001,13.890/<0.001);Logistic regression analysis showed that LVEF<50%,E/e'>14,and an increase of≥6 B-lines in pulmonary ultrasound were independent risk factors for cardiac factor weaning failure[OR(95%CI)=21.119(1.411-316.056),18.119(1.089-46.615),7.126(2.839-115.642)];ROC curve analysis showed that the area under the curve(AUC)for predicting cardiogenic factors of weaning failure by weaning cardiopulmonary ultrasound score was 0.913,which was higher than that predicted by LVEF and IVCD alone(Z/P=0.015/0.044,2.352/0.019),and there was no statistically significant difference in predicting changes in E/e and the number of pulmonary ultrasound B-lines(Z/P=0.928/0.353,1.558/0.119).Conclusion Cardiopulmonary ultrasound technology has high application value in identifying withdrawal failures caused by cardiogenic factors,with the highest predictive value of withdrawal cardiopulmonary ultrasound scores.