基于心脏、肺、膈肌超声多模态参数预测危重症患者机械通气脱机结局

Prediction of weaning outcomes of mechanical ventilation in critically ill patients based on the combination of ultrasound parameters of heart,lung and diaphragm

目的探索心脏、肺及膈肌超声多模态参数联合应用是否能够预测危重症患者脱机结局。方法前瞻性选取2022年12月至2023年12月南京大学医学院附属鼓楼医院重症医学科机械通气>48 h且准备进行自主呼吸试验(SBT)的患者53例。患者满足脱机拔管的条件,并且准备进行30 min SBT,在SBT期间对患者进行心脏、肺及膈肌的超声检查。根据脱机结果将患者分为脱机成功组与脱机失败组。将单因素分析中差异有统计学意义的超声参数纳入二元Logistic回归模型中分析脱机结局的独立影响因素,绘制ROC曲线并计算曲线下面积(AUC)进行统计学分析。结果53例患者中13例患者脱机失败,成功组与失败组膈肌移动度(DE)、膈肌增厚率(DTF)、双侧肺部超声评分(LUS)、LUS总分及左心室射血分数(LVEF)差异有统计学意义(均P<0.05)。LVEF的AUC为0.709(95%CI=0.534~0.883,P=0.025),截断值为57.95%,敏感性为85.0%,特异性为61.5%;LUS总分的AUC为0.878(95%CI=0.772~0.984,P<0.001),截断值为17.50,敏感性为77.5%,特异性为92.3%;DE的AUC为0.876(95%CI=0.777~0.975,P<0.001),截断值为1.205 cm,敏感性为80.0%,特异性为92.3%;DTF的AUC为0.902(95%CI=0.818~0.986,P<0.001),截断值为22.1%,敏感性为82.5%,特异性为92.3%。将差异有统计学意义的超声参数LVEF、LUS、DE、DTF四者联合绘制ROC曲线的AUC为0.948(95%CI=0.889~1.000,P<0.001),敏感性为85.0%,特异性为92.3%。结论心脏、肺和膈肌的超声参数提供了SBT期间心肺功能和膈肌功能的关键信息。若存在LUS升高,LVEF、DE及DTF降低,则脱机失败的结局更为常见,四者联合可提高对脱机结局预测的准确性。

Objective To explore whether the application of combined multimodal ultrasound parameters of heart,lung and diaphragm can predict the weaning outcome in critically ill patients.Methods A total of 53 patients mechanically ventilated>48 hours and prepared for spontaneous breathing trial(SBT),were prospectively selected from the Department of Critical Care Unit,Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School from December 2022 to December 2023.The patients were eligible for weaning extubation and prepared to undergo a 30-minute SBT,during which the doctors examined the patient′s heart,lungs and diaphragm with ultrasound probes.According to the weaning outcomes,the patients were divided into successful group and failed group.The ultrasound parameters with statistical significance in the univariate analysis were incorporated into the binary logistic regression model to explore the independent influencing factors of weaning outcomes,and the ROC curve was plotted and the area under the curve(AUC)was calculated for statistical analysis.Results Thirteen of the 53 patients failed weaning.There were significant differences in diaphragm excursion(DE),diaphragm thickening fraction(DTF),bilateral lung ultrasound score(LUS),total LUS and left ventricular ejection fraction(LVEF)between successful and failed groups(all P<0.05).The AUC for LVEF was 0.709(95%CI=0.534-0.883,P=0.025)with the cutoff value 57.95%,the sensitivity 85.0%,and the specificity 61.5%.The AUC for the total LUS score was 0.878(95%CI=0.772-0.984,P<0.001),with the cutoff value 17.50,the sensitivity 77.5%,and the specificity 92.3%.The AUC for the DE was 0.876(95%CI=0.777-0.975,P<0.001)with the cutoff value 1.205 cm,the sensitivity 80.0%,and the specificity 92.3%.The AUC for DTF was 0.902(95%CI=0.818-0.986,P<0.001)with the cutoff value 18.1%,the sensitivity 82.5%,and the specificity 92.3%.The AUC for the combination plotting of statistically significant ultrasound parameters,consisting of LVEF,LUS,DE and DTF,was 0.948(95%CI=0.889-1.000,P<0.001)with the sensitivity 85.0%and the specificity 92.3%.Conclusions Ultrasound parameters of the heart,lungs,and diaphragm provide critical information on cardiopulmonary and diaphragmatic function during SBT.Weaning failure is more common in patients with increased LUS and decreased LVEF,DE and DTF.The combination of four aspects can improve the accuracy of the prediction of weaning outcome.