应用多模态超声技术预测重症机械通气患者的撤机结局

Effect of diaphragm function evaluated with multimodal ultrasound in predicting weaning outcomes in critically ill patients with mechanical ventilation

关键词:  多模态超声技术  机械通气  膈肌功能  撤机结局

Key words:  multimodal ultrasound technology  mechanical ventilation  diaphragm function  weaning outcome

摘要:

目的利用多模态超声技术对重症机械通气患者的膈肌功能进行评估,并研究其在预测撤机结局中的应用价值。 方法本研究招募符合纳入标准的重症监护室的机械通气患者，收集临床相关数据并进行床旁超声检查。记录自主呼吸试验(spontaneous breathing trial, SBT)进行30 min时的超声数据，包括吸气末膈肌厚度(end inspiratory diaphragm thickness, DTei)与呼气末的膈肌厚度(end respiratory diaphragm thickness, DTee)、膈肌厚度分数(diaphragm thickening fraction, DTF)、膈肌厚度分数浅快呼吸指数(diaphragmatic thickening fraction rapid shallow breathing index, DTF-RSBI)、膈肌位移(diaphragmatic excursion, DE)、膈肌位移时间指数(diaphragm excursion-time index, DE-Ti)、膈肌收缩速度(diaphragmatic movement speed, DMS)、膈肌位移浅快呼吸指数(diaphragmatic excursion rapid shallow breathing index, DE-RSBI)和膈肌剪切波弹性成像相关参数。根据撤机结果分为成功组和失败组，比较两组患者一般资料及超声数据；使用多因素Logistic回归模型分析影响重症机械通气患者撤机结果的参数；利用绘制受试者工作特征(receiver operating characteristic, ROC)曲线评估膈肌超声参数对重症机械通气患者撤机结局的价值。 结果本研究包含103例患者，其中SBT首次成功率77.67%(80例)，撤机成功率72.82%(75例)，死亡率14.74%(14例)。撤机成功组年龄及机械通气时间短于撤机失败组，膈肌超声参数除DTee外，其余参数DTee,DTei,DTF,DE,DE-Ti,DMS,DTF-RSBI和DE-RSBI，两组比较差异均有统计学意义(P＜0.05)。机械通气时间(OR=1.239,95%CI: 1.043~1.472，P=0.015)、DTF(OR=0.772，95%CI: 0.601~0.992，P=0.043)、DE-RSBI(OR=1.945，95%CI: 1.088~3.478，P=0.025)是重症机械通气患者撤机结局的影响因素。DTF(最佳截断值30%，灵敏度94.67%，特异度67.86%)，DE-RSBI[最佳截断值13.76次/(min·cm),灵敏度82.67%，特异度82.14%]，械通气时间(最佳截断值4 d，灵敏度69.33%，特异度82.14%)对撤机结局有预测价值。三者联合应用，可进一步提升预测特异度至89.29%。 结论采用多模态超声技术评估膈肌功能，获取参数DTF、DE-RSBI对重症机械通气患者撤机结局有预测价值，同时联合应用机械通气时间，可以进一步提高预测价值。

Abstract:

ObjectiveTo assess diaphragm function in critically ill patients with mechanical ventilation using multimodal ultrasound and explore its predictive value for weaning outcomes. MethodsThis study included patients admitted to the intensive care unit(ICU) who met specific inclusion criteria. Clinical information was gathered from all participants, and bedside ultrasound examinations were conducted to assess various parameters related to diaphragm function, such as end inspiratory diaphragm thickness(DTei), end respiratory diaphragm thickness(DTee), diaphragm thickening fraction(DTF), diaphragmatic thickening fraction rapid shallow breathing index(DTF-RSBI), diaphragmatic excursion(DE), diaphragm excursion-time index(DE-Ti), diaphragmatic movement speed(DMS), diaphragmatic excursion rapid shallow breathing index(DE-RSBI) and parameters obtained from diaphragm shear wave elastography. The patients were divided into two groups according to ventilation weaning outcome: success group and failure group. The general clinical characteristics and ultrasound parameters in the patients were compared between the two groups. The multivariable Logistic regression model was utilized to analyze the factors influencing the weaning outcome in critically ill patients with mechanical ventilation. The receiver operating characteristic(ROC) curve was drew to analyze the predictive values of diaphragmatic ultrasound parameters for the weaning outcome in critically ill patients with mechanical ventilation. ResultsThis study included 103 patients. The success rate of the first SBT was 77.67%(80 cases), the success rate of weaning from mechanical ventilation was 72.82%(75 cases), the mortality rate was 14.74%(14 cases). The successful weaning group had a younger age and shorter duration of mechanical ventilation compared to the failed weaning group. Except for DTee, there were statistically significant differences in other diaphragmatic ultrasound parameters, such as DTee, DTei, DTF, DE, DE-Ti, DMS, DTF-RSBI and DE-RSBI, between the two groups(all P<0.05).Duration of mechanical ventilation(OR=1.239, 95%CI： 1.043-1.472, P=0.015), DTF(OR=0.772, 95%CI： 0.601-0.992, P=0.043), DE-RSBI(OR=1.945, 95%CI： 1.088-3.478, P=0.025) were impact factors of weaning outcomes in critically ill patients with mechanical ventilation. DTF(cut-off value 30%, sensitivity 94.67%, specificity 67.86%), DE-RSBI(cut-off value 13.76 beats·min-1·cm-1, sensitivity 82.67%, specificity 82.14%), mechanical ventilation time(cut-off value 4 days, sensitivity 69.33%, specificity 82.14%) had predictive value for weaning outcome in critically ill patients with mechanical ventilation. By combining the above three factors, the predictive specificity can be further improved to 89.29%. ConclusionThe assessment of diaphragm function with multimodal ultrasound, the parameters like DTF and DE-RSBI, have substantial predictive value in predicting weaning outcome. Additionally, the concurrent application of mechanical ventilation duration markedly improves the predictive accuracy.