膈肌麻痹35例临床特点分析及文献复习  

Diaphragmatic paralysis:clinical features and review of literature

作　　者：孙雪峰[1] 柳涛[1] 蔡柏蔷[1] 

机构地区：[1]中国医学科学院北京协和医学院北京协和医院呼吸内科,北京100730

出　　处：《中国实用内科杂志》2011年第11期844-846,共3页Chinese Journal of Practical Internal Medicine

摘　　要：目的提高膈肌麻痹(DP)的诊治水平。方法回顾性分析1995年1月至2010年3月北京协和医院诊断的14例及1980—2009年中国医院知识仓库(CHKD)中的21例非心脏手术非分娩相关DP患者的临床资料。结果北京协和医院资料男女比为2∶5,中位年龄60岁。病变累及右侧、左侧和双侧之比为4∶2∶1。发病至确诊的平均时间为9.8个月。11例主诉胸闷气短,尤以活动或平卧加重。透视下sniff试验在双侧DP患者中均为阴性,在单侧8例可见受累侧膈肌运动减弱,1例可见膈肌矛盾运动。所有患者PO2均明显下降,较预计值平均降低11.8 mmHg(1 mmHg=0.133 kPa),卧位PO2较立位又平均降低11.0 mmHg,单侧与双侧DP各项血气指标比较差异无统计学意义。肺功能检查为典型限制性通气功能障碍,第1秒用力呼气容积占预计值百分比(FEV1%)由立位59.0%下降至卧位25.5%,平均降低50.3%。14例原发病为感染6例、特发性3例、肿瘤和手术相关各2例和重症肌无力1例;单纯对因治疗有效率为66.7%。文献统计结果我院结果大致相同。结论 DP主要临床特点为卧位明显的呼吸困难,影像表现具有特征性。卧立位血气、卧立位肺功能检查有助诊断,膈神经刺激、跨膈压测定以及超声检查具有重要意义。治疗疗效取决于原发病的治疗,机械通气作为辅助治疗可以缓解病情。Objective To improve the diagnosis and treatment of diaphragmatic paralysis （DP）. Methods A retrospective analysis was perform on clinical data of non heart surgery and non beating related DP （ NHSNB- DP） among 14 eases from Peking Union Medical College Hospital （PUMCH） and 21 cases from domestic literature in CHKD database. Results In the PUMCH group, the male to female ratio was 2： 5, and the median age 60 years old. Right,left and bilateral involvement of the diaphragm was noted with a proportion of 4： 2：1 among the patients. The mean time from onset to a confirmed diagnosis was 9. 8 months. Eleven patients complained dyspnea which was worsened after exertion or lying down. In sniff test, two patients with bilateral DP showed negative resuits,while 8 with unilateral DP showed attenuated diaphragmatic movement and one with the unilateral DP showed paradoxical movement. PO2 was markedly lowered in all patients, with a mean reduction by 11.8 mmHg below normal predicted value, and a mean reduction by 11.0 mmHg in supine position compared with in upright position. There was no significant difference in blood gas analysis between patients with bilateral and unilateral DP. Pulmonary function test revealed typical restrictive ventilatory dysfunction, with a mean 50. 3% decrease in FEV1% ranging from 59. 0% in uptight position to 25.5% in supine position. Among the 14 cases of DP,related etiolog31 y included infection in 6 cases,idiopathic causes in 3, tumor in 2, surgery in 2 and myasthenia gravis in 1. The rate of response to etiology-targeted therapy alone was 66. 7%. The literature group showed similar results compared to the PUMCH group. Conclusion DP is clinically featured by dyspnea that is worsened with supine position and specific findings in image studies. Supine arterial blood gas and pulmonary function test may help diagnosis. Diaphragmatic nerve stimulation, trans-diaphragmatic pressure measurement and ultrasonography are important tools for diagnosis of DP. The outcomes of treatment depe

关 键 词：膈肌麻痹 膈肌抬高 sniff试验 膈肌肌电图 

分 类 号：R565[医药卫生—呼吸系统]