重症心肺超声评估新生儿呼吸窘迫综合征机械通气的应用价值  

Application of point-of-care cardiopulmonary ultrasound in mechanical ventilation of neonatal respiratory distress syndrome

作　　者：左莉莉[1] 陈筱青[1] 周洁[1] 李玲[1] 刘晋 颜琪 Zuo Lili;Chen Xiaoqing;Zhou Jie;Li Ling;Liu Jin;Yan Qi(Department of Pediatrics,First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China;Clinical Medicine Research Institute,First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China;Department of Pediatric Ophthalmology,First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,China)

机构地区：[1]南京医科大学第一附属医院儿科,南京210029 [2]南京医科大学第一附属医院临床医学研究院,南京210029 [3]南京医科大学第一附属医院儿童眼科,南京210029

出　　处：《中华超声影像学杂志》2022年第11期953-959,共7页Chinese Journal of Ultrasonography

基　　金：国家自然科学基金面上项目(81871195)。

摘　　要：目的:探讨重症心肺超声在新生儿呼吸窘迫综合征(RDS)机械通气中及评估撤机时机的应用价值。方法:选择2019年1月至2020年10月于南京医科大学第一附属医院新生儿重症监护病房住院并启用有创机械通气治疗的RDS患儿为研究对象,共纳入82例,达临床撤机标准后拔除气管插管,根据撤机成功与否分为成功组及失败组。在插管上机0.5 h及撤机拔管0.5 h内均进行重症心肺超声评估,记录肺部超声积分(LUS)、左室射血分数(LVEF)、三尖瓣环收缩期位移(TAPSE)、左心室偏心指数(LVEI)、肺动脉收缩压(PASP)及动脉血气、呼吸机参数、机械通气时间、氧疗时间。比较组间以上各项指标,评估重症心肺超声对机械通气撤离的预测价值。结果:撤机失败组胎龄[(28.6±4.2)周比(32.5±3.7)周]、体重[(1289±790)g比(1969±771)g]、通气初始动脉氧分压(PaO 2)[(41.2±8.5)mmHg比(50.1±12.2)mmHg]、撤机时LVEF[(62.7±3.9)%比(66.9±3.1)%]低于成功组(均P<0.05),撤机时LUS[(13.7±1.0)分比(11.1±1.6)分]、PASP[(40.5±7.2)mmHg比(32.9±6.2)mmHg]及机械通气时间[(5.4±4.7)d比(3.6±2.3)d]、总氧疗时间[(48.5±25.0)d比(24.5±18.5)d]高于成功组(均P<0.05)。机械通气初始LUS与机械通气时间呈正相关(r=0.188,P<0.01),TAPSE与机械通气时间呈负相关(r=-0.344,P<0.01)。初始及撤机时刻LUS与X线分级、平均气道压力(MAP)呈正相关(rs=0.790,P<0.01及rs=0.686,P<0.01;r=0.383,P<0.01及r=0.548,P<0.01)。LUS预测撤机失败ROC曲线下面积(AUC)为0.922;ΔLUS(LUS前后差值)≤7分联合ΔPASP(PASP前后差值)≤9.5 mmHg预测AUC为0.912;联合LUS、PASP、LVEF预测AUC为0.937,约登指数0.736,截断值为0.185,敏感性89.5%,特异性84.1%。Logistic回归分析显示LUS≥13分,PASP≥43 mmHg,LVEF≤60%与撤机失败相关(均P<0.05)。结论:床旁使用重症心肺超声可有效评估新生儿RDS机械通气进程并预测撤机,实时精准,可实践性强,值得临床推广。Objective To explore the value of point-of-care cardiopulmonary ultrasound(POCUS)in the evaluation of modifying mechanical ventilation and weaning timing of neonates with respiratory distress syndrome(RDS).Methods A total of 82 infants with RDS received invasive mechanical ventilation in the neonatal intensive care unit of the First Affiliated Hospital of Nanjing Medical University from January 2019 to October 2020 were enrolled.Endotracheal tube was extubated after getting in line with the clinical weaning standard.According to the results of ventilator withdrawal,infants were divided into successful group and failure group.POCUS were performed within half hour of intubation and extubation.Lung ultrasound score(LUS),left ventricular ejection fraction(LVEF),tricuspid annular plane systolic excursion(TAPSE),left ventricular eccentricity index(LVEI)and pulmonary artery systolic pressure(PASP)were recorded also with the arterial blood gas,ventilator parameters,duration of mechanical ventilation and oxygen therapy.The above indexes were compared between two groups to evaluate the predictive value of POCUS for mechanical ventilation evacuation.Results The gestational age[(28.6±4.2)W vs(32.5±3.7)W],body weight[(1289±790)g vs(1969±771)g],initial ventilation PaO2[(41.2±8.5)mmHg vs(50.1±12.2)mmHg],LVEF of ventilator withdrawal[(62.7±3.9)%vs(66.9±3.1)%]of the failed weaning group were lower than those of successful group(all P<0.05).LUS at ventilator withdrawal[(13.7±1.0)points vs(11.1±1.6)points],PASP[(40.5±7.2)mmHg vs(32.9±6.2)mmHg]and the duration of mechanical ventilation[(5.4±4.7)d vs(3.6±2.3)d],duration of oxygen therapy[(48.5±25.0)d vs(24.5±18.5)d]were higher than those of successful group(all P<0.05).The initial LUS of mechanical ventilation was positively correlated with the duration of mechanical ventilation(r=0.188,P<0.01),and TAPSE was negatively correlated with the duration of mechanical ventilation(r=-0.344,P<0.01).LUS was positively correlated with X-ray grading and mean airway pressure at th

关 键 词：重症超声 新生儿呼吸窘迫综合征 机械通气 

分 类 号：R445.1[医药卫生—影像医学与核医学] R722.1[医药卫生—诊断学]