支气管镜检查快速现场评估对重症侵袭性支气管肺曲霉病的诊断价值  

Diagnostic yield of bronchoscopic rapid on-site evaluation in severe invasive bronchopulmonary aspergillosis

作　　者：徐思成[1] 万秋风 李婧文 史玉娇 罗茜 贾文婷 杨婷[1] 胡鑫莹 谷兴丽 刘光明[1] Xu Sicheng;Wan Qiufeng;Li Jingwen;Shi Yujiao;Luo Xi;Jia Wenting;Yang Ting;Hu Xinying;Gu Xingli;Liu Guangming(Department of Respiratory Intensive Care Unit,Pulmonary and Critical Care Medical Center,the First Affiliated Hospital of Xinjiang Medical University,Urumqi 830054,Xinjiang Uygur Autonomous Region,China)

机构地区：[1]新疆医科大学第一附属医院呼吸与危重症医学中心RICU,乌鲁木齐830054

出　　处：《中华危重病急救医学》2023年第11期1164-1170,共7页Chinese Critical Care Medicine

基　　金：新疆维吾尔自治区临床重点专科建设项目(2016-56)。

摘　　要：目的探讨支气管镜检查快速现场评估(B-ROSE)在重症侵袭性支气管肺曲霉病(IBPA)中的诊断价值,旨在为获得微生物学证据之前开始抗真菌治疗提供依据。方法采取前瞻性队列研究方法,入选2014年6月至2022年6月新疆医科大学第一附属医院呼吸加强监护治疗病房(RICU)收治的疑诊为IBPA的重症肺炎患者作为研究对象,并排除入院时以其他病原体(如细菌、结核分枝杆菌)感染为主者。入RICU 24 h内尽快实施床旁B-ROSE,从而指导是否开始抗真菌治疗。以目前侵袭性曲霉病国际诊断标准作为"金标准",计算B-ROSE的诊断符合率、敏感度和特异度等,并绘制受试者工作特征曲线(ROC曲线),评估该方法对诊断IBPA的预测价值。结果共176例疑诊IBPA的重症肺炎患者纳入研究。依据国际诊断标准,IBPA 81例,非IBPA 95例;根据B-ROSE早期诊断,IBPA 89例,非IBPA 87例。B-ROSE的诊断符合率为84.09%(148/176),B-ROSE诊断重症IBPA的ROC曲线下面积(AUC)为0.844,95%可信区间(95%CI)为0.782~0.905,敏感度为87.65%,特异度为81.05%,阳性预测值为79.78%,阴性预测值为88.51%,漏诊率为12.35%(10/81),误诊率为18.95%(18/95)。与真阴性组比较,假阴性组(漏诊组)长时间(≥14 d)使用糖皮质激素的比例〔70.0%(7/10)比9.1%(7/77),P<0.01〕以及伴有糖尿病的比例〔40.0%(4/10)比10.4%(8/77),P<0.05〕均显著性升高;但两组B-ROSE均表现为黏膜出血、充血及水肿〔100.0%(10/10)比94.8%(73/77),P>0.05〕,提示黏膜急性炎症改变为非特征性。与真阳性组比较,假阳性组(误诊组)长时间(≥14 d)使用糖皮质激素的比例显著降低〔33.3%(6/18)比60.6%(43/71),P<0.05〕;B-ROSE结果显示,误诊组表现为黏膜白斑、黑斑及伪膜的病例比例亦显著降低〔16.7%(3/18)比52.1%(37/71),P<0.01〕,提示长时间(≥14 d)使用糖皮质激素的病例以及B-ROSE表现为黏膜白斑、黑斑和伪膜的病例不容易误诊。容易误诊为IBPA的肺炎样表现的疾�ObjectiveTo explore the diagnostic yield of bronchoscopic rapid on-site evaluation(B-ROSE)in patients with severe invasive bronchopulmonary aspergillosis(IBPA)and provide evidence for starting antifungal treatment before microbiological results were available.MethodsA prospective cohort study was conducted to select patients with severe pneumonia suspected of IBPA admitted to the respiratory intensive care unit(RICU)in the First Affiliated Hospital of Xinjiang Medical University from June 2014 to June 2022,and those who were primarily infected with other pathogens(such as bacteria,Mycobacterium tuberculosis)at admission were excluded.Whether the antifungal treatment was initiated or not on the basis of the bedside B-ROSE,the B-ROSE was administered as soon as possible within 24 hours after admission to RICU.The current international definition of invasive aspergillosis was used as the gold diagnostic standard,the diagnostic accordance rate,the sensitivity and specificity of B-ROSE were calculated respectively,and the receiver operator characteristic curve(ROC curve)was also plotted,to evaluate the predictive value in diagnosing IBPA.ResultsA total of 176 patients with severe pneumonia suspected of IBPA were included in the study.According to international diagnostic standards,there were 81 cases of IBPA and 95 cases of non-IBPA.According to the early diagnosis of B-ROSE,there were 89 cases of IBPA and 87 cases of non-IBPA.The diagnostic accordance rate of B-ROSE was 84.09%(148/176),the area under the ROC curve for B-ROSE in diagnosing severe IBPA was 0.844,the 95%confidence interval(95%CI)was 0.782-0.905,the sensitivity was 87.65%,the specificity was 81.05%,the positive predictive value was 79.78%,the negative predictive value was 88.51%,the rate of underdiagnosis was 12.35%(10/81),and the rate of misdiagnosis was 18.95%(18/95).Compared with the true negative group,the proportion of long-term(≥14 days)use of glucocorticoid[70.0%(7/10)vs.9.1%(7/77),P<0.01]and the proportion of cases with diabetes[40.0%(4/10)vs.1

关 键 词：重症肺炎 侵袭性肺曲霉病 支气管镜检查 快速现场评估 

分 类 号：R519[医药卫生—内科学]