膈肌联合肋间肌超声对脓毒症机械通气患者脱机评估的价值  

Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis

作　　者：沈浩亮[1] 袁恺豪 余磊 阳娜娜 王逸平[1] 赵宏胜[1] 郭凤梅[3] 孙晨靓[1] SHEN Haoliang;YUAN Kaihao;YU Lei;YANG Nana;WANG Yiping;ZHAO Hongsheng;GUO Fengmei;SUN Chenliang(Department of Critical Care Medicine,Affiliated Hospital of Nantong University,Nantong 226001,China;Department of Critical Care Medicine,Chengdu Fifth People's Hospital,Sichuan Province,Chengdu 611130,China;Department of Critical Care Medicine,Zhongda Hospital Southeast University,Nanjing 210009,China)

机构地区：[1]南通大学附属医院重症医学科,南通226001 [2]四川省成都市第五人民医院重症医学科,成都611130 [3]东南大学附属中大医院重症医学科,南京210009

出　　处：《上海交通大学学报(医学版)》2025年第2期186-193,共8页Journal of Shanghai Jiao tong University:Medical Science

基　　金：南通市卫生健康委员会科研课题专项(MS2024015)。

摘　　要：目的·探索膈肌与肋间肌超声联合评估相较于传统膈肌超声对预测脓毒症机械通气患者脱机结局的价值。方法·选取2022年10月—2023年12月入住南通大学附属医院重症医学科接受机械通气的脓毒症患者为研究对象。在患者脓毒症病情改善并通过自主呼吸试验(spontaneous breathing trial,SBT)后的围脱机期间,对患者进行膈肌与肋间肌的超声评估,分别测量膈肌移动度(diaphragm excursion,DE)、膈肌增厚率(thickening fraction of diaphragm,TFD)、肋间肌增厚率(thickening fraction of intercostal muscle,TFic)。根据脱机结果将患者分为脱机成功组(n=114例)和脱机失败组(n=24例)。采用受试者操作特征(receiver operator characteristic,ROC)曲线分析膈肌超声、肋间肌超声单独和联合预测呼吸机脱机结果的价值。结果·SBT期间脱机失败组的TFic和TFic/TFD比值均明显高于脱机成功组(均P<0.05)。SBT期间DE、TFD、TFic预测脓毒症机械通气患者脱机失败的ROC曲线下面积分别为0.689(0.591~0.776)、0.657(0.557~0.747)和0.769(0.676~0.846),而联合指标TFic/TFD比值和TFic&TFD_mix的ROC曲线下面积分别为0.867(0.786~0.925)和0.860(0.778~0.920)。其中TFic/TFD以>0.95为截值,其预测脱机失败的灵敏度为86.7%,特异度为75.3%;TFic&TFD_mix以>0.13为截值,其预测脱机失败的灵敏度为86.6%,特异度为80.9%。肋间肌超声检查法在测量可靠性方面,其观察者内部测量一致性组内相关系数(intraclass correlation coefficient,ICC)为0.890(0.788~0.951),观察者外部测量一致性ICC为0.876(0.718~0.949),可靠性等级均为良好(P<0.001)。结论·膈肌联合肋间肌超声评估能更全面地反映患者的整体呼吸肌的情况,在预测脓毒症机械通气患者的脱机结局方面,较单独运用膈肌超声具有更高的指导价值。Objective·To explore the value of combined diaphragm and intercostal muscle ultrasound assessment compared with conventional diaphragm ultrasound in predicting the weaning outcome in mechanically ventilated patients with sepsis.Methods·Mechanically ventilated patients with sepsis,consecutively admitted to the Department of Critical Care Medicine of Affiliated Hospital of Nantong University from October 2022 to December 2023,were selected.During the peri-weaning period,after the patient's sepsis condition improved and the patient passed the spontaneous breathing trial(SBT),ultrasound evaluation of respiratory muscles was performed by ultrasound qualified personnel with ultrasound qualification and experience in bedside ultrasound examination.Diaphragm excursion(DE),thickening fraction of diaphragm(TFD),and thickening fraction of intercostal muscle(TFic)were measured,respectively.The patients were divided into a successful weaning group(n=114)and a failed weaning group(n=24)according to the weaning results.Receiver operating characteristic(ROC)curves were used to analyze the value of diaphragm ultrasound and intercostal muscle ultrasound,alone and in combination,in predicting ventilator weaning outcome.Results·TFic and TFic/TFD were significantly higher in the failed weaning group during SBT than in the successful weaning group(all P<0.05).The areas under the ROC curve(AUROC)of DE,TFD,and TFic to predict weaning failure in mechanically ventilated patients with sepsis during the period of SBT were 0.689(0.591‒0.776),0.657(0.557‒0.747),and 0.769(0.676‒0.846),respectively,whereas the combined indexes TFic/TFD and TFic&TFD_mix had AUROCs of 0.867(0.786‒0.925)and 0.860(0.778‒0.920),respectively.TFic/TFD with a cutoff value of>0.95 had a sensitivity of 86.7%and a specificity of 75.3%in predicting weaning failure,and TFic&TFD_mix with a cutoff value of>0.13 had a sensitivity of 86.6%and a specificity of 80.9%in predicting weaning failure.Moreover,the intercostal muscle ultrasonography method had an intra-obse

关 键 词：膈肌超声 肋间肌超声 脓毒症 机械通气 脱机评估 

分 类 号：R445.1[医药卫生—影像医学与核医学]