床旁超声技术在胸部急症中的临床应用研究

发布时间：2018-06-23 21:11

本文选题：床旁超声 + 呼吸机相关肺炎　；参考：《中国人民解放军医学院》2017年硕士论文

【摘要】：目的:探讨床旁超声在呼吸机相关性肺炎(VAP)及急性张力性气胸中的诊断价值。方法:(1)对2013年1月至2015年2月在重症监护室诊治并行气管插管48h～72h以上、临床疑诊VAP的82例患者,使用便携式超声诊断仪行床旁超声检查,然后行CT检查,以临床最终诊断为诊断金标准,分析床旁超声检查图像特征及其诊断价值,并与CT比较优劣。(2)回顾性分析2013年1月至2015年12月20例(23侧)急性张力性气胸患者的超声图像,以CT为诊断张力性气胸金标准,分析床旁超声检查图像特征及诊断价值。结果:(1) VAP的超声诊断:82例临床疑诊VAP患者,临床最终诊断VAP75例。CT诊断VAP74例、肺不张3例、肺梗死2例、肺部无异常3例。床旁超声诊断VAP 72例、肺不张3例、心力衰竭4例、漏诊3例,床旁超声诊断VAP的敏感度96%(72/75),特异度100%。超声与CT诊断VAP的一致性较好(κ=0.875),超声与CT诊断VAP的准确性差异无统计学差异(p0.05)。超声能敏感显示胸腔积液,累及肺周边的肺实变表现局灶性低回声区,不同程度的异常B线征。高频超声显示病变处壁层胸膜、生理性胸膜腔液体和脏层胸膜结构模糊,表现为增厚的软组织回声减低、不均匀。(2)二维灰阶超声诊断急性张力性气胸的敏感度91.3%(21/23),特异度100%,主要表现为“A线”征(深部平行线状高回声)、“彗星尾”征和“肺滑动”征和均消失;能量多普勒通过识别“肺滑动”征诊断张力性气胸的敏感度为91.3% (21/23),特异度100%;正常胸壁及肺超声M型表现为“海岸”征,23侧气胸中未见1例普通气胸的“间歇海岸”征,“间歇海岸”征诊断张力性气胸的敏感度为0%。结论:床旁超声诊断呼吸机性相关性肺炎和张力性气胸均具有较高的准确率,床旁超声方便、无创、经济、可反复检查,可作为呼吸机性相关性肺炎和张力性气胸诊断、随访的主要影像学诊断方法之一,值得进一步研究并推广应用。灰阶超声和能量多普勒诊断张力性气胸的价值较大,M型超声在张力性气胸诊断中的价值有限。
[Abstract]:Objective: to evaluate the diagnostic value of bedside ultrasound in ventilator-associated pneumonia (VAP) and acute tension pneumothorax. Methods: (1) from January 2013 to February 2015, 82 patients who were diagnosed and treated in intensive care unit with tracheal intubation and suspected 48h~72h were examined by bedside ultrasound and CT. The characteristics and diagnostic value of bedside ultrasonography were analyzed and compared with CT. (2) 20 cases (23 sides) of acute tension pneumothorax from January 2013 to December 2015 were analyzed retrospectively. Using CT as the diagnostic standard of tension pneumothorax, the imaging features and diagnostic value of bedside ultrasonography were analyzed. Results: (1) 82 cases of suspected VAP were diagnosed by ultrasound in VAP. 75 cases of VAP.CT diagnosed 74 cases of VAP, 3 cases of atelectasis, 2 cases of pulmonary infarction and 3 cases of no abnormal lung. There were 72 cases of VAP diagnosed by bedside ultrasound, 3 cases of atelectasis, 4 cases of heart failure and 3 cases of missed diagnosis. The sensitivity and specificity of bedside ultrasound in diagnosing VAP were 96% (72 / 75) and 100% respectively. There was good consistency between ultrasound and CT in the diagnosis of VAP (魏 0.875), but there was no significant difference in the accuracy between ultrasound and CT in the diagnosis of VAP (p0.05). Ultrasound can sensitively display pleural effusion, pulmonary consolidation around the lung, focal hypoechoic area, abnormal B-line sign of different degree. High frequency ultrasound showed that the wall pleura, the physiologic pleural cavity fluid and the visceral pleural structure were blurred, and the thickened soft tissue echo was decreased. (2) the sensitivity of two-dimensional gray scale ultrasonography in diagnosing acute tension pneumothorax was 91.3% (21 / 23), and the specificity was 100%. The main manifestations were "A line" sign (deep parallel hyperechoic), "comet tail" sign and "lung sliding" sign and disappeared. The sensitivity of diagnosis of tension pneumothorax by power Doppler imaging was 91.3% (21 / 23), and the specificity was 100. The "intermittent coast" sign of normal chest wall and lung ultrasound was not seen in 23 sides of pneumothorax with "coast" sign. The sensitivity of intermittent Coast sign for the diagnosis of tension pneumothorax is 0. Conclusion: bedside ultrasound has high accuracy in diagnosing ventilator-associated pneumonia and tension pneumothorax. Bedside ultrasound is convenient, non-invasive, economical, and can be used to diagnose ventilator-associated pneumonia and tension pneumothorax. One of the main imaging diagnostic methods in follow-up is worthy of further study and application. The diagnostic value of gray-scale ultrasonography and power Doppler in the diagnosis of tension pneumothorax is higher than that of M-mode ultrasound. The diagnostic value of M-mode ultrasound in tension pneumothorax is limited.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R445.1;R56

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