放射性核素显像误检测法的完善及食用色素床旁误吸筛查方法的探讨

发布时间：2018-05-19 16:02

本文选题：误吸 + 放射性核素显像　；参考：《广州医科大学》2017年硕士论文

【摘要】：【背景及目的】误吸指固体食物、流质、口咽分泌物或胃内容物通过声门进入下呼吸道。误吸后可出现咳嗽、气喘、甚至窒息危机生命,也可以没有任何不适。根据误吸后有无咳嗽分为显性误吸和隐性误吸。目前对误吸的检查分床旁评估、仪器检查及气道分泌物生物标记,由于床旁评估对隐性误吸容易漏诊,临床上诊断隐性误吸的“金标准”是吞钡电视透视检查(VFSS)、纤维内镜吞咽评估(FEES)及放射性核素显像,前两种方法在评估吞咽动作、渗漏、误吸及吞咽后残留上的敏感性相一致;1991年,Langmore进行比较,这两种方法在误吸诊断上一致率达90%,但Abtin Tabaee在2006年通过回顾性分析54例2周内同时行VFSS和FESS检查的患者资料发现他们完全一致率只有52%;提示:这两种方法对误吸的诊断意义存在争议,有必要寻求更理想的方法。2012年我们科研组建立了“^99Tc^m-硫胶体唾液显像法”,使用此法对慢阻肺急性加重(Acute exacerbation of COPD,AECOPD)患者进行误吸筛查,3年后对53例进行了误吸筛查的患者进行生存分析发现:误吸组的死亡风险是非误吸组的2倍(附录1),尽管目前没有相关核素评估误吸准确性的报道,但Baikie对63名14月-16岁脑瘫儿进行吞钡透视和唾液显像比较时发现:核素唾液显像法检测误吸的敏感性更高,并且认为持续滴定、并同时进行图像扫描检测误吸的可靠性更高。基于顺行性误吸除了与口咽分泌物及进食食物有关外,也与鼻咽部分泌物有关。有文献报道:在睡眠期间,利用放射性核素检测意识障碍患者及正常人群夜间鼻咽部分泌物的误吸情况,对于存在分泌物增多的鼻炎或鼻窦炎患者来说,隐性误吸的发生可能发生在任何时间点及不同体位下。2013年,我们科研组再次建立了“鼻咽部分泌物误吸检测法”,使用此种方法检测了32例确诊为肺炎的住院患者,其中19人存在鼻塞、流涕症状,16人显示核素误吸检测阳性,而没有鼻部症状的肺炎患者只有3例核素误吸检测阳性。我们科研组开展的核素误吸检查方法在国内属于首次开展,为了能在临床中推广,我们拟完善此检查方法,包括检查持续时间和检查体位对核素误吸试验阳性率的影响,及其阳性的重复性;同时,为了减少临床工作量和患者负担,我们拟建立一种简单而特异性高的误吸筛查方法,并对既往进行了核素检测的患者进行回顾性生存分析,以探讨误吸对慢阻肺患者远期生存率的影响。为此本研究包括两部分:第一部分:观察时间和体位改变对核素显像误吸试验结果的影响及其结果的可重复性第二部分:食用色素床旁误吸筛查方法的探讨;第一部分:观察时间和体位改变对核素显像误吸试验结果的影响及其结果的可重复性【目的】对放射性核素显像误吸检测法进行完善,包括误吸检查需要的时间长度、检查体位姿势,同时探讨核素误吸检查的重复性。【方法】对166名2014年8月~2016年12月连续入住广州医科大学附属第一医院呼吸内科的慢阻肺急性加重住院患者行放射性核素显像检查:通过鼻咽管,以24ml/h的恒速,(利用向在鼻咽部滴注溶解了111.0 MBq锝99m-硫胶体的生理盐水,以模仿鼻咽分泌物增多,将111.0 MBq锝99m-硫胶体溶解于24ml生理盐水中,然后通过鼻咽管以24ml/h的恒速滴入鼻咽部,用SPECT/CT动态采集口腔至胃的后前位图像),包括留枕(6cm)平躺体位和坐位(或踏车运动)两个两步各30min;第一步:患者进行留枕平躺体位30min后,用SPECT/CT动态采集口腔至胃的后前位图像及停滴注后静态采集图像5min,若第一步核素显示误吸阳性则剔除,阴性者进入第二步试验;第二步:阴性者随机分为三组:继续采取原体位(A组)、安静坐位(B组,头稍后仰靠椅背,垂直角度约25°)、坐位下双下肢踏车运动(C组,以患者能自己承受的运动功率),三组均继续经鼻咽部并同时恒速滴入鼻咽部核素溶液30min,结束后进行5min静态采集口腔至胃的后前位图像。因急性加重再次入院的已经检测核素误吸实验的慢阻肺患者,按照上述方法进行重复性检查。【结果】166名慢阻肺急性加重患者中,核素阳性和阴性者分别66例和100例;100例阴性患者通过随机数字法分为:A组33例、B组35例、和C组32例;阴性者继续经鼻咽部滴入核素溶液,其中A组33例阳性0例,B组35例阳性9例,C组32例阳性11例,3组阳性率存在统计学差异(x~2=13.097,p=0.001),组间比较A组与B组、A组与C组阳性率存在统计学差异(x~2=9.78,13.655;p=0.002,0.000),B组与C组阳性率无统计学差异(x~2=0.599,p=0.439)。12名患者进行了重复性检验,两次均阳性7人,两次均阴性4人,1例第一次阴性,第二次阳性,Mc Nemar(M)一致性检验法Kappa值为0.82(U=5.05,p0.001)。【结论】平躺30min后,再延长平躺时间,并不能增加核素误吸发生率;平躺阴性患者改为坐位或坐位下四肢活动后,误吸发生率明显增加,但活动并不影响坐位核素误吸的发生率。核素显像检测误吸时,建议先平躺位留枕30min及延迟5min图像采集,对于阴性结果建议改为坐位继续检查30min以减少漏诊。放射性核素检查误吸重复性高。基于核素误吸试验诊断误吸敏感性和特异性高,且重复性高,是值得推广的误吸检查方法。第二部分:床旁食用色素误吸试验方法的探讨【目的】探讨床旁食用色素误吸试验的方法。【方法】对2016年8月~2017年3月入住广州医科大学附属第一医院呼吸内科的可疑吞咽障碍住院患者进行放射性核素唾液显像法检查,收集患者临床资料,进行床旁洼田饮水试验后,给予行唾液核素显像误吸试验,其中唾液显像核素液中混有食用色素,检查前留痰,检查结束后嘱患者清洁口腔及咽喉食道残留核素,半小时后进行咳嗽排痰,肉眼观察2小时内痰液颜色,与检查前痰液对照,判断食用色素检测误吸的可行性、敏感性及特异性,以便建立床旁简易误吸试验。【结果】1.一般资料33例患者参与了研究,男28例,女5例,年龄(50-90)岁,平均(68.1±11.4)岁。2.洼田饮水试验结果显示:1级17例,2级11例,3级1例,4级4例;3.核素显像误吸试验和床旁食用色素误吸试验结果核素显像误吸试验结果阳性的有4例,床旁食用色素误吸试验阳性的有6例,其中核素显像误吸试验和床旁食用色素误吸试验二者均阳性的3例。4.洼田饮水试验与核素显像误吸试验的相关性洼田饮水试验正常17例,可疑及异常16例,与核素比较敏感度和特异度分别为50%和51.7%,Mc Nemar(M)一致性检验法Kappa值为0.008(U=0.045,p0.05);5.床旁食用色素误吸试验与核素显像误吸试验的相关性食用色素与核素比较敏感度为75%,特异度为89.7%,阳性似然比为7.25,阴性似然比为0.279。Mc Nemar(M)一致性检验法Kappa值为0.532(U=3.28,p0.025),食用色素检验误吸与核素检验误吸呈中度一致性。【结论】1.洼田饮水试验作为临床床旁吞咽评估敏感性和特异性均低,不适宜作为误吸普查。2.食用色素作为床旁误吸评估方法可行,但敏感性偏低;3.食用色素+90ml饮水试验联合评估,如食用色素+90ml饮水试验后,痰有食用色素,则可诊断误吸;如有咳嗽,但没有食用色素者,建议进一步行核素显像误吸试验。
[Abstract]:[background and purpose] mistaken aspiration refers to solid food, fluid, oropharyngeal secretions or gastric contents into the lower respiratory tract through the glottis. After mistaken aspiration, it may occur in the life of coughing, asthma and even asphyxia. There is no discomfort. The "gold standard" for clinical diagnosis of recessive aspiration was barium swallowing television fluoroscopy (VFSS), fiberoptic endoscopic swallowing assessment (FEES) and radionuclide imaging. The first two methods were used to assess swallowing, leakage, aspiration, and residual deglutition. Sensitivity is consistent; in 1991, Langmore was compared, and the two methods had a consistent rate of 90% in the diagnosis of mistaken aspiration, but Abtin Tabaee in 2006, through retrospective analysis of 54 cases of VFSS and FESS examination within 2 weeks, found that their complete consensus rate was only 52%; it was suggested that the diagnostic significance of these two methods was controversial and necessary. To find a better way to find a better method.2012, our research group established the "^99Tc^m- colloid saliva imaging method", using this method to screen the patients with acute exacerbation of Acute exacerbation of COPD (AECOPD). 3 years later, the survival analysis of 53 patients who had been screened by mistaken aspiration found that the risk of death in the mistaken group was not mistaken. 2 times (Appendix 1) (Appendix 1), although there was no report on the accuracy of the related nuclide assessment, Baikie found that 63 14 months of 14 months of cerebral palsy was compared with the barium fluoroscopy and saliva imaging: the sensitivity of the nuclide saliva imaging method to detect the mistaken aspiration was higher, and the reliability of the scintigraphy was maintained and the reliability of the image scanned detection was reliable. Higher. Misbiasation based on anterograde is associated with some nasopharyngeal secretions in addition to oropharyngeal secretions and food intake. It is reported that during sleep, the use of radionuclides for detection of nocturnal nasopharyngeal secretions in patients with consciousness disorders and normal people, for patients with increased nasopharynx or sinusitis with increased secretions It is said that the occurrence of recessive aspiration may occur at any time point and.2013 years in different positions. Our scientific research group has once again established a "nasopharyngeal partial secreting detection method", and 32 hospitalized patients with pneumonia confirmed by this method were detected, of which 19 had nasal congestion, runny symptoms, and 16 showed positive nuclide aspiration. There are only 3 cases of nuclide misting positive in the patients with nasal symptoms. The method of nuclide aspiration in our scientific research group is first developed in China. In order to be popularized in the clinic, we should perfect this method, including checking the duration and checking the effect of the body position on the positive rate of the nuclide aspiration test, and the positive repetition. At the same time, in order to reduce the clinical workload and the burden of patients, we propose to establish a simple and high specific screening method of mispriming and retrospective survival analysis of patients who have previously been tested for nuclide to explore the effect of aspiration on the long-term survival of patients with chronic obstructive pulmonary disease. This study includes two parts: the first part: observation The effect of inter and position changes on the results of nuclide imaging and the repeatability of the results: the second part: the study of the screening method for the bedside mistaken aspiration of the edible pigment; the first part: the effect of the observation time and the change of body position on the results of the nuclide imaging error test and the refolding of the results The detection method was perfected, including the length of time required for the aspiration, the posture of the body, and the repeatability of the nuclide mistaken examination. [Methods] radionuclide imaging was performed on 166 hospitalized patients in the respiratory department of the respiratory department of the first hospital of Guangzhou Medical University, the first hospital of Guangzhou Medical University, August 2014, in December. Over the nasopharyngeal tube, at a constant speed of 24ml/h, (using a saline solution that dissolves 111 MBq technetium 99m- sulfur colloids to the nasopharynx, imitating the increase of nasopharynx secretion, the 111 MBq technetium 99m- sulphur colloid is dissolved in 24ml physiological saline, then the nasopharynx is dripped into the nasopharynx at the constant speed of the nasopharynx tube, and the mouth to the stomach is dynamically collected with SPECT/CT. The position and sitting position (6cm) and sitting position (or the treadmill movement) were two two steps of each 30min. The first step: after the patient carried on the resting position of the pillow on the pillow, the image of the posterior front of the mouth to the stomach was collected dynamically with the SPECT/CT, and the image 5min was collected after the drop injection. If the first step of the nuclide showed false positive, the patient was removed and the negative person entered the second step. The second steps: the negative people were randomly divided into three groups: continue to take the original position (group A), quiet sitting position (group B, head back to the back of the chair, the vertical angle of about 25 degrees), the double lower limb treadmill in the seat (group C, with the patient's own exercise power), the three groups continued through nasopharynx and at the same time drip into nasopharyngeal nuclide solution 30min at the same time. 5min static acquisition of the posterior anterior image of the mouth to the stomach. Patients with chronic obstructive pulmonary disease which had been tested for the acute exacerbation of the nuclide aspiration were repeated. [results] in 166 patients with acute exacerbation of chronic obstructive pulmonary disease, 66 cases of nuclide positive and 100 cases were positive and 100 cases, and 100 negative patients passed the random number. The method was divided into 33 cases in group A, 35 cases in group B and 32 cases in group C, and the negative ones continued to drip into the nuclide solution by nasopharynx, of which 33 cases were positive in group A 0 cases, 9 in group B and 11 in C group, 32 positive in group 3 (x~2=13.097, p=0.001), and between group A group and B group, A group and C group positive rates were statistically different 2,0.000), the positive rate of group B and C group was not statistically different (x~2=0.599, p=0.439).12 patients had repeated tests, two times positive 7, two times negative 4, 1 cases first negative, second positive, Mc Nemar (M) consistency test, Kappa value 0.82 (U= 5.05, p0.001). [conclusion] lie lying again, and extend the lying time, and can not The incidence of nuclide mistaken was increased; the incidence of mistaken aspiration increased obviously after the negative patients were replaced by the sitting or sitting position, but the activity did not affect the incidence of nuclide mistaken. When the nuclide imaging was detected, the 30min and the delayed 5min image collection was suggested first, and the negative results were suggested to be replaced by the sitting position to continue to check 30 Min to reduce missed diagnosis. Radionuclide mispriming is high repeatability. Based on nuclide mispriming test, the sensitivity and specificity of mistaken aspiration, high specificity and high repeatability are worth popularizing. The second part: Discussion on the method of mispriming test for bedside food pigments. [Methods] Radionuclide saliva imaging for patients with suspicious swallowing disorders in the respiratory medicine department of the first hospital of Guangzhou Medical University, Guangzhou, in March August 2016, was examined by radionuclide imaging, and the patient's clinical data were collected. After the bed side depression water test was carried out, the saliva radionuclide imaging mistaken test was carried out, in which the saliva imaging nuclides were mixed with food. Pigments were used to check the sputum before the examination. After the examination, the patients were ordered to clean the residual nuclides in the oral and pharynx esophagus. After half an hour, the sputum was discharged and the sputum color was observed within 2 hours by the naked eye. Compared with the sputum before examination, the feasibility, sensitivity and specificity of the food pigments detection were determined, so as to establish a simple bed mistaken aspiration test. [results] 1. General data 33 patients participated in the study, 28 men, 5 women, 5 women, age (50-90) years, the average (68.1 + 11.4) years old.2. wa Tian drinking test results showed: 1, 17 cases, 11 cases, 11 cases, 3 grade 1, 4 level 4. There were 6 cases of positive inhalation test, of which 3 cases of.4. dewa field drinking test and nuclide imaging mistaken test were normal 17 cases, 17 suspicious and 16 cases were normal, and the sensitivity and specificity of comparison with nuclides were 50% and 51.7% and Mc Nemar (M) consistency respectively. The Kappa value of the test method was 0.008 (U=0.045, P0.05); the relative sensitivity of the edible pigments and nuclides was 75%, the specificity was 89.7%, the positive likelihood ratio was 7.25, the negative likelihood ratio was 0.279.Mc Nemar (M), and the Kappa value was 0.532 (U=3.28, p0.025), and the test of edible pigment was tested. [Conclusion] 1. dewa field drinking test was low sensitivity and specificity as the clinical bedside swallowing assessment. It was not suitable to be used as a mistaken.2. edible pigment as a bedside mistaken evaluation method, but the sensitivity was low; 3. food pigments + 90ml drinking water test combined evaluation, such as edible pigment +90ml After drinking the test, the edible pigment can be diagnosed by aspiration. If there is cough, but no food coloring, it is suggested that further radionuclide imaging aspiration test.
【学位授予单位】：广州医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.9

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