肺栓塞临床诊断方法研究进展及其应用价值

发布时间：2018-07-11 12:03

本文选题：肺栓塞 + D-二聚体　；参考：《吉林大学》2017年硕士论文

【摘要】：目的:探讨肺栓塞常用的诊断方法在肺栓塞早期诊断中的价值,及其对肺栓塞合理治疗及疾病预后评估的意义,以提高肺栓塞的早期诊断率,降低肺栓塞的漏诊率、误诊率及死亡率。方法:回顾性分析2008年1月至2016年12月在我院临床疑诊肺栓塞的476例患者的临床辅助检查资料,并对其中确诊肺栓塞的406例患者的相关辅助检查资料进行详细分析,分析内容包括实验室检查(D-二聚体检测、动脉血气分析)、心电图检查及影像学检查(超声心动图、上下肢静脉彩超、X线胸片、64排CT胸部平扫、肺通气/灌注显像、肺灌注单光子发射计算机断层显像、64排螺旋CT肺动脉造影)。依据所做的检查项目不同将纳入研究的476例临床疑诊肺栓塞患者分成三组,A组(64排螺旋CT肺动脉造影组即64-MSCTPA组),B组(肺通气/灌注显像组即V/Q显像组),C组(肺灌注单光子发射计算机断层显像组即肺灌注SPECT显像组)。分别将A组、B组、C组检查方法对肺栓塞诊断的灵敏性、特异性、阳性预测值、阴性预测值进行对比分析。结果:406例确诊的肺栓塞患者中有370例(91.13%)D-二聚体检测结果大于500ug/L,最高者为6818ug/L;406例确诊肺栓塞患者中有333例进行了动脉血气分析检测,其中低氧血症232例(69.67%),低碳酸血症291例(65.77%);406例确诊肺栓塞患者中仅有49例(12.07%)心电图检查有典型的SIQIIITIII表现;406例确诊肺栓塞患者中有369例行经胸超声心动图检查,其中20例(5.42%)发现肺动脉主干血栓形成,7例(1.90%)发现右心房血栓;406例确诊肺栓塞患者均行下肢静脉彩超检查,有296例(72.91%)存在下肢静脉血栓;406例确诊肺栓塞患者中有321例行X线胸片检查,其中16例(4.98%)有尖端指向肺门、底面朝向胸膜的楔形阴影的典型表现;406例确诊肺栓塞患者中有292例行64排CT胸部平扫检查(包括所有胸片检查正常的69例患者),异常者256例(87.67%),其中41例(14.04%)有尖端指向肺门、底面朝向胸膜的三角形、类圆形或楔形高密度影的典型表现;476例疑诊肺栓塞患者中有134例行肺灌注/通气显像,其中105例结果为阳性,其对肺栓塞诊断的灵敏性为88.98%,特异性为62.50%,阳性预测值为94.59%,阴性预测值为43.48%;476例疑诊肺栓塞患者中有163例患者行肺灌注单光子发射计算机断层显像,其中131例为阳性,其对肺栓塞诊断的灵敏性为95.62%,特异性为92.31%,阳性预测值为98.50%,阴性预测值为80.00%;476例疑诊肺栓塞患者中有179例行64排螺旋CT肺动脉造影,其中170例结果为阳性,其对肺栓塞诊断的灵敏性为99.42%,特异性为87.50%,阳性预测值为99.42%,阴性预测值为87.50%。170例64排螺旋CT肺动脉造影阳性患者中共发现肺动脉内栓子876处,其中段与段以上动脉栓子568处,亚段及以下5-6级动脉栓子308处,其中动脉直径最小者1mm。170例中部分充盈缺损111例,523处(59.70%),附壁充盈缺损72例,228处(26.03%),轨道征40处(4.57%);完全闭塞98处(11.19%)。结论:1.血浆D-二聚体、动脉血气分析实验室检查对肺栓塞诊断的特异性不高,可作为肺栓塞诊断的参考指标、排除指标和疗效评价指标;血浆D-二聚体可作为急性肺栓塞的急诊筛查手段。2.超声心动图对心腔内及肺动脉主干血栓具有较高诊断价值。X线胸片、64排CT胸部平扫对肺栓塞诊断特异性低,不能作为肺栓塞的独立确诊方法。3.肺通气/灌注显像对亚肺段肺栓塞具有较高敏感性,可作为肺栓塞的独立确诊手段,尤其对造影剂过敏、肾功能衰竭的肺栓塞患者更为适用。4.64排螺旋CT肺动脉造影对肺栓塞诊断的灵敏性、特异性、阳性预测值、阴性预测值均较高,分别为99.42%、87.50%、99.42%、87.50%,且该检查无创并对新旧血栓的鉴别具有重要意义,可作为目前临床确诊肺栓塞的重要独立诊断方法。5.肺灌注单光子发射计算机断层显像对肺栓塞诊断的灵敏性、特异性、阳性预测值、阴性预测值与64排螺旋CT肺动脉造影相当,但对造影剂过敏、肾功能衰竭等特殊人群仍适用,可以弥补64排螺旋CT肺动脉造影的不足。
[Abstract]:Objective: To explore the value of the diagnosis of pulmonary embolism in the early diagnosis of pulmonary embolism, and its significance to the rational treatment of pulmonary embolism and the evaluation of the prognosis of the disease, in order to improve the early diagnosis rate of pulmonary embolism, reduce the missed diagnosis rate of pulmonary embolism, the rate of misdiagnosis and mortality. Methods: a retrospective analysis of the clinical diagnosis from January 2008 to December 2016 in our hospital. The clinical auxiliary examination data of 476 patients with pulmonary embolism were analyzed and analyzed in detail in 406 patients with pulmonary embolism, including laboratory examination (D- two polymer detection, arterial blood gas analysis), electrocardiogram examination and imaging examination (ultrasonic cardiogram, upper and lower limb venous color Doppler ultrasound, X-ray chest film, 64). CT chest plain scan, lung ventilation / perfusion imaging, lung perfusion single photon emission computed tomography, 64 row spiral CT pulmonary arteriography. According to the different examination items, 476 cases of clinically suspected pulmonary embolism were divided into three groups, group A (64 row spiral CT pulmonary angiography group, 64-MSCTPA group), group B (lung ventilation / perfusion imaging group) V/Q group), group C (lung perfusion single photon emission computed tomography group, that is, lung perfusion SPECT Imaging Group). The sensitivity, specificity, positive predictive value and negative predictive value of group A, B and C were compared and analyzed respectively. Results: 406 cases of pulmonary embolism were detected in 370 cases (91.13%) D- two polymer. The results were more than 500ug/L, the highest was 6818ug/L, and 333 of 406 patients with pulmonary embolism were detected by arterial blood gas analysis, of which 232 cases of hypoxemia (69.67%), 291 cases of hypocapnia (65.77%), 406 cases with pulmonary embolism, only 49 (12.07%) electrocardiographic examination had typical SIQIIITIII manifestations; 406 cases of pulmonary embolism were confirmed. 369 cases were examined by transthoracic echocardiography, of which 20 cases (5.42%) found the main arterial thrombosis of the pulmonary artery, 7 cases (1.90%) found the right atrial thrombus, 406 cases of pulmonary embolism patients underwent lower extremity venous color Doppler examination, 296 cases (72.91%) had lower limb venous thrombosis, and 321 cases of pulmonary embolism were examined by X-ray chest X-ray examination, of which 16 cases were performed. 4.98%) a typical manifestation of wedge-shaped shadow on the tip of the lung and the bottom facing the pleural; of the 406 cases of pulmonary embolism, 292 of the 64 rows of CT chest scans (including 69 patients with all chest radiographs), 256 (87.67%) of the abnormality, of which 41 (14.04%) had a tip pointing to the pulmonary portal, the bottom facing the pleural triangle, round or round. There were 134 cases of pulmonary perfusion / ventilation imaging in 476 cases of suspected pulmonary embolism, of which 105 cases were positive, the sensitivity to pulmonary embolism was 88.98%, the specificity was 62.50%, the positive predictive value was 94.59%, and the negative predictive value was 43.48%. 476 patients with suspected pulmonary embolism had 163 patients with lung perfusion single. Photon emission computed tomography, of which 131 were positive, had a sensitivity of 95.62%, a specificity of 92.31%, a positive predictive value of 92.31%, a positive predictive value of 98.50%, and a negative predictive value of 80%, and 179 cases of 476 suspected pulmonary embolism patients with 64 rows of spiral CT pulmonary arteriography, of which 170 were positive, and were sensitive to the diagnosis of pulmonary embolism. The sex was 99.42%, the specificity was 87.50%, the positive predictive value was 99.42%. The negative predictive value of the 87.50%.170 64 row spiral CT pulmonary angiography positive patients was found in 876 of the pulmonary embolus, including 568 of the segment and the arterial embolus, and 308 of the subsegments and the lower 5-6 arterial embolus, of which the arterial diameter was the smallest in the partial filling of the 1mm.170 cases. There were 111 cases of defect, 523 (59.70%), 72 cases with wall filling defect, 228 (26.03%), 40 orbital sign (4.57%) and 98 complete occlusion (11.19%). Conclusion: 1. plasma D- two polymer, the specificity of arterial blood gas analysis laboratory examination on pulmonary embolism diagnosis is not high, can be used as a reference index for pulmonary embolism diagnosis, excluding index and evaluation index of curative effect; plasma D- two Polymer can be used as an emergency screening method for acute pulmonary embolism..2. echocardiography has a high diagnostic value for thrombus in the heart and the main trunk of the pulmonary artery. X-ray chest film, 64 rows of CT chest radiographs are very low in diagnosis of pulmonary embolism, and can not be used as an independent diagnostic method for pulmonary embolism..3. lung ventilation / perfusion imaging has a high sensitivity to pulmonary embolism. It can be used as an independent diagnostic method for pulmonary embolism, especially for contrast medium allergy. The patients with renal failure of pulmonary embolism are more suitable for the sensitivity, specificity, positive predictive value and negative predictive value of.4.64 spiral CT pulmonary angiography for the diagnosis of pulmonary embolism, which are 99.42%, 87.50%, 99.42%, 87.50% respectively, and the examination is noninvasive and new and old blood. The identification of thrombus is of great significance. It can be used as an important independent diagnostic method for clinical diagnosis of pulmonary embolism..5. lung perfusion single photon emission computed tomography has the sensitivity, specificity, positive predictive value, negative predictive value and 64 row spiral CT pulmonary arteriography, but it is special for contrast agent allergy and renal failure. The crowd still applies, which can make up for the shortage of 64 slice spiral CT pulmonary angiography.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.5

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