CL评分与CPIS评分诊断肺炎的比较

发布时间：2019-06-10 09:13

【摘要】：目的:肺炎在重症医学科(intensive care unit ICU)是一种极为常见的疾病,近年来其发病率逐年上升,病情发展迅速,伴随住院时间及医疗费用的增加,乃至危及生命。因此早期、准确、迅速诊断肺炎非常重要,目前传统影像学诊断肺炎的方法中胸部X光胸片(Chest X Radiography CXR)诊断肺炎的敏感性与特异性均较低,经常存在漏诊及误诊的情况。CT作为诊断肺炎的影像学金标准,其准确率较高,但重症患者转运困难,不利于动态监测,且两种方法都存在高辐射的缺点。本研究应用近年来发展迅速的肺部超声(Lung ultrasound LUS)与临床肺部感染评分(Clinical Pulmonary Infection Score CPIS)。目的是以2005年IDSA/ATS临床实践指南联合肺部CT为诊断的标准,将入选患者CPIS评分中CXR替换为超声,重新组合CPIS+LUS评分,简称CL评分,将CPIS评分、CPIS+PCT评分、CL评分、CL+PCT评分诊断肺炎的敏感性、特异性、阳性预测值、阴性预测值进行分析,寻找肺炎诊断最佳方法,指导肺炎的早期诊断与治疗。方法:本研究收集2016年1月至2016年12月入住河北省人民医院重症医学科疑似肺炎的患者,根据入选和排除标准对所有收集者进行筛选。所有疑似肺炎患者入科后均行床旁肺部超声检查,将两肺分为12个区,以人体胸骨中线及胸骨中轴面将胸部分为上下2个区,再将每一个区以腋前线与腋后线为分界线分为前、中、后3个区。扫查分3个步骤:(1)患者取仰卧位,操作者站在患者一侧先扫查前胸壁2个区,观察胸膜及胸膜下病变;(2)患者仰卧位,扫查范围由前胸壁延至侧壁,在侧胸壁探查中层肺野,观察有无胸腔积液和肺部实变;(3)抬高患者一侧身体,扫查背部肺野,进一步探查胸腔积液和小片实变区。超声检查均由一位受过重症超声培训的医师完成,并使患者于24小时内完善CXR、肺部CT检查。飞测Ⅲ全自动免疫荧光定量分析仪处理患者血样得出PCT结果。入科留取痰培养及革兰染色标准,待结果回报后联合临床其余指标评估CPIS评分,由另外一位重症医师完成。观察床旁肺部超声影像,包括正常肺组织内气体反射、是否存在肺实变及病变部位、范围、肺实变区内部回声、是否有胸膜下病变、是否有胸膜形态变化,观察并记录影像结果,并引用LUS评分概念,按照肺部病变严重程度进行分级评分:胸膜增厚或胸膜下病变≥2个,1分;肺部实变或动态支气管充气征,2分;2种情况同时存在,3分。PCT结果根据中国急诊临床应用的专家共识进行分级:PCT0.5ng/ml,0分;0.5≤PCT2ng/ml,1分;PCT≥2ng/ml,2分。将CPIS评分中CXR替换为超声,其余五项指标未做改动,重新组合CL评分。将CPIS评分、CPIS+PCT评分、CL评分、CL+PCT评分诊断肺炎的敏感性、特异性、阳性预测值、阴性预测值进行分析,并作出ROC曲线,并对曲线下面积进行分析,寻找诊断肺炎的最佳方法。结果:本研究共纳入72名疑似肺炎患者,根据本研究诊断标准分为肺炎组患者(52例)及非肺炎组患者(20例)包括气胸患者1例、胸腔积液患者10例、急性呼吸窘迫综合征患者9例。主要临床特点:性别、年龄、SOFA评分、APACHEII评分、体重指数、休克与否、住院时间、死亡率未见明显差异。两组患者唯一显著差异参数为:PCT结果为7.91(0.13-100)与1.62(0.17-4.50),P=0.041。当患者肺部超声可探查出实变或支气管充气征二者之一与胸膜增厚及胸膜下病变≥2个的情况同时存在的情况下,诊断肺炎的准确性达100%。CPIS评分,CPIS+PCT评分,CL评分和CL+PCT评分诊断肺炎的比较,P值均0.05,4种诊断方法与标准相比无明显差别,考虑4种诊断肺炎方法有效。患者CPIS评分、CPIS+PCT评分、CL评分、CL+PCT评分绘制ROC曲线,曲线下面积(AUC)分别为0.726(0.591-0.862)、0.788(0.670-0.906)、0.913(0.835-0.991)、0.925(0.864-0.986),曲线下面积由大到小依次为:CL+PCT评分、CL评分、CPIS+PCT评分、CPIS评分(P均0.05)。CPIS评分、CPIS+PCT评分对肺炎诊断的分析:CPIS≥6分对肺炎诊断的敏感性、特异性、阳性预测值、阴性预测值分别为71.2%、55%、80.4%和42.3%。CPIS+PCT≥6分诊断的敏感性、特异性、阳性预测值、阴性预测值分别为90.3%、50%、82.4%、66.7%。当CPIS+PCT≥10分,其特异性及阳性预测值均达100%。CL评分、CL+PCT评分对肺炎诊断的分析见:CL≥6分诊断肺炎的敏感性、特异性、阳性预测值、阴性预测值分别为88.5%、75%、90.2%、71.4%。CL+PCT≥6分诊断的敏感性、特异性、阳性预测值、阴性预测值分别为96.2%、86.2%、60%、85.7%。当CL+PCT≥9分及10分情况下,诊断肺炎的特异性及阳性预测值均达100%。结论:1在影像学资料中,超声诊断肺炎的准确性较高,联合患者临床症状可用于患者入科病情的初步评估。2 CL评分诊断肺炎的准确率明显优于CPIS评分,当联合PCT时准确率更高。
[Abstract]:Objective: Pneumonia in the intensive care unit (ICU) is a very common disease. In recent years, the incidence of pneumonia has increased year by year, the development of the disease is rapid, the hospital stay time and the medical expenses are increased, and even the life is life-threatening. Therefore, in the early, accurate and rapid diagnosis of pneumonia, the sensitivity and specificity of the chest X-ray chest X-ray (chest X-ray (CXR) in the diagnosis of pneumonia are low, and there are frequent missed and misdiagnosed cases. As the imaging gold standard for diagnosis of pneumonia, CT has high accuracy, but it is difficult for severe patients to transport, which is not conducive to dynamic monitoring, and both methods have the disadvantage of high radiation. In recent years, the present study has developed rapid lung ultrasound (lung ultrasound) and clinical pulmonary infection score (CPIS). The purpose of this study was to replace the CXR in the CPIS score of the patients with ultrasound, to realign the CPIS + LUS score and the CL score, to compare the sensitivity, specificity and positive predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score in the diagnosis of pneumonia with the 2005 IDSA/ ATS clinical practice guidance and the lung CT as the diagnostic criteria. The negative predictive value is analyzed to find the best method for the diagnosis of pneumonia and to guide the early diagnosis and treatment of pneumonia. Methods: The study collected the patients with suspected pneumonia from January 2016 to December 2016 at the People's Hospital of Hebei Province. All the collectors were screened according to the inclusion and exclusion criteria. All patients with suspected pneumonia were divided into 12 regions, and the chest was divided into two upper and lower regions with the middle axis of the sternum and the middle axis of the sternum. The dividing line between the axilla front line and the back line of the sternum was divided into the first, the middle and the last three regions. The method comprises the following steps of: (1) taking the supine position of a patient, scanning the two regions of the front chest wall by an operator at the side of the patient, and observing the pleural and pleural lesions; (2) the patient is in a supine position, the scanning range is extended to the side wall by the front chest wall, the middle lung field is detected on the side chest wall, To observe the presence or absence of pleural effusion and a solid lung change; (3) elevate the patient's side, scan back the lung field, and further explore the pleural effusion and the solid area of the small die. The ultrasound examination was performed by an intensive care physician and the patient was allowed to complete the CXR and lung CT examination within 24 hours. The results of PCT were obtained from the blood samples of the patients treated with the FFII full-automatic immunofluorescence quantitative analyzer. Phlegm culture and Gram-staining criteria were taken into the Section, and the CPIS score was assessed by the combination of the rest of the clinical indicators after the results were reported, and the other intensive care physician was completed. To observe the ultrasound image of the lung beside the bed, including the reflection of the gas in the normal lung tissue, the presence or absence of the internal echo in the area of the lung and the area of the lesion, the internal echo in the real area of the lung, whether there is a subpleural lesion, the change of the pleura, the observation and recording of the image results, and the concept of the LUS score, Grading scores were performed according to the severity of the lung lesions:2,1 in the pleural thickening or subpleural lesions;2 points for pulmonary or dynamic bronchogenic signs; and 3 for 2 cases. The PCT results were graded according to the expert consensus of China's emergency clinical application: PCT0.5 ng/ ml,0 min; 0.5% PCT2ng/ ml,1 point; PCT/2 ng/ ml,2 min. The CXR in the CPIS score was replaced with the ultrasound and the remaining five indices were not modified and the CL score was re-combined. The sensitivity, specificity, positive predictive value and negative predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score, the specificity, the positive predictive value and the negative predictive value were analyzed, and the ROC curve was taken and the area under the curve was analyzed to find the best method to diagnose the pneumonia. Results: A total of 72 patients with suspected pneumonia were included in this study. According to this study, the diagnosis criteria were divided into pneumonia group (52 cases) and non-pneumonia group (20 cases), including 1 case of pneumothorax,10 cases of pleural effusion and 9 cases of acute respiratory distress syndrome. Main clinical features: sex, age, SOFA score, APACHEII score, body weight index, shock, hospital stay, and death rate were not significantly different. The only significant difference between the two groups was: PCT was 7.91 (0.13-100) and 1.62 (0.17-4.50), P = 0.041. The accuracy of the diagnosis of pneumonia is 100%, the CPIS score, the CPIS + PCT score, the CL score, and the CL + PCT score are compared with the diagnosis of pneumonia, There was no significant difference between the four diagnostic methods and the standard, and four methods of diagnosis of pneumonia were considered to be effective. The ROC curve was drawn by the CPIS score, the CPIS + PCT score, the CL score and the CL + PCT score. The area under the curve (AUC) was 0.726 (0.591-0.862), 0.788 (0.670-0.906), 0.913 (0.835-0.991), 0.925 (0.864-0.986), and the area under the curve was in the order of: CL + PCT score, CL score, CPIS + PCT score, and CPIS score (P <0.05). The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 71.2%,55%, 80.4% and 42.3%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 90.3%, respectively. 50%, 82.4%, 66.7%. The sensitivity, specificity, positive predictive value and negative predictive value of CL-6 were 88.5%,75%, 90.2%, 71.4%. The positive predictive value and negative predictive value were 96.2%, 86.2%,60% and 85.7%, respectively. The specificity and positive predictive value of the diagnosis of pneumonia were 100% in the cases of CL + PCT,9 and 10. Conclusion:1 In the imaging data, the accuracy of the ultrasonic diagnosis of pneumonia is high, and the clinical symptoms of the combined patients can be used for the preliminary assessment of the condition of the patients. The accuracy of the 2CL score in the diagnosis of pneumonia is obviously superior to that of the CPIS score, and the accuracy rate is higher when the joint PCT is combined.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.1

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