特重度烧伤伴吸入性损伤支气管壁厚度诊断价值及预后评价研究

发布时间：2018-04-13 17:43

本文选题：特重度烧伤 + 吸入性损伤　；参考：《天津医科大学》2017年硕士论文

【摘要】：目的探讨特重度烧伤伴吸入性损伤时支气管壁厚度与病死率的关系,支气管壁厚度动态变化趋势,确定支气管壁厚度的预测诊断价值。方法选取2016年7月~2016年11月急诊收治的特重度烧伤伴吸入性损伤患者43例,所有患者均在入院时完成纤维支气管镜(FOB)检查,确定其存在吸入性损伤。分别于入院时、24h、3d、7d、14d行胸部高分辨率CT(HRCT)检查,测量右肺上叶支气管主干的支气管壁厚度(BWT)。分析BWT与病死率的关系。依据患者14天内预后情况分为存活组、死亡组,分析不同预后不同时段的BWT变化趋势。利用ROC曲线比较入院时BWT和FOB预测肺炎及死亡的诊断价值。结果入院时、24h、3d、7d、14d的BWT与病死率之间均呈正相关(r=0.763、r=0.884、r=0.973、r=0.960、r=0.807,P0.001)。死亡组患者入院时支气管壁厚度(BWT)显著高于存活组患者(P0.001),死亡组患者BWT在入院后迅速升高,存活组患者BWT在入院后缓慢升高,均于入院24小时达峰值。存活组患者BWT在24h~3天之间出现“陡坡式”下降,并且在入院后第7~14天,出现BWT下降平坦期;而死亡组患者BWT在入院24h~3天下降缓慢,呈现下降平坦期,入院3天后呈现“抛物线形”下降,死亡组患者BWT显著下降时间迟于存活组,且死亡组患者BWT于入院第14天仍然显著高于存活组(P0.001),大约为存活组患者BWT的1.44倍。入院时支气管壁厚度2.45mm时,预测肺炎的ROC曲线下面积为(0.954±0.044)(95%CI:0.867~1.000),入院时支气管壁厚度预测肺炎的准确性为95.35%,灵敏性为85.71%,特异性为97.22%,阳性预测值85.71%,阴性预测值为97.22%;入院时支气管壁厚度2.75mm时,预测死亡的ROC曲线下面积为(0.956±0.038)(95%CI:0.882~1.000),入院时支气管壁厚度预测死亡准确性为90.70%,灵敏性为83.33%,特异性为96%,阳性预测值93.75%,阴性预测值为88.89%。入院时纤维支气管镜简明损伤评分分级1.5时,预测肺炎的ROC曲线下面积为(0.679±0.099)(95%CI:0.484~0.873),入院时纤维支气管镜简明损伤评分分级预测肺炎的准确性为62.79%,灵敏性为75%,特异性为60%,阳性预测值30%,阴性预测值为91.30%;入院时纤维支气管镜简明损伤评分分级1.5时,预测死亡的ROC曲线下面积为(0.880±0.057)(95%CI:0.768~0.991),入院时纤维支气管镜简明损伤评分分级预测死亡准确性为81.40%,灵敏性为87.50%,特异性为77.78%,阳性预测值70%,阴性预测值为91.30%。入院时BWT预测诊断价值优于入院时FOB简明损伤评分分级。结论BWT测量是一种简便易行、无创高效、可重复性强、可量化吸入性损伤程度及预测预后的检查方法。BWT有利于弥补纤维支气管镜的局限性,开展治疗性干预。
[Abstract]:Objective to investigate the relationship between bronchial wall thickness and mortality in severe burn patients with inhalation injury, and to determine the predictive diagnostic value of bronchial wall thickness.Methods 43 cases of severe burn with inhalation injury were selected from July 2016 to November 2016. All the patients were examined with fiberoptic bronchoscopy (FOB) on admission to determine the presence of inhalation injury.The thickness of the bronchial wall of the main trunk of the upper lobe of the right lung was measured by HRCT at 24 h, 3 d, 7 d and 14 d after admission.The relationship between BWT and mortality was analyzed.According to the prognosis of 14 days, the patients were divided into survival group and death group. The trend of BWT changes in different prognosis and different period was analyzed.ROC curve was used to compare the diagnostic value of BWT and FOB in predicting pneumonia and death.Results there was a positive correlation between BWT and fatality rate at 24 h, 3 d, 7 d and 14 d after admission. There was a positive correlation between BWT and fatality rate.The bronchial wall thickness in the death group was significantly higher than that in the survival group (P 0.001). The BWT of the patients in the death group increased rapidly after admission, and the BWT increased slowly in the survival group, reaching the peak at 24 hours after admission.In the survival group, the BWT decreased "steeply" between the 24h~3 days and the BWT decreased flat on the 7th and 14th day after admission, while the BWT in the death group decreased slowly on the 24h~3 day after admission, showing a flat phase.Three days after admission, there was a "parabola" decline. The BWT of the dead group was significantly lower than that of the survival group, and the BWT of the death group was still significantly higher than that of the surviving group on the 14th day, which was about 1.44 times of the BWT of the surviving group.On admission, bronchial wall thickness (2.45mm),The area under the ROC curve for predicting pneumonia was 0.954 卤0.044 / 95CI: 0.8671.000. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of bronchial wall thickness on admission were 95.3535, 85.71, 97.22, 85.71 and 97.22, respectively.The area under the ROC curve for predicting death was 0.956 卤0.038 / 95 CI: 0.882 / 1.000. The accuracy of predicting death was 90.70 on admission, the sensitivity was 83.33, the specificity was 96 and the positive predictive value was 93.75 and the negative predictive value was 88.89.The brief injury score of fiberoptic bronchoscopy was 1.5 at admission.The area under the ROC curve for predicting pneumonia was 0.679 卤0.099 ~ 95CI: 0.484 / 0.8730.The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of fiberoptic bronchoscopy on admission were 62.79, 75, 60, 30 and 91.30, respectively.The concise injury score of tube mirror was 1.5.The area under the ROC curve for predicting death was 0.880 卤0.057, CI: 0.768 / 0.991g. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 81.40, 87.50, 77.78, and 91.30, respectively.The predictive value of BWT on admission was better than that on admission by FOB concise injury score.Conclusion BWT measurement is a simple, non-invasive, effective and reproducible method. It can quantify the degree of inhalation injury and predict the prognosis. BWT is helpful to remedy the limitation of fiberoptic bronchoscopy and to carry out therapeutic intervention.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R644;R816.4

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