ICU床旁重症超声对呼吸机相关性肺炎早期诊断和动态评估价值探讨

目的 探讨床旁重症超声对ICU呼吸机相关性肺炎(VAP)早期诊断和动态评估的价值。方法 对56例临床疑诊为呼吸机相关性肺炎的患者同时行肺超声(LUS)和胸部 CT 及实验室检查,以临床最终确诊为标准,分析LUS对VAP的早诊断价值。运用ROC分析患者在治疗第1、3、7、10天肺部超声评分、白细胞计数(WBC)、降钙素原(PCT)、超敏 C 反应蛋白(hs- CRP)、临床肺部感染评分(CPIS)结果。结果 与临床随访诊断标准比较,床旁LUS诊断VAP的灵敏度和特异度分别为：93%、76.9%。胸部CT诊断VAP的灵敏度和特异度为分别为：95.3%、84.6%,卡方检验LUS与CT诊断VAP的灵敏度与特异度差异均无统计学意义(p＞0.05)。随访第1、3、7、10d,VAP患者肺部超声评分及WBC、PCT、hs-CRP感染指标、CPIS评分均随治疗时间的延长而下降,床旁LUS高评分值与炎性指标升高具有一致性但下降速率慢。ROC分析显示第1、3、7、10d,LUS评分曲线下面积(AUC)分别为：0.918、0.920、0.900和0.900(均p＜0.05),且与CPIS具有较好一致性；其中第1d床旁LUS评分95%CI(0.823～0.998)和第3dCPIS的95%CI(0.806～1)为最佳。结论 肺超声诊断呼吸机相关性肺炎准确率高,能动态实时观察病灶变化,是一种无创的、重复性好的、可靠的检查手段,对于ICU呼吸机相关性肺炎的早期诊断和动态评估具有临床应用价值。

The value of early diagnosis and dynamic assessment of ventilator-associated pneumonia by ICU bedside ultrasound

Objective To investigate the value of bedside ultrasound in the early diagnosis and dynamic assessment of ICU ventilator-associated pneumonia (VAP). Methods A total of 56 patients with clinically suspected ventilator-associated pneumonia underwent lungSultrasound (LUS) and chest CT and laboratory examinations. The clinical value of LUS in diagnosing VAP was analyzed. ROC (receiver operating characteristic) was used to analyze pulmonary ultrasound score, white blood cell count (WBC), procalcitonin (PCT), high-sensitivity C-reactive protein (hs-CRP), and clinical pulmonary infection scores(CPIS) at days 1, 3, 7, and 10 after treatment. Results Compared with the clinical follow-up diagnostic criteria, the sensitivity and specificity of bedside LUS in diagnosing VAP were 93% and 76.9%, respectively. The sensitivity and specificity of chest CT in diagnosing VAP were 95.3% and 84.6%, respectively. There was no significant difference in the sensitivity and specificity of chi-square test between LUS and CT for diagnosis of VAP (p>0.05). At the 1st, 3rd, 7th and 10th d after treatment, the pulmonary ultrasound score and WBC, PCT, hs-CRP infection index and CPIS score of VAP patients decreased with the prolongation of treatment time. Among them, the LUS score and inflammatory index were consist in increasing, but had a slow decrease. ROC analysis showed that the area under curve (AUC) of the LUS scoring at 1, 3, 7, and 10d after treatment was 0.918, 0.920, 0.900, and 0.900,respectively(P<0.05), which was consistent with CPIS; The 95% CI of the bedside LUS score at the 1_^st day (0.823 to 0.998) and the 95% CI of CPIS at the 3_^rd d (0.806 to 1) were the best value. Conclusions Pulmonary ultrasound for diagnosing ventilator-associated pneumonia has high accuracy, can dynamically observe lesion changes in real time. It is a non-invasive, reproducible and reliable method for early diagnosis and dynamic assessment of ICU ventilator-associated pneumonia, which is worthy of clinical application.