Wunderink R G, Woldenberg L S, Zeiss J, Day C M, Ciemins J, Lacher D A
Department of Medicine, Medical College of Ohio, Toledo.
Chest. 1992 Feb;101(2):458-63. doi: 10.1378/chest.101.2.458.
An abnormal chest roentgenogram is essential for the diagnosis of ventilator-associated pneumonia. The diagnostic accuracy of various roentgenographic signs of pneumonia has not been assessed previously in the portable anteroposterior roentgenograms obtained in ventilated patients. Seven roentgenographic signs (air bronchograms, alveolar infiltrates, silhouette sign, cavities, fissure abutment, atelectasis, and asymmetric infiltrates superimposed on diffuse bilateral infiltrates) were evaluated for their accuracy in predicting pneumonia alone, in combination with other signs, or in combination with clinical parameters. The last roentgenogram prior to autopsy of 69 ventilated patients was interpreted by three reviewers and the above signs were correlated with autopsy evidence of pneumonia. Pneumonia was present in 24 (35 percent) of the 69 autopsies. No roentgenographic sign had a diagnostic efficiency of greater than 68 percent. By stepwise logistic regression, the presence of air bronchograms was the only roentgenographic sign that correlated with pneumonia in the total group, correctly predicting 64 percent of pneumonias. In patients without adult respiratory distress syndrome (ARDS), the presence of air bronchograms or alveolar infiltrates correlated with pneumonia, while in patients with ARDS, no roentgenographic sign and only the clinical parameter of purulent sputum correlated with pneumonia. Only a minority (7/22) of worsening alveolar infiltrates in all groups were due to pneumonia and were often confused with ARDS. Alveolar hemorrhage occurred with a surprising frequency (38 percent of autopsies), including 13/45 (29 percent) patients without pneumonia. Alveolar hemorrhage was associated with 29 percent of multiple air bronchograms and 30 percent of bilateral alveolar infiltrates in patients without pneumonia. We conclude that in intubated patients with diffuse bilateral roentgenographic infiltrates, no roentgenographic sign correlates well with pneumonia. No clinical parameter added to the accuracy of either an alveolar infiltrate or an air bronchogram in patients without diffuse infiltrates. Pulmonary hemorrhage and/or infarction are frequent autopsy findings in intubated patients and may be confused radiologically with pneumonia.
胸部X线片异常对呼吸机相关性肺炎的诊断至关重要。此前尚未在通气患者的便携式前后位X线片中评估各种肺炎X线征象的诊断准确性。对七种X线征象（空气支气管征、肺泡浸润、轮廓征、空洞、叶间裂贴近、肺不张以及叠加在双侧弥漫性浸润上的不对称浸润）单独预测肺炎、与其他征象联合或与临床参数联合时的准确性进行了评估。69例通气患者尸检前的最后一张X线片由三名阅片者解读，上述征象与肺炎的尸检证据相关。69例尸检中有24例（35%）存在肺炎。没有任何X线征象的诊断效率高于68%。通过逐步逻辑回归分析，空气支气管征是全组中唯一与肺炎相关的X线征象，正确预测了64%的肺炎病例。在没有成人呼吸窘迫综合征（ARDS）的患者中，空气支气管征或肺泡浸润与肺炎相关，而在患有ARDS的患者中，没有X线征象与肺炎相关，仅有脓性痰这一临床参数与肺炎相关。所有组中肺泡浸润加重的情况只有少数（7/22）是由肺炎引起的，且常与ARDS混淆。肺泡出血的发生率令人惊讶（占尸检的38%），包括45例无肺炎患者中的13例（29%）。在无肺炎患者中，肺泡出血与29%的多发空气支气管征和30%的双侧肺泡浸润相关。我们得出结论，在插管且有双侧弥漫性X线浸润的患者中，没有X线征象与肺炎有良好的相关性。在没有弥漫性浸润的患者中，没有任何临床参数能提高肺泡浸润或空气支气管征的诊断准确性。肺出血和/或梗死是插管患者尸检时常见的发现，在放射学上可能与肺炎混淆。
