早期胸部计算机断层扫描以协助疑似社区获得性肺炎的诊断和指导治疗决策。

Early Chest Computed Tomography Scan to Assist Diagnosis and Guide Treatment Decision for Suspected Community-acquired Pneumonia.

机构信息

1 Department of Emergency Medicine, Centre Hospitalier Princesse Grace, Principality of Monaco.

2 Department of Radiodiagnosis.

出版信息

Am J Respir Crit Care Med. 2015 Oct 15;192(8):974-82. doi: 10.1164/rccm.201501-0017OC.

DOI:10.1164/rccm.201501-0017OC

PMID:26168322

Abstract

RATIONALE

Clinical decision making relative to community-acquired pneumonia (CAP) diagnosis is difficult. Chest radiograph is key in establishing parenchymal lung involvement. However, radiologic performance may lead to misdiagnosis, rendering questionable the use of chest computed tomography (CT) scan in patients with clinically suspected CAP.

OBJECTIVES

To assess whether early multidetector chest CT scan affects diagnosis and management of patients visiting the emergency department with suspected CAP.

METHODS

A total of 319 prospectively enrolled patients with clinically suspected CAP underwent multidetector chest CT scan within 4 hours. CAP diagnosis probability (definite, probable, possible, or excluded) and therapeutic plans (antibiotic initiation/discontinuation, hospitalization/discharge) were established by emergency physicians before and after CT scan results. The adjudication committee established the final CAP classification on Day 28.

MEASUREMENTS AND MAIN RESULTS

Chest radiograph revealed a parenchymal infiltrate in 188 patients. CAP was initially classified as definite in 143 patients (44.8%), probable or possible in 172 (53.8%), and excluded in 4 (1.2%). CT scan revealed a parenchymal infiltrate in 40 (33%) of the patients without infiltrate on chest radiograph and excluded CAP in 56 (29.8%) of the 188 with parenchymal infiltrate on radiograph. CT scan modified classification in 187 (58.6%; 95% confidence interval, 53.2-64.0), leading to 50.8% definite CAP and 28.8% excluded CAP, and 80% of modifications were in accordance with adjudication committee classification. Because of CT scan, antibiotics were initiated in 51 (16%) and discontinued in 29 (9%), and hospitalization was decided in 22 and discharge in 23.

CONCLUSIONS

In CAP-suspected patients visiting the emergency unit, early CT scan findings complementary to chest radiograph markedly affect both diagnosis and clinical management. Clinical trial registered with www.clinicaltrials.gov (NCT 01574066).

摘要

背景

临床医生在进行社区获得性肺炎（CAP）诊断时面临着诸多挑战。胸部 X 线摄影是确定肺部实质受累的关键，但影像学表现可能导致误诊，这使得临床疑似 CAP 患者行胸部 CT 检查的必要性受到质疑。

目的

评估疑似 CAP 患者就诊急诊时，早期行多层螺旋 CT 扫描对诊断和治疗的影响。

方法

前瞻性纳入 319 例临床疑似 CAP 患者，在 4 小时内行多层螺旋 CT 扫描。急诊医师在 CT 扫描前后建立 CAP 诊断概率（确诊、可能、疑似、排除）和治疗计划（开始/停止使用抗生素、住院/出院）。第 28 天，裁决委员会确定最终的 CAP 分类。

测量和主要结果

188 例患者的胸部 X 线片显示有实质浸润，143 例（44.8%）CAP 被初始分类为确诊，172 例（53.8%）为可能或疑似，4 例（1.2%）为排除。40 例胸部 X 线片未见浸润的患者 CT 扫描显示有实质浸润，188 例 X 线片有实质浸润的患者中有 56 例（29.8%）排除 CAP。187 例（58.6%；95%置信区间，53.2-64.0）的分类被 CT 扫描改变，导致 50.8%确诊 CAP 和 28.8%排除 CAP，80%的改变与裁决委员会的分类一致。由于 CT 扫描，51 例（16%）开始使用抗生素，29 例（9%）停止使用抗生素，22 例决定住院，23 例决定出院。