肺部超声在呼吸机相关性肺炎早期诊断中的应用。
Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia.
机构信息
Réanimation Chirurgicale, Groupe Hospitalier Saint Joseph, Paris, France; First Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Section of Surgery and Anesthesiology, Unit of Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy.
First Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
出版信息
Chest. 2016 Apr;149(4):969-80. doi: 10.1016/j.chest.2015.12.012. Epub 2015 Dec 22.
BACKGROUND
Lung ultrasound (LUS) has been successfully applied for monitoring aeration in ventilator-associated pneumonia (VAP) and to diagnose and monitor community-acquired pneumonia. However, no scientific evidence is yet available on whether LUS reliably improves the diagnosis of VAP.
METHODS
In a multicenter prospective study of 99 patients with suspected VAP, we investigated the diagnostic performance of LUS findings of infection, subpleural consolidation, lobar consolidation, and dynamic arborescent/linear air bronchogram. We also evaluated the combination of LUS with direct microbiologic examination of endotracheal aspirates (EA). Scores for LUS findings and EA were analyzed in two ways. First, the clinical-LUS score (ventilator-associated pneumonia lung ultrasound score [VPLUS]) was calculated as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; and purulent EA, 1 point. Second, the VPLUS-direct gram stain examination (EAgram) was scored as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; purulent EA, 1 point; and positive direct gram stain EA examination, 2 points.
RESULTS
For the diagnosis of VAP, subpleural consolidation and dynamic arborescent/linear air bronchogram had a positive predictive value of 86% with a positive likelihood ratio of 2.8. Two dynamic linear/arborescent air bronchograms produced a positive predictive value of 94% with a positive likelihood ratio of 7.1. The area under the curve for VPLUS-EAgram and VPLUS were 0.832 and 0.743, respectively. VPLUS-EAgram ≥ 3 had 77% (58-90) specificity and 78% (65-88) sensitivity; VPLUS ≥ 2 had 69% (50-84) specificity and 71% (58-81) sensitivity.
CONCLUSIONS
By detecting ultrasound features of infection, LUS was a reliable tool for early VAP diagnosis at the bedside.
TRIAL REGISTRY
ClinicalTrials.gov; No.: NCT02244723; URL: www.clinicaltrials.gov.
背景
肺部超声（LUS）已成功应用于监测呼吸机相关性肺炎（VAP）的通气，并用于诊断和监测社区获得性肺炎。然而，目前尚无科学证据表明 LUS 是否能可靠地改善 VAP 的诊断。
方法
在一项对 99 例疑似 VAP 患者的多中心前瞻性研究中，我们研究了感染、胸膜下实变、肺叶实变和动态树状/线性空气支气管征的 LUS 发现的诊断性能。我们还评估了 LUS 与气管内抽吸物（EA）直接微生物检查的组合。LUS 发现和 EA 的评分以两种方式进行分析。首先，计算临床-LUS 评分（呼吸机相关性肺炎肺部超声评分[VPLUS]）如下：≥ 2 个胸膜下实变区，1 分；≥ 1 个动态树状/线性空气支气管征区，2 分；脓性 EA，1 分。其次，VPLUS-直接革兰染色检查（EAgram）评分如下：≥ 2 个胸膜下实变区，1 分；≥ 1 个动态树状/线性空气支气管征区，2 分；脓性 EA，1 分；直接革兰染色 EA 检查阳性，2 分。
结果
对于 VAP 的诊断，胸膜下实变和动态树状/线性空气支气管征的阳性预测值为 86%，阳性似然比为 2.8。两个动态线性/树状空气支气管征的阳性预测值为 94%，阳性似然比为 7.1。VPLUS-EAgram 和 VPLUS 的曲线下面积分别为 0.832 和 0.743。VPLUS-EAgram≥3 时，特异性为 77%（58-90），敏感性为 78%（65-88）；VPLUS≥2 时，特异性为 69%（50-84），敏感性为 71%（58-81）。
结论
通过检测感染的超声特征，LUS 是床边早期 VAP 诊断的可靠工具。
试验注册
ClinicalTrials.gov；编号：NCT02244723；网址：www.clinicaltrials.gov。
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