肺部及膈肌超声对机械通气撤机成功的预测作用
Lung and diaphragm ultrasound as predictors of success in weaning from mechanical ventilation.
作者信息
Tenza-Lozano Eva, Llamas-Alvarez Ana, Jaimez-Navarro Enrique, Fernández-Sánchez Javier
机构信息
Intensive Care Unit, Department of Intensive Care Medicine, Elche General University Hospital, Camino de la Almazara 11, 03203, Elche, Spain.
Department of Clinical Medicine, Miguel Hernandez University, Sant Joan d'Alacant, Spain.
出版信息
Crit Ultrasound J. 2018 Jun 18;10(1):12. doi: 10.1186/s13089-018-0094-3.
BACKGROUND
Lung and diaphragm ultrasound methods have recently been introduced to predict the outcome of weaning from mechanical ventilation (MV). The aim of this study is to assess the reliability and accuracy of these techniques for predicting successful weaning in critically ill adults.
METHODS
We conducted two studies: a cross-sectional interobserver agreement study between two sonographers and a prospective cohort study to assess the accuracy of lung and diaphragm ultrasound for predicting weaning and extubation outcome. For the interobserver agreement study, we included 50 general critical care patients who were consecutively admitted to the ICU. For the predictive accuracy study, we included consecutively 69 patients on MV who were ready for weaning. We assessed interobserver agreement of ultrasound measurements, using the weighted kappa coefficient for LUSm score (modified lung ultrasound score) and the intraclass correlation coefficient (ICC) and Bland-Altman method for TI (diaphragm thickening index). We assessed the predictive value of LUSm and TI in weaning outcome by plotting the corresponding ROC curves.
RESULTS
We found adequate interobserver agreement for both LUSm (weighted kappa 0.95) and TI (ICC 0.78, difference according to Bland-Altman analysis ± 12.5%). LUSm showed good-moderate discriminative power for successful weaning and extubation (area under the ROC curve (AUC) for successful weaning 0.80, and sensitivity and specificity at optimal cut-off point 0.76 and 0.73, respectively; AUC for successful extubation 0.78, and optimal sensitivity and specificity 0.76 and 0.47, respectively. TI was more sensitive but less specific for predicting successful weaning (AUC 0.71, optimal sensitivity and specificity 0.93 and 0.48) and successful extubation (AUC 0.76, optimal sensitivity and specificity 0.93 and 0.58). The area under the ROC curve for predicting weaning success was 0.83 for both ultrasound measurements together.
CONCLUSIONS
Interobserver agreement was excellent for LUSm and moderate-good for TI. A low TI value or high LUSm value indicates high risk of weaning failure.
背景
肺和膈肌超声方法最近被用于预测机械通气（MV）撤机的结果。本研究的目的是评估这些技术在预测危重症成年患者成功撤机方面的可靠性和准确性。
方法
我们进行了两项研究：一项是两名超声检查人员之间的横断面观察者间一致性研究，另一项是前瞻性队列研究，以评估肺和膈肌超声在预测撤机和拔管结果方面的准确性。在观察者间一致性研究中，我们纳入了50例连续入住重症监护病房（ICU）的普通危重症患者。在预测准确性研究中，我们连续纳入了69例准备撤机的MV患者。我们使用LUSm评分（改良肺超声评分）的加权kappa系数以及TI（膈肌增厚指数）的组内相关系数（ICC）和Bland-Altman方法评估超声测量的观察者间一致性。通过绘制相应的ROC曲线，我们评估了LUSm和TI在撤机结果中的预测价值。
结果
我们发现LUSm（加权kappa 0.95）和TI（ICC 0.78，根据Bland-Altman分析差异为±12.5%）的观察者间一致性良好。LUSm对成功撤机和拔管显示出中等良好的判别能力（成功撤机的ROC曲线下面积（AUC）为0.80，最佳截断点处的敏感性和特异性分别为0.76和0.73；成功拔管的AUC为0.78，最佳敏感性和特异性分别为0.76和0.47）。TI在预测成功撤机（AUC 0.71，最佳敏感性和特异性为0.93和0.48）和成功拔管（AUC 0.76，最佳敏感性和特异性为0.93和0.58）方面更敏感但特异性较低。两种超声测量方法一起预测撤机成功的ROC曲线下面积为0.83。
结论
LUSm的观察者间一致性极佳，TI的观察者间一致性为中等良好。低TI值或高LUSm值表明撤机失败风险高。
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