Department of Respiratory and Critical Care Medicine, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Number 826, XiNan Road, Dalian, 116033, Liaoning Province, China.
Department of Digestive System, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, 116033, China.
Sci Rep. 2022 Jul 1;12(1):11126. doi: 10.1038/s41598-022-15454-6.
The diagnostic procedure of pleural effusion (PEs) is challenging due to low detection rates and numerous aetiologies. Hence, any attempt to enhance diagnosis is worthwhile. We present a clinical pathway to guide combined application of interventional pulmonology (IP) for tracing causes of undiagnosed PEs. Subjects with undiagnosed PEs were identified in the Hospital Information System of Dalian Municipal Central Hospital from January 1, 2012, to December 31, 2018. Eligible subjects were divided into a group of combined tests and a group of medical thoracoscopy (MT). Optimal and subsequent diagnostic tests were performed depending on the guidance of the clinical pathway by matching profitable chest lesions with the respective adaptation. As the guidance of clinical pathway, common bronchoscopy would be preferentially selected if pulmonary lesions involved or within the central bronchus, EBUS-TBNA was favoured when pulmonary lesions were adjacent to the central bronchus or with the enlarged mediastinal/hilar lymph nodes, guided bronchoscopy would be preferred if pulmonary nodules/masses were larger than 20 mm with discernible bronchus signs, CT-assisted transthoracic core biopsy was preferred if pulmonary nodules were less than 20 mm, image guided cutting needle biopsy was the recommendation if the pleural thickness was larger than 10 mm and pulmonary lesions were miliary. MT was preferred only when undiagnosed PEs was the initial symptom and pulmonary lesions were miliary or absent. A total of 83.57% cases of undiagnosed PEs were eligible for the clinical pathway, and 659 and 216 subjects were included in the combined tests and MT groups, respectively, depending on the optimal recommendation of the clinical pathway. The total diagnostic yields in the combined tests and MT groups were 95.99% and 91.20%, respectively, and the difference in total diagnostic yield was statistically significant (χ = 7.510, p = 0.006). Overall, clinical pathway guidance of the combined application of IP is useful for tracing the causes of undiagnosed PEs. The diagnostic yield of undiagnosed PEs is significantly increased compared with that of MT alone.
胸腔积液（PEs）的诊断程序具有挑战性，因为其检出率低且病因众多。因此，任何旨在提高诊断率的尝试都是值得的。我们提出了一种临床路径，以指导介入性肺病学（IP）联合应用，以追踪未确诊的 PEs 的病因。2012 年 1 月 1 日至 2018 年 12 月 31 日，我们在大连市市中心医院的医院信息系统中识别出未确诊的 PEs 患者。在纳入标准中，合格的患者被分为联合检查组和胸腔镜检查（MT）组。根据临床路径的指导，根据盈利性胸部病变与相应适应度的匹配，进行最佳和后续诊断性检查。作为临床路径的指导，如果病变涉及或位于中央支气管，应优先选择常规支气管镜检查；如果病变邻近中央支气管或伴有纵隔/肺门淋巴结肿大，则应优先选择超声支气管镜经支气管针吸活检术（EBUS-TBNA）；如果肺结节/肿块大于 20mm 且具有可识别的支气管征象，则应优先选择支气管镜引导活检；如果肺结节小于 20mm，则应优先选择 CT 引导下经胸核心活检；如果胸膜厚度大于 10mm 且肺部病变呈粟粒状，则应推荐图像引导切割针活检；仅当胸腔积液为初始症状且肺部病变呈粟粒状或不存在时，才推荐胸腔镜检查。根据临床路径的最佳推荐，共有 83.57%的胸腔积液患者符合临床路径标准，分别有 659 例和 216 例患者进入联合检查和胸腔镜检查组。联合检查和胸腔镜检查组的总诊断率分别为 95.99%和 91.20%，差异有统计学意义（χ²=7.510，p=0.006）。总的来说，IP 联合应用的临床路径指导对于追踪未确诊的 PEs 的病因是有用的。与单独使用胸腔镜检查相比，未确诊的 PEs 的诊断率显著提高。
