Tagliabue M, Merlini L
Servizio di Radiodiagnostica, Ospedale San Gerardo, Monza, Milano.
Radiol Med. 1994 Jan-Feb;87(1-2):45-52.
In the patients suffering from adult respiratory distress syndrome (ARDS), pulmonary barotrauma is a frequent and fearful complication, whose timely and accurate diagnosis is therefore needed. To this purpose, bedside chest films often exhibit some diagnostic drawbacks. Computed tomography (CT) of the chest is rarely used because of the problems concerning the transfer and the control of these critically ill patients outside the Intensive Care Unit. The chest CT findings of 84 ARDS patients were retrospectively reviewed, investigating: a) the presence of barotrauma (pulmonary bullae, pneumothorax, pneumomediastinum, subcutaneous emphysema); b) the positioning of thoracostomy tubes; c) the chest films performed on the same day as CT. CT showed the presence of barotrauma in 41 patients. Pulmonary bullae were seen in 26 cases (31%), pneumothorax (mainly in anteromedial location) in 27 cases (32%) and pneumomediastinum in 11 cases (13%). In 22 patients with thoracostomy tubes CT demonstrated the exact site of the drainages: in 7 cases only the tubes were correctly positioned, or were working properly. The presence of pulmonary bullae (regarded as the evidence of interstitial pulmonary emphysema) proved to be associated with a higher mortality rate than that of the entire sample (58% vs 38%); in 30 of 41 patients with barotrauma (73%) CT proved to be superior to chest films, especially to demonstrate pulmonary bullae (26 cases detected by CT vs 7 cases diagnosed by chest films). In 14 of 41 patients with barotrauma the information yielded by CT directed the choice of treatment: thoracostomy tubes were positioned in the cases of pneumothorax undetected by chest films and in the cases of only partially drained multilocular pneumothorax, or replaced in the event of tube mispositioning. In conclusions, in ARDS patients the use of chest CT is recommended in selected cases only, when complications (especially barotrauma) are suspected and unrevealed by bedside chest films.
在患有成人呼吸窘迫综合征（ARDS）的患者中，肺气压伤是一种常见且可怕的并发症，因此需要及时、准确的诊断。为此，床边胸部X光片常常存在一些诊断缺陷。由于将这些重症患者转运出重症监护病房并进行管控存在问题，胸部计算机断层扫描（CT）很少使用。我们回顾性分析了84例ARDS患者的胸部CT结果，研究内容包括：a）气压伤的存在情况（肺大疱、气胸、纵隔气肿、皮下气肿）；b）胸腔造瘘管的位置；c）与CT同一天进行的胸部X光片。CT显示41例患者存在气压伤。26例（31%）可见肺大疱，27例（32%）出现气胸（主要位于前内侧），11例（13%）出现纵隔气肿。在22例置有胸腔造瘘管的患者中，CT显示了引流的确切位置：7例引流管位置正确或工作正常。肺大疱（被视为间质性肺气肿的证据）的存在被证明与高于整个样本的死亡率相关（58%对38%）；在41例有气压伤的患者中，30例（73%）的CT表现优于胸部X光片，尤其是在显示肺大疱方面（CT检测到26例，胸部X光片诊断出7例）。在41例有气压伤的患者中，14例患者CT提供的信息指导了治疗选择：对于胸部X光片未检测到的气胸以及仅部分引流的多房性气胸患者，放置胸腔造瘘管；若引流管位置不当，则进行更换。总之，对于ARDS患者，仅在怀疑有并发症（尤其是气压伤）且床边胸部X光片未显示的特定情况下，才建议使用胸部CT。
