【摘要】：背景和目的： 孕婦社區(qū)獲得性肺炎(Community acquired pneumonia CAP)是一種妊娠期間嚴重的疾病,妊娠期肺炎的病程、嚴重程度和病死率均較非妊娠期增加并增加早產(chǎn)和低出生體重兒的風險。因此早期及時準確的診斷對妊娠期肺炎具有重要的意義。本研究對2014年1月1日至9月30日,杭州市第一人民醫(yī)院急診科收治的疑似肺炎的45例孕婦患者進行肺部超聲(Lung ultrasound LUS)和X線胸片檢查,分析LUS和X線胸片之間的一致性。通過與X線胸片比較,探索肺部超聲在孕婦肺炎診斷中的可靠性,希望能夠為妊娠期肺炎的診斷尋找一種無輻射、簡便易行、可靠且重復性好的手段。 方法： 本研究為前瞻性診斷性研究,經(jīng)過醫(yī)院倫理委員會批準,并獲得患者及家屬知情同意。將2014年1月1日至2014年9月30日期間,納入我院急診科有發(fā)熱咳嗽咳痰而疑似肺炎的45例孕周4周孕婦患者,在知情同意的前提下,入院后24h內(nèi)行X線胸片、LUS及血常規(guī)檢查,X線胸片由具有資質(zhì)的放射科醫(yī)師出具報告,LUS由經(jīng)過床邊B超訓練的急診醫(yī)師或具有資質(zhì)的B超醫(yī)師進行檢查。B超檢查者并不知曉X線胸片報告,B超結(jié)果不影響臨床醫(yī)師的治療決策。安靜狀態(tài)下,孕婦患者取仰臥、側(cè)臥或坐位,以腋前線、腋中線、腋后線為界,將肺臟分為前、側(cè)、后三個區(qū)域,探頭與肋骨垂直分別對雙側(cè)肺臟的每個區(qū)域進行掃查,觀察是否存在肺實變(Lung consolidation LC)、A-線(A-line)消失、多量B-線(B-line)出現(xiàn)及肺搏動(Lung pulse LP),出現(xiàn)上述4個特征性影像學改變中的1個或以上即為陽性。根據(jù)臨床癥狀、放射影像學、實驗室檢查由2名副高以上的臨床醫(yī)師做出肺炎的診斷。確診肺炎的孕婦患者作為肺炎組,非肺炎的孕婦患者作為對照組,分析LUS在孕婦肺炎中的影像學特點,對LUS與X線胸片進行相關(guān)性分析,使用SPSS19.0軟件對數(shù)據(jù)進行統(tǒng)計分析,計量資料以x±s標準差表示,組間比較采用t檢驗。計算LUS對孕婦CAP診斷的特異性、敏感性、假陽性率、假陰性率、陽性預(yù)測值、陰性預(yù)測值和準確度。對LUS與X線胸片診斷CAP的一致性進行Kappa檢驗。P0.05為差異有統(tǒng)計學意義。 結(jié)果： (1)共入組45例患者,平均年齡28.0±2.54歲。孕4周～12周占20%(9/45),13周～27周占46.7%(21/45),28周～40周占33.3%(15/45)。肺炎組27例(60%),對照組占18例(40%)。肺炎組白細胞數(shù)目較對照組明顯升高(P0.05),而年齡、孕周無明顯差異(P0.05)。 (2)對照組患者中,LUS中的肺實變、肺搏動出現(xiàn)例數(shù)均為0,多量B-線出現(xiàn)1例(5.6%),A線消失2例(11.1%)；肺炎組患者中,肺實變21例次(77.8%),多量B-線25例次(92.6%),A-線消失25例次(92.6%),肺搏動5例次(18.5%),兩組間差異有統(tǒng)計學意義,P值均0.001。 (3)LUS對CAP診斷的敏感度為92.6%,特異度為89.5%,假陽性率10.5%,假陰性率3.8%,陽性預(yù)測值82.6%,陰性預(yù)測值94.4%,準確度93.3%,KAPPA值0.862,說明與X線胸片的一致性好。 結(jié)論： 肺部超聲與X線胸片診斷孕婦社區(qū)獲得性肺炎的一致性較好,超聲檢查具有無輻射、方便易行、可重復的特點,適用于于對疑似肺炎的孕婦的診斷,值得進一步研究。
[Abstract]:Background and purpose:
Community acquired pneumonia CAP is a serious disease during pregnancy. The course of pregnancy, severity and mortality of gestation are higher than those in non pregnancy and increase the risk of premature and low birth weight. Therefore, early and accurate diagnosis is of great significance for pregnancy pneumonia. From January 1, 2014 to September 30th, 45 pregnant women with suspected pneumonia in the emergency department of No.1 People's Hospital of Hangzhou were examined by lung ultrasound (Lung ultrasound LUS) and X-ray chest X-ray. The consistency between LUS and X-ray chest films was analyzed. The reliability of lung ultrasound in the diagnosis of pneumonia in pregnant women was explored by comparing with X-ray chest films. It is a simple, reliable and reproducible method for the diagnosis of pregnancy pneumonia.
Method:
This study was a prospective diagnostic study, approved by the hospital ethics committee, and obtained the informed consent of the patients and their families. From January 1, 2014 to September 30, 2014, 45 pregnant women with fever, cough and expectoration and suspected pneumonia were included in the emergency department of our hospital from January 1, 2014 to September 30, 2014. On the premise of knowledge consent, 24h X-ray chest films were performed in the hospital after admission, LU S and blood routine examination, X-ray chest radiographs issued by a qualified radiologist, LUS by an emergency physician or a qualified B ultrasonic doctor trained by bedside B-ultrasound. B ultrasonic examiners do not know the chest x-ray report. B ultrasonic results do not affect the treatment decision of the clinician. In quiet state, pregnant women are supine, lateral or sitting. Position, with the frontline of axillary, midline of axillary and axillary posterior line as boundary, the lung was divided into the front, the side, and the back three regions, the probe and the ribs were scanned in each area of the bilateral lungs respectively, and the presence of Lung consolidation LC, the A- line (A-line) disappeared, the multiple B- line (B-line) and the lung pulsation (Lung pulse LP), and the above 4 characteristics appeared. 1 or more of the changes in sexual imaging were positive. According to clinical symptoms, Radiology, and laboratory examination, the diagnosis of pneumonia was made by 2 clinicians above the subtropical high. The pregnant women who confirmed pneumonia were treated as pneumonia group and non pneumonia pregnant woman as control group. The imaging characteristics of LUS in pregnant women were analyzed, and LUS and X ray were used. Correlation analysis of chest films, statistical analysis of data using SPSS19.0 software, x + s standard deviation of measurement data and t test among groups. The specificity, sensitivity, false positive rate, false negative rate, false negative rate, positive predictive value, negative pretest value and accuracy of LUS for pregnant women's CAP were calculated. The consistency of LUS with X-ray chest X-ray diagnosis of CAP Kappa test was performed. The difference was statistically significant in P 0.05.
Result:
(1) the average age of 45 patients, the average age of 28 + 2.54 years, 4 weeks to 12 weeks of pregnancy 20% (9/45), 13 to 27 weeks, 46.7% (21/45), 28 to 40 weeks occupy 33.3% (15/45), pneumonia group, the number of leukocytes in the pneumonia group was significantly higher than the control group (P0.05), but the age, no significant difference between the gestational weeks (P0.05).
(2) in the control group, the pulmonary consolidation in LUS and the number of pulmonary pulsation were 0, the multiple B- line appeared in 1 cases (5.6%), and the A line disappeared in 2 cases (11.1%); in the pneumonia group, the pulmonary consolidation was 21 times (77.8%), the multiple B- line was 25 (92.6%), the A- line disappeared (92.6%), and the pulmonary pulsation was statistically significant, and the P value was 0.001.
(3) the sensitivity of LUS to the diagnosis of CAP was 92.6%, the specificity was 89.5%, the false positive rate was 10.5%, the false negative rate was 3.8%, the positive predictive value was 82.6%, the negative predictive value was 94.4%, the accuracy was 93.3%, and the KAPPA value was 0.862, indicating good consistency with the X-ray chest film.
Conclusion:
The consistency of pulmonary ultrasound and X-ray chest X-ray diagnosis of pregnant women's community acquired pneumonia is better. Ultrasound examination has no radiation, convenient and repeatable characteristics. It is suitable for the diagnosis of pregnant women with suspected pneumonia. It is worth further study.
【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R445.1;R714.253

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