本文選題：誤吸 + 放射性核素顯像　； 參考：《廣州醫(yī)科大學(xué)》2017年碩士論文

【摘要】：【背景及目的】誤吸指固體食物、流質(zhì)、口咽分泌物或胃內(nèi)容物通過(guò)聲門(mén)進(jìn)入下呼吸道。誤吸后可出現(xiàn)咳嗽、氣喘、甚至窒息危機(jī)生命,也可以沒(méi)有任何不適。根據(jù)誤吸后有無(wú)咳嗽分為顯性誤吸和隱性誤吸。目前對(duì)誤吸的檢查分床旁評(píng)估、儀器檢查及氣道分泌物生物標(biāo)記,由于床旁評(píng)估對(duì)隱性誤吸容易漏診,臨床上診斷隱性誤吸的“金標(biāo)準(zhǔn)”是吞鋇電視透視檢查(VFSS)、纖維內(nèi)鏡吞咽評(píng)估(FEES)及放射性核素顯像,前兩種方法在評(píng)估吞咽動(dòng)作、滲漏、誤吸及吞咽后殘留上的敏感性相一致;1991年,Langmore進(jìn)行比較,這兩種方法在誤吸診斷上一致率達(dá)90%,但Abtin Tabaee在2006年通過(guò)回顧性分析54例2周內(nèi)同時(shí)行VFSS和FESS檢查的患者資料發(fā)現(xiàn)他們完全一致率只有52%;提示:這兩種方法對(duì)誤吸的診斷意義存在爭(zhēng)議,有必要尋求更理想的方法。2012年我們科研組建立了“^99Tc^m-硫膠體唾液顯像法”,使用此法對(duì)慢阻肺急性加重(Acute exacerbation of COPD,AECOPD)患者進(jìn)行誤吸篩查,3年后對(duì)53例進(jìn)行了誤吸篩查的患者進(jìn)行生存分析發(fā)現(xiàn):誤吸組的死亡風(fēng)險(xiǎn)是非誤吸組的2倍(附錄1),盡管目前沒(méi)有相關(guān)核素評(píng)估誤吸準(zhǔn)確性的報(bào)道,但Baikie對(duì)63名14月-16歲腦癱兒進(jìn)行吞鋇透視和唾液顯像比較時(shí)發(fā)現(xiàn):核素唾液顯像法檢測(cè)誤吸的敏感性更高,并且認(rèn)為持續(xù)滴定、并同時(shí)進(jìn)行圖像掃描檢測(cè)誤吸的可靠性更高。基于順行性誤吸除了與口咽分泌物及進(jìn)食食物有關(guān)外,也與鼻咽部分泌物有關(guān)。有文獻(xiàn)報(bào)道:在睡眠期間,利用放射性核素檢測(cè)意識(shí)障礙患者及正常人群夜間鼻咽部分泌物的誤吸情況,對(duì)于存在分泌物增多的鼻炎或鼻竇炎患者來(lái)說(shuō),隱性誤吸的發(fā)生可能發(fā)生在任何時(shí)間點(diǎn)及不同體位下。2013年,我們科研組再次建立了“鼻咽部分泌物誤吸檢測(cè)法”,使用此種方法檢測(cè)了32例確診為肺炎的住院患者,其中19人存在鼻塞、流涕癥狀,16人顯示核素誤吸檢測(cè)陽(yáng)性,而沒(méi)有鼻部癥狀的肺炎患者只有3例核素誤吸檢測(cè)陽(yáng)性。我們科研組開(kāi)展的核素誤吸檢查方法在國(guó)內(nèi)屬于首次開(kāi)展,為了能在臨床中推廣,我們擬完善此檢查方法,包括檢查持續(xù)時(shí)間和檢查體位對(duì)核素誤吸試驗(yàn)陽(yáng)性率的影響,及其陽(yáng)性的重復(fù)性;同時(shí),為了減少臨床工作量和患者負(fù)擔(dān),我們擬建立一種簡(jiǎn)單而特異性高的誤吸篩查方法,并對(duì)既往進(jìn)行了核素檢測(cè)的患者進(jìn)行回顧性生存分析,以探討誤吸對(duì)慢阻肺患者遠(yuǎn)期生存率的影響。為此本研究包括兩部分:第一部分:觀察時(shí)間和體位改變對(duì)核素顯像誤吸試驗(yàn)結(jié)果的影響及其結(jié)果的可重復(fù)性第二部分:食用色素床旁誤吸篩查方法的探討;第一部分:觀察時(shí)間和體位改變對(duì)核素顯像誤吸試驗(yàn)結(jié)果的影響及其結(jié)果的可重復(fù)性【目的】對(duì)放射性核素顯像誤吸檢測(cè)法進(jìn)行完善,包括誤吸檢查需要的時(shí)間長(zhǎng)度、檢查體位姿勢(shì),同時(shí)探討核素誤吸檢查的重復(fù)性�！痉椒ā繉�(duì)166名2014年8月~2016年12月連續(xù)入住廣州醫(yī)科大學(xué)附屬第一醫(yī)院呼吸內(nèi)科的慢阻肺急性加重住院患者行放射性核素顯像檢查:通過(guò)鼻咽管,以24ml/h的恒速,(利用向在鼻咽部滴注溶解了111.0 MBq锝99m-硫膠體的生理鹽水,以模仿鼻咽分泌物增多,將111.0 MBq锝99m-硫膠體溶解于24ml生理鹽水中,然后通過(guò)鼻咽管以24ml/h的恒速滴入鼻咽部,用SPECT/CT動(dòng)態(tài)采集口腔至胃的后前位圖像),包括留枕(6cm)平躺體位和坐位(或踏車(chē)運(yùn)動(dòng))兩個(gè)兩步各30min;第一步:患者進(jìn)行留枕平躺體位30min后,用SPECT/CT動(dòng)態(tài)采集口腔至胃的后前位圖像及停滴注后靜態(tài)采集圖像5min,若第一步核素顯示誤吸陽(yáng)性則剔除,陰性者進(jìn)入第二步試驗(yàn);第二步:陰性者隨機(jī)分為三組:繼續(xù)采取原體位(A組)、安靜坐位(B組,頭稍后仰靠椅背,垂直角度約25°)、坐位下雙下肢踏車(chē)運(yùn)動(dòng)(C組,以患者能自己承受的運(yùn)動(dòng)功率),三組均繼續(xù)經(jīng)鼻咽部并同時(shí)恒速滴入鼻咽部核素溶液30min,結(jié)束后進(jìn)行5min靜態(tài)采集口腔至胃的后前位圖像。因急性加重再次入院的已經(jīng)檢測(cè)核素誤吸實(shí)驗(yàn)的慢阻肺患者,按照上述方法進(jìn)行重復(fù)性檢查�！窘Y(jié)果】166名慢阻肺急性加重患者中,核素陽(yáng)性和陰性者分別66例和100例;100例陰性患者通過(guò)隨機(jī)數(shù)字法分為:A組33例、B組35例、和C組32例;陰性者繼續(xù)經(jīng)鼻咽部滴入核素溶液,其中A組33例陽(yáng)性0例,B組35例陽(yáng)性9例,C組32例陽(yáng)性11例,3組陽(yáng)性率存在統(tǒng)計(jì)學(xué)差異(x~2=13.097,p=0.001),組間比較A組與B組、A組與C組陽(yáng)性率存在統(tǒng)計(jì)學(xué)差異(x~2=9.78,13.655;p=0.002,0.000),B組與C組陽(yáng)性率無(wú)統(tǒng)計(jì)學(xué)差異(x~2=0.599,p=0.439)。12名患者進(jìn)行了重復(fù)性檢驗(yàn),兩次均陽(yáng)性7人,兩次均陰性4人,1例第一次陰性,第二次陽(yáng)性,Mc Nemar(M)一致性檢驗(yàn)法Kappa值為0.82(U=5.05,p0.001)�！窘Y(jié)論】平躺30min后,再延長(zhǎng)平躺時(shí)間,并不能增加核素誤吸發(fā)生率;平躺陰性患者改為坐位或坐位下四肢活動(dòng)后,誤吸發(fā)生率明顯增加,但活動(dòng)并不影響坐位核素誤吸的發(fā)生率。核素顯像檢測(cè)誤吸時(shí),建議先平躺位留枕30min及延遲5min圖像采集,對(duì)于陰性結(jié)果建議改為坐位繼續(xù)檢查30min以減少漏診。放射性核素檢查誤吸重復(fù)性高�；诤怂卣`吸試驗(yàn)診斷誤吸敏感性和特異性高,且重復(fù)性高,是值得推廣的誤吸檢查方法。第二部分:床旁食用色素誤吸試驗(yàn)方法的探討【目的】探討床旁食用色素誤吸試驗(yàn)的方法。【方法】對(duì)2016年8月~2017年3月入住廣州醫(yī)科大學(xué)附屬第一醫(yī)院呼吸內(nèi)科的可疑吞咽障礙住院患者進(jìn)行放射性核素唾液顯像法檢查,收集患者臨床資料,進(jìn)行床旁洼田飲水試驗(yàn)后,給予行唾液核素顯像誤吸試驗(yàn),其中唾液顯像核素液中混有食用色素,檢查前留痰,檢查結(jié)束后囑患者清潔口腔及咽喉食道殘留核素,半小時(shí)后進(jìn)行咳嗽排痰,肉眼觀察2小時(shí)內(nèi)痰液顏色,與檢查前痰液對(duì)照,判斷食用色素檢測(cè)誤吸的可行性、敏感性及特異性,以便建立床旁簡(jiǎn)易誤吸試驗(yàn)�！窘Y(jié)果】1.一般資料33例患者參與了研究,男28例,女5例,年齡(50-90)歲,平均(68.1±11.4)歲。2.洼田飲水試驗(yàn)結(jié)果顯示:1級(jí)17例,2級(jí)11例,3級(jí)1例,4級(jí)4例;3.核素顯像誤吸試驗(yàn)和床旁食用色素誤吸試驗(yàn)結(jié)果核素顯像誤吸試驗(yàn)結(jié)果陽(yáng)性的有4例,床旁食用色素誤吸試驗(yàn)陽(yáng)性的有6例,其中核素顯像誤吸試驗(yàn)和床旁食用色素誤吸試驗(yàn)二者均陽(yáng)性的3例。4.洼田飲水試驗(yàn)與核素顯像誤吸試驗(yàn)的相關(guān)性洼田飲水試驗(yàn)正常17例,可疑及異常16例,與核素比較敏感度和特異度分別為50%和51.7%,Mc Nemar(M)一致性檢驗(yàn)法Kappa值為0.008(U=0.045,p0.05);5.床旁食用色素誤吸試驗(yàn)與核素顯像誤吸試驗(yàn)的相關(guān)性食用色素與核素比較敏感度為75%,特異度為89.7%,陽(yáng)性似然比為7.25,陰性似然比為0.279。Mc Nemar(M)一致性檢驗(yàn)法Kappa值為0.532(U=3.28,p0.025),食用色素檢驗(yàn)誤吸與核素檢驗(yàn)誤吸呈中度一致性。【結(jié)論】1.洼田飲水試驗(yàn)作為臨床床旁吞咽評(píng)估敏感性和特異性均低,不適宜作為誤吸普查。2.食用色素作為床旁誤吸評(píng)估方法可行,但敏感性偏低;3.食用色素+90ml飲水試驗(yàn)聯(lián)合評(píng)估,如食用色素+90ml飲水試驗(yàn)后,痰有食用色素,則可診斷誤吸;如有咳嗽,但沒(méi)有食用色素者,建議進(jìn)一步行核素顯像誤吸試驗(yàn)。
[Abstract]:[background and purpose] mistaken aspiration refers to solid food, fluid, oropharyngeal secretions or gastric contents into the lower respiratory tract through the glottis. After mistaken aspiration, it may occur in the life of coughing, asthma and even asphyxia. There is no discomfort. The "gold standard" for clinical diagnosis of recessive aspiration was barium swallowing television fluoroscopy (VFSS), fiberoptic endoscopic swallowing assessment (FEES) and radionuclide imaging. The first two methods were used to assess swallowing, leakage, aspiration, and residual deglutition. Sensitivity is consistent; in 1991, Langmore was compared, and the two methods had a consistent rate of 90% in the diagnosis of mistaken aspiration, but Abtin Tabaee in 2006, through retrospective analysis of 54 cases of VFSS and FESS examination within 2 weeks, found that their complete consensus rate was only 52%; it was suggested that the diagnostic significance of these two methods was controversial and necessary. To find a better way to find a better method.2012, our research group established the "^99Tc^m- colloid saliva imaging method", using this method to screen the patients with acute exacerbation of Acute exacerbation of COPD (AECOPD). 3 years later, the survival analysis of 53 patients who had been screened by mistaken aspiration found that the risk of death in the mistaken group was not mistaken. 2 times (Appendix 1) (Appendix 1), although there was no report on the accuracy of the related nuclide assessment, Baikie found that 63 14 months of 14 months of cerebral palsy was compared with the barium fluoroscopy and saliva imaging: the sensitivity of the nuclide saliva imaging method to detect the mistaken aspiration was higher, and the reliability of the scintigraphy was maintained and the reliability of the image scanned detection was reliable. Higher. Misbiasation based on anterograde is associated with some nasopharyngeal secretions in addition to oropharyngeal secretions and food intake. It is reported that during sleep, the use of radionuclides for detection of nocturnal nasopharyngeal secretions in patients with consciousness disorders and normal people, for patients with increased nasopharynx or sinusitis with increased secretions It is said that the occurrence of recessive aspiration may occur at any time point and.2013 years in different positions. Our scientific research group has once again established a "nasopharyngeal partial secreting detection method", and 32 hospitalized patients with pneumonia confirmed by this method were detected, of which 19 had nasal congestion, runny symptoms, and 16 showed positive nuclide aspiration. There are only 3 cases of nuclide misting positive in the patients with nasal symptoms. The method of nuclide aspiration in our scientific research group is first developed in China. In order to be popularized in the clinic, we should perfect this method, including checking the duration and checking the effect of the body position on the positive rate of the nuclide aspiration test, and the positive repetition. At the same time, in order to reduce the clinical workload and the burden of patients, we propose to establish a simple and high specific screening method of mispriming and retrospective survival analysis of patients who have previously been tested for nuclide to explore the effect of aspiration on the long-term survival of patients with chronic obstructive pulmonary disease. This study includes two parts: the first part: observation The effect of inter and position changes on the results of nuclide imaging and the repeatability of the results: the second part: the study of the screening method for the bedside mistaken aspiration of the edible pigment; the first part: the effect of the observation time and the change of body position on the results of the nuclide imaging error test and the refolding of the results The detection method was perfected, including the length of time required for the aspiration, the posture of the body, and the repeatability of the nuclide mistaken examination. [Methods] radionuclide imaging was performed on 166 hospitalized patients in the respiratory department of the respiratory department of the first hospital of Guangzhou Medical University, the first hospital of Guangzhou Medical University, August 2014, in December. Over the nasopharyngeal tube, at a constant speed of 24ml/h, (using a saline solution that dissolves 111 MBq technetium 99m- sulfur colloids to the nasopharynx, imitating the increase of nasopharynx secretion, the 111 MBq technetium 99m- sulphur colloid is dissolved in 24ml physiological saline, then the nasopharynx is dripped into the nasopharynx at the constant speed of the nasopharynx tube, and the mouth to the stomach is dynamically collected with SPECT/CT. The position and sitting position (6cm) and sitting position (or the treadmill movement) were two two steps of each 30min. The first step: after the patient carried on the resting position of the pillow on the pillow, the image of the posterior front of the mouth to the stomach was collected dynamically with the SPECT/CT, and the image 5min was collected after the drop injection. If the first step of the nuclide showed false positive, the patient was removed and the negative person entered the second step. The second steps: the negative people were randomly divided into three groups: continue to take the original position (group A), quiet sitting position (group B, head back to the back of the chair, the vertical angle of about 25 degrees), the double lower limb treadmill in the seat (group C, with the patient's own exercise power), the three groups continued through nasopharynx and at the same time drip into nasopharyngeal nuclide solution 30min at the same time. 5min static acquisition of the posterior anterior image of the mouth to the stomach. Patients with chronic obstructive pulmonary disease which had been tested for the acute exacerbation of the nuclide aspiration were repeated. [results] in 166 patients with acute exacerbation of chronic obstructive pulmonary disease, 66 cases of nuclide positive and 100 cases were positive and 100 cases, and 100 negative patients passed the random number. The method was divided into 33 cases in group A, 35 cases in group B and 32 cases in group C, and the negative ones continued to drip into the nuclide solution by nasopharynx, of which 33 cases were positive in group A 0 cases, 9 in group B and 11 in C group, 32 positive in group 3 (x~2=13.097, p=0.001), and between group A group and B group, A group and C group positive rates were statistically different 2,0.000), the positive rate of group B and C group was not statistically different (x~2=0.599, p=0.439).12 patients had repeated tests, two times positive 7, two times negative 4, 1 cases first negative, second positive, Mc Nemar (M) consistency test, Kappa value 0.82 (U= 5.05, p0.001). [conclusion] lie lying again, and extend the lying time, and can not The incidence of nuclide mistaken was increased; the incidence of mistaken aspiration increased obviously after the negative patients were replaced by the sitting or sitting position, but the activity did not affect the incidence of nuclide mistaken. When the nuclide imaging was detected, the 30min and the delayed 5min image collection was suggested first, and the negative results were suggested to be replaced by the sitting position to continue to check 30 Min to reduce missed diagnosis. Radionuclide mispriming is high repeatability. Based on nuclide mispriming test, the sensitivity and specificity of mistaken aspiration, high specificity and high repeatability are worth popularizing. The second part: Discussion on the method of mispriming test for bedside food pigments. [Methods] Radionuclide saliva imaging for patients with suspicious swallowing disorders in the respiratory medicine department of the first hospital of Guangzhou Medical University, Guangzhou, in March August 2016, was examined by radionuclide imaging, and the patient's clinical data were collected. After the bed side depression water test was carried out, the saliva radionuclide imaging mistaken test was carried out, in which the saliva imaging nuclides were mixed with food. Pigments were used to check the sputum before the examination. After the examination, the patients were ordered to clean the residual nuclides in the oral and pharynx esophagus. After half an hour, the sputum was discharged and the sputum color was observed within 2 hours by the naked eye. Compared with the sputum before examination, the feasibility, sensitivity and specificity of the food pigments detection were determined, so as to establish a simple bed mistaken aspiration test. [results] 1. General data 33 patients participated in the study, 28 men, 5 women, 5 women, age (50-90) years, the average (68.1 + 11.4) years old.2. wa Tian drinking test results showed: 1, 17 cases, 11 cases, 11 cases, 3 grade 1, 4 level 4. There were 6 cases of positive inhalation test, of which 3 cases of.4. dewa field drinking test and nuclide imaging mistaken test were normal 17 cases, 17 suspicious and 16 cases were normal, and the sensitivity and specificity of comparison with nuclides were 50% and 51.7% and Mc Nemar (M) consistency respectively. The Kappa value of the test method was 0.008 (U=0.045, P0.05); the relative sensitivity of the edible pigments and nuclides was 75%, the specificity was 89.7%, the positive likelihood ratio was 7.25, the negative likelihood ratio was 0.279.Mc Nemar (M), and the Kappa value was 0.532 (U=3.28, p0.025), and the test of edible pigment was tested. [Conclusion] 1. dewa field drinking test was low sensitivity and specificity as the clinical bedside swallowing assessment. It was not suitable to be used as a mistaken.2. edible pigment as a bedside mistaken evaluation method, but the sensitivity was low; 3. food pigments + 90ml drinking water test combined evaluation, such as edible pigment +90ml After drinking the test, the edible pigment can be diagnosed by aspiration. If there is cough, but no food coloring, it is suggested that further radionuclide imaging aspiration test.
【學(xué)位授予單位】：廣州醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R563.9

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