CL評(píng)分與CPIS評(píng)分診斷肺炎的比較
發(fā)布時(shí)間：2019-06-10 09:13
【摘要】：目的:肺炎在重癥醫(yī)學(xué)科(intensive care unit ICU)是一種極為常見的疾病,近年來其發(fā)病率逐年上升,病情發(fā)展迅速,伴隨住院時(shí)間及醫(yī)療費(fèi)用的增加,乃至危及生命。因此早期、準(zhǔn)確、迅速診斷肺炎非常重要,目前傳統(tǒng)影像學(xué)診斷肺炎的方法中胸部X光胸片(Chest X Radiography CXR)診斷肺炎的敏感性與特異性均較低,經(jīng)常存在漏診及誤診的情況。CT作為診斷肺炎的影像學(xué)金標(biāo)準(zhǔn),其準(zhǔn)確率較高,但重癥患者轉(zhuǎn)運(yùn)困難,不利于動(dòng)態(tài)監(jiān)測(cè),且兩種方法都存在高輻射的缺點(diǎn)。本研究應(yīng)用近年來發(fā)展迅速的肺部超聲(Lung ultrasound LUS)與臨床肺部感染評(píng)分(Clinical Pulmonary Infection Score CPIS)。目的是以2005年IDSA/ATS臨床實(shí)踐指南聯(lián)合肺部CT為診斷的標(biāo)準(zhǔn),將入選患者CPIS評(píng)分中CXR替換為超聲,重新組合CPIS+LUS評(píng)分,簡(jiǎn)稱CL評(píng)分,將CPIS評(píng)分、CPIS+PCT評(píng)分、CL評(píng)分、CL+PCT評(píng)分診斷肺炎的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值進(jìn)行分析,尋找肺炎診斷最佳方法,指導(dǎo)肺炎的早期診斷與治療。方法:本研究收集2016年1月至2016年12月入住河北省人民醫(yī)院重癥醫(yī)學(xué)科疑似肺炎的患者,根據(jù)入選和排除標(biāo)準(zhǔn)對(duì)所有收集者進(jìn)行篩選。所有疑似肺炎患者入科后均行床旁肺部超聲檢查,將兩肺分為12個(gè)區(qū),以人體胸骨中線及胸骨中軸面將胸部分為上下2個(gè)區(qū),再將每一個(gè)區(qū)以腋前線與腋后線為分界線分為前、中、后3個(gè)區(qū)。掃查分3個(gè)步驟:(1)患者取仰臥位,操作者站在患者一側(cè)先掃查前胸壁2個(gè)區(qū),觀察胸膜及胸膜下病變;(2)患者仰臥位,掃查范圍由前胸壁延至側(cè)壁,在側(cè)胸壁探查中層肺野,觀察有無胸腔積液和肺部實(shí)變;(3)抬高患者一側(cè)身體,掃查背部肺野,進(jìn)一步探查胸腔積液和小片實(shí)變區(qū)。超聲檢查均由一位受過重癥超聲培訓(xùn)的醫(yī)師完成,并使患者于24小時(shí)內(nèi)完善CXR、肺部CT檢查。飛測(cè)Ⅲ全自動(dòng)免疫熒光定量分析儀處理患者血樣得出PCT結(jié)果。入科留取痰培養(yǎng)及革蘭染色標(biāo)準(zhǔn),待結(jié)果回報(bào)后聯(lián)合臨床其余指標(biāo)評(píng)估CPIS評(píng)分,由另外一位重癥醫(yī)師完成。觀察床旁肺部超聲影像,包括正常肺組織內(nèi)氣體反射、是否存在肺實(shí)變及病變部位、范圍、肺實(shí)變區(qū)內(nèi)部回聲、是否有胸膜下病變、是否有胸膜形態(tài)變化,觀察并記錄影像結(jié)果,并引用LUS評(píng)分概念,按照肺部病變嚴(yán)重程度進(jìn)行分級(jí)評(píng)分:胸膜增厚或胸膜下病變≥2個(gè),1分;肺部實(shí)變或動(dòng)態(tài)支氣管充氣征,2分;2種情況同時(shí)存在,3分。PCT結(jié)果根據(jù)中國(guó)急診臨床應(yīng)用的專家共識(shí)進(jìn)行分級(jí):PCT0.5ng/ml,0分;0.5≤PCT2ng/ml,1分;PCT≥2ng/ml,2分。將CPIS評(píng)分中CXR替換為超聲,其余五項(xiàng)指標(biāo)未做改動(dòng),重新組合CL評(píng)分。將CPIS評(píng)分、CPIS+PCT評(píng)分、CL評(píng)分、CL+PCT評(píng)分診斷肺炎的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值進(jìn)行分析,并作出ROC曲線,并對(duì)曲線下面積進(jìn)行分析,尋找診斷肺炎的最佳方法。結(jié)果:本研究共納入72名疑似肺炎患者,根據(jù)本研究診斷標(biāo)準(zhǔn)分為肺炎組患者(52例)及非肺炎組患者(20例)包括氣胸患者1例、胸腔積液患者10例、急性呼吸窘迫綜合征患者9例。主要臨床特點(diǎn):性別、年齡、SOFA評(píng)分、APACHEII評(píng)分、體重指數(shù)、休克與否、住院時(shí)間、死亡率未見明顯差異。兩組患者唯一顯著差異參數(shù)為:PCT結(jié)果為7.91(0.13-100)與1.62(0.17-4.50),P=0.041。當(dāng)患者肺部超聲可探查出實(shí)變或支氣管充氣征二者之一與胸膜增厚及胸膜下病變≥2個(gè)的情況同時(shí)存在的情況下,診斷肺炎的準(zhǔn)確性達(dá)100%。CPIS評(píng)分,CPIS+PCT評(píng)分,CL評(píng)分和CL+PCT評(píng)分診斷肺炎的比較,P值均0.05,4種診斷方法與標(biāo)準(zhǔn)相比無明顯差別,考慮4種診斷肺炎方法有效。患者CPIS評(píng)分、CPIS+PCT評(píng)分、CL評(píng)分、CL+PCT評(píng)分繪制ROC曲線,曲線下面積(AUC)分別為0.726(0.591-0.862)、0.788(0.670-0.906)、0.913(0.835-0.991)、0.925(0.864-0.986),曲線下面積由大到小依次為:CL+PCT評(píng)分、CL評(píng)分、CPIS+PCT評(píng)分、CPIS評(píng)分(P均0.05)。CPIS評(píng)分、CPIS+PCT評(píng)分對(duì)肺炎診斷的分析:CPIS≥6分對(duì)肺炎診斷的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值分別為71.2%、55%、80.4%和42.3%。CPIS+PCT≥6分診斷的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值分別為90.3%、50%、82.4%、66.7%。當(dāng)CPIS+PCT≥10分,其特異性及陽(yáng)性預(yù)測(cè)值均達(dá)100%。CL評(píng)分、CL+PCT評(píng)分對(duì)肺炎診斷的分析見:CL≥6分診斷肺炎的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值分別為88.5%、75%、90.2%、71.4%。CL+PCT≥6分診斷的敏感性、特異性、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值分別為96.2%、86.2%、60%、85.7%。當(dāng)CL+PCT≥9分及10分情況下,診斷肺炎的特異性及陽(yáng)性預(yù)測(cè)值均達(dá)100%。結(jié)論:1在影像學(xué)資料中,超聲診斷肺炎的準(zhǔn)確性較高,聯(lián)合患者臨床癥狀可用于患者入科病情的初步評(píng)估。2 CL評(píng)分診斷肺炎的準(zhǔn)確率明顯優(yōu)于CPIS評(píng)分,當(dāng)聯(lián)合PCT時(shí)準(zhǔn)確率更高。
[Abstract]:Objective: Pneumonia in the intensive care unit (ICU) is a very common disease. In recent years, the incidence of pneumonia has increased year by year, the development of the disease is rapid, the hospital stay time and the medical expenses are increased, and even the life is life-threatening. Therefore, in the early, accurate and rapid diagnosis of pneumonia, the sensitivity and specificity of the chest X-ray chest X-ray (chest X-ray (CXR) in the diagnosis of pneumonia are low, and there are frequent missed and misdiagnosed cases. As the imaging gold standard for diagnosis of pneumonia, CT has high accuracy, but it is difficult for severe patients to transport, which is not conducive to dynamic monitoring, and both methods have the disadvantage of high radiation. In recent years, the present study has developed rapid lung ultrasound (lung ultrasound) and clinical pulmonary infection score (CPIS). The purpose of this study was to replace the CXR in the CPIS score of the patients with ultrasound, to realign the CPIS + LUS score and the CL score, to compare the sensitivity, specificity and positive predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score in the diagnosis of pneumonia with the 2005 IDSA/ ATS clinical practice guidance and the lung CT as the diagnostic criteria. The negative predictive value is analyzed to find the best method for the diagnosis of pneumonia and to guide the early diagnosis and treatment of pneumonia. Methods: The study collected the patients with suspected pneumonia from January 2016 to December 2016 at the People's Hospital of Hebei Province. All the collectors were screened according to the inclusion and exclusion criteria. All patients with suspected pneumonia were divided into 12 regions, and the chest was divided into two upper and lower regions with the middle axis of the sternum and the middle axis of the sternum. The dividing line between the axilla front line and the back line of the sternum was divided into the first, the middle and the last three regions. The method comprises the following steps of: (1) taking the supine position of a patient, scanning the two regions of the front chest wall by an operator at the side of the patient, and observing the pleural and pleural lesions; (2) the patient is in a supine position, the scanning range is extended to the side wall by the front chest wall, the middle lung field is detected on the side chest wall, To observe the presence or absence of pleural effusion and a solid lung change; (3) elevate the patient's side, scan back the lung field, and further explore the pleural effusion and the solid area of the small die. The ultrasound examination was performed by an intensive care physician and the patient was allowed to complete the CXR and lung CT examination within 24 hours. The results of PCT were obtained from the blood samples of the patients treated with the FFII full-automatic immunofluorescence quantitative analyzer. Phlegm culture and Gram-staining criteria were taken into the Section, and the CPIS score was assessed by the combination of the rest of the clinical indicators after the results were reported, and the other intensive care physician was completed. To observe the ultrasound image of the lung beside the bed, including the reflection of the gas in the normal lung tissue, the presence or absence of the internal echo in the area of the lung and the area of the lesion, the internal echo in the real area of the lung, whether there is a subpleural lesion, the change of the pleura, the observation and recording of the image results, and the concept of the LUS score, Grading scores were performed according to the severity of the lung lesions:2,1 in the pleural thickening or subpleural lesions;2 points for pulmonary or dynamic bronchogenic signs; and 3 for 2 cases. The PCT results were graded according to the expert consensus of China's emergency clinical application: PCT0.5 ng/ ml,0 min; 0.5% PCT2ng/ ml,1 point; PCT/2 ng/ ml,2 min. The CXR in the CPIS score was replaced with the ultrasound and the remaining five indices were not modified and the CL score was re-combined. The sensitivity, specificity, positive predictive value and negative predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score, the specificity, the positive predictive value and the negative predictive value were analyzed, and the ROC curve was taken and the area under the curve was analyzed to find the best method to diagnose the pneumonia. Results: A total of 72 patients with suspected pneumonia were included in this study. According to this study, the diagnosis criteria were divided into pneumonia group (52 cases) and non-pneumonia group (20 cases), including 1 case of pneumothorax,10 cases of pleural effusion and 9 cases of acute respiratory distress syndrome. Main clinical features: sex, age, SOFA score, APACHEII score, body weight index, shock, hospital stay, and death rate were not significantly different. The only significant difference between the two groups was: PCT was 7.91 (0.13-100) and 1.62 (0.17-4.50), P = 0.041. The accuracy of the diagnosis of pneumonia is 100%, the CPIS score, the CPIS + PCT score, the CL score, and the CL + PCT score are compared with the diagnosis of pneumonia, There was no significant difference between the four diagnostic methods and the standard, and four methods of diagnosis of pneumonia were considered to be effective. The ROC curve was drawn by the CPIS score, the CPIS + PCT score, the CL score and the CL + PCT score. The area under the curve (AUC) was 0.726 (0.591-0.862), 0.788 (0.670-0.906), 0.913 (0.835-0.991), 0.925 (0.864-0.986), and the area under the curve was in the order of: CL + PCT score, CL score, CPIS + PCT score, and CPIS score (P <0.05). The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 71.2%,55%, 80.4% and 42.3%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 90.3%, respectively. 50%, 82.4%, 66.7%. The sensitivity, specificity, positive predictive value and negative predictive value of CL-6 were 88.5%,75%, 90.2%, 71.4%. The positive predictive value and negative predictive value were 96.2%, 86.2%,60% and 85.7%, respectively. The specificity and positive predictive value of the diagnosis of pneumonia were 100% in the cases of CL + PCT,9 and 10. Conclusion:1 In the imaging data, the accuracy of the ultrasonic diagnosis of pneumonia is high, and the clinical symptoms of the combined patients can be used for the preliminary assessment of the condition of the patients. The accuracy of the 2CL score in the diagnosis of pneumonia is obviously superior to that of the CPIS score, and the accuracy rate is higher when the joint PCT is combined.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.1
本文編號(hào)：2496354
[Abstract]:Objective: Pneumonia in the intensive care unit (ICU) is a very common disease. In recent years, the incidence of pneumonia has increased year by year, the development of the disease is rapid, the hospital stay time and the medical expenses are increased, and even the life is life-threatening. Therefore, in the early, accurate and rapid diagnosis of pneumonia, the sensitivity and specificity of the chest X-ray chest X-ray (chest X-ray (CXR) in the diagnosis of pneumonia are low, and there are frequent missed and misdiagnosed cases. As the imaging gold standard for diagnosis of pneumonia, CT has high accuracy, but it is difficult for severe patients to transport, which is not conducive to dynamic monitoring, and both methods have the disadvantage of high radiation. In recent years, the present study has developed rapid lung ultrasound (lung ultrasound) and clinical pulmonary infection score (CPIS). The purpose of this study was to replace the CXR in the CPIS score of the patients with ultrasound, to realign the CPIS + LUS score and the CL score, to compare the sensitivity, specificity and positive predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score in the diagnosis of pneumonia with the 2005 IDSA/ ATS clinical practice guidance and the lung CT as the diagnostic criteria. The negative predictive value is analyzed to find the best method for the diagnosis of pneumonia and to guide the early diagnosis and treatment of pneumonia. Methods: The study collected the patients with suspected pneumonia from January 2016 to December 2016 at the People's Hospital of Hebei Province. All the collectors were screened according to the inclusion and exclusion criteria. All patients with suspected pneumonia were divided into 12 regions, and the chest was divided into two upper and lower regions with the middle axis of the sternum and the middle axis of the sternum. The dividing line between the axilla front line and the back line of the sternum was divided into the first, the middle and the last three regions. The method comprises the following steps of: (1) taking the supine position of a patient, scanning the two regions of the front chest wall by an operator at the side of the patient, and observing the pleural and pleural lesions; (2) the patient is in a supine position, the scanning range is extended to the side wall by the front chest wall, the middle lung field is detected on the side chest wall, To observe the presence or absence of pleural effusion and a solid lung change; (3) elevate the patient's side, scan back the lung field, and further explore the pleural effusion and the solid area of the small die. The ultrasound examination was performed by an intensive care physician and the patient was allowed to complete the CXR and lung CT examination within 24 hours. The results of PCT were obtained from the blood samples of the patients treated with the FFII full-automatic immunofluorescence quantitative analyzer. Phlegm culture and Gram-staining criteria were taken into the Section, and the CPIS score was assessed by the combination of the rest of the clinical indicators after the results were reported, and the other intensive care physician was completed. To observe the ultrasound image of the lung beside the bed, including the reflection of the gas in the normal lung tissue, the presence or absence of the internal echo in the area of the lung and the area of the lesion, the internal echo in the real area of the lung, whether there is a subpleural lesion, the change of the pleura, the observation and recording of the image results, and the concept of the LUS score, Grading scores were performed according to the severity of the lung lesions:2,1 in the pleural thickening or subpleural lesions;2 points for pulmonary or dynamic bronchogenic signs; and 3 for 2 cases. The PCT results were graded according to the expert consensus of China's emergency clinical application: PCT0.5 ng/ ml,0 min; 0.5% PCT2ng/ ml,1 point; PCT/2 ng/ ml,2 min. The CXR in the CPIS score was replaced with the ultrasound and the remaining five indices were not modified and the CL score was re-combined. The sensitivity, specificity, positive predictive value and negative predictive value of the CPIS score, the CPIS + PCT score, the CL score, the CL + PCT score, the specificity, the positive predictive value and the negative predictive value were analyzed, and the ROC curve was taken and the area under the curve was analyzed to find the best method to diagnose the pneumonia. Results: A total of 72 patients with suspected pneumonia were included in this study. According to this study, the diagnosis criteria were divided into pneumonia group (52 cases) and non-pneumonia group (20 cases), including 1 case of pneumothorax,10 cases of pleural effusion and 9 cases of acute respiratory distress syndrome. Main clinical features: sex, age, SOFA score, APACHEII score, body weight index, shock, hospital stay, and death rate were not significantly different. The only significant difference between the two groups was: PCT was 7.91 (0.13-100) and 1.62 (0.17-4.50), P = 0.041. The accuracy of the diagnosis of pneumonia is 100%, the CPIS score, the CPIS + PCT score, the CL score, and the CL + PCT score are compared with the diagnosis of pneumonia, There was no significant difference between the four diagnostic methods and the standard, and four methods of diagnosis of pneumonia were considered to be effective. The ROC curve was drawn by the CPIS score, the CPIS + PCT score, the CL score and the CL + PCT score. The area under the curve (AUC) was 0.726 (0.591-0.862), 0.788 (0.670-0.906), 0.913 (0.835-0.991), 0.925 (0.864-0.986), and the area under the curve was in the order of: CL + PCT score, CL score, CPIS + PCT score, and CPIS score (P <0.05). The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 71.2%,55%, 80.4% and 42.3%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of CPIS + PCT-6 were 90.3%, respectively. 50%, 82.4%, 66.7%. The sensitivity, specificity, positive predictive value and negative predictive value of CL-6 were 88.5%,75%, 90.2%, 71.4%. The positive predictive value and negative predictive value were 96.2%, 86.2%,60% and 85.7%, respectively. The specificity and positive predictive value of the diagnosis of pneumonia were 100% in the cases of CL + PCT,9 and 10. Conclusion:1 In the imaging data, the accuracy of the ultrasonic diagnosis of pneumonia is high, and the clinical symptoms of the combined patients can be used for the preliminary assessment of the condition of the patients. The accuracy of the 2CL score in the diagnosis of pneumonia is obviously superior to that of the CPIS score, and the accuracy rate is higher when the joint PCT is combined.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.1
【參考文獻(xiàn)】
相關(guān)期刊論文 前2條
1 趙華;王小亭;劉大為;張宏民;何懷武;隆云;;重癥超聲快速診斷方案在急性呼吸衰竭病因診斷中的作用[J];中華醫(yī)學(xué)雜志;2015年47期
2 張山紅;張洪波;劉笑雷;張國(guó)強(qiáng);;床旁超聲和胸部X線檢查在重癥肺炎診斷中的臨床對(duì)比觀察[J];中華急診醫(yī)學(xué)雜志;2014年12期
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