摘要
目的评价肺部超声在体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗重度急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)患儿肺部病情评估中的价值。方法采用前瞻性研究的方法,纳入2016年1月至2019年12月期间在上海交通大学附属儿童医院重症医学科符合柏林标准的重度ARDS患儿,排除ECMO治疗时间<3 d、缺乏合适声窗、严重气胸及继发于先天性心脏病或慢性肺部疾病的患儿。采用肺部超声评估ECMO挽救患儿的肺部病变资料,包括ECMO启动时、ECMO治疗后24 h、48 h、72 h、第7天及撤机时动态肺部超声评分(lung ultrasound score,LUS),分别记录为LUS-0 h、LUS-24 h、LUS-48 h、LUS-72 h,LUS-7 d,LUS-w。根据出院时生存状态分为死亡组及存活组,采用受试者工作特征(receiver operating characteristic,ROC)曲线及Kaplan-Meier生存分析曲线分析LUS与预后的关系。结果研究共纳入26例患儿,其中18例存活,8例死亡。ECMO启动时,第三代小儿死亡危险评分、肺动态顺应性(pulmonary dynamic compliance,Cdyn)、氧合指数、动脉血氧分压/吸入氧体积分数、二氧化碳分压等两组之间均差异无统计学意义(P>0.05)。死亡组LUS-72 h和LUS-w明显高于存活组[26(24,29)vs 16(13,19),P<0.01]和[30(26,35)vs 11(10,13),P<0.01]。存活组Cdyn-72 h、Cdyn-7 d和Cdyn-w明显高于死亡组[0.48(0.42,0.54)mL/cmH2O·kg vs 0.36(0.29,0.40)mL/cmH2O·kg,P<0.01]、[0.60(0.52,0.67)mL/cmH2O·kg vs 0.27(0.13,0.30)mL/cmH2O·kg,P<0.01;0.66(0.62,0.70)mL/cmH2O·kg vs 0.30(0.13,0.35)mL/cmH2O·kg,P<0.01]。ROC曲线分析显示LUS-72 h预测患儿生存状态的AUC为0.955(95%CI:0.864~1.000,P<0.01);截断值为24时灵敏度为87.5%,特异度为100.0%。以LUS-72 h≥24和LUS-72 h<24分组进行Kaplan-Meier生存分析:LUS-72 h≥24组病死率显著高于LUS-72 h<24组(P<0.01)。结论肺部超声LUS测定对ECMO挽救ARDS患儿病情和预后判断具有参考价值。
Objective To evaluate the predictive value of lung ultrasound on mortality in children with severe acute respiratory distress syndrome(ARDS)undergoing extracorporeal membrane oxygenation(ECMO)support.Methods A prospective observational study was used to enroll patients with severe ARDS who met the Berlin criteria in the Pediatric Intensive Care Unit of Children’s Hospital of Shanghai Jiao Tong University from January 2016 to December 2019.Patients with ECMO support<3 d,lack of appropriate acoustic windows,with severe pneumothorax,and secondary to congenital heart disease or chronic lung disease were excluded.ECMO parameters,respiratory mechanics parameters and outcome were collected and analyzed.Lung ultrasound score(LUS)was measured at the initiation of ECMO as LUS-0 h,then at 24 h,48 h,72 h,and 7 d after ECMO support as the value of LUS-24 h,LUS-48 h,LUS-72 h,LUS-7 d,as well as after weaning ECMO as LUS-w.The patients were divided into survivors and non-survivors according to hospital survival status.Receiver operating characteristic(ROC)curve and Kaplan-Meier survival analysis curve were performed to explore the predictive value of lung ultrasound on mortality in patients with severe ARDS undergoing ECMO.Results A total of 26 patients were enrolled in this study,of which 18 patients survived and 8 died.There were no significant differences in PRISMⅢ,dynamic pulmonary compliance(Cdyn),oxygenation index,PaO2/FiO2,and PaCO2 on PICU admission between the two groups(all P>0.05).The values of LUS-72 h and LUS-w in non-survivors were significantly higher than those in survivors[26(24,29)vs16(13,19),P<0.01]and[30(26,35)vs11(10,13),P<0.01].The values of Cdyn-72 h,Cdyn-7 d and Cdyn-w in survivors were significantly higher than those in non-survivors[0.48(0.42,0.54)mL/cmH2O·kg vs 0.36(0.29,0.40)mL/cmH2O·kg,P<0.01;0.60(0.52,0.67)mL/cmH2O·kg vs 0.27(0.13,0.30)mL/cmH2O·kg,P<0.01,and 0.66(0.62,0.70)mL/cmH2O·kg vs 0.30(0.13,0.35)mL/cmH2O·kg,P<0.01].ROC curve analysis showed that an area under ROC curve(AUC)of LUS-72 h for predicting PICU mortality was 0.955(95%CI:0.864-1.000;P<0.01).The cutoff value of LUS-72 h was 24 with a sensitivity of 87.5%and a specificity of 100.0%.Kaplan-Meier survival analysis showed that PICU mortality of patients with LUS-72 h≥24 was significantly higher than that in patients with LUS-72 h<24(P<0.01).Conclusions Lung ultrasound is an effective tool for monitoring progress of children with severe ARDS received ECMO support.LUS-72 h>24 is an index to predict the worsen outcome in children with severe ARDS under ECMO support.
作者
王斐
周益平
史婧奕
单怡俊
王春霞
张育才
Wang Fei;Zhou Yiping;Shi Jingyi;Shan Yijun;Wang Chunxia;Zhang Yucai(Department of Critical Care Medicine,Children’s Hospital of Shanghai Jiao Tong University,Shanghai 200062,China)
出处
《中华急诊医学杂志》
CAS
CSCD
北大核心
2021年第11期1334-1339,共6页
Chinese Journal of Emergency Medicine
基金
上海市科委"科技创新行动计划"医学创新研究专项和临床医学领域项目(20Y11901300,18411951000)。
关键词
肺部超声评分
体外膜肺氧合
急性呼吸窘迫综合征
儿童
Lung ultrasound score
Extracorporeal membrane oxygenation
Acute respiratory distress syndrome
Children
