膈肌联合肋间肌超声对脓毒症机械通气患者脱机评估的价值

doi:10.3969/j.issn.1674-8115.2025.02.007

上海交通大学学报（医学版） ›› 2025, Vol. 45 ›› Issue (2): 186-193.doi: 10.3969/j.issn.1674-8115.2025.02.007

膈肌联合肋间肌超声对脓毒症机械通气患者脱机评估的价值

沈浩亮¹(), 袁恺豪²(), 余磊¹, 阳娜娜¹, 王逸平¹, 赵宏胜¹, 郭凤梅³, 孙晨靓¹()

^1.南通大学附属医院重症医学科，南通 226001
^2.四川省成都市第五人民医院重症医学科，成都 611130
^3.东南大学附属中大医院重症医学科，南京 210009

收稿日期:2024-10-21 接受日期:2025-01-06 出版日期:2025-02-24 发布日期:2025-02-28
通讯作者: 孙晨靓 E-mail:Shenhaoliang2006@126.com;1814352750@qq.com;scl8210@163.com
作者简介:沈浩亮（1979—），男，主治医师，硕士；电子信箱：Shenhaoliang2006@126.com
袁恺豪（1998—），男，住院医师，硕士；电子信箱：com1814352750@qq.com。
第一联系人：*为共同第一作者。
基金资助:
南通市卫生健康委员会科研课题专项(MS2024015)

Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis

SHEN Haoliang¹(), YUAN Kaihao²(), YU Lei¹, YANG Nana¹, WANG Yiping¹, ZHAO Hongsheng¹, GUO Fengmei³, SUN Chenliang¹()

^1.Department of Critical Care Medicine, Affiliated Hospital of Nantong University, Nantong 226001, China
^2.Department of Critical Care Medicine, Chengdu Fifth People's Hospital, Sichuan Province, Chengdu 611130, China
^3.Department of Critical Care Medicine, Zhongda Hospital Southeast University, Nanjing 210009, China

Received:2024-10-21 Accepted:2025-01-06 Online:2025-02-24 Published:2025-02-28
Contact: SUN Chenliang E-mail:Shenhaoliang2006@126.com;1814352750@qq.com;scl8210@163.com
Supported by:
Scientific Research Foundation of Nantong Municipal Health Commission(MS2024015)

摘要/Abstract

摘要：

目的·探索膈肌与肋间肌超声联合评估相较于传统膈肌超声对预测脓毒症机械通气患者脱机结局的价值。方法·选取2022年10月—2023年12月入住南通大学附属医院重症医学科接受机械通气的脓毒症患者为研究对象。在患者脓毒症病情改善并通过自主呼吸试验（spontaneous breathing trial，SBT）后的围脱机期间，对患者进行膈肌与肋间肌的超声评估，分别测量膈肌移动度（diaphragm excursion，DE）、膈肌增厚率（thickening fraction of diaphragm，TFD）、肋间肌增厚率（thickening fraction of intercostal muscle，TFic）。根据脱机结果将患者分为脱机成功组（n=114例）和脱机失败组（n=24例）。采用受试者操作特征（receiver operator characteristic，ROC）曲线分析膈肌超声、肋间肌超声单独和联合预测呼吸机脱机结果的价值。结果·SBT期间脱机失败组的TFic和TFic/TFD比值均明显高于脱机成功组（均P<0.05）。SBT期间DE、TFD、TFic预测脓毒症机械通气患者脱机失败的ROC曲线下面积分别为0.689（0.591~0.776）、0.657（0.557~0.747）和0.769（0.676~0.846），而联合指标TFic/TFD比值和TFic&TFD_mix的ROC曲线下面积分别为0.867（0.786~0.925）和0.860（0.778~0.920）。其中TFic/TFD以>0.95为截值，其预测脱机失败的灵敏度为86.7%，特异度为75.3%；TFic&TFD_mix以>0.13为截值，其预测脱机失败的灵敏度为86.6%，特异度为80.9%。肋间肌超声检查法在测量可靠性方面，其观察者内部测量一致性组内相关系数（intraclass correlation coefficient，ICC）为0.890（0.788~0.951），观察者外部测量一致性ICC为0.876（0.718~0.949），可靠性等级均为良好（P<0.001）。结论·膈肌联合肋间肌超声评估能更全面地反映患者的整体呼吸肌的情况，在预测脓毒症机械通气患者的脱机结局方面，较单独运用膈肌超声具有更高的指导价值。

关键词: 膈肌超声, 肋间肌超声, 脓毒症, 机械通气, 脱机评估

Abstract:

Objective ·To explore the value of combined diaphragm and intercostal muscle ultrasound assessment compared with conventional diaphragm ultrasound in predicting the weaning outcome in mechanically ventilated patients with sepsis. Methods ·Mechanically ventilated patients with sepsis, consecutively admitted to the Department of Critical Care Medicine of Affiliated Hospital of Nantong University from October 2022 to December 2023, were selected. During the peri-weaning period, after the patient's sepsis condition improved and the patient passed the spontaneous breathing trial (SBT), ultrasound evaluation of respiratory muscles was performed by ultrasound qualified personnel with ultrasound qualification and experience in bedside ultrasound examination. Diaphragm excursion (DE), thickening fraction of diaphragm (TFD), and thickening fraction of intercostal muscle (TFic) were measured, respectively. The patients were divided into a successful weaning group (n=114) and a failed weaning group (n=24) according to the weaning results. Receiver operating characteristic (ROC) curves were used to analyze the value of diaphragm ultrasound and intercostal muscle ultrasound, alone and in combination, in predicting ventilator weaning outcome. Results ·TFic and TFic/TFD were significantly higher in the failed weaning group during SBT than in the successful weaning group (all P<0.05). The areas under the ROC curve (AUROC) of DE, TFD, and TFic to predict weaning failure in mechanically ventilated patients with sepsis during the period of SBT were 0.689 (0.591‒0.776), 0.657 (0.557‒0.747), and 0.769 (0.676‒0.846), respectively, whereas the combined indexes TFic/TFD and TFic&TFD_mix had AUROCs of 0.867 (0.786‒0.925) and 0.860 (0.778‒0.920), respectively. TFic/TFD with a cutoff value of >0.95 had a sensitivity of 86.7% and a specificity of 75.3% in predicting weaning failure, and TFic&TFD_mix with a cutoff value of >0.13 had a sensitivity of 86.6% and a specificity of 80.9% in predicting weaning failure. Moreover, the intercostal muscle ultrasonography method had an intra-observer intraclass correlation coefficient (ICC) of 0.890 and an extra-observer ICC of 0.876 for measurement reliability, which were both rated as good (P<0.001). Conclusion ·Combined diaphragm and intercostal muscle ultrasonography provides a more comprehensive picture of the patient's overall respiratory muscles, and has a higher guiding value in predicting the weaning outcomes in mechanically ventilated patients with sepsis than diaphragm ultrasound alone.

Key words: diaphragm ultrasound, intercostal muscle ultrasound, sepsis, mechanical ventilation, weaning assessment

中图分类号:

R445.1

沈浩亮, 袁恺豪, 余磊, 阳娜娜, 王逸平, 赵宏胜, 郭凤梅, 孙晨靓. 膈肌联合肋间肌超声对脓毒症机械通气患者脱机评估的价值[J]. 上海交通大学学报（医学版）, 2025, 45(2): 186-193.

SHEN Haoliang, YUAN Kaihao, YU Lei, YANG Nana, WANG Yiping, ZHAO Hongsheng, GUO Fengmei, SUN Chenliang. Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(2): 186-193.

图/表 7

参考文献 33

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摘要

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t/Z value	P value
Age/year	73.6±12.7	75.3±6.4	-0.967	0.337
Sex/n(%)			2.421	0.120
Male	61 (53.5)	17 (70.8)
Female	53 (46.5)	7 (29.2)
BMI/(kg·m^-2)	22.6±2.3	23.2±1.4	-1.648	0.105
APACHEⅡ	16.4±4.9	17.3±2.2	-1.517	0.133
SOFA	6.9±2.4	8.0±1.6	-2.039	0.043
Sepsis source/n(%)
Respiratory system	32 (28.1)	5 (20.8)	0.529	0.467
Digestive system	36 (31.6)	10 (41.7)	0.908	0.341
Urinary system	29 (25.4)	7 (29.2)	0.143	0.705
Others	17 (14.9)	2 (8.3)	‒	0.527
Patient source/n(%)			0.164	0.686
Post-operation	71 (62.3)	16 (66.7)
General medicine	43 (37.7)	8 (33.3)
Causes of mechanical ventilation/n(%)			0.095	0.758
Intrapulmonary factors	39 (34.2)	9 (37.5)
Extrapulmonary factors	75 (65.8)	15 (62.5)
Mechanical ventilation time/h	47 (29‒93)	180 (103‒210)	-5.694	<0.001
Length of ICU stay/d	5 (4‒8)	21 (14‒33)	-6.730	<0.001
Total length of stay/d	17 (12‒22)	31 (22‒42)	-4.536	<0.001
28-day mortality/n(%)	15 (13.2)	7 (29.2)	‒	0.066

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t/Z value	P value
Age/year	73.6±12.7	75.3±6.4	-0.967	0.337
Sex/n(%)			2.421	0.120
Male	61 (53.5)	17 (70.8)
Female	53 (46.5)	7 (29.2)
BMI/(kg·m^-2)	22.6±2.3	23.2±1.4	-1.648	0.105
APACHEⅡ	16.4±4.9	17.3±2.2	-1.517	0.133
SOFA	6.9±2.4	8.0±1.6	-2.039	0.043
Sepsis source/n(%)
Respiratory system	32 (28.1)	5 (20.8)	0.529	0.467
Digestive system	36 (31.6)	10 (41.7)	0.908	0.341
Urinary system	29 (25.4)	7 (29.2)	0.143	0.705
Others	17 (14.9)	2 (8.3)	‒	0.527
Patient source/n(%)			0.164	0.686
Post-operation	71 (62.3)	16 (66.7)
General medicine	43 (37.7)	8 (33.3)
Causes of mechanical ventilation/n(%)			0.095	0.758
Intrapulmonary factors	39 (34.2)	9 (37.5)
Extrapulmonary factors	75 (65.8)	15 (62.5)
Mechanical ventilation time/h	47 (29‒93)	180 (103‒210)	-5.694	<0.001
Length of ICU stay/d	5 (4‒8)	21 (14‒33)	-6.730	<0.001
Total length of stay/d	17 (12‒22)	31 (22‒42)	-4.536	<0.001
28-day mortality/n(%)	15 (13.2)	7 (29.2)	‒	0.066

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	t/Z value	P value
Body temperature/℃	37.0±0.7	36.8±0.6	1.025	0.311
Heart rate/(beat·min^-1)	90.8±15.0	94.5±13.6	-1.129	0.261
Mean arterial pressure/mmHg	86.3±11.5	91.2±11.9	-1.904	0.059
Respiratory rate/(times·min^-1)	16.2±4.6	17.2±3.6	-0.965	0.336
Voluntary tidal volume/mL	440 (377‒474)	398 (341‒457)	-1.697	0.090
Rapid shallow breathing index/(times·L^-1·min^-1)	37.0 (28‒45)	40.0 (32‒54)	-1.706	0.088
Albumin/(g·L^-1)	27.3 (23.8‒31.0)	28.1 (23.3‒32.6)	-0.360	0.719
Pre-albumin/(mg·L^-1)	289.3±47.9	275.7±50.3	1.249	0.214
White blood cell/(×10⁹·L^-1)	16.0 (13.8‒18.1)	16.7 (13.9‒18.4)	-0.677	0.498
C-reactive protein/(mg·L^-1)	75.2 (61.0‒90.5)	81.2 (62.2‒89.9)	-0.768	0.443
Procalcitonin/(μg·L^-1)	71.9 (63.7‒83.5)	74.3 (62.9‒85.4)	-0.003	0.998
Artery blood gas
pH value	7.42±0.05	7.45±0.04	-2.623	0.010
PaO₂/mmHg	97.4±19.5	92.9±14.8	1.053	0.294
PaCO₂/mmHg	39.6±6.2	42.3±6.1	-1.917	0.057
PaO₂/FiO₂	316.9±64.9	309.8±49.3	0.506	0.613
Base excess/(mmol·L^-1)	1.95±3.73	3.10±2.81	-1.723	0.092
Lactate/(mmol·L^-1)	1.32±0.64	1.48±0.73	-1.109	0.269

Item	Successful weaning group (n=114)	Failed weaning group (n=24)	t/Z value	P value
Body temperature/℃	37.0±0.7	36.8±0.6	1.025	0.311
Heart rate/(beat·min^-1)	90.8±15.0	94.5±13.6	-1.129	0.261
Mean arterial pressure/mmHg	86.3±11.5	91.2±11.9	-1.904	0.059
Respiratory rate/(times·min^-1)	16.2±4.6	17.2±3.6	-0.965	0.336
Voluntary tidal volume/mL	440 (377‒474)	398 (341‒457)	-1.697	0.090
Rapid shallow breathing index/(times·L^-1·min^-1)	37.0 (28‒45)	40.0 (32‒54)	-1.706	0.088
Albumin/(g·L^-1)	27.3 (23.8‒31.0)	28.1 (23.3‒32.6)	-0.360	0.719
Pre-albumin/(mg·L^-1)	289.3±47.9	275.7±50.3	1.249	0.214
White blood cell/(×10⁹·L^-1)	16.0 (13.8‒18.1)	16.7 (13.9‒18.4)	-0.677	0.498
C-reactive protein/(mg·L^-1)	75.2 (61.0‒90.5)	81.2 (62.2‒89.9)	-0.768	0.443
Procalcitonin/(μg·L^-1)	71.9 (63.7‒83.5)	74.3 (62.9‒85.4)	-0.003	0.998
Artery blood gas
pH value	7.42±0.05	7.45±0.04	-2.623	0.010
PaO₂/mmHg	97.4±19.5	92.9±14.8	1.053	0.294
PaCO₂/mmHg	39.6±6.2	42.3±6.1	-1.917	0.057
PaO₂/FiO₂	316.9±64.9	309.8±49.3	0.506	0.613
Base excess/(mmol·L^-1)	1.95±3.73	3.10±2.81	-1.723	0.092
Lactate/(mmol·L^-1)	1.32±0.64	1.48±0.73	-1.109	0.269

Peri-weaning period	Successful weaning group (n=114)	Failed weaning group (n=24)	χ²/t value	P value
Before extubation (during SBT)
DE/cm	1.13±0.35	0.88±0.15	4.558	<0.001
TFD/%	19.1±3.2	17.4±3.0	1.855	0.066
TFic/%	16.3±3.5	19.5±2.9	-3.343	0.001
TFic/TFD	0.87±0.19	1.14±0.16	-5.265	<0.001
After extubation (within 2 h)
DE/cm	1.14±0.34	0.96±0.20	1.928	0.057
TFD/%	18.3±4.8	15.4±3.4	2.277	0.025
TFic/%	15.6±5.7	19.8±4.8	-2.738	0.007
TFic/TFD	0.86±0.25	1.36±0.47	-4.073	0.001

膈肌联合肋间肌超声对脓毒症机械通气患者脱机评估的价值

Value of combined diaphragm and intercostal muscle ultrasonography in guiding weaning assessment in mechanically ventilated patients with sepsis

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Metrics

Observer consistency		ICC	95% CI	Reliability level	P value
Intra-observer consistency		0.890	0.788‒0.951	Good	<0.001
Observer 1^stTic^exp/mm	3.70±0.55
Observer 2^ndTic^exp/mm	3.63±0.40
Observer 3^rdTic^exp/mm	3.68±0.48
Inter-observer consistency		0.876	0.718‒0.949	Good	<0.001
Observer A Tic^exp/mm	3.68±0.45
Observer B Tic^exp/mm	3.62±0.41

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