目的 比较不同膈肌超声功能指标:平静呼吸膈肌移动度(diaphragmatic excursion during quiet breathing,DE-QB)、深呼吸膈肌移动度(diaphragmatic excursion during deep breathing,DE-DB)、膈肌增厚分数(thickening fraction of diaphragm,TFdi)在腹部手术术后肺部并发症(postoperative pulmonary complications,PPCs)中的预测价值.方法 选取全麻下行腹腔镜腹部手术患者 154 例,在术前和术后 24h分别行床旁超声测量患者DE-QB、DE-DB和TFdi.记录术后 7d肺部并发症情况,以是否发生PPCs,将患者分为PPCs组(n=48)和n-PPCs组(n=106),比较两组患者膈肌功能指标间的差异.选取差异显著的膈肌功能指标绘制受试者工作特征(receiver operat-ing characteristic,ROC)曲线,以 3 种功能指标ROC曲线的最佳界值将患者分为PPCs高风险组和PPCs低风险组.分析3 种膈肌超声功能指标对腹部手术PPCs预测价值,通过Lasso-Logistic回归分析建立PPCs的预测模型,并与单一膈肌功能指标进行对比.结果 PPCs组和n-PPCs组术前DE-QB、DE-DB和TFdi差异无统计学意义(P>0.05),PPCs组术后DE-QB、DE-DB和TFdi均低于n-PPCs组,差异有统计学意义(P<0.001),术后DE-QB,DE-DB,TFdi的ROC曲线的曲线下面积(area under the curve,AUC)分别为 0.780、0.779、0.713,三者间无明显差异.以术后DE-QB区分患者时(最佳界值为0.93 cm),PPCs高风险组与PPCs低风险组肺部并发症发生率差异有统计学意义(14.1%vs.61.8%,P<0.001);以术后DE-DB区分患者时(最佳界值为 2.41 cm),PPCs高风险组与PPCs低风险组肺部并发症发生率差异有统计学意义(13.3%vs.56.3%,P<0.001);以术后TFdi区分患者时(最佳界值为 0.23),PPCs高风险组与 PPCs 低风险组肺部并发症发生率差异有统计学意义(16.5%vs.52.4%,P<0.001).通过Lasso-Logistic回归分析,最终纳入预测模型的危险因素包括年龄、吸烟史、手术时间、术后DE-QB和术后DE-DB,Lasso-Logistic回归模型(AUC=0.851)优于任一单一膈肌功能指标.结论 术后 24 h DE-QB、DE-DB和TFdi单独使用时均能在一定程度上预测PPCs的发生率,但通过测量膈肌移动度(diaphragmatic excur-sion,DE)对PPCs的预测价值优于TFdi.通过Lasso-Logistic回归建立的预测模型相较于单一膈肌功能指标可以更好地预测PPCs的发生率.
Comparison of different diaphragmatic ultrasound functional indices in predicting pulmonary complications after abdominal surgery
Objective To compare different diaphragmatic ultrasound functional indices,diaphragmatic excursion dur-ing quiet breathing(DE-QB),diaphragmatic excursion during deep breathing(DE-DB),thickening fraction of dia-phragm(TFdi),in predicting postoperative pulmonary complications(PPCs)after abdominal surgery.Methods A total of 154 patients scheduled for elective laparoscopic abdominal surgery under general anesthesia were selected.DE-QB,DE-DB,and TFdi were measured by bedside ultrasound before and 24 hours after surgery.Postoperative pulmonary complications were recorded for 7 days.Patients were divided into two groups according to the occurrence of pulmonary complications:the pulmonary complications group(PPCs group,n=48)and the non-pulmonary complica-tions group(n-PPCs group,n=106).The differences in diaphragm function indices between the two groups were com-pared,and those with significant differences were selected to plot ROC curves.The ROC curves were compared to assess the predictive value of three ultrasound diaphragmatic functional indices for postoperative pulmonary complica-tions after abdominal surgery.A predictive model for postoperative pulmonary complications was created using Lasso Logistic regression analysis and compared with individual diaphragmatic functional indices.Results The differences in preoperative DE-QB,DE-DB,and TFdi between the two groups were not statistically significant(P>0.05).However,the postoperative DE-QB,DE-DB,and TFdi in the PPCs group were lower than those in the n-PPCs group,with statis-tically significant differences(P<0.001).The areas under the ROC curve(AUC)for postoperative DE-QB,DE-DB,and TFdi were 0.780,0.779,and 0.713,respectively,with no significant differences.Patients were divided into high-risk PPCs and low-risk PPCs groups according to the optimal cut-off value of the ROC curves of the three functional indices.When patients were differentiated by postoperative DE-QB(optimal cut-off value of 0.93 cm),the incidence of pulmonary complications differed between the high-risk and the low-risk groups(14.1%vs.61.8%,P<0.001);when patients were differentiated by postoperative DE-DB(optimal cut-off value of 2.41 cm),there was a difference in the incidence of pulmonary complications between the high-risk and the low-risk groups(13.3%vs.56.3%,P<0.001);when patients were differentiated by postoperative TFdi(optimal cut-off value of 0.23),there was a difference in the incidence of pulmonary complications between the high-risk and the low-risk groups(16.5%vs.52.4%,P<0.001).By Lasso Logistic regression analysis,the final risk factors included in the prediction model were age,smoking history,duration of surgery,DE-QB(postoperative),and DE-DB(postoperative),and the Lasso Logistic regression model(AUC=0.851)outperformed any single index of diaphragm function.Conclusion The DE-QB,DE-DB and TFdi measured at 24h post-operatively alone can predict the occurrence of post-operative pulmonary complications(PPCs)to some extent when used individually,however the measurement of diaphragmatic excursion(DE)provided better predic-tive value for PPCs than TFdi.The predictive model established by Lasso Logistic regression can better predict the inci-dence of PPCs than any single diaphragm function index.
Diaphragm excursionFraction of diaphragm thickeningAbdominal surgeryUltrasoundPulmonary complications
万方数据
维普
