超声评价慢性阻塞性肺疾病患者膈肌运动异常

目的 探讨超声评价慢性阻塞性肺疾病（COPD）患者膈肌运动异常的价值。方法 收集64例COPD急性加重期患者,根据2017GOLD指南综合评估将其分为C组（n=34）和D组（n=30）,以超声测量膈肌厚度、膈肌运动幅度及对合角,计算膈肌增厚分数及膈肌移动度。结果 C组膈肌增厚分数和收缩速度均明显大于D组（P均<0.05）,而2组膈肌移动度和对合角差异无统计学意义（P均>0.05）。膈肌增厚分数与第1秒用力呼气量/用力肺活量（FEV1/FVC）呈正相关（r=0.26,P=0.04）,膈肌移动度（r=0.35,P<0.01）、膈肌收缩速度（r=0.43,P<0.01）均与FVC呈正相关。DTF对鉴别诊断C、D组COPD性能相对较好（AUC为0.78）,DTF=30.22%,其诊断敏感度70.60%,特异度83.30%。结论 超声可评价COPD患者膈肌功能障碍,指导稳定期康复治疗。     

动态X线胸片评估平静呼吸下慢性阻塞性肺疾病患者横膈运动

目的 观察动态X线胸片定量分析平静呼吸下慢性阻塞性肺疾病（COPD）患者横膈运动的价值。方法 对96例COPD患者（COPD组）和50名健康对照者（对照组）行平静呼吸下动态X线胸片检查，经后处理获得横膈运动幅度、速度及时间；记录2组肺功能检查结果，比较组间动态X线胸片及肺功能参数值差异，分析COPD横膈运动参数与肺功能参数的相关性。结果 平静呼吸下COPD组左、右侧横膈运动幅度[（18.63±7.45）mm、（15.64±5.98）mm]均大于对照组[（14.69±5.40）mm、（13.13±4.84）mm，P均<0.05]；吸气时和呼气时COPD组左侧横膈运动速度18.79（15.67，22.67）mm/s、16.00（12.36，21.23）mm/s，右侧为17.00（12.71，19.73）mm/s、13.75（9.50，16.83）mm/s；对照组左侧为15.33（13.96，17.71）mm/s、11.42（9.63，16.00）mm/s，右侧为（14.91±4.38）mm/s、（10.66±3.66）mm/s（P均<0.05）。2组肺功能检查结果差异均有统计学意义（P均<0.01）。COPD组肺功能参数与动态胸片检查各参数均无明显相关（P均>0.05）。结论 动态X线胸片可定量分析COPD患者横膈运动，有望为临床精准评估COPD提供新的手段。     

经会阴超声评估女性直肠脱垂性病变患者直肠脱垂程度

目的 探讨经会阴超声评估女性直肠脱垂性病变患者直肠脱垂程度的价值。方法 根据直肠是否脱出肛管将26例女性直肠脱垂性病变患者分为内脱垂组（IRP组,n=18）和外脱垂组（ERP组,n=8）,另选20名健康女性作为对照组。行经会阴超声检查,测量并比较静息时和力排时直肠壶腹部位置、直肠移动度、盆膈裂孔面积及肛直角。结果 与静息时比较,3组力排时盆膈裂孔面积均增大,直肠壶腹部位置均下降（P均<0.05）。IRP组和ERP组静息时和力排时盆膈裂孔面积均大于对照组,力排时直肠壶腹部位置下降均大于对照组（P均<0.05）。ERP组静息时直肠壶腹部位置低于IRP组和正常组（P均<0.05）,IRP组与对照组差异无统计学意义（P>0.05）。IRP组和ERP组直肠移动度均大于对照组（P均<0.05）。3组静息时和力排时肛直角大小差异均无统计学意义（P均>0.05）。结论 经会阴超声可评估女性直肠脱垂性病变患者直肠脱垂程度。     

膈肌和肋间肌增厚率及肋间肌代偿指数评估老年机械通气患者呼吸肌功能

目的 观察超声监测膈肌增厚率（DTF）、肋间肌增厚率（ICMTF）及肋间肌代偿指数（ICMTF/DTF）评估老年机械通气患者呼吸肌功能的价值。方法 对危重监护病房的34例老年机械通气患者（机械通气组）根据其机械通气时间分为长期（时间≥30 d）通气亚组（n=15）与短期（3 d≤时间<30 d）通气亚组（n=19）;另以28名既往无肺部及严重心脏疾病的自主呼吸老年志愿者为自主呼吸组。采用床旁超声监测受试者呼吸周期内膈肌吸气末厚度（DTei）、呼气末厚度（DTee）及肋间肌吸气末厚度（ICMTei）和呼气末厚度（ICMTee）,计算DTF、ICMTF及ICMTF/DTF,比较组间及亚组间各指标差异,分析其评价呼吸肌功能的价值。结果 长期通气亚组DTei、DTee和DTF均明显低于短期通气亚组（P均<0.05）,而两亚组均明显低于自主呼吸组（P均<0.05）;长期通气亚组ICMTei、ICMTee、ICMTF和ICMTF/DTF均明显高于自主呼吸组（P均<0.05）,且ICMTei高于短期通气亚组（P<0.05）,而两亚组间ICMTee、ICMTF和ICMTF/DTF差异均无统计学意义（P均>0.05）。所有受试者DTF与ICMTF呈负相关（r=-0.405,P<0.05）。结论 采用DTF、ICMTF和ICMTF/DTF均可有效评估呼吸肌功能。     

极速成像技术评价慢性阻塞性肺疾病患者颈动脉僵硬度

目的 探讨极速成像技术评价慢性阻塞性肺疾病（COPD）患者颈动脉僵硬度的价值。方法 48例COPD患者（COPD组）和45名志愿者（对照组）接受常规颈动脉超声检查后,应用超声极速成像技术测量颈总动脉脉搏波传导速度（ufPWV）,包括收缩期起始时PWV值（PWV-BS）及收缩期结束时PWV值（PWV-ES）,并进行统计学分析。结果 与对照组比较,COPD组PWV-BS值和PWV-ES值均升高（P<0.05）;COPD患者ufPWV值与第1秒用力呼气容积呈负相关（PWV-BS：r=-0.40,P<0.01;PWV-ES：r=-0.41,P<0.01）。结论 极速成像技术可早期评价慢性阻塞性肺疾病患者颈动脉硬化,为临床治疗方案的选择及预后评价提供重要依据。     

实时三维超声评估产后女性盆底器官运动及肛提肌裂孔

目的 采用经会阴实时三维超声动态观察和评估产后女性盆底三腔室器官的位置及肛提肌裂孔面积。方法 选取年龄、体质量指数匹配的60名产妇（产后组）和35名未育女性（对照组）,采用经会阴超声分别在静息状态及瓦氏动作下测量膀胱、子宫颈、直肠壶腹部的最低点与参考线（耻骨联合后下缘的水平线）之间的距离,采用实时三维超声测量瓦氏动作下肛提肌裂孔面积,并进行统计学分析。结果 产后组在静息状态和瓦氏动作下膀胱及子宫颈的最低点位置均低于对照组（P均<0.05）,直肠壶腹部位置在静息状态下两组差异无统计学意义（t=0.405,P=0.398）,在瓦氏动作下产后组低于对照组（t=17.378,P<0.001）。产后组在静息状态和瓦氏动作下肛提肌裂孔面积均大于对照组（t=11.253、9.625,P均<0.001）。结论 经会阴实时三维超声可动态观察女性盆底三腔室器官的位置、运动情况及肛提肌裂孔面积,从而评价妊娠和分娩对盆底支持组织的影响。     

超声监测膈肌厚度吸气变化率对机械通气患者拔管结局评价

目的 评估超声检测膈肌增厚率对预测机械通气（MV）患者拔管结局的价值。方法 选取重症医学科（ICU）行MV>48 h且准备拔管的54例患者，于自主呼吸试验（SBT）期间以床旁超声测量并计算膈肌增厚率（DTF）和膈肌增厚浅快呼吸指数（DTF-RSBI），同时记录浅快呼吸指数（RSBI）及其他生理指标。采用ROC曲线评价DTF和DTF-RSBI预测拔管成败的价值。结果 36例拔管成功（成功组），18例失败（失败组），成功组患者DTF明显高于失败组，RBSI及DTF-RBSI明显低于失败组（P均<0.05）。取28.50%为截断值，DTF预测拔管的AUC为0.702，敏感度和特异度分别为78.80%和61.10%；DTF-RBSI取72.6次/（min·mm）为截断值，预测拔管的AUC为0.903，敏感度和特异度分别为100.00%和72.20%。结论 DTF-RSBI预测拔管结果比DTF及传统RSBI更准确，具有较高实用价值。     

MSCT诊断慢性阻塞性肺疾病合并慢性肺源性心脏病

目的 比较不同严重程度慢性阻塞性肺疾病（COPD）及COPD合并慢性肺源性心脏病患者右心室功能,评价MSCT诊断COPD合并慢性肺源性心脏病的价值。方法 对53例COPD患者（轻中度组13例、重度组22例及合并慢性肺源性心脏病组18例）和36名健康志愿者（对照组）行肺功能和MSCT检查。记录肺功能和右心室功能参数。比较各组右心室功能差异,分析COPD患者肺功能与右心室功能的相关性。分别绘制右心室每搏输出量（SV）、射血分数（EF）的ROC曲线,评价MSCT在COPD合并慢性肺源性心脏病中的诊断价值。以预试验确定的右心室SV<48 ml或EF<40%作为诊断慢性肺源性心脏病的标准,计算诊断敏感度和特异度。结果 4组间右心室舒张末容积（EDV）、EDV/体质量指数（BMI）、SV、SV/BMI及EF差异有统计学意义（P均<0.05）,而收缩末容积（ESV）及ESV/BMI差异无统计学意义（P均>0.05）。COPD患者右心室SV/BMI、EF与第1秒用力呼气容积（FEV1）（r=0.321、0.296,P=0.019、0.031）、第1秒用力呼气容积/用力肺活量（FEV1/FVC）（r=0.305、0.280,P=0.026、0.043）及FEV1占预计值百分比（FEV1%_pred;r=0.457、0.351,P=0.001、0.001）均呈正相关。分别绘制右心室EF、SV ROC曲线,AUC分别为0.973、0.930（P均<0.001）,MSCT诊断慢性肺源性心脏病的敏感度分别为77.77%、77.77%,特异度分别为98.59%、88.63%。结论 COPD患者在未达到慢性肺源性心脏病诊断标准前右心室功能已出现减退,且其肺功能与右心室功能呈正相关。MSCT能早期发现COPD患者右心室功能不全,且对于诊断慢性肺源性心脏病具有重要价值。     

肌松程度对腹腔镜胆囊切除术中患者肺功能的影响

目的：探讨肌松程度对腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中患者肺功能的影响。方法：选取2018年9月到2020年1月复旦大学附属上海市第五人民医院收治的择期LC患者90例，采用随机数字表法分为3组（n=30）：浅度肌松组（S组）、中度肌松组（M组）和深度肌松组（D组），3组均在肌松监测下采用罗库溴铵维持目标肌松程度，S组、M组和D组目标肌松程度分别为TOF计数4、TOF计数1~3、PTC计数≤2，分别于插管后（T₁）、气腹10 min（T₂）、气腹结束后（T₃）和术毕（T₄）时记录气道峰压（P_peak）、气道平台压（P_plat）和肺顺应性（lung compliance，CL），在T₁、T₂、T₄时采集桡动脉血样行血气分析，计算氧合指数（oxygenation index，OI）、呼吸指数（respiratory index，RI）和肺内分流率（Qs/Qt），术后进行手术条件满意度评级，并记录拔管时间和罗库溴铵用量。结果：与S组相比，M组和D组T₂时CL和OI较高、RI和Qs/Qt较低（P<0.01），T₄时各指标差异无统计学意义，M组和D组手术条件满意度较高，但拔管时间明显延长（P<0.01），罗库溴铵用量增加（M组P<0.05，D组P<0.01）。D组与M组相比，拔管时间延长11 min，罗库溴铵用量增加（P<0.01），其余指标无统计学意义。3组各时间点P_peak和P_plat差异均无统计学意义。结论：中度肌松能够提供与深度肌松相似的手术条件，在改善气腹期间肺功能的同时，拔管时间较短，是腹腔镜胆囊切除术中较为适宜的肌松程度。     

反馈式呼吸电刺激训练对肺癌术后患者膈肌运动和肺功能的影响

目的:探讨反馈式呼吸电刺激训练对肺癌术后患者膈肌运动和肺功能的影响。方法:将30例肺癌术后患者按随机数字表分为试验组和对照组,每组各15例。试验组在常规护理基础上给予反馈式呼吸电刺激训练,对照组接受常规护理和腹式呼吸训练,呼吸训练强度均为20min/次,3次/周,共4周。两组患者均于训练前、训练4周后、术后3个月时完成M型超声下观察平静呼吸、深吸气2种呼吸状态时的双侧膈肌运动幅度和肺功能检测。肺功能观察指标包括用力肺活量(forced vital capacity,FVC)、第一秒用力呼气容积(forced expiratory volume in first second,FEV1)及其各自占预测值的百分比。结果:训练4周后,两组患者膈肌运动幅度和肺功能均较基线值改善,但与对照组比较,试验组的FVC、FEV1%、FVC%、平静呼吸和深吸气时的术侧膈肌运动幅度改善程度更显著(P0.05);在术后3个月,试验组的FVC、FEV1%、深吸气时的双侧膈肌运动幅度均较对照组增加,差异具有显著性意义(P0.05)。结论:反馈式呼吸电刺激训练可以改善肺癌术后患者的膈肌运动和肺功能。     

Assessment of diaphragmatic function by ultrasonography: Current approach and perspectives

This article reports the various methods used to assess diaphragmatic function by ultrasonography. The excursions of the two hemidiaphragms can be measured using two-dimensional or M-mode ultrasonography, during respiratory maneuvers such as quiet breathing, voluntary sniffing and deep inspiration. On the zone of apposition to the rib cage for both hemidiaphragms, it is possible to measure the thickness on expiration and during deep breathing to assess the percentage of thickening during inspiration. These two approaches make it possible to assess the quality of the diaphragmatic function and the diagnosis of diaphragmatic paralysis or dysfunction. These methods are particularly useful in circumstances where there is a high risk of phrenic nerve injury or in diseases affecting the contractility or the motion of the diaphragm such as neuro-muscular diseases. Recent methods such as speckle tracking imaging and ultrasound shear wave elastography should provide more detailed information for better assessment of diaphragmatic function.     

膈肌超声评分预测机械通气撤机的价值探讨

目的探讨膈肌超声评分在预测机械通气患者成功撤机中的价值。方法对64例机械通气患者行床旁超声检查,记录其自主呼吸试验时膈肌厚度的变化、双侧膈肌的运动幅度、膈肌相关的浅快呼吸指数(D-RSBI)。根据患者撤机是否成功分为撤机成功组39例和撤机失败组25例。绘制受试者工作特征(ROC)曲线分析自主呼吸试验时膈肌增厚率、膈肌运动幅度、D-RSBI对撤机失败的预测价值,根据最佳临界值将相关的连续性变量转化为二分类变量,进行多因素Logistic回归分析,建立膈肌超声评分系统,预测患者撤机失败率。结果撤机成功组和撤机失败组膈肌增厚率、膈肌运动幅度、D-RSBI比较差异均有统计学意义(均P<0.05)。ROC曲线分析显示撤机成功患者膈肌增厚率的最佳临界值53%,敏感性89.6%,特异性45.4%,约登指数0.283;膈肌运动幅度的最佳临界值11.8 mm,敏感性62.3%,特异性79.4%,约登指数0.413;D-RSBI的最佳临界值1.7 mm·min/n,敏感性58.6%,特异性81.3%,约登指数0.312。膈肌增厚率≥53%、膈肌运动幅度≥11.8 mm及D-RSBI≤1.7 mm·min/n均是呼吸机撤机失败的独立影响因素(OR=5.982、2.966、4.356)。根据膈肌超声评分情况将25例撤机失败患者分为低危8例(0~2分)、中危11例(3~6分)和高危6例(7~8分),其撤机失败发生率分别为11.4%、52.6%、89.7%。结论膈肌超声评分可较准确地预测机械通气患者撤机结局,具有较好的临床应用价值。     

Diaphragmatic breathing training program improves abdominal motion during natural breathing in patients with chronic obstructive pulmonary disease: a randomized controlled trial

Yamaguti WP, Claudino RC, Neto AP, Chammas MC, Gomes AC, Salge JM, Moriya HT, Cukier A, Carvalho CR. Diaphragmatic breathing training program improves abdominal motion during natural breathing in patients with chronic obstructive pulmonary disease: a randomized controlled trial.ObjectiveTo investigate the effects of a diaphragmatic breathing training program (DBTP) on thoracoabdominal motion and functional capacity in patients with chronic obstructive pulmonary disease.DesignA prospective, randomized controlled trial.SettingAcademic medical center.ParticipantsSubjects (N=30; forced expiratory volume in 1s, 42%±13% predicted) were randomly allocated to either a training group (TG) or a control group (CG).InterventionsSubjects in the TG completed a 4-week supervised DBTP (3 individualized weekly sessions), while those in the CG received their usual care.Main Outcome MeasuresEffectiveness was assessed by amplitude of the rib cage to abdominal motion ratio (RC/ABD ratio) (primary outcome) and diaphragmatic mobility (secondary outcome). The RC/ABD ratio was measured using respiratory inductive plethysmography during voluntary diaphragmatic breathing and natural breathing. Diaphragmatic mobility was measured by ultrasonography. A 6-minute walk test and health-related quality of life were also evaluated.ResultsImmediately after the 4-week DBTP, the TG showed a greater abdominal motion during natural breathing quantified by a reduction in the RC/ABD ratio when compared with the CG (F=8.66; P<.001). Abdominal motion during voluntary diaphragmatic breathing after the intervention was also greater in the TG than in the CG (F=4.11; P<.05). The TG showed greater diaphragmatic mobility after the 4-week DBTP than did the CG (F=15.08; P<.001). An improvement in the 6-minute walk test and in health-related quality of life was also observed in the TG.ConclusionsDBTP for patients with chronic obstructive pulmonary disease induced increased diaphragm participation during natural breathing, resulting in an improvement in functional capacity.     

不同平面脊髓损伤患者膈肌运动和肺功能的相关分析

目的:探讨不同平面脊髓损伤患者的肺功能和膈肌运动的特点及其影响因素。方法:选取我院105例脊髓损伤患者进行研究,分析颈、胸、腰段各平面脊髓损伤患者的肺功能指标,包括第1秒用力呼气容积(FEV1)、用力呼气肺活量(FVC)、最大通气量(MVV)、肺活量(VC)和膈肌运动功能(右侧隔肌平静呼吸和用力呼吸时的运动幅度),并对肺功能与性别、年龄、吸烟史、损伤平面、残损分级、ASIA感觉/运动评分、膈肌运动幅度的相关性进行分析。结果:不同平面脊髓损伤肺功能指标差异具有统计学意义(P0.05);不同平面脊髓损伤平静呼吸和深呼吸时右侧膈肌运动幅度、ASIA感觉/运动评分差异具有统计学意义(P0.05);回归分析显示肺功能下降与损伤平面、残损分级、膈肌运动、ASIA感觉/运动评分和性别、吸烟史具有相关性(P0.05)。结论:脊髓损伤患者(特别是颈髓损伤患者)均存在不同程度肺功能障碍,而损伤平面、残损分级、ASIA感觉/运动评分和膈肌运动是影响脊髓损伤患者肺功能的重要指标。     

Sonographic evaluation of diaphragmatic function during breathing control

Objective: To investigate the effect of “breathing control” on sonographic diaphragmatic excursion. Method: A prospective, randomized, assessor-blinded study design involving 20 physiotherapy students; ten with knowledge of the breathing control technique (Group BC) and ten without (Group CON). All participants were asked to perform a Chester step test. Group BC performed BC, while Group CON adopted their own breathing pattern during recovery after the step test. Respiratory rate and sonographic parameters of the diaphragm including diaphragmatic excursion, speed of diaphragmatic contraction (slope of contraction), and inspiratory time were recorded before and after the step test. Results: All baseline data were similar for both groups except age. Respiratory rate at 1 min post-step test was higher in Group CON (24.6±4.9 bpm) compared to Group BC (15.6 ± 3.8 bpm) (p < 0.001). Post-step test sonographic evaluation demonstrated an increase in diaphragmatic excursion with a significant time and group interaction (F_(4,72) = 5.499, p = 0.005). Post hoc analysis revealed that the diaphragmatic excursion was significantly higher in Group BC compared to Group CON at first, second and third minute post-step test. Time and group interactions were not significant in inspiration time (F_(4,72) = 2.459, p = 0.082) nor the slope of contraction (F_(4,72) = 0.655, p = 0.582)]. Conclusion: Post-exercise diaphragmatic excursion was higher in participants applying BC. Non-invasive ultrasonography is able to promote objective evaluation of the relationship between breathing techniques and diaphragmatic function.     

Sonographic evaluation of the diaphragm in critically ill patients. Technique and clinical applications

The use of ultrasonography has become increasingly popular in the everyday management of critically ill patients. It has been demonstrated to be a safe and handy bedside tool that allows rapid hemodynamic assessment and visualization of the thoracic, abdominal and major vessels structures. More recently, M-mode ultrasonography has been used in the assessment of diaphragm kinetics. Ultrasounds provide a simple, non-invasive method of quantifying diaphragmatic movement in a variety of normal and pathological conditions. Ultrasonography can assess the characteristics of diaphragmatic movement such as amplitude, force and velocity of contraction, special patterns of motion and changes in diaphragmatic thickness during inspiration. These sonographic diaphragmatic parameters can provide valuable information in the assessment and follow up of patients with diaphragmatic weakness or paralysis, in terms of patient–ventilator interactions during controlled or assisted modalities of mechanical ventilation, and can potentially help to understand post-operative pulmonary dysfunction or weaning failure from mechanical ventilation. This article reviews the technique and the clinical applications of ultrasonography in the evaluation of diaphragmatic function in ICU patients.     

肺移植围术期膈肌运动与肺功能和运动耐量相关性的初步研究

目的:探讨肺移植围术期膈肌运动与肺功能和运动耐量之间的关联性,并进一步分析可能的影响因素,为肺移植围术期膈肌功能、肺功能等恢复提供参考。方法:以无锡市惠山区康复医院肺移植康复中心从2020年6月—2021年7月收治入院的61例肺移植围术期患者为研究对象(其中术前37例,术后24例)。入院进行病历书写,获取患者一般信息,完善相关检查,包括膈肌超声、常规肺功能(PFT)、6min步行试验等。采用独立样本t检验比较术前术后两组患者膈肌运动功能、肺功能和运动耐量的差异,Pearson相关性检验和典型相关性分析方法比较两组膈肌运动与肺功能和运动耐量相关性。结果:两组患者肺功能指标(FVC、FEV1)差异有显著性意义(P<0.05);在双变量相关性中,两组膈肌厚度之间、用力呼吸幅度和平静呼吸幅度之间呈极强或强正相关性(0.8相似文献   

Paradoxical Motion

Objective. The purpose of this series was to determine whether paradoxical motion of the diaphragm reliably identifies congenital diaphragmatic hernias (CDHs). Methods. Sonographic evaluation of diaphragmatic motion was attempted in all fetuses undergoing a targeted examination for findings suggestive of a possible CDH. During any respiratory motion or hiccupping, the posterior chest and abdomen were visualized in a coronal plane at the level of the descending aorta to evaluate ascent and descent of the hemidiaphragms. Normal motion was defined as descent of both during inspiration. Paradoxical motion was defined as descent of one hemidiaphragm and ascent of the opposite one during inspiration. If no breathing motion was observed during the examination, the results were termed “poor visualization.” If there was poor visualization, the diaphragm was reevaluated at any return visits. In the second part of this study, diaphragmatic motion in 120 fetuses of at least 15 weeks' gestational age without abnormalities was evaluated. The diagnosis of a CDH needed to be confirmed by pathologic examination or surgery. Results. No fetus without abnormalities showed paradoxical breathing. There were 15 fetuses who had a confirmed CDH and showed breathing during an examination. Fourteen of 15 had paradoxical motion; the fetus who did not had a very small defect containing a single loop of bowel. Thirteen fetuses had CDHs, and 2 had eventrations. Conclusions. Paradoxical motion is specific for CDHs and eventrations and can be seen as early as 17 weeks' gestation.