肺通气/灌注与CT肺动脉造影诊断肺栓塞对比分析

目的:探讨肺通气/灌注(V/Q)显像与CT肺动脉造影(CTPA)在肺栓塞诊断中的应用价值。方法:选择我院2006年4月～2010年4月收治的肺栓塞患者164例,按照疾病程度分为大面积肺栓塞组(48例)、次大面积肺栓塞组(56例)和非大面积肺栓塞组(60例)3组,对3组患者V/Q显像与CTPA检出率进行比较。结果:肺V/Q显像总检出率为91.46%,CTPA总检出率为90.24%,2种方法总检出率差异无统计学意义(P>0.05)。不同方法对A、B、C组阳性检出率不同,A组CTPA检出率明显高于肺V/Q显像,B、C组V/Q显像检出率明显高于CTPA,差异均有统计学意义(t分别为5.83、5.02、5.13,P均<0.05)。结论:肺V/Q显像与CTPA诊断栓塞各有优缺点,临床中根据患者情况结合应用,为治疗提供准确有效的信息。     

呼吸重症监护病房住院患者疾病构成与死亡原因分析

目的分析呼吸重症监护病房患者疾病构成与死亡原因分布特征,为重症呼吸系统疾病的诊治与防控提供参考资料。方法回顾性分析沈阳市某三级甲等医院呼吸重症监护病房2017年1月1日-2019年12月31日收治的1653例患者病案首页资料,收集不同性别、年龄组住院患者的主要疾病构成和死因分布等信息进行统计分析。结果呼吸重症监护病房排名前3位疾病依次为肺炎(18.73%)、肺部感染(14.51%)和肺栓塞(8.63%)。男女性别比为1.19:1。男性肺部感染(χ^2=6.533,P=0.011)、慢性阻塞性肺疾病急性加重(χ^2=4.017,P=0.045)和吸入性肺炎(χ^2=10.453,P=0.001)的构成比高于女性。65岁及以上老年患者占比62.97%,65岁以上年龄组慢性支气管炎急性发作和慢性阻塞性肺疾病急性加重的构成比高于65岁以下患者。肺部感染是呼吸重症监护病房患者的首要死亡原因。结论某院呼吸重症监护病房疾病以肺炎、肺部感染和肺栓塞为主,65岁以上老年患者居多。建议有关部门加强对肺部感染及其相关危险因素的监测,提升重症呼吸系统疾病的诊疗水平和抢救能力。     

心电图、超声心动图与CTPA在诊断急性肺栓塞中的应用

目的探析心电图、超声心动图与CT肺动脉造影(CTPA)在诊断急性肺栓塞中的应用。方法选取2016年4月-2018年4月我院收治的疑诊急性肺栓塞患者125例,均行心电图、超声心动图及CTPA检查,根据其影像学特征分析心电图、超声心动图与CTPA对诊断急性肺栓塞的应用价值。结果125例疑诊患者采用CTPA检查确诊为急性肺栓塞者89例,排除急性肺栓塞者36例,共检出栓子数量641个,腔内呈不均匀低密度影,左侧肺动脉栓子共55个、右侧肺动脉主干栓子187个、右下肺动脉栓子93个、支气管分支及肺叶动脉栓子306个,血管均呈不同程度的充盈缺损;确诊组心电图呈IRBBB(不完全性右束支传导阻滞)、典型的SⅠQⅢTⅢ型、V1导联T波倒置、V2导联T波倒置、V1-V2导联ST段抬高<0.1mV、心房颤动、顺钟转位征象的比例明显高于排除组(P<0.05);确诊组患者右室增大、三尖瓣反流、肺动脉高压、肺动脉血栓比例明显高于排除组(P<0.05);采用心电图诊断急性肺栓塞准确率、灵敏度、特异度分别为68.80%、84.27%、30.56%,超声心动图分别为92.00%、95.51%、83.33%,心电图联合超声心动图分别为95.20%、97.75%、88.89%,联合诊断准确率、灵敏度、特异度均较高。结论采用CTPA可准确进行急性肺栓塞疾病诊断,但其为有创检查,且价格相对昂贵,心电图联合超声心动图检查准确率、灵敏度、特异度较高,操作简单,安全性高,费用低廉,可作为早期急性肺栓塞疾病诊断的首选检查方案。     

SPECT/CT肺灌注显像与肺通气/灌注平面显像在肺栓塞诊断中的应用比较

目的分析单光子发射型计算机断层/低剂量平扫CT(SPECT/CT)肺灌注显像与肺通气/灌注(V/Q)平面显像在肺栓塞诊断中的应用。方法将2017年6月至2018年10月我院收治的120例疑似肺栓塞患者作为研究对象,所有患者均进行SPECT/CT肺灌注显像和V/Q平面显像检查,以临床最终诊断结果为准,评估SPECT/CT肺灌注显像和V/Q平面显像对肺栓塞的诊断效能。结果 120例患者中最终有100例诊断为肺栓塞,其中肺段病变247个,亚肺段病变285个。SPECT/CT肺灌注显像对肺栓塞诊断灵敏度、特异度、准确度、阳性预测值、阴性预测值分别为89.00%、90.00%、89.17%、97.80%、62.07%,均大于V/Q平面显像的81.00%、80.00%、80.83%、95.29%、45.71%。SPECT/CT肺灌注显像对肺栓塞肺段病变检出率87.04%与V/Q平面显像的82.19%无显著差异(P>0.05),对亚肺段病变检出率92.28%高于V/Q平面显像的85.96%(P<0.05)。结论 SPECT/CT肺灌注显像对肺栓塞的诊断效能优于V/Q平面显像,且可提高对亚肺段病变检出率。     

V/Q显像与CT肺动脉造影在慢性血栓栓塞性肺动脉高压不同栓塞水平中的研究

目的对比肺通气/灌注显像(ventilation/perfusion scan,V/Q)与CT肺动脉造影(CT pulmonary angiography,CTPA)在慢性血栓栓塞性肺动脉高压(chronic thromboembolic pulmonary hypertension,CTEPH)肺段动脉及亚段动脉栓子的检出效能。方法选取经临床Wells评分、临床资料、实验室检查及X线肺动脉造影综合确诊为慢性血栓栓塞性肺动脉高压的39例患者,其中男28例,女11例,平均年龄(51.0±16.1)岁,合并近期手术者4例、心力衰竭者7例、既往存在急性肺栓塞12例、合并下肢深静脉血栓26例。临床Wells评分,高度可能性者17例,中度可能性者22例。所有患者均接受V/Q单光子发射计算机断层成像术(single photon emission CT,SPECT)断层显像、CTPA及X线肺动脉造影(pulmonary artery angiography,PAG)检查,检查于3～7 d内完成并由放射科及核医学科有经验医师进行独立、双盲法阅片。采用SPSS 13.0统计软件对V/Q SPECT及CTPA与PAG段及亚段的检查结果进行χ2检验及Kappa一致性检验。结果对于肺段动脉栓子,V/Q SPECT与CTPA的敏感度、特异度、准确度分别为84.7%、77.7%,94.6%、98.2%,90.9%、91.2%;亚段肺动脉栓子,V/Q SPECT与CTPA敏感度、特异度、准确度分别为63.2%、50.4%,94.8%、94.8%,93.8%、83.9%。结论 V/Q显像对段及亚段病变定位的敏感性较高,临床中V/Q显像正常即可排除CTEPH,若存在异常须进一步行CTPA、PAG及磁共振成像(magnetic resonance imaging,MRI)等检查进一步明确。     

前瞻性心电触发大螺距CT肺动脉成像对肺栓塞的诊断价值

 目的探讨第2代双源CT前瞻性心电触发大螺距扫描（Flash模式）肺动脉成像对肺栓塞的诊断价值。方法回顾性分析19例行双源CT前瞻性心电触发大螺距扫描肺动脉成像并诊断肺栓塞患者的影像资料,总结肺栓塞的直接、间接征象及分型。结果19例肺栓塞共显示肺动脉1614支,发现栓子381支,栓塞发生率为23.6%。381支栓子中累及肺动脉主干1支,左右肺动脉干7支,叶肺动脉16支,段肺动脉83支,亚段肺动脉274支。直接征象为肺动脉管腔内的充盈缺损,其中中心型113支（占29.7%）,偏心型24支（占6.3%）,混合型8支（占2.1%）,闭塞型236支（占61.9%）。间接征象包括马赛克征1例,肺梗死2例,肺动脉高压1例,胸腔积液7例。结论双源CT前瞻性心电触发大螺距扫描肺动脉成像简单、快捷、安全、无创,可清晰显示肺动脉栓子,对诊断肺栓塞有重要价值。     

血浆D-二聚体的测定在排除肺栓塞诊断中的临床意义

目的探讨D-二聚体(D-dimer,DD)在排除肺栓塞诊断中的临床价值。方法使用ELISA法对可疑肺栓塞患者血浆中纤维蛋白降解产物DD进行检测,并对这些可疑肺栓塞患者进行半年的随访,了解是否有肺栓塞或深静脉栓塞的症状。结果共有102例患者参加检测,42例患者(41.1%)的DD检测值<500μg/L,60例患者血浆中的DD检测值>500μg/L,其中有11例患者通过肺通气灌注扫描(V/Q)证实为肺栓塞。ELISADD法的敏感性为100%,阴性预期值为100%。结论DD检测方法简便易行,设备要求不高,可作为排除肺栓塞的首选试验,易在临床诊断中推广使用。     

A prospective investigation of pulmonary embolism in women and men.

OBJECTIVE. The aim of this study was to compare, in women and men suspected of pulmonary embolism, the frequency, risk factors, diagnosis, and presentation of pulmonary embolism as well as the accuracy of the ventilation/perfusion scan (V/Q scan) as a diagnostic tool. DESIGN. Data were collected during a prospective study (the Prospective Investigation of Pulmonary Embolism Diagnosis) to establish the accuracy of the V/Q scan compared with pulmonary angiograms. SETTING. Six tertiary medical centers in Massachusetts, Michigan, Connecticut, Pennsylvania, and North Carolina. PARTICIPANTS. Patients suspected of pulmonary embolism for whom a request was made for a V/Q scan or pulmonary angiogram (496 women and 406 men). RESULTS. Women 50 years old and under had a decreased frequency of pulmonary embolism compared with men of that age (16% vs 32%), but there was no difference in patients over 50 years old (Breslow-Day test, P less than .01). Risk factors for pulmonary embolism, the usefulness of the V/Q scan, and 1-year mortality were not different for women and men. Estrogen use in women was not associated with an increased frequency of pulmonary embolism, except in women using oral contraceptives who had undergone surgery within 3 months; four of five (80%) had emboli compared with four of 28 (14%) age-matched surgical patients not using estrogens (P less than .01). CONCLUSION. Women 50 years old and under (even young women using oral contraceptives) who were suspected of having pulmonary emboli and were enrolled in the Prospective Investigation of Pulmonary Embolism Diagnosis study had a smaller frequency of pulmonary embolism than men of that age, The risk factors for pulmonary embolism were the same for women and men, except that women using oral contraceptives had an increased risk of pulmonary embolism following surgery. Although the V/Q scan was a useful tool in the preliminary evaluation for pulmonary embolism in these women, a pulmonary angiogram was often needed for accurate diagnosis.     

Percutaneous dilational tracheostomy: An initial experience in community based teaching hospital

Percutaneous dilational tracheostomy (PDT) is frequently performed in the intensive care unit to prevent the long term complications associated with prolonged endotracheal intubation. Objective: To report the analysis of our experience with percutaneous dilation tracheostomy. Study Design: A prospective documentation of 40 patients who received percutaneous dilational tracheostomy in a multidisciplinary intensive care unit during a 12-month period. Method: The patients demographic, indications of intubation and PDT, time required to perform the procedure, complications and the outcome of these patients in the intensive care unit were noted. Result: Among 425 patients, 40 underwent percutaneous dilational tracheostomy that included 22 females and 18 males with the median age of 35 years. Prolonged ventilatory support was the most common indication for tracheostomy. The average duration of intubation before PDT was 5 days. Median procedure time was 20 minutes. Complications included minor bleeding in two (5%), subcutaneous emphysema with pneumothorax in two patients (5%), tracheal stenosis in three (7.5%), tracheo-esophageal fistula and glottic granuloma in one patient each (2.5%). Among forty patients, 28 (70%) were discharged to the ward, 8 died in intensive care unit and 4 left hospital against medical advice. Conclusion: Percutaneous dilational tracheostomy is a safe, quick and effective way for long term airway management in critically ill patients.     

CT肺动脉造影与肺灌注断层显像对肺栓塞诊断价值的Meta分析

目的对研究CT肺动脉造影(computed tomographic pulmonary angiography,CTPA)和单光子发射计算机断层成像术(single-photon emission computed tomography,SPECT)诊断肺动脉栓塞(pulmonary embolism,PE)的文献进行Meta汇总分析,评价两者对肺栓塞的临床诊断价值。方法检索1990年1月至2012年1月在Pubmed、Ovid数据库和中国期刊网中关于CTPA和SPECT显像的文献,应用Meta-Disc软件分别汇总两者的敏感度和特异度及其95%可信区间。根据汇总受试者工作特征曲线(summary receiver operating characteristic,SROC),计算曲线下面积(areas under curve,AUC),得出各自的Q*值,评价两种方法的诊断效能。结果共有16篇文献符合纳入标准。CTPA汇总敏感度和特异度分别为0.79(0.75,0.83)和0.90(0.87,0.93),SPECT显像的汇总敏感度和特异度为0.86(0.78,0.93)和0.95(0.92,0.98)。两者的SROC曲线下面积分别为93.72%和97.64%。两者的Q*值分别为0.8740和0.9306。比较两者Q*值,CTPA与SPECT显像差异无统计学意义(P>0.05)。结论CTPA与SPECT显像在诊断肺栓塞方面均具有较高的诊断准确性,两者比较差异无统计学意义。     

多层螺旋CT在肺动脉栓塞诊断中的价值

目的探讨多层螺旋CT肺动脉血管成像（Multi-slice spiral CT pulmonary angiography，MSCTPA）技术对肺动脉栓塞（Pulmonary embolism，PE）的诊断价值．方法收集MSCTPA检查并证实为PE的患者21例，采用16层螺旋CT行肺动脉造影检查并采用多平面重建（MPR）、最大强度投影（MIP）和容积重建（VR）等多种后处理技术。结果本组21例PE患者中，主肺动脉、左及右肺动脉、叶间肺动脉、叶肺动脉、舌支肺动脉的显示率均达100％，对段肺动脉的显示率达93．3%．其中左右肺动脉栓塞共5支，叶肺动脉栓塞28支，段肺动脉栓塞65支。结论MSCTPA技术为临床及早发现并明确诊断PE的可靠检查手段之一。     

Incidence of Pleural Effusion in Patients with Pulmonary Embolism

Background:

No data on the incidence of pleural effusion (PE) in Chinese patients with pulmonary embolism are available to date. The aim of the current study was to investigate the frequency of PE in a Chinese population of patients with pulmonary embolism.

Methods:

This was a retrospective observational single-center study. All data of computed tomography pulmonary angiography (CTPA) performed over 6-year period on adult patients with clinically suspected pulmonary embolism were analyzed.

Results:

From January 2008 until December 2013, PE was identified in 423 of 3141 patients (13.5%) with clinically suspected pulmonary embolism who underwent CTPA. The incidence of PE in patients with pulmonary embolism (19.9%) was significantly higher than in those without embolism (9.4%) (P < 0.001). Majority of PEs in pulmonary embolism patients were small to moderate and were unilateral. The locations of emboli and the numbers of arteries involved, CT pulmonary obstruction index, and parenchymal abnormalities at CT were not associated with the development of PE.

Conclusions:

PEs are present in about one fifth of a Chinese population of patients with pulmonary embolism, which are usually small, unilateral, and unsuitable for diagnostic thoracentesis.     

V/Q显像与SPECT-CT断层显像在慢性血栓栓塞性肺动脉高压中的研究

目的对比肺通气/灌注平面显像与肺灌注SPECT-CT同机融合断层显像在慢性血栓栓塞性肺动脉高压肺段动脉及亚段动脉栓子的检出效能。方法选取经临床Wells评分、临床资料、实验室检查及X线肺动脉造影综合确诊为慢性血栓栓塞性肺动脉高压的35例患者,其中男25例,女10例,平均年龄（52.4±16.5）岁,合并近期手术者3例、心力衰竭者7例、既往存在急性肺栓塞10例、合并下肢深静脉血栓21例;临床Wells评分,高度可能性者15例,中度可能性者20例。所有患者均接受肺通气/灌注平面显像、肺灌注SPECT-CT断层同机融合显像及X线肺动脉造影检查,检查于5 d内完成并由核医学科及放射科有经验医师进行独立、双盲法阅片。采用SPSS19.0统计软件对肺通气/灌注平面显像、SPECT-CT同机融合显像及X线肺动脉造影段及亚段的检查结果进行χ2检验及Kappa一致性检验。结果对于肺段动脉栓子,肺通气/灌注平面显像与肺灌注SPECT-CT的敏感度、特异度、准确度分别为89.63%、69.41%、77.14%;92.53%、93.57%、93.17%。亚段肺动脉栓子,肺通气/灌注平面显像与肺灌注SPECT-CT敏感度、特异度、准确度分别为60.97%、89.05%、82.14%;63.87%、94.0%、86.59%。结论肺灌注SPECT-CT在保留了肺通气/灌注平面显像对肺段及亚段病变定位较高的敏感性同时,提高了对肺段及亚段病变定位的特异性。     

肺癌全肺切除术后常见并发症临床分析

目的总结肺癌全肺切除术术后常见并发症,分析其预防及处理方法。方法回顾性分析我科2009年1月至2011年10月施行全肺切除手术的155例肺癌患者的临床资料,统计患者年龄、术前夹杂病史、肺功能、术后带管时间及术后住院时间等指标。结果 51例术后发生各类并发症,占32.90%,其中心律失常31例,肺部感染13例,急性呼吸衰竭1例,肺栓塞3例,支气管胸膜瘘2例,术后胸腔内活动性出血1例。全组围术期死亡5例,手术死亡率3.23%,其中3例考虑为肺栓塞引起死亡,其余2例为术后肺部感染导致呼吸衰竭死亡。结论肺癌全肺切除是一种高风险术式,心律失常、肺部感染、急性呼吸衰竭、支气管胸膜瘘及肺栓塞是术后常见的并发症。对拟行全肺切除的患者,要严格掌握手术适应证,术前检查应更加全面准确;术后加强围术期管理,严密监护,做到及时、正确的处理。     

The role of nuclear medicine in liver transplantation

The role of hepatobiliary isotopic scanning after liver transplantation was assessed in the first 12 adult patients in the Pilot National Liver Transplantation Programme who underwent this procedure at the Royal Prince Alfred Hospital. Iminodiacetic-acid derivative (HIDA) studies were useful in the non-invasive assessment of hepatic function and biliary excretion. The following four clinical situations were assessed by hepatobiliary scans: early graft function; rejection episodes; vascular complications; and biliary-tract problems. Nuclear medicine has an important and valuable role in the postoperative monitoring of patients after liver transplantation. The studies are non-invasive and can be performed readily at the bedside in the intensive care unit.     

37例肺栓塞的临床分析

目的:对肺栓塞进行临床分析,评价肺栓塞的诊断程序及治疗效果。方法:对2003年1月～2007年3月入院并确诊的37例栓塞的临床表现、检查、诊断及治疗方法进行临床分析。结果:37例肺栓塞患者中,首次误诊率为64.86%,D-二聚体大于500mg/l者占94.59%,超声心动呈典型改变占86.48%,血气分析异常者占91.89%,增强螺旋CT和肺动脉造影敏感性为97.29%和100%。接受溶栓治疗的18例中无死亡,接受抗凝治疗19例中死亡1例。结论:肺栓塞的发病与易患因素密切相关,肺栓塞的临床症状体征不典型,需结合辅助检查进行诊断。溶栓治疗可提高患者生存率。肺栓塞的误诊率高,提高诊断意识和诊断水平是临床医生的当务之急。     

One year's experience with a noninvasively monitored intermediate care unit for pulmonary patients

Many studies have shown that selected cardiac patients can be safely and economically cared for in intermediate care units rather than intensive care units. However, there are only limited data concerning intermediate care units for pulmonary patients. We prospectively followed up all Medicare patients from May 5, 1987, through May 4, 1988, who were admitted to a pulmonary noninvasive monitoring unit. Ninety-four patients were admitted 104 times; 33 required mechanical ventilatory support for an average of 26 days. The overall cost savings were greater than $173,000, while high-quality medical care was maintained. We conclude that a noninvasive monitoring unit can be effectively used as an alternative to the intensive care unit for selected pulmonary patients.     

V／Q显像、SCTPA和血浆D-二聚体分析在PE诊断中的价值

目的探讨肺通气／灌注（ventilation-perfusion, V/Q）显像、螺旋CT肺动脉造影（spiral computed tomographic pulmonary angiography, SCTPA）和血浆D-二聚体（D-dimer）分析在肺栓塞（pulmonary embolism, PE）诊断中的临床价值。方法对2006年1月至2008年11月同济大学附属同济医院临床高度疑诊PE的86例住院患者,分别行肺V／Q显像、SCTPA和血浆D-二聚体分析以及相关检查,以最终临床诊断为依据,分别评价3种检查方法单独及联合应用对PE诊断的临床价值。结果86例高度疑诊病例经上述各项检查确诊PE42例。肺V,Q显像、SCTPA、血浆D-二聚体分析诊断PE的灵敏度、特异性和准确性分别为85．7％（36／42）、79．5％（35／44）、82．6％（71／86）;81％（34／42）、86．4％（38／44）、83．7％（72／86）;90．5％（38／42）、59．1％（26／44）、74．4％（64／86）,联合应用3种检查方法,则诊断的灵敏度、特异性和准确性可分别提高到95．2％（40／42）、88．6％（39／44）、91．9％（79／86）。结论将高特异性的SCTPA与高敏感度的肺V／Q显像和血浆D-二聚体分析联合应用．可以明显提高临床诊断PE的准确性。     

肺通气/血流灌注显像与螺旋CT肺动脉造影诊断肺栓塞的实验研究

目的评价肺通气/血流灌注(pulmonary perfusion/ventilation,V/Q)显像与64层螺旋CT肺动脉造影(spiral computed tomographic pulmonary angiography,SCTPA)诊断肺栓塞的灵敏度和特异性。方法12只家兔按不同时间点分成4个实验组,每组3只,另设2只作为对照组。实验组经颈静脉插管注入海绵栓子制备急性肺栓塞模型,建模后分组行V/Q显像和SCTPA检查,随后处死实验动物行病理解剖,查找并记录肺动脉栓子位置及数目。对照组颈静脉插管注入生理盐水,于24 h和第3天处死。结果实验组家兔术中死亡1只,11只建模成功。家兔处死后共解剖动脉165支,发现栓子43个,栓塞肺动脉39支。V/Q显像共检出36处节段肺动脉栓塞,与病理解剖对照,假阳性7处、假阴性10处;SCTPA共诊断栓塞肺动脉32支,假阳性6支、假阴性13支。V/Q显像、SCTPA诊断实验家兔肺栓塞的灵敏度分别为74.4%、66.7%,特异性分别为94.4%和95.2%,准确性分别为89.7%和88.5%。结论肺通气/血流灌注显像诊断肺栓塞的灵敏度和准确性高于64层螺旋CT肺动脉造影,...     

肺栓塞在16排螺旋CT血管成像

目的：对13例肺栓塞患者的16排螺旋CT各种血管成像进行分析、对比,寻求一种更有效、简便、直观、快捷的成像方法显示肺栓塞。方法：经血管造影（CTPA）后,应用最大密度投影（MIP）、多平面重建（MPR）、容积显示重建（VRT）及仿真内窥镜（VE）成像技术,对于栓塞部位不同者选择不同的层厚（SL）进行图像重建处理。结果：VRT成像对显示肺动脉主干部位的栓塞最为直观,依次为MIP、MPR及VE图像,其中MIP、MPR成像对显示肺叶以下动脉小栓塞情况较好。结论：肺栓塞在16排螺旋CT血管造影后的成像中应以MIP、MPR为主,VRT及VE成像作为一辅助方法。