摘要目的:通过比较不同膈肌测量方法评估不同严重程度慢性阻塞性肺疾病(COPD)的准确性以探索最优的膈肌检查方法。方法:选择我院COPD患者120例,并根据COPD全球倡议(GOLD)分为4级,每一级患者30例。对所有GOLD 1~4级患者分别行膈肌的M型超声法和B超直接法检查。记录患者用力呼气时的膈肌运动幅度(DMA)以及开始呼气到呼气第一秒内膈肌的运动幅度(DMA1)。采用同样方法对所有患者行X线膈肌运动角度测量,记录右侧膈肌呼气末顶点和右肋膈角顶点连线与水平线所成角度(DMAG),以及开始呼气到呼气第一秒时膈肌的运动角度(DMAG1)。采用Kappa一致性分析法评估超声、X线测量膈肌运动与肺功能检测结果的一致性。利用ROC曲线分析超声及X线鉴别COPD不同严重程度的准确性。结果:三种膈肌测量方法获得的结果均随着GOLD分级的逐渐升高而逐渐降低,差异均有统计学意义(均P<0.05)。M型超声法与GOLD分级的一致性最好(Kappa=0.911,P=0.000),X线测量法次之(Kappa=0.700,P=0.000)。M型超声法和X线测量法在鉴别GOLD 1级 vs. GOLD 2级方面AUC均较低(0.711,0.750)。在鉴别GOLD 2级 vs. GOLD 3级方面,M型超声法和X线测量法均获得最好的AUC(0.928,0.938)。在鉴别GOLD 3级 vs. GOLD 4级方面,M型超声法的AUC(0.916)大于X线测量法(0.764),差异有统计学意义(z=2.101,P=0.036)。M型超声法的最佳诊断点为4.58 cm,此时敏感性为100%,特异性为73.33%。结论:M型超声法相比X线测量法和B超直接法能够更准确的区分不同严重程度的COPD。
Abstract:Objective: To evaluate the optimal diaphragmatic examination methods by comparing the accuracy of different diaphragm measurements in chronic obstructive pulmonary disease(COPD) patients of different severity. Methods: A total of 120 patients with COPD were enrolled in our hospital. According to the global initiative for chronic obstructive pulmonary disease(GOLD), patients were divided into 4 groups with 30 patients in each group. M-mode ultrasound and B-ultrasound direct examination of the diaphragm were performed in all patients with GOLD 1~4. The diaphragm movement amplitude(DMA) when the patient was forced to exhale and the diaphragm movement amplitude in one second(DMA1) were recorded. All patients underwent X-ray diaphragm movement angle measurement in the same way, and the right diaphragm movement angle(DMAG) and diaphragm movement angle in one second(DMAG1) were recorded. Kappa consistency analysis was used to evaluate the consistency of ultrasound and X-ray measurements of diaphragm movement and lung function tests. ROC curves of ultrasound and X-ray were used to identify the accuracy of different severity of COPD. Results: The data obtained by the three diaphragm measurements were gradually decreased with the increase of GOLD grade, and the differences were statistically significant(P<0.05). M-mode ultrasound had the best agreement with GOLD classification(Kappa=0.911, P=0.000), followed by X-ray measurement(Kappa=0.700, P=0.000). M-mode ultrasound and X-ray measurements had lower AUC(0.711, 0.750) in the identification of GOLD 1 vs. GOLD 2. In the identification of GOLD 2 vs. GOLD 3, the best AUC(0.928, 0.938) were obtained for both M-mode ultrasound and X-ray measurements. In the identification of GOLD 3 vs. GOLD 4, the AUC(0.916) of the M-mode ultrasound method was greater than the X-ray measurement(0.764), and the difference was statistically significant(z=2.101, P=0.036). The best diagnostic point for M-mode ultrasound was 4.58 cm, where the sensitivity was 100% and the specificity was 73.33%. Conclusion: M-mode ultrasound method can identify COPD of different severity more accurately compared with X-ray measurement and B-ultrasound direct examination.
沈惠英,朱新秀,陈 琪,赵琳琳,钟连江. 不同检查方法评估COPD患者膈肌运动状态的比较[J]. 中国临床医学影像杂志, 2019, 30(10): 698-702.
SHEN Hui-ying, ZHU Xin-xiu, CHEN Qi, ZHAO Lin-lin, ZHONG Lian-jiang. Comparison of different examination methods in evaluating diaphragmatic motion in patients with COPD. JOURNAL OF CHINA MEDICAL IMAGING, 2019, 30(10): 698-702.
[1]Santana PV, Albuquerque A. Respiratory muscles in COPD: be aware of the diaphragm[J]. J Bras Pneumol, 2018, 44(1): 1-2.
[2]Cimsit C, Bekir M, Karakurt S, et al. Ultrasound assessment of diaphragm thickness in COPD[J]. Marmara Med J, 2016, 29(1): 8-13.
[3]戴百章,任朝凤,郑勤玲,等. 慢性阻塞性肺病急性加重患者膈肌影像变化[J]. 临床放射学杂志,2015,34(3):386-388.
[4]Leal BE, Lisboa LG, Linné LMS, et al. Validity and reliability of fluoroscopy for digital radiography: a new way to evaluate diaphragmatic mobility[J]. BMC Pulm Med, 2017, 17(1): 62-72.
[5]陈重泽,连细华,杨如容,等. 超声研究膈肌移动度与对合角度对COPD病情初步判定[J]. 中国超声医学杂志,2016,32(1):34-36.
[6]Baria MR, Shahgholi L, Sorenson EJ, et al. B-Mode Ultrasound Assessment of Diaphragm Structure and Function in Patients With COPD[J]. Chest, 2014, 146(3): 680-685.
[7]王飞飞,朱晓萍,马少林. 超声评估膈肌结构和功能[J]. 中华危重病急救医学,2017,29(3):276-280.
[8]The Asia Pacific COPD Round table Group. Global Initiative for Chronic Obstructive Lung Disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: An Asia-Pacific perspective[J]. Respirology, 2010, 10(1): 9-17.
[9]Hellebrandová L, Chlumsky J, Vostatek P, et al. Airflow limitation is accompanied by diaphragm dysfunction[J]. Physiol Res, 2016, 65(3): 469-479.
[10]Chun EM, Han SJ, Modi HN. Analysis of diaphragmatic movement before and after pulmonary rehabilitation using fluoroscopy imaging in patients with COPD[J]. Int J Chron Obstruct Pulmon Dis, 2015, 2015(Issue 1): 193-199.
[11]李亚,田燕歌,李素云. 膈肌疲劳在慢性阻塞性肺疾病中的研究进展[J]. 中国老年学杂志,2014,34(1):263-265.
[12]郭先健,张睢阳. 五年来有关膈肌功能的研究[J]. 第三军医大学学报,1993,15(2):126-131.
[13]戴百章,任朝凤,郑勤玲,等. 慢性阻塞性肺疾病患者膈肌功能与CAT评分相关研究[J]. 临床肺科杂志,2015,20(4):690-692.
[14]徐杉,步涨,潘纯,等. B超下膈肌活动度监测对重度慢性阻塞性肺疾病患者困难撤机的预测价值[J]. 中国急救医学,2017,37(1):49-52.
[15]李明秋,郭瑞君,张谱,等. M型超声观察膈肌运动与肺功能的相关性研究[J]. 首都医科大学学报,2014,35(2):189-193.