Objective: To investigate the application of Critical Care Chest Ultrasonic Examination (CCUE)-plus (CCUE-plus) in the etiological diagnosis in patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities. Methods: Patients who suffered from dyspnea and/or hemodynamic instability in the Department of Critical Care Medicine, Xiangya Hospital, Central South University from September 2013 to September 2016 were recruited in this study. A total of 255 consecutive patients completed CCUE within 2hrs of admission. If the diaphragm could not be seen in the routine phrenic points according to Bedside Lung Ultrasound Evaluation (BLUE) protocol, it would be found along midaxillary line and defined m-point. The 59 patients with altered diaphragmatic position (m-point was more than 2 cm higher than phrenic point) received sequential abdominal ultrasonography. The latter ultrasonographic findings were compared with CT results. Results: There were 42(71.19%) cases with positive findings of abdominal ultrasonography, including 18 cases of seroperitoneum, 16 cases of intestinal obstruction and 8 cases combined. Compared with 56 patients who applied with CT exam, the abdominal ultrasonography revealed a sensitivity of 76.7% and a specificity of 100.0% to diagnose seroperitoneum (AUC(ROC) 0.917); whereas the sensitivity was 75.0% and the specificity was 90.9% (AUC(ROC) 0.778) to diagnose intestinal obstruction. Moreover, there were 44(74.58%) patients with normal left ventricular systolic function; more than three quarters (46/59, 77.97%) patients had pulmonary consolidation. Conclusion: In patients with dyspnea and/or hemodynamic instability caused by abdominal abnormalities and altered diaphragmatic position in BLUE protocol, CCUE-plus protocol has a high positive predictive value of more than 90% in abdominal abnormality. The findings of abdominal ultrasonography may change therapeutic target from cardio-pulmonary optimization to relief of intestinal obstruction or drainage of seroperitoneum.
目的： 探讨改良重症超声快速管理(CCUE)方案在重症腹源性呼吸困难和/或血流动力学不稳定患者腹部病因诊断中的作用。 方法： 选2013年9月—2016年9月中南大学湘雅医院重症医学科收治的呼吸困难和/或血流动力学不稳定者255例，入科2 h内完成CCUE方案，若在膈肌点不能看到肺和肝/脾交界，按照改良床旁肺部超声(m－BLUE)方案定位膈肌点和m点。若m－BLUE方案的膈肌点较CCUE方案的膈肌点距头侧近2 cm以上认为膈肌上移，立即实施包括肝肾间隙、脾肾间隙、左右结肠旁沟、脐周及耻骨联合上方6个部位的腹部超声筛查。将超声评估结果与腹部CT比较，分析改良CCUE方案腹部超声诊断腹源性呼吸困难和/或血流动力学不稳定者的腹部病因的敏感性和特异性。 结果： 255例患者完成CCUE方案检查，发现膈肌上移者59例，男性39例，女性20例，年龄(58±16)岁。42例患者(71.19%)改良CCUE方案腹部超声发现异常，18例腹腔积液，16例肠梗阻，8例同时存在中量以上腹腔积液和肠梗阻。3例因病情未行CT检查，56例患者完成了腹部CT检查。腹部CT诊断18例腹腔积液，22例肠梗阻，12例同时存在中量以上腹腔积液和肠梗阻，4例无异常发现。改良CCUE方案腹部超声病因临床诊断正确率为81.36%(48/59)。与腹部CT比，改良CCUE方案腹部超声诊断腹腔积液的正确率为87.5%，敏感性为76.7%，特异性为100.0%；诊断肠梗阻的正确率为75.0%，敏感性为64.7%，特异性为90.9%。 结论： 对CCUE方案发现膈肌上移的患者，改良CCUE方案腹部超声有助于早期发现呼吸困难和/或血流动力学不稳定者的腹源性病因，可作为高度怀疑腹腔异常患者的初筛诊断手段。.
Keywords: Critical care ultrasonography; Critical illness; Dyspnea; Etiological diagnosis; Intestinal obstruction.