【作者】 王欣；

【导师】 张雪宁；

【作者基本信息】 天津医科大学 ， 影像医学与核医学（专业学位）， 2017， 硕士

【摘要】 目的探讨特重度烧伤伴吸入性损伤时支气管壁厚度与病死率的关系,支气管壁厚度动态变化趋势,确定支气管壁厚度的预测诊断价值。方法选取2016年7月~2016年11月急诊收治的特重度烧伤伴吸入性损伤患者43例,所有患者均在入院时完成纤维支气管镜(FOB)检查,确定其存在吸入性损伤。分别于入院时、24h、3d、7d、14d行胸部高分辨率CT(HRCT)检查,测量右肺上叶支气管主干的支气管壁厚度(BWT)。分析BWT与病死率的关系。依据患者14天内预后情况分为存活组、死亡组,分析不同预后不同时段的BWT变化趋势。利用ROC曲线比较入院时BWT和FOB预测肺炎及死亡的诊断价值。结果入院时、24h、3d、7d、14d的BWT与病死率之间均呈正相关(r=0.763、r=0.884、r=0.973、r=0.960、r=0.807,P<0.001)。死亡组患者入院时支气管壁厚度(BWT)显著高于存活组患者(P<0.001),死亡组患者BWT在入院后迅速升高,存活组患者BWT在入院后缓慢升高,均于入院24小时达峰值。存活组患者BWT在24h~3天之间出现“陡坡式”下降,并且在入院后第7~14天,出现BWT下降平坦期;而死亡组患者BWT在入院24h~3天下降缓慢,呈现下降平坦期,入院3天后呈现“抛物线形”下降,死亡组患者BWT显著下降时间迟于存活组,且死亡组患者BWT于入院第14天仍然显著高于存活组(P<0.001),大约为存活组患者BWT的1.44倍。入院时支气管壁厚度>2.45mm时,预测肺炎的ROC曲线下面积为(0.954±0.044)(95%CI:0.867~1.000),入院时支气管壁厚度预测肺炎的准确性为95.35%,灵敏性为85.71%,特异性为97.22%,阳性预测值85.71%,阴性预测值为97.22%;入院时支气管壁厚度>2.75mm时,预测死亡的ROC曲线下面积为(0.956±0.038)(95%CI:0.882~1.000),入院时支气管壁厚度预测死亡准确性为90.70%,灵敏性为83.33%,特异性为96%,阳性预测值93.75%,阴性预测值为88.89%。入院时纤维支气管镜简明损伤评分分级>1.5时,预测肺炎的ROC曲线下面积为(0.679±0.099)(95%CI:0.484~0.873),入院时纤维支气管镜简明损伤评分分级预测肺炎的准确性为62.79%,灵敏性为75%,特异性为60%,阳性预测值30%,阴性预测值为91.30%;入院时纤维支气管镜简明损伤评分分级>1.5时,预测死亡的ROC曲线下面积为(0.880±0.057)(95%CI:0.768~0.991),入院时纤维支气管镜简明损伤评分分级预测死亡准确性为81.40%,灵敏性为87.50%,特异性为77.78%,阳性预测值70%,阴性预测值为91.30%。入院时BWT预测诊断价值优于入院时FOB简明损伤评分分级。结论BWT测量是一种简便易行、无创高效、可重复性强、可量化吸入性损伤程度及预测预后的检查方法。BWT有利于弥补纤维支气管镜的局限性,开展治疗性干预。更多还原

【Abstract】 Objective:Objective to investigate the relationship between bronchial wall thickness and mortality in patients with severe burn with inhalation injury.To investigate the dynamic trend of bronchial wall thickness in patients with severe burn with inhalation injury.To determine the predictive diagnostic value of bronchial wall thickness.Methods: From July 2016 to November 2016,43 patients with severe burn with inhalation injury admitted to emergency department were selected.All patients underwent fiberoptic bronchoscopy(FOB)at admission to determine their presence of inhalation injury.High resolution CT(HRCT)examination was performed at admission,24 h,3d,7d,and 14 d to measure the bronchial wall thickness of the upper trunk of the upper right lung(BWT).The relationship between BWT and mortality was analyzed.The patients were divided into survival group and death group according to the prognosis within 14 days,analysis of two groups of patients with different periods changing tendency of bronchial wall thickness.Using ROC curve comparing the predictive diagnostic value of BWT and FOB.Results:There was a positive correlation between BWT and fatality rate at admission,24 hours,3 days,7 days and 14 days(r=0.763,r=0.884,r=0.973,r=0.960,r=0.807,P<0.001).The bronchial wall thickness(BWT)of the death group was significantly higher than that of the survival group(P<0.001)on admission.Death group BWT increased rapidly after admission.In the survival group,BWT increased slowly after admission.The survival group and the death group reached peak value at 24 hours.In the survival group,BWT showed a steep decline in 24 h to 3 days,7 to 14 days after admission,the BWT decreased flat.In the death group,BWT decreased slowly at admission from 24 h to 3 days,3 days after admission showed a parabolic shape significantly decreased.The significantly decrease time of BWT in the death group was lower than that in the survival group.The BWT of the death group was significantly higher than that of the survival group(P<0.001)at fourteenth days after admission,about 1.44 times as much as the survival group BWT.At the time of admission,the critical value of bronchial wall thickness was 2.45 mm,the area under the ROC curve for predicting pneumonia was(0.954±0.044)(95%CI:0.867~1.000).The accuracy of prediction pneumonia of bronchial wall thickness at admission was 95.35%,with sensitivity of 85.71%,specificity of 97.22%,positive predictive value of 85.71%,and negative predictive value of 97.22%.At the time of admission,the critical value of bronchial wall thickness was 2.75 mm,the area under the ROC curve for predicting death was(0.956±0.038)(95%CI:0.882~1.000).The accuracy of prediction death of bronchial wall thickness at admission was 90.70%,with sensitivity of 83.33%,specificity of 96%,positive predictive value of 93.75%,and negative predictive value of 88.89%.At the time of admission,the critical value of fiberoptic bronchoscopy(FOB)abbreviated injury score was 1.5,the area under the ROC curve for predicting pneumonia was(0.679±0.099)(95%CI:0.484~0.873).The accuracy of prediction pneumonia of fiberoptic bronchoscopy(FOB)abbreviated injury score at admission was 62.79%,with sensitivity of 75%,specificity of 60%,positive predictive value of 30%,and negative predictive value of91.30%.At the time of admission,the critical value of fiberoptic bronchoscopy(FOB)abbreviated injury score was 1.5,the area under the ROC curve for predicting death was(0.880±0.057)(95%CI:0.768~0.991).The accuracy of prediction death of fiberoptic bronchoscopy(FOB)abbreviated injury score at admission was 81.40%,with sensitivity of 87.50%,specificity of 77.78%,positive predictive value of 70%,and negative predictive value of 91.30%.The predictive diagnostic value of BWT is better than that of FOB.Conclusion:BWT measurement is a simple,noninvasive,highly effective,repeatable method,which can quantify the degree of inhalation injury and predict the prognosis.BWT is beneficial to make up for the limitation of fiberoptic bronchoscopy and to carry out therapeutic intervention.更多还原