吸入治疗是呼吸系统疾病治疗的基础.氦氧混合气作为一种低密度、雷诺系数偏低、使气体通过气道趋于层流的可吸入性气体,自19世纪30年代起作为非药物治疗方式,其主要应用于呼吸系统疾病的治疗,具有减少呼吸做功、提高扩散率、改善分钟通气量,促进气溶胶输送、改善通气分布、提高二氧化碳清除等特性,治疗效果受到广泛关注.本文对氦氧混合气在慢性阻塞性肺疾病、支气管哮喘、急性呼吸窘迫综合征、肺康复等成人呼吸系统疾病中的应用作以简单综述.

目的 通过系统评价分析支气管肺泡灌洗液(BALF)半乳甘露聚糖(GM)检测对侵袭性肺曲霉病(IPA)的诊断准确性并确定最佳诊断界值.方法 检索Pubmed、EMBASE、OVID、Cochrane Library、中国知网(CNKI)、万方、中国生物医学(CBM)等数据库,自建库至2018年10月31日的相关数据,不限制语言,纳入符合标准的26个研究(71组数据),对其进行质量评价、异质性分析,然后分析计算每个诊断界值的合并指标,绘制受试者工作特征曲线,最终确定最佳诊断界值.结果 BALF-GM(诊断界值为0.5时)诊断IPA(确诊和临床诊断IPA)的合并灵敏度为0.87(95％CI 0.84～0.89),合并特异度为0.79(95％CI 0.77～0.81),合并阳性似然比为4.60(95％CI 3.49～6.05),合并阴性似然比为0.19(95％CI 0.14～0.25),合并诊断比值比为38.84(95％CI 22.99～52.81),集成受试者工作特征(SROC)曲线下面积(AUC)为0.92(95％CI 0.90～0.95).在BALF-GM诊断界值为1.0时,受试者工作特征(ROC)曲线下面积(AUC)最大为0.94(95％CI 0.93～0.97).结论 BALF-GM易于检测,对IPA的诊断准确性高,可以对IPA进行早期诊断,早期治疗,降低病死率,目前建议BALF-GM最佳诊断界值为1.0.

Objective To investigate the value of integrative weaning index (IWI) on weaning from mechanical ventilation. Methods The PubMed, Web of Science, EMbase, CNKI, WangFang Databases were searched for IWI diagnostic accuracy on weaning from mechanical ventilation up to October 2018. Two reviewers independently screened the literatures based on the inclusion and exclusion criteria. The methodological quality of included studies was assessed by QUADAS-2. Data were analyzed by Meta-DiSc software. Results Five studies involving 783 patients were included. The summary estimates for IWI diagnostic accuracy on weaning from mechanical ventilation included: sensitivity 0.95 (95%CI: 0.90-0.99), specificity 0.81 (95%CI: 0.68-0.94), positive likelihood ratio 4.46 (95%CI: 1.98~10.07), negative likelihood ratio 0.08 (95%CI: 0.03-0.19), diagnosis odds ratio 60.34 (95%CI: 16.54-220.05), and the area under the curve of SROC was 0.9466. Conclusion IWI can improve the diagnostic accuracy on weaning from mechanical ventilation. Key words: Integrative weaning indexl; Mechanical ventilation; Weaning; Meta-analysis

任何肺部疾病的发生、发展都伴随着肺组织水、气的变化,影像学表现为肺组织不同程度的实变和不同区域的肺通气改变[1-4].床旁胸部X线检查是诊断和治疗重症呼吸系统疾病的首选方法,但其敏感性和特异性有限,不能用于实时重复监测[5].胸部CT检查是诊断呼吸系统疾病更加有效的手段,但不能床旁连续监测以及较强的辐射也限制了其临床的应用[6-8].近些年由于肺部超声具有无创、快捷、安全、可重复性强、无电离辐射等优点[9],越来越受到临床医生的重视.特别在慢性阻塞性肺疾病[10]、心源性肺水肿[11]、急性呼吸衰竭[12]等疾病中,肺部超声具有非常重要的监测与评估意义,也弥补了胸部X线、CT检查的不足[1-3].

Objective To assess the predictive value of percent change in brain natriuretic peptide (BNP%) for endotracheal tube extubation in invasive mechanically ventilated patients during spontaneous breathing trial (SBT). Methods Searches were conducted in the PubMed, Embase, Medline, Ovid, Cochrane Central Register of Controlled Trails and Information Sciences Institute Web of Science for studies on the predictive value of BNP% for endotracheal tube extubation in invasive mechanically ventilated patients published up to March 31, 2018. The Quality Assessment of Diagnostic Accuracy Studies (Quasas-2) was used for quality assessment. The MetaDiSc was used for heterogeneity analysis, and the pooled diagnostic odds ratio (DOR), pooled sensitivity, pooled specificity, pooled positive likelihood ratio (PLR), pooled negative likelihood ratio (NLR), and the area under the summary receiver operating characteristic (SROC) curve were calculated. Results A total of 213 patients were recruited from 5 trials. Meta-analysis showed that the pooled DOR was 22.33 [95% confidence interval (CI) (9.25, 53.91)], the pooled sensitivity was 85% [95%CI (0.78, 0.91)], the pooled specificity was 80% [95%CI (0.68, 0.90)], the pooled PLR was 3.72 [95%CI (2.11, 6.55)], and the pooled NLR was 0.18 [95%CI (0.12, 0.28)]. The pooled DOR, sensitivity, specificity, PLR, and NLR showed no significant heterogeneity (all P > 0.1, all I2 < 50%), and the area under the SROC curve was 0.913. Conclusion BNP% can elevate the predictive value for endotracheal tube extubation in invasive mechanically ventilated patients during SBT. Key words: Brain natriuretic peptide; Ventilators, mechanical; Spontaneous breathing trial

有创机械通气是一种侵入性治疗手段,也是呼吸衰竭患者的重要生命支持方式[1].据相关文献报道,约90％的危重患者需要机械通气[2].机械通气时间延长(prolonged mechanical ventilation,PMV)使其脱机困难,导致5％～15％的机械通气患者发展为"慢重症"[3].若患者在原发病控制后及时脱离呼吸机和拔除插管(以下简称脱机拔管),可以避免因机械通气过久导致的并发症,降低呼吸机的依赖性,改善患者预后[4].影响患者脱机拔管的因素较多,除患者的病情外,还有很多指标可用于评价患者脱机的效果,如呼吸力学指标(呼吸频率、气道闭合压、最大吸气负压)、呼吸综合指数、呼吸驱动指数、浅快呼吸指数(rapid shallow breathing index,RSBI)、改良浅快呼吸指数、综合脱机指数及改良综合脱机指数、呼吸参数变异率(呼吸流变率、心率变异率等)、自主呼吸试验(spontaneous breathing trial,SBT)及气囊漏气试验、自主生理反射(手握强度、咳嗽反射等)等相关指标[5-14].

In the area of invasive ventilation, monitoring the patient′s respiratory mechanics, spontaneous breathing tests, clinical signs and symptoms can help the physicians to determine if extubation is conducted. However, different predictors are discrepant. Thus it is important for clinicians to seek the more safe and successful predictors. Bedside ultrasound as a diagnostic method has some merits, such as rapid, noninvasive, less radiation, reproducible operation and continuous monitor. It has been widely used in critical patients. The observation of diaphragm and liver or spleen mobility by ultrasound may predict the weaning from ventilation. Many studies has showed beside ultrasound is feasible and successful. Now we described briefly the application of bedside ultrasound on weaning. Key words: Beside ultrasound; Mechanical ventilation; Spontaneous breathing test; Diaphragm