ICU机械通气患者的经胸超声心动图的图像获取研究

doi:10.24920/003685

摘要/Abstract

摘要：

目的探讨重症患者行机械通气后接受经胸超声心动图（transthoracic echocardiography, TTE）成像检查时图像采集过程易于受到不利影响的心脏功能参数。
方法研究组纳入90例ICU接受机械通气的患者,在同期接受介入治疗的非机械通气患者中,以年龄和体重指数按照1：1与研究组患者进行匹配后作为对照组。对所有纳入研究的患者进行心脏超声检查,通过目测（Eyeballing）法获取右心室（right ventricular, RV）大小、室间隔运动、左室射血分数（left ventricular ejection fraction, LVEF）,通过M型超声测量三尖瓣环状平面收缩期偏移（tricuspid annular plane systolic excursion, TAPSE）,二尖瓣环状平面收缩期偏移（mitral annular plane systolic excursion,MAPSE）,通过脉冲-多普勒超声测量右心室流出道（right ventricular outflow tract,RVOT）的速度-时间积分（velocity-time integral, VTI）和左心室流出道（left ventricular outflow tract,LVOT）VTI,通过心内膜示踪法测量右心室面积变化率（fraction of area change, FAC）及左心室射血分数（left ventricular ejection fraction, LVEF Simpson）。比较在测量以上各参数时,两组之间获得可测量图像的人数差异,以及机械通气ICU患者测量各个参数时获得最佳图像的人数差异。
结果在研究组中采用M型超声法、脉冲多普勒法和心内膜示踪法获得最佳心脏超声图像的患者明显少于对照组(P<0.05);通过目测法获取RV和LVEF参数时最佳图像获取率在两组之间无显著差异。在研究组中,可取得FAC测量值的患者比率（22.2%）明显少于可获取TAPSE（72.2%,X²=45.139,P<0.001）和可获取RVOT测量值的患者比率（71.1%,X²=43.214,P<0.001）。可获取LVEF Simpson最佳图像的患者比率（37.8%）也明显少于MAPSE（84.4%,X²=41.236,P<0.001）和LVOT VTI（85.6%,X²=43.455,P<0.001）。
结论在ICU接受机械通气的部分患者中,通过TTE获取最佳心脏超声图像存在一定困难,但采用目测法可较好地评估这类患者的心脏功能。对于定量参数的测量,基于M型超声的心脏纵向运动功能参数评估和基于脉冲多普勒法的VTI参数获取优于心内膜示踪法。

关键词: 危重症, 经胸超声心动图, 医学成像

Abstract:

Objective This study aimed to determine which parameters in transthoracic echocardiography (TTE) are more likely to be affected when applied in a critical care setting with mechanical ventilation.
Methods Ninety mechanically ventilated ICU patients were enrolled into the study group. The control group consisted of 90 patients who underwent interventional therapy. All patients had bedside TTE for parametric measurements including the right ventricular size, septal kinetics and left ventricular ejection fraction (LVEF) by eyeballing (visual assessment), the tricuspid annular plane systolic excursion (TAPSE), mitral annular plane systolic excursion (MAPSE) by M-mode sonography, the right ventricular outflow tract velocity-time integral (RVOT VTI) and left ventricular outflow tract velocity-time integral (LVOT VTI) by pulse-Doppler, the right ventricular fraction of area change (FAC) and left ventricular ejection fraction (LVEF Simpson) by endocardium tracing. We compared the differences in the frequency of optimal image acquisition in assessments of these parameters between the two groups, as well as the differences in acquisition rates of parameter measurements in ventilated ICU patients.
Results There were significantly fewer patients in the study group than in the control group who had optimal images acquisitions for parameter assessments with M-mode method, pulse Doppler method and endocardium-tracing method (P<0.05); no significant difference was obsered in the number of patients with optimal images for RV eyeballing and LVEF eyeballing between the two groups. In the study group, significantly fewer optimal images were acquired for FAC than for TAPSE (22.2% vs. 72.2%, χ²=45.139, P<0.001) and RVOT VTI (22.2% vs. 71.1%, χ²=43.214, P<0.001); there were also fewer optimal images acquired for LVEF Simpson than for MAPSE (37.8% vs. 84.4%, χ²=41.236, P<0.001) and LVOT VTI (37.8% vs. 85.6%, χ²=43.455, P<0.001).
Conclusions Images acquisition of optimal TTE images tend to be difficult in mechanically ventilated ICU patients, but eyeballing method for functional evaluation could be an alternative method. For quantitative parameters measurements, M-mode based longitudinal function evaluation and pulse Doppler-based VTI were superior to the endocardium-tracing based parameter assessments.

Key words: critically ill, transthoracic echocardiography, medical image

Cui Wang, Xiaodong Deng, Hongmin Zhang, Dawei Liu, Xiaoting Wang. Study on Image Acquisition of Transthoracic Echocardiography in Mechanically Ventilated ICU Patients[J].Chinese Medical Sciences Journal, 2020, 35(4): 323-329.

图/表 3

参考文献 25.

1.	Narasimhan M, Koenig SJ, Mayo PH. Advanced echocardiography for the critical care physician: part 2. Chest 2014; 145(1):135-42. doi: 10.1378/chest.12-2442. doi: 10.1378/chest.12-2442 pmid: 24394824
2.	Moore CL, Rose GA, Tayal VS, et al. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med 2002; 9(3):186-93. doi: 10.1197/aemj.9.3.186. pmid: 11874773
3.	Randazzo MR, Snoey ER, Levitt MA, et al. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med 2003; 10(9):973-7. doi: 10.1111/j.1553-2712.2003.tb00654.x pmid: 12957982
4.	Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: A report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010; 23(7):685-713. doi: 10.1016/j.echo.2010.05.010. pmid: 20620859
5.	Jensen MB, Sloth E, Larsen KM, et al. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesth 2004; 21(9):700-7. doi: 10.1097/00003643-200409000-00006.
6.	Popescu BA, Andrade MJ, Badano LP, et al. European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. Eur J Echocardiogr 2009; 10(8):893-905. doi: 10.1093/ejechocard/jep151.
7.	American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med 2009; 53(4):550-70. doi: 10.1016/j.annemergmed.2008.12.013 pmid: 19303521
8.	Gudmundsson P, Rydberg E, Winter R, et al. Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods. Int J Cardiol 2005; 101(2):209-12. doi: 10.1016/j.ijcard.2004.03.027. doi: 10.1016/j.ijcard.2004.03.027 pmid: 15882665
9.	Quinones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of Doppler echocardiography: A report from the Doppler quantification task force of the nomenclature and standards committee of the American Society of Echocardiography. J Am Soc Echocardiogr 2002; 15(2):167-84. doi: 10.1067/mje.2002.120202. doi: 10.1067/mje.2002.120202 pmid: 11836492
10.	Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28(1):1-39. doi: 10.1016/j.echo.2014.10. pmid: 25559473
11.	Feng M, McSparron JI, Kien DT, et al. Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database. Intensive Care Med 2018; 44(6):884-92. doi: 10.1007/s00134-018-5208-7. doi: 10.1007/s00134-018-5208-7 pmid: 29806057
12.	Moreno O, Ochagavia A, Artigas A, et al. Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery. Med Intensiva 2019; 43(9):538-45. doi: 10.1016/j.medin.2018.06.004. doi: 10.1016/j.medin.2018.06.004 pmid: 30072143
13.	Mercado P, Maizel J, Beyls C, et al. Transthoracic echocardiography: an accurate and precise method for estimating cardiac output in the critically ill patient. Crit Care 2017; 21(1):136. doi: 10.1186/s13054-017-1737-7. doi: 10.1186/s13054-017-1737-7 pmid: 28595621
14.	American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. American College of Emergency Physicians. Ann Emerg Med 2006; 48(4):487-510. doi: 10.1016/j.annemergmed.2006.07.946. pmid: 16997700
15.	Sarti A, Cipani S, Innocenti C. Ultrasound morphology of the heart: transthoracic examination. In: Sarti A, Lorini F. editors. Textbook of echocardiography for intensivists and emergency physicians. Milan: Springer; 2019. p. 21-36.
16.	Siadecki SD, Frasure SE, Lewiss RE, et al. High body mass index is strongly correlated with decreased image quality in focused bedside echocardiography. J Emerg Med 2016; 50(2):295-301. doi: 10.1016/j.jemermed.2015.07.023. doi: 10.1016/j.jemermed.2015.07.023 pmid: 26432081
17.	Sarti A, Lorini FL. Echocardiography for intensivists. Milan: Springer; 2012. p. 81-2.
18.	Hope MD, de la Pena E, Yang PC, et al. A visual approach for the accurate determination of echocardiographic left ventricular ejection fraction by medical students. J Am Soc Echocardiogr 2003; 16(8):824-31. doi: 10.1067/S0894-7317(03)00400-0. doi: 10.1067/S0894-7317(03)00400-0 pmid: 12878991
19.	Horton KD, Meece RW, Hill JC. Assessment of the Right Ventricle by Echocardiography: A Primer for Cardiac Sonographers. J Am Soc Echocardiogr 2009; 22(7):776-92. doi: 10.1016/j.echo.2009.04.027. pmid: 19560657
20.	Chan KL, Veinot JP. Right ventricular diseases. In: Chan KL. Anatomic basis of echocardiographic diagnosis. London: Springer; 2010. p. 207-26.
21.	Kaul S, Tei C, Hopkins JM, et al. Assessment of right ventricular function using two-dimensional echocardiography. Am Heart J 1984; 107:526-31. doi: 10.1016/0002-8703(84)90095-4. pmid: 6695697
22.	Gajanana D, Seetha Rammohan H, Alli O, et al. Tricuspid annular plane systolic excursion and its association with mortality in critically ill patients. Echocardiography 2015; 32(8):1222-7. doi: 10.1111/echo.12926. doi: 10.1111/echo.12926 pmid: 25728401
23.	Matos J, Kronzon I, Panagopoulos G, et al. Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction. J Am Soc Echocardiogr 2012; 25(9):969-74. doi: 10.1016/j.echo.2012.06.011. doi: 10.1016/j.echo.2012.06.011 pmid: 22795199
24.	Robson SC, Murray A, Peart I, et al. Reproducibility of cardiac-output measurement by cross-sectional and doppler echocardiography. Brit Heart J 1988; 59(6):680-4. doi: 10.1136/hrt.59.6.680. doi: 10.1136/hrt.59.6.680 pmid: 3395526
25.	Huang SJ. Measuring cardiac output at the bedside. Curr Opin Crit Care 2019; 25(3):266-72. doi: 10.1097/MCC. 0000000000000599. doi: 10.1097/MCC.0000000000000599 pmid: 31022088

Grading score	Definitions
1	No recognizable structures, no objective data can be gathered
2	Minimally recognizable structures but insufficient for diagnosis
3	Minimal criteria met for diagnosis, recognizable structures but with some technical or other flaws
4	Minimal criteria met for diagnosis, all structures displayed well and diagnosis easily supported
5	Minimal criteria met for diagnosis, all structures displayed in excellent image quality and diagnosis completely supported

Categories	Study group (n=90)	Control group (n=90)	t/X² value	P value
Age(y/o, mean±SD)	58.7±15.3	55.8±15.5	1.538	0.215
Sex-male [n(%)]	41(45.6)	48(53.3)	1.089	0.371
BMI	23.2±3.2	22.7±3.3	1.257	0.367
APACHE Ⅱ score	14.5±6.4	9.7±3.2	7.706	0.000
Comorbidities
HTN [n(%)]	37(41.1)	26(28.9)	2.955	0.086
CAD [n(%)]	20(22.2)	14(15.6)	1.305	0.253
DM [n(%)]	19(21.1)	17(18.9)	0.139	0.709
CRF [n(%)]	7(7.8)	4(4.4)	0.871	0.351
COPD [n(%)]	3(3.3)	2(2.2)	0.206	0.650
Sinus rhythm [n(%)]	90(100)	89(98.9)	1.006	0.316

Imaging and parameters	Study group (n=90)	Control group (n=90)	X² value	P value
Eyeballing parameters
RV function eyeballing [n(%)]	78(86.7)	85(94.4)	3.183	0.074
LVEF eyeballing [n(%)]	82(88.9)	87(97.8)	2.421	0.119
M-mode parameters
TAPSE [n(%)]	65(72.2)	82(91.1)	10.724	0.001
MAPSE [n(%)]	76(84.4)	88(97.8)	9.878	0.002
Pulse doppler parameters
RVOT VTI [n(%)]	64(71.1)	78(86.7)	6.538	0.011
LVOT VTI [n(%)]	77(85.6)	88(97.8)	8.800	0.003
Endocardium-tracing based parameters
FAC [n(%)]	20(22.2)*	58(64.4)	32.670	0.000
LVEF Simpson [n(%)]	34(37.8)^#	73(81.1)	35.051	0.000

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