The Value of Lung Ultrasound Score and Diaphragm Ultrasound Combined with Routine Indicators in Predicting ARDS in Children with Severe Pneumonia
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摘要:
目的 探究肺部超声评分（LUS）、膈肌超声联合常规指标预测小儿重症肺炎（SP）并发急性呼吸窘迫综合征（ARDS）的价值。 方法 选取2022年8月至2023年8月昆明市儿童医院SP患儿160例，均行肺部超声、膈肌超声检查获取LUS、膈肌超声参数[膈肌移动度（DM）、膈肌厚度变化率（TF）]，根据SP患儿住院期间是否并发ARDS分为ARDS组67例和非ARDS组93例，比较两组入院时一般资料、血清炎症因子水平、LUS、膈肌超声参数，分析SP患儿并发ARDS的影响因素，并分析LUS、膈肌超声参数预测SP患儿并发ARDS的价值。 结果 SP患儿住院期间ARDS发生率为41.88%（67/160）；ARDS组入院时APS、APACHEⅡ评分、血清C反应蛋白（CRP）、白介素-6（IL-6）、高迁移率族蛋白B1（HMGB1）水平、LUS、DM高于非ARDS组，TF低于非ARDS组（P < 0.05）；入院时APS、APACHEⅡ评分及血清CRP、IL-6、HMGB1水平、LUS、DM、TF均为SP患儿并发ARDS的影响因素（P < 0.05）；LUS、DM、TF预测ARDS的曲线下面积（AUC）分别为0.718、0.742、0.720；常规预测方案（入院时APS、APACHEⅡ评分及血清CRP、IL-6、HMGB1水平联合）的AUC为0.852，新预测方案（常规预测方案基础上联合LUS、DM、TF）的AUC为0.930，新预测方案的AUC明显大于常规预测方案的AUC（P < 0.05）。 结论 LUS、膈肌超声参数DM、TF与SP患儿并发ARDS显著相关，联合常规指标可为临床预测SP患儿并发ARDS提供可靠依据。 Abstract:Objective To explore the value of lung ultrasound score （LUS） and diaphragm ultrasound combined with routine indicators in predicting the occurrence of acute respiratory distress syndrome （ARDS） in children with severe pneumonia （SP）. Methods A total of 160 patients with SP were selected from Kunming Children’s Hospital from August 2022 to August 2023, all of whom underwent lung ultrasound and diaphragm ultrasound examination to obtain LUS and diaphragm ultrasound parameters [diaphragm mobility （DM）, diaphragm thickness change rate （TF）]. The patients with SP were divided into ARDS group and non-ARDS group according to whether they were complicated with ARDS during hospitalization. The general data, serum inflammatory factor levels, LUS and diaphragm ultrasound parameters were compared between the two groups at admission, and the influencing factors of ARDS in children with SP were analyzed, and the value of LUS and diaphragm ultrasound parameters in predicting ARDS in children with SP was analyzed. Results The incidence of ARDS in SP patients was 41.88% （67/160）. APS, APACHEⅡ scores, serum C-reactive protein （CRP）, interleukin-6 （IL-6）, high mobility group protein B1 （HMGB1） levels, LUS and DM in ARDS group were higher than those in non-ARDS group, TF were lower than those in non-ARDS group （P < 0.05）. APS, APACHEⅡ scores, serum CRP, IL-6, HMGB1 levels, LUS, DM, TF were the influencing factors of ARDS in SP children at admission （P < 0.05）. The area under the curve （AUC） of LUS, DM and TF predicted ARDS were 0.718, 0.742 and 0.720, respectively. The AUC of the conventional prediction scheme （APS, APACHEⅡ score combined with serum CRP, IL-6 and HMGB1 levels at admission） was 0.852, while that of the new prediction scheme （combined with LUS, DM and TF based on the conventional prediction scheme） was 0.930. The AUC of the new prediction scheme was significantly higher than that of the conventional prediction scheme （P < 0.05）. Conclusion LUS, DM, TF, and SP parameters of the diaphragm are significantly correlated with ARDS in children with SP, and the combination of routine indicators can provide reliable evidence for clinical prediction of ARDS in children with SP. -
图 1 ARDS组典型病例肺部超声、膈肌超声图像
A：入院时肺部超声图像，显示左肺大面积实变，右肺为肺间质综合征，沿胸膜线下实变及支气管充气，LUS为28分；B：入院时膈肌超声图像，左侧显示膈肌厚度，右侧显示膈肌移动度，DM、TF分别为1.6 cm、35%。
Figure 1. Ultrasound images of lung and diaphragm of typical cases of ARDS group
图 2 非ARDS组典型病例肺部超声、膈肌超声图像
A：入院时肺部超声图像，显示双肺部分肋间实变及碎片征，LUS为20分；B：入院时膈肌超声图像，显示左侧显示膈肌厚度，右侧显示膈肌移动度，DM、TF分别为1.3 cm、39%。
Figure 2. Ultrasound images of lung and diaphragm of typical cases in non-ARDS grou
图 3 LUS、膈肌超声参数预测SP患儿并发ARDS的ROC曲线
Figure 3. ROC curve of LUS and diaphragm ultrasound parameters predicting ARDS in SP children
图 4 两种预测方案预测SP患儿并发ARDS的ROC曲线
Figure 4. ROC curves of ARDS in SP children predicted by two prediction schemes
表 1 两组入院时一般资料及血清炎症因子水平比较[（$ \bar x \pm s $）/n（%）]
Table 1. Comparison of general information and serum levels of inflammatory factors between the two groups at admission [（$ \bar x \pm s $）/n（%）]
项目 ARDS组（n=67） 非ARDS组（n=93） t/χ2 P 性别 0.417 0.519 男 43（64.18） 55（59.14） 女 24（35.82） 38（40.86） 年龄（岁） 7.82±1.15 8.03±1.22 1.100 0.273 体重指数（kg/m2） 16.95±1.46 17.28±1.71 1.279 0.203 患病至就诊时间（d） 3.10±0.78 2.93±0.73 1.412 0.160 既往肺部感染病史 0.596 0.440 有 14（20.90） 15（16.13） 无 53（79.10） 78（83.87） 病原菌类型 0.206 0.902 革兰阴性菌 45（67.16） 60（64.52） 革兰阳性菌 21（31.34） 32（34.41） 真菌 1（1.49） 1（1.08） 机械通气 0.282 0.596 是 28（41.79） 35（37.63） 否 39（58.21） 58（62.37） 心率（次/min） 162.39±14.71 157.86±15.24 1.882 0.062 呼吸频率（次/min） 68.31±6.42 67.79±6.25 0.513 0.608 体温（℃） 39.01±0.85 38.84±0.81 1.283 0.201 APS（分） 22.17±4.36 19.45±3.94 4.119 <0.001* APACHEⅡ评分 21.53±1.95 19.29±1.13 9.154 <0.001* 白细胞计数（×109/L） 11.25±2.56 10.58±2.21 1.770 0.079 血小板计数（×109/L） 172.28±35.46 181.59±37.02 1.597 0.112 CRP（mg/L） 41.26±10.53 32.49±9.21 5.594 <0.001* IL-6（pg/mL） 82.39±16.78 65.87±14.35 6.689 <0.001* HMGB1（μg/L） 138.72±25.19 110.46±21.41 7.646 <0.001* *P < 0.05。 
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表 2 两组入院时LUS及膈肌超声参数比较（$ \bar x \pm s $）
Table 2. Comparison of LUS and diaphragm ultrasound parameters between the two groups at admission （$ \bar x \pm s $）
组别 n LUS（分） DM（cm） TF（%） ARDS组 67 20.15±3.26 1.41±0.34 37.24±3.65 非ARDS组 93 17.48±2.51 1.12±0.28 41.08±4.13 t 5.852 5.905 6.087 P <0.001* <0.001* <0.001* *P < 0.05。
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表 3 SP患儿并发ARDS的影响因素分析
Table 3. Analysis of influencing factors of ARDS in children with SP
变量 β SE Wald OR 95%CI P 下限 上限 APS 0.275 0.097 8.024 1.316 1.185 1.462 <0.001* APACHEⅡ 0.207 0.075 7.618 1.230 1.129 1.340 <0.001* CRP 0.251 0.089 7.925 1.285 1.164 1.418 <0.001* IL-6 0.301 0.098 9.409 1.351 1.201 1.519 <0.001* HMGB1 0.233 0.084 7.676 1.262 1.150 1.385 <0.001* LUS 0.380 0.112 11.487 1.462 1.302 1.641 <0.001* DM 0.318 0.096 10.946 1.374 1.228 1.537 <0.001* TF −0.118 0.041 8.243 0.889 0.813 0.972 <0.001* *P < 0.05。
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表 4 LUS、膈肌超声参数预测SP患儿并发ARDS的价值
Table 4. Value of LUS and diaphragm ultrasound parameters in predicting ARDS in children with SP
指标 AUC 95%CI 截断值 敏感度（%） 特异度（%） LUS 0.718 0.641～0.786 19.02分 68.66 69.89 DM 0.742 0.668～0.809 1.33 cm 73.13 75.27 TF 0.720 0.644～0.788 38.50% 64.18 73.12
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表 5 不同预测方案的预测SP患儿并发ARDS的价值比较
Table 5. Comparison of the value of different prediction schemes in predicting ARDS in children with SP
成对对比 AUC差异 标准误差 95%CI上限 95%CI下限 Z P 新预测方案vs常规预测方案 0.079 0.032 0.141 0.014 2.400 0.016* *P < 0.05。
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