超聲技術(shù)在ards患者應(yīng)用價(jià)值

1、肺部超聲及其在ARDS診治中的應(yīng)用進(jìn)展,山東大學(xué)齊魯醫(yī)院重癥醫(yī)學(xué)科 杜鵑,大綱,超聲的一般原理,超聲波可進(jìn)入人體組織，由于不同組織聲阻抗不同，在不同界面上產(chǎn)生反射，回波被探頭接收器所接受，經(jīng)儀器處理產(chǎn)生圖像,超聲的一般原理,超聲的一般原理,M型超聲,肺部超聲技術(shù)的原理,正常肺組織因?yàn)楹写罅繗怏w，聲波在胸膜與肺的界面上被全反射，產(chǎn)生偽影（A線與滑動(dòng)征)病變的肺組織因?yàn)楹壤黾?，含氣量減少而使偽影發(fā)生變化 (B線)當(dāng)肺發(fā)生實(shí)變時(shí)

2、，因?yàn)椴缓瑲怏w，而使肺在超聲下可視當(dāng)存在胸腔積液時(shí)，為無回聲液性暗區(qū)氣胸發(fā)生時(shí)，肺滑動(dòng)征消失,肺部超聲探頭的選擇,線陣、微凸陣、凸陣探頭均可用于肺部探查,正常肺部超聲,胸膜線 A線：位于胸膜線下與胸膜線平行，相互之間等距的線沙灘征：肺的運(yùn)動(dòng)及胸膜的滑動(dòng)引起,蝙蝠征及沙灘征,肺部超聲模式圖,正常肺部超聲,蝙蝠征及肺滑動(dòng)征,肺部超聲的異常征象（1）,肺是“干”還是“濕”？B線 間質(zhì)綜合征界限

3、清楚的縱行偽影起源于胸膜，延伸至屏幕遠(yuǎn)端，無衰減若胸膜存在滑動(dòng)，B線隨之運(yùn)動(dòng)消除A線提示肺水含量增加出現(xiàn)在后側(cè)胸部的B線可能是生理性的（見于28%的健康人）,,間質(zhì)綜合征,間質(zhì)綜合征：B線的形成,B線產(chǎn)生原理示意圖,間質(zhì)綜合征,B模式=3條及以上的B線，提示間質(zhì)綜合征,間質(zhì)綜合征,B線間距大于等于7mm或B線散在對(duì)應(yīng)CT上小葉間隔間隔增厚,B-7 line,肺泡間質(zhì)綜合征,B線間距小于3mm對(duì)應(yīng)CT上磨玻璃影,B

4、-3 line,肺泡間質(zhì)綜合征,白肺：B線聚集，以致肺野變成較均質(zhì)的回聲,間質(zhì)綜合征,健康人CT上看下肺也可見小葉間隔，對(duì)應(yīng)于相應(yīng)位置的肺部超聲可見散在的B線,肺泡間質(zhì)綜合征,肺部各種偽像的形成取決于肺組織氣與水的構(gòu)成比例,肺部超聲的異常征象（2）,肺實(shí)變（肝樣變）常見病因感染肺栓塞肺部腫瘤及轉(zhuǎn)移壓迫性肺不張阻塞性肺不張肺挫傷,LUS異常征象（2）—肺實(shí)變,肺實(shí)變,LUS的異常征象（3）—胸腔積液,胸腔積液,LUS異常征象

5、（3）—胸腔積液,胸腔積液伴有纖維條索的產(chǎn)生及胸膜粘連,LUS異常征象（3）—胸腔積液,LUS異常征象（4）—?dú)庑?氣胸 —胸膜滑動(dòng)征消失,LUS異常征象（4）—?dú)庑?正常 沙灘征,氣胸 條形碼/平流層征,LUS異常征象（4）—?dú)庑?氣胸的除外征象：一切顯示臟壁層胸膜相互接觸的征象 B 線Lung pulse,LUS異常征象（4）—?dú)庑?氣胸的特異性征象—肺點(diǎn),肺部超聲 VS CT,The Use of Point-o

6、f-Care Bedside Lung ultrasound Significantly Reduces the Number of Radiographs and Computed Tomography Scans in Critically Ill Patients,肺部超聲的診斷流程舉例—BULE方案,Blue 方案,肺部超聲對(duì)急性呼吸困難的鑒別診斷-BLUE方案,肺部超聲對(duì)急性呼吸困難的鑒別診斷-BLUE方案,肺部超聲對(duì)急性呼吸

7、困難的鑒別診斷-BLUE方案,CHEST.July 2008;134(1):117-125,Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure*: The BLUE Protocol,續(xù)上表,,CHEST.July 2008;134(1):117-125,肺部超聲對(duì)ARDS的診斷價(jià)值,Comparative Diagnostic Perfo

8、rmances of Auscultation,Chest Radiography, and Lung Ultrasonography in AcuteRespiratory Distress Syndrome,Anesthesiology:January 2004 - Volume 100 - Issue 1,ARDS早期診斷,ARDS超聲特點(diǎn),1) Alveolar-interstitial syndrome ：the pre

9、sence of more than 3 ULCs or "white lung" appearance for each examined area2) Pleural lines abnormalities ：thickenings greater than 2 mm, evidence of small subpleural consolidations or coarse appearance of the

10、 pleural line3) Areas with absent or reduced “sliding”： sign with respect to adjacent or controlateral zones at the same level on the opposite hemithorax4) “Spared areas” ：areas of normal lung pattern in at least one i

11、ntercostal space surrounded by areas of AIS.5) Consolidations： areas of hepatisation (tissue pattern) with presence of air bronchograms 6) Pleural effusion ：anechoic dependent collections limited by the diaphragm and t

12、he pleura 7) “Lung pulse”： absence of lung sliding with the perception of heart activity at the pleural line,鑒別診斷,ARDS vs 急性心源性肺水腫(APE),A: ARDS的前側(cè)肺野,雙側(cè)均存在。白肺或密集的B線臨近常存在相對(duì)正常的 區(qū)域，提示肺泡間質(zhì)綜合征分布并不均質(zhì),B：白肺，出現(xiàn)在APE的后側(cè)肺野，分布較為均質(zhì),

13、鑒別診斷,ARDS vs APE,A與B均出現(xiàn)于ARDS的后側(cè)尤其是基底肺野，實(shí)變的肺組織中支氣管充氣，呈動(dòng)態(tài)或靜態(tài)的支氣管充氣征，一般不發(fā)生在APE,ARDS vs APE,A：出現(xiàn)于ARDS，胸膜線不規(guī)則、增粗、模糊，滑動(dòng)減小，由存在的小的胸膜下實(shí)變導(dǎo)致,B：出現(xiàn)于APE,正常的胸膜線,ARDS vs PAE,A：出現(xiàn)于ARDS，胸膜下的小實(shí)變,B：出現(xiàn)于APE,無胸膜下實(shí)變,ARDS vs APE,見于ARDS，胸膜線的改變與肺泡

14、間質(zhì)綜合征的 分布相對(duì)應(yīng),ARDS vs APE,A：出現(xiàn)于ARDS，少量胸腔積液,B：出現(xiàn)在APE，較大量的胸腔積液,ARDS vs APE,病例一,病例二,ARDS vs APE,Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrom

15、e,Cardiovascular Ultrasound 2008, 6 :16,LUS評(píng)價(jià)肺復(fù)張,實(shí)變的肺下葉,,正常通氣肺組織,實(shí)變的肺下葉,,聚集的B線,聚集的B線,,散在的B線,B3 線,B7線,,LUS評(píng)價(jià)肺復(fù)張,Bedside Ultrasound Assessment of Positive End-Expiratory Pressure–induced Lung Recruitment,Am. J. Respir. C

16、rit. Care Med. February 1, 2011 vol. 183,Compare the pressure–volume (PV) curve method with LUS for assessingPEEP-induced lung recruitment in patients with ARDS/ALI,總 結(jié),肺部超聲主要原則：簡單的機(jī)器肺臟是立體的器官氣、液混合產(chǎn)生偽影肺部超聲基于對(duì)偽影的觀察肺臟