VlETHAM MEDICAL JOURHAL NH - DFCEMBER - 2016 NGHIEN CUTJ AP DUNG SIEU AM TRONG CHAN D O A N VIEM PHOI CONG DONG
TOMTAT
Muc tieu: Nhan xet hinh anh hoc va gia tri chan doan ciia sieu am trong chan doan viem phoi cong dong (CAP). &Si tu'dng va phtfOng phap nghien d h i : SO^benh nhan co trieu chuhg lam sang nghi ngd viem phoi cfing dong vao kiioa cap aiu tiong thdi gian tir thang 3/2016- den thang 10/2016 dudc thSm kham lam sang, xet nghiem, sieu am phoi, diup X- quang phoi thSng va CT nguc de chan doan. Tieu chuan dlSn do3n CAP tren sieu 3m phoi dua vao phac d5 dlln doan BLUEU]. Ktt qua: 50 blnti nhan duBc lua chon o6 40 benh nhan dtfdc chan doan CAP, trong do c i 38_benh nhan co ket qua sieu am phoi dudng tinh vdi sieu am pha. Do nhay, dp d3c hieu, gia tri chan doan diing ciia sieu am piiol ia 95% (95% a , 93%- 96%), 90% (95% a , S8%- 91%): 94% (95% O, 92%- 95.2%) vdi ti so kh^ di dudng tinh va am tfnh tuHng ling la 9.5 (95% a , 3.8-17.0); O.OS (95% Q, 0-02-^3.17). Cac hinh anh dien hinh ciia CAP tren sigu am la ton thudng phe nang ho§c mang phoi phfa sau (PLAPS) (90%), phe quSn chOa khi dong (87.5%).
icet luSn: Sleu am phcSI la mpt ki thu|t chin doan co gla tri cao, cd till duoc ap dung de chin doan xac dinh holcloai trif CAP.
Td /dida: viem phoi mic phai cpng dong, sieu am phoi, phic d3 chan doan BLUE
SUIVIIVIARY
EVALUATI LUNG ULTRASOUND I N THE DIAGNOSIS OF COMMUNITY ACQUIRED
PNEUMONIA
Objective: Evaluate imaging and ttie value of lung ulhasound in diagnosis community acquired pneumonia (CAP). Subjects and research methods: 50 patients suspecting CAP m Bach Mai Emergency IDepartment from March to October 2016 was examined, received bkxjd test, lung ulhasound (LUS), anterior- posterior chest x-ray, and chest scan to detect CAP. Criteria to diagnosis CAP by LUS based on BLUE protocol. Results: 50 patients was enrolled, 40 patienls had CAP, and 38 of ttiem mere posMve wltti LUS. The sensitivity, specificity, acuracv of LUS i-s
95% (95% a, 93%-96%rm%(?sl?^a S i - 91%): 94% (95% a 92%-9S.2%)'2 F t e l S
'Kboadpcdu, Binh viin Bach maiChiu ttich nhiem chinh: Nguyen v i n Oil Email: [email protected](xn Ngay nhin baj: 21.9.2016 Ngay phan b i ^ khoa hgc: 25.11.2016 Ngiy duyet bli:30.11.2016
Khu-ong Quoc Bai*, Nguyen Van Chi«
ratio of 9.5 (95% a , 3.8-17.0) for posittve and 0 8 (95% a , 0.02-0.17) for negative. The most common sign is posterior-latero alveolar and/or pleural syniirome (PLAPS) (90%), and dynamic air bronchogram (87.5%) Condusion: LUS Is a gogil technique, can be used to rule in and rule out CAP with high acuracy diagnostic value.
Keywords: Community acquired pneumona
lung ultrasound, BLUE protocol. ' L D A T V A N O l
Viem phoi m i c phai cong dong (CAP) la mfit trong nhij-rig benh ly nhiem khuan thuftng gap tren lam sang [2]. Van de chan doan CAP cliiJ yeu dtfa vao cac trieu chiitig cd nang, ttilm kham _ lam sang, cac xet nghiem can lam sang nhtf cdng thtfc mau, cac chi diem viem va hinti anh ton thydng tham nhiem mdi xuat hien d phoi. Cac ton thuHng tham nhllm duftc xlc dinh qua cac kT thuat chan doan hinh anh nhtf'x- quang tim phoi thang, CT ngtfc, hole sieu am.
Trong t^ ngifc cd dp chinh x i e cao nhat, diHlc COI la tISu chuan vang, tuy nhien Ial dSt Ben, phai v i n chuyen benh nhan tdl phong chgp, va tSng IuBng hap phu Ha phong xa [3-5]. X- quanj ngyc thing Ja bien phap thuSng quy va kinh dien de chan doan, tuy nhien d6 chinh xlc khong cao, ket qua b[ anh htfdng bdi nhieu y&
to nhtf ki thuat chup, ctfdng do tia, chup diing thi hit vao, kinh nghiem ngtfdi doc phim... [6]
Sleu am trong chan doan' CAP mdi a # nghien ctfu nhieu trong nhiing n i m gan day »s cd nhtfng tfu thg nhat djnh vdi dp chinh xlc ttfdng doi cao, co the ti?n hanh t?l gluftng, ddn glan, cho ket qua nhanh chong va khong b! hap phg tia phong xa. Do do chiing tdl Hen hanh nghien cud de tai:'Nghiin ctlu ip dyng sleu am trong Chan doan viem phoi mic phil cing dond vdi muc tieu:
_ - Nhin xet hinh inh hoc viim phoi mk phil cgng dong din sieu im.
- Nh$n xet gii tq cua siiu im trong chit, doan viem phoi mic phii cong dpng.
II. OOI TU-pNQ v A PHU-ONG PHAP N G H I § N COU 2 . 1 . Thfti gian va d|a d i e m nghien cijfu NghiSn ctfu dudc tien hanh ttf thing 3 nim 2016 den thing 10 n»m 2016, tai khoa CSp ciili Benh vien Bach Mai.
34
YHOC WET HAM Tap 449-THAHS 1 2 - s o 1-2016 2.2. Doi ttfdng nghien ctfu
2.2.1. niu chuan chgn binh nhan - Bent, nhat, > 18 tuol.
, - Cd cac trieu chiiHg nghl ngft viem phoi:
o Ho mdi xuat hien hoac gla tang, va /hoac , kh|c ddm vdi stf thay dffl ve mau sac va tfnh , chat ddm.
o Sot tren 38° C hoac ha than nhlet < 35° c o Cac trieu chiiHg khong d i e hieu khac nhtf • dau ngtfc:, khd thd, met mol, chan an.
oKham phoi cd cac ton thtfdng ciia hol Chung dong dac: rale am, rale no...
2.2.2. Tieu ChuSn loai triif benh nhan - Benh nhan oo thai.
- Benh nhan khong cd kha nang van chuyen di chup CT ngtfc khi kel qua glffa sieu am phoi va X- quang ngtfc thang co stf khac biet.
- Benh nhan viem phoi nghi ngd nguon goc benh vi?n: tat ca cac truftng hop dudc chan doan viem phoi sau 48 gid nhap vien.
- B$nh nhan lao lihoi,' sarcoidosis, amyloidosis, ung thtf phoi, viem phoi tia xa
2.3. Phu'dng phap nghien cu-u 2.3.1. PhUdng phip nghiin cuU - Thiet ke nghien ctfu: tien ctfu mo ta - CB mau: c9 mau thuin tien 2.3.2. Oc budc Oen hinh _ B?nh nhan vao cap ciili dtfdc hol tien stf benh stf, cac trISu chutig co ning, thtfc the, xet nghllm mau.
3.10|c digm nhom b§nh nhin Bang 3.1; B3c aigm nhdm b6nh nhSn
Sau do tat ca cac benh nhan du Heu chuan liiS_chon dtfdc Hen hanh sieu am phoi. Sleu am phoi dUBc Hiuc hien ttieo quy hinh. Vi tti sieu am gom 3 diem BLUE Hen, BLUE dufti va PLAPS. Cac hmh anh sieu am duBc ttiu ttiap ttieo benh an nghien ciiti.
Sau khi sleu am phoi, tat ca cac benh nhan deu duftc Hen hanh chup X- quang ngut ttiSng, Ol ttie diup lai khoa dian doan hinh anh Benh vien Bach Mai hoac chup tai gluftng neu tt'nh tt^tig benh nhan khorig dio phep van chuyen an toan.
So sanh k a qua giiis sleu Sm phoi va X- quang ngtfc Hiang, neu cd stf hfdng dong ciing am Hnh hoac dtfdng tt'nh, khang dinh chan doan viem phoi, ket Hiiic qua ttinh thu thap so lieu Neu ket qua glDs sieu am phoi va X- quang ngtfc thang khong ttfdng dong. Hep Hjc tien haiih chup c r ngut de khang cflnh chan cioan.
Thu ttiap so lieu theo bo cau hoi nghien ciili ill. KET QuA NGHIEN CO'U
Trong ttldl gian nghien ciiu co 54 benh nhan du beu chuan luS chon, 4 benh nhin bi loai trtf khoi nghien clfu. Nhdm benh nhan nghien ctfu CO 40 benh nhan dtfdc chan doin viem phoi bang X-quang ngtfc t h i n g , sleu am phoi hole CT ngtfc. Co_^5 benh nhan cd stf khong Hfdng dong ttong Chan doan glDs sleu am phoi va X- quang ngtfc ttiang va cSn chup CT ngtfc.Chling toi xin ada ra mpt so ket qua nghien ctfu sau:
Tuoi Gidi nam eigm APACHE i r
BIgmPSI BI6llCURB-65~
Bgnh nhan viem phoi
56.4± 15.4 29 (72.5%) 11 (8-15)
55 (30-70) 3(2-51W n g 3.2: Trieu chlj-nq ISm sang
Sot Ho khac dftm
Khd ttift
Oau ngut TrIgu chiitiq tteu hdaBenh nhan viem ph£i ( n = 4 0 )
37 (92.5%)
19 (47.5%1 39 (97.5%)21 (52.5%) 4 (10%)
Nh^n xit: CIc ttif u chtfng lam sang ttiuftng g i p la nhung Hieu chtfng kinh dien ciia viem phdi.Benh nhan Ichong vifim phgi ( n = 10)
3 (30%) 2 (20%) 7(70%) 2 (20%)
Tong { n = 50)
40 (80%)
21 (42%)
46 (92%)
23 (46%)
i khd Hid (92%), sdt (80%), dau ngtfc ( 46%3.3 Ton thu'tfng viem phoi
VlETHAM MEDICAL JOURNAL N'l - DECEMBER -2016
^ Hinh 3 . 1 : Vj tri ton thu'dng viem phoi.
man xet: Ton thuWng thu-cftig gap la ton thu'dng phoi phai ddn thuan (3^%) hoac ton thuttna
ca hai phoi (42%). ^ 3.4 Ket qua chan doan sieu am phSi
Trong so 50 benh nhan trong nghien culj co 40 benh nhan chan doan CAP du^ vao ton thuWna 38/^_tru'dng hdp. O nhom khong co CAP, co 1/10 ca co ket qua sigu am phoi du'dng tfnh
Bang 3.3 Gia tti chan doan ciia sieu am phcii So nhay
Do dac hieu Gia tri chan doan du'dng tfnh
Gia trj chan doan am ti'nh Gia tn chan doan dung Ti so kha dT du'dng tfnh Ti so kha dl am tfnh
Sieu 3m 9 5 % ( 9 5 % a , 93%-96%) 90% (95% a , 88%- 91%) 97.4% (95% g , 96.1%-98.2%) 81.8% (95% g 80.2%- 83.1%)
94% (95% g , 92%- 95.2%) 9.5 (95% g , 3.8-17.0)
«hS.,^A.. ,- - ^ ri, r—' 0.05 (95% g , 0.02-0.17)
cha-n*^n j S g l % " ^ ' ' ° " ' ' ' ' " ' ' ° ' " " ' " ' ^ P'°' '° ^^ "h^^' ^ ^ ^ ^ ^ ° 05%, 90%), gla td 3.5 Cic hinh anh ton thudng CAP tt^n sieu Sm
Bang 3.4 Cic hinh anh ton BiUdng CAP tren sieu ani Oinh danq B'
Bjnh danq A/B Dinh danq C Ojnh dang PLAPS Gan hda + Phequan chiia khi
Nep gap oiay Tran dich mang phoi khu trii
DuftnqB
Phoi phai ( n = 3 6 ) 9 (25%) 4(11.1%) 12 (3.3%) 33 (91.6%) 32 (88.8
8 (22.2%) 10 (27.7%) 12 (33.3%)
Phoi trai ( n = 2 4 ) 5 (20.8%) 2 ( 8.3%) 4 (16.6%) 21 (87.5%) 20 (83.3%) 5 (20.E 7 (29.1%) 8 (33.3%)
Chung ( n = 40) 11 (27.5%)
5 (12.5%) 15 (37.5%) 36 (90%) 35 (87.5 11 (27.5%) 13 (32.5%) 16 (40%) ( 9 0 % T S ' n g ' S a n ? c ^ ^ a V h r , u " n ^ a i ^ l ? . S I ^ ^ ^ ^
IV. BAN LUAN
4.1 Hinh anh ton thu-dng vi6m phoi trong stiu Sm
Khi silf dung sleu am chan doan CAP dua vao phac dB Chan doan BLUE vfti cac dinh dang ton ttiuftng B-, A/B, C, PLAPS vdi cac ti ie lan Iddt la 27.5%; 12.5%; 37.5%; 90%.
Nghien ciilj cua D. Uchtenstein cd U le cac dinh dang ton thuftng tuftng litig la i l % ;
36
14.5%;_21%; va 42% [ I J . Ton thddng Uiuftng gap nhat trdng ca hal nghien ciJu la PLAPS. Tuy nhien d nghien ciiti ciia chung tdl H ii gSp P L A ^ cao hdn. Sd khac bl?t co t h ^ d o nghien cifu cM Chung toi tap trung vao nhdm liSnh nhan Cd tM tneu Chung nghi ngft CAP,' trang khi C ^ Lichtenstein nghien ciju Hen nhdm benh nhan suy ho hap chung.
Trong djnh dang ton HiUdng PLAPS C d i t h t CO cac ton Oiudng gan hoa to chdc k i m i * f ,
YHOC VIET HAM Tin 44S--mMG12.s6l.JDlS quan chua Wii, dau hieu nep gap giSy hoac Iran
dich mang phoi khu t n i . Dlnh dang tfin thddng B' la ton ttiuHng dyftng B ket hdp vdi mat dau hieu trUdt mang phoi va dfnh dang A/B cd dau hiSu ton ttiu-dng la duftng B mot ben phoi. Ti le cic dau h f " ton thu-dng gan hoa va phe quan chiia
I
) khi; nep gap giay; tran djch mang phoi khu dii- du-dng B hiftng iihg la 87.5%; 27.5%- 32 5%' va 40%. Dau hieu gan hoa va phe quan chiia khi^ t o n thuftng thudng gap nhat Ket qua ciia Chung toi tUdng dong vdi nghien a i d aia A.Reissg vdl tl le ton thUdng phe quan chiia khi I gap la 86.7% [7].
4.2 Gia t r i chan doan ciia sieu am t r o n g chan doan CAP
' , , - ' ' ' ? " " ^ '^"^ ^ " " S ^' * ° * S y do nhay I di d|c hieu, va gia tn chan doan rat cao ciJa , n g ^ thSng va CT ngdc lam doi chirng. Co 2
^m nhan CO k a qua sleu am phoi khong chinh s t r o n g nghien ciid, trong dd cd mot benh n w t . t o n ttiu-dng phia sau ph3l trai,m6t blnh nhan ton thudng phia sau phoi phai. Day la hal v i m ton thUdng kho thSm kham tren sleu am do mgt phan Idn vimg phSl phia sau bl che phu bdi xu-diig ba vai. Mpt li do niia co ttie gial ttiich la do sleu am phoi d i i cd the ttiam kham va chan doan duBc cac ton ttiudng lan tdl mang phoi
SL??h*lS-"' r5" '"''"."S '=" W' ™"9 Ph3l se
khong the tham kham tren sieu am.
Theo M. Chavez phan tfch ghop 12 nghien cull, gom 1172 benh nhan cho cac ket qua do nhay dg dac hieu, gla tri chan doan diing tUdno
uhg ia 94%; 96%; 95.3%. ^ Theo A. Relssig nghiSn cud tren 262 benh
nhan thi dp nhay, dp dac hieu, gla tn chan doan dung cua sleu am tudng dng la 93.4%- 97 7%.
95.3%. Dp nhay va gla tti chan doan diing trong nghien a m cua chiing toi va A.Reisslg it cd su khic bi?t. Op dSc hleu ttong nghien cud cil^
A.Reisslg CO gla trj rat cao 97.7%, trong khi ft nghlSn cud cua chiing toi con so nay la 90%
dSu nay co ttig dd c9 mau trong nghien a i d aia Chung toi con nhd.
_ Nghien ciift ciia chiing toi ciing cho ttiay sISu am phoi khdng nhihig giiip chan doan xac dinh CAP ma Cdn cd ttie sd dung de loai trii- dian ddan Vdi dp chinh xac cao. Ti so khi di duftng tlnh va am ttnh tuftng iihg la 9.5 (95% 0 3 8- 17.0), 0.05 (95% a , 0.02-0.17). NghiSn d!ii cCia A.Reissig cho cic ket qua tuftng iJng la 40 5 (95% a , 13.2-123.9), 0.07 (95% a , 0.O1-0.11).
V. KFT I U A N
_ - Ton Uiuftng CAP ttiudng gap nhat ttong M U am la dinh dang PLAPS vdi dau hISu ton ttiu-dng gan hda va phe quan chiia khi dong .
- Sieu am phoi la mpt ki ttiuat chan doan CAP 00 dp nhay, dp d i e hiSu va gla tti chan doan dung cao.
- S i e u am phoi co ttie dung de chan doan xac dinh cung nhu chan doan loai trir CAP.
KIEN NGHI: NSn ap dung sISu am phdi rong rail ttong chan doan CAP tai cac khoa cap ciid hoi sue ttch cu-c do nhiihg uft diem vddt ttoi nhU kl ttiuat ddn gian, dudc lam tai giuftna ttifti gian tham kham nhanh, co dp nhay, do dac hiSu cao T n o i ^ nghien a i l i oia diiing toi cdtleuchuan
^ 1 fru te cac benh nhan mang Oiai do IiSn quan tffl van (K dao ddc ttong nghien cdu. Tuy nhien ttong qua ttinh tten hanh nghien cifu chiing toi van tten hanh sieu am phoi frong dian doan CAP d bpnh nhan mang Oial va ttiu dudc cac ket qua nhat dinh. Do dd siSu am phoi la' mdt cong cu dian doan CAP rat tdt d nhdm benh nlian nay. ' TAi U f u THAIVl KHAO
' • " M M C " ' ^ , ' ^ ' " ' ^ " = ' - BLUE-protocol and FAUS.pn*icol: two applications of lung 1 6 ^ 6 7 0 '" ""^ ° * " ^ " ' '"• °^^' " ' ' ' ) ' 2. L A. Mandell, R. G. Wunderink, A. Anzueto va
cong SM- (2007). Infectious Diseases Society of Amenca/Amencan Thoradc Sodety consensus guidelmes on the management of community- acquired pneumonia in adults, am Infect Dis, 44 auppi 2, S27.72.
"' "r',SoS?'"L'!: ° " " ' ' '• * ' ' " ' " ° ™ <*ng su- (1998). High-rcsoluBon oimputed tomography nn.„n, ^Snosis Of oimmunity.acquired pneumonia. o,n/nfecf as, 27 (2), 358-363
• 'JZ-J^'' '• * ' • ' " * ™ " • t . Muller (2003).
RadBOon exposure at diest CT: a statement of the ffeisdiner Sodety./^,ist?sK 228(1), 15-21 T ^ ^ T 1? '• '• ""' '"<">• Cl>mputed Tomography - An Increasing Source of Radiation
^ ^ ^ ^ ^ l ^ n d Joumal Of Medicine, 3T7
° ' " r ' j ^ ' n i ' S ' ''• °''^'' =• '^"'"l »» <«"9 SM-{2010). Diagnostic value of diest radiographs in , . - ^ ^ - ^ ^ f - ' ^ ^ W - S " ; author reply el5.
MtoJ, u'n ^ * " " " " " '" "^^ Olaonosls and folteMv of mmmunrty-acqulred pneumonia: a
