1 苏州大学附属第一医院呼吸与危重症医学科，江苏 苏州 215005
2 苏州市立医院东区心血管内科，江苏 苏州 215002
3 苏州大学附属第一医院心脏超声科，江苏 苏州 215005
目的：评估呼吸科医师主导的床旁经胸廓超声心动图(transthoracic echocardiography，TTE)在危重患者心血管疾病诊断中的准确率，分析导致TTE操作失败的主要因素。方法：在熟悉TTE相关理论和正常超声影像的基础上开始为期2周的床旁TTE现场学习。由1名呼吸科医师对106例危重患者进行床旁TTE检查，观察胸骨旁长轴切面、胸骨旁短轴切面、心尖四腔心切面、肋下四腔心切面及肋缘下下腔静脉切面超声影像。记录各切面所见异常，并以正规TTE报告为金标准进行对比。结果：呼吸科医师顺利完成94例患者床旁TTE检查，所需时间(10.5±4.2) min，42%患者合并两种以上异常TTE影像。呼吸科医师主导的床旁TTE对于心包积液、心室扩张、三尖瓣返流压差增高、下腔静脉异常诊断的准确率均在100%，对瓣膜返流、左心室节段性室壁活动减弱、左心室整体收缩功能下降及室间隔矛盾运动诊断的准确率分别为92.6%，95.7%，96.8%，96.8%。12例TTE操作失败的患者中，单纯有创机械通气2例，皮下水肿4例，有创机械通气+气胸3例，气胸、胸廓畸形及被动体位各1例。结论：经过短期床旁TTE现场学习，呼吸科医师可以相对系统性地完成危重患者床旁TTE检查，能够可靠地解释心脏各切面所提示的信息，从而为危重患者的紧急诊治提供一定指导。有创机械通气、皮下水肿、气胸是导致呼吸科床旁TTE操作失败的主要原因。同时该研究也为临床医师学习床旁TTE提供一种新的思路。
Feasibility of using bedside transthoracic echocardiography in diagnosing cardiovascular diseases of critically ill patients
This work was supported by the National Natural Science Foundation (81300026), the Youth Medical Talent of Jiangsu Province Science and Education to Enhance Sanitary Project (QNRC2016747)
Objective: To evaluate the accuracy rate of transthoracic echocardiography (TTE) conducted by respiratory physicians in diagnosing cardiovascular diseases of critically ill patients and analyze the associated causes of operation failure. Methods: We introduced a 2-week of comprehensively onsite TTE study under the guidance of echocardiographers on the basis of being familiar with the associated theory and normal echocardiography imaging. A total of 106 critically ill patients who hospitalized in our department were enrolled in this study. The parasternal long axis view, parasternal short axis view, apical four chamber view, subcostal four-chamber view, and the subcostal inferior vena cava view were performed by one specific physician. All of the information obtained from the five views were recorded and compared to formal echocardiography. Results: The bedside TTE was successfully performed by respiratory physicians in 94 cases. The operation time was (10.5±4.2) minutes and 42% patients showed two more abnormal TTE imagings. The accuracy rate of diagnosis in pericardial effusion, ventrical dilation, elevated tricuspid regurgitation pressure gradient value, and the abnormal inferior vena cava were all 100%. The accuracy rate of valvular regurgitation, regional ventricular wall motion abnormities, reduction of left ventricular systolic function, and septal dyskinesia were 92.6%, 95.7%, 96.8%, and 96.8% respectively. The reasons for the twelve patients with failed operation was recognized as follows: invasive mechanical ventilation (MV) in two cases, cutaneous dropsy in four cases, pneumothorax combined with invasive MV in three cases, simple pneumothorax, thoracocyllosis and positioning limitations in one case respectively. Conclusion: Respiratory physician could accomplish the TTE systematically through short-term learning and give the reliable interpretation for interested views which would be beneficial for clinical diagnosis and treatment in emergency conditions. Invasive MV, cutaneous dropsy, and pneumothorax were considered as the main reasons for operation failure in respiratory department. Furthermore, this study demonstrated a possibly new thought of TTE study for clinicians.
echocardiography; critically ill patient; accuracy rate