缺血性中风患者误吸的预测：临床表现和自主咳嗽空气动力学检测的比较
2009/03/09
背景：临床表现常常不能鉴别中风患者误吸的风险是否增加。我们认为自主咳嗽这项客观检查能够较好的预测误吸风险。
方法：对顺续就诊诊为中风的96名患者进行全面的诊断评估，包括认知测试、床旁临床吞咽检查、自主咳嗽的空气动力学和声压水平检测以及吞咽检查金指标的各项检查(可视性透视检查、VSE或纤维内窥镜检查，FEES)。采用加拿大神经学量表回顾性评价患者中风的严重程度。
结果：基于VSE/FEES，33名患者(34％)具有误吸高风险，其它63名(66％)患者无误吸风险。临床表现(吞咽缺失、分泌物处理困难或饮水后反射性咳嗽)对检测误吸的总体准确性为74％，敏感性为58％，特异性为83％。自主咳嗽的三个客观性指标(排出相上升时间、容积加速和排出相峰值流量)均与误吸的风险类型（曲线下面积AUCs分别为0.93、0.92和0.86）有相关性。当排出相上升时间≥55 m/s，容积加速＜50 L/s/s，排出相峰值流量＜2.9 L/s时，它们在鉴别误吸者中的敏感性分别为91%、91%和82%，特异性为81%、92%和83%。
结论：自主咳嗽的客观检测能够鉴别中风患者是否具有误吸的风险，可以作为标准的床旁临床评价的一个补充。
（苏楠 审校）
Smith Hammond CA, et al. Chest. 2008 Nov 18. [Epub ahead of print]
Predicting Aspiration in Patients With Ischemic Stroke: Comparison of Clinical Signs and Aerodynamic Measures of Voluntary Cough.
Smith Hammond CA, Goldstein LB, Horner RD, et al. Chest. 2008 Nov 18. [Epub ahead of print]
Background: Clinical signs often fail to identify stroke patients at increased risk of aspiration. We hypothesized that objective measures of voluntary cough would better predict those at risk.
Methods: A comprehensive diagnostic evaluation was completed for 96 consecutive stroke patients that included cognitive testing, a bedside clinical swallow examination, aerodynamic and sound pressure level measures of voluntary cough, and "gold standard" instrumental swallowing studies (videofluoroscopy, VSE or fiberoptic endoscopy, FEES). Stroke severity was assessed retrospectively using the Canadian Neurologic Scale.
Results: Based on VSE/FEES, 33 patients (34%) were at high risk of aspiration and (66%) were nonaspirators. Clinical signs (absent swallow, difficulty handling secretions or reflexive cough after water bolus) had an overall accuracy of 74% with a sensitivity of 58% and a specificity of 83% for the detection of aspiration. Three objective measures of voluntary cough (expulsive phase rise time; volume acceleration, and expulsive phase peak flow) were each associated with aspiration risk category (areas under the curves, AUCs, were 0.93, 0.92 and 0.86, respectively). Expulsive phase rise time >/= 55 m/s, volume acceleration < 50 L/s/s, and expulsive phase peak flow < 2.9 L/s had sensitivities of 91%, 91%, and 82%, and specificities of 81%, 92% and 83% for the identification of aspirators.
Conclusion: Objective measures of voluntary cough can identify stroke patients at risk for aspiration and may be useful as an adjunct to the standard bedside clinical assessment.
