今日の臨床サポート

呼吸困難

著者: 志賀隆 国際医療福祉大学 医学部救急医学/国際医療福祉大学病院 救急医療部

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/07/07
患者向け説明資料

概要・推奨   

  1. 心電図や身体所見単独では肺塞栓の診断にはならない。
  1. BLUE protocolによる超音波を使用した鑑別診断を推奨する(推奨度2)。
  1. Dダイマーのオーダーは選択的に行うべきである(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
志賀隆 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. 定期レビューを行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 呼吸困難は、換気の需要が呼吸の機能を上回ったときに生じる。酸素の需要供給のミスマッチ、二酸化炭素の排出不全がその中心である。
  1. 正常の呼吸機能を持った成人が呼吸困難の自覚をするにはかなりの換気の需要が必要となる。逆に、基礎に呼吸機能の低下のある患者では少々の機能低下でも呼吸困難を感じることがある。
  1. 呼吸困難の自覚は、心理的要素・文化的要素によって大きくことなることもあるため、「階段を上がれるか?日常生活はできるか?」という量的な評価が必要である。
  1. SpO2は呼吸困難の患者のアセスメントに必要であるが、二酸化炭素に関する情報がないので、それだけでは呼吸不全がないとはいえない。
  1. COPDの患者で、呼吸ドライブへの心配から低酸素の是正を待つのではなく、先に低酸素の是正をすべきである。
問診・診察のポイント  
 
  1. まずは気道閉塞がなく酸素化が適正であることを確認し診察を始める。

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文献 

著者: Peter A McCullough, Richard M Nowak, James McCord, Judd E Hollander, Howard C Herrmann, Philippe G Steg, Philippe Duc, Arne Westheim, Torbjørn Omland, Cathrine Wold Knudsen, Alan B Storrow, William T Abraham, Sumant Lamba, Alan H B Wu, Alberto Perez, Paul Clopton, Padma Krishnaswamy, Radmila Kazanegra, Alan S Maisel
雑誌名: Circulation. 2002 Jul 23;106(4):416-22.
Abstract/Text BACKGROUND: We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF).
METHODS AND RESULTS: The Breathing Not Properly Multinational Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P<0.0001 for all pairwise comparisons).
CONCLUSIONS: The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.

PMID 12135939  Circulation. 2002 Jul 23;106(4):416-22.
著者: Hans-Gerhard Schneider, Louisa Lam, Amaali Lokuge, Henry Krum, Matthew T Naughton, Pieter De Villiers Smit, Adam Bystrzycki, David Eccleston, Jacob Federman, Genevieve Flannery, Peter Cameron
雑誌名: Ann Intern Med. 2009 Mar 17;150(6):365-71.
Abstract/Text BACKGROUND: B-type natriuretic peptide (BNP) is used to diagnose heart failure, but the effects of using the test on all dyspneic patients is uncertain.
OBJECTIVE: To assess whether BNP testing alters clinical outcomes and health services use of acutely dyspneic patients.
DESIGN: Randomized, single-blind study. Patients were assigned to a treatment group through randomized numbers in a sealed envelope. Patients were blinded to the intervention, but clinicians and those who assessed trial outcomes were not.
SETTING: 2 Australian teaching hospital emergency departments.
PATIENTS: 612 consecutive patients who presented with acute severe dyspnea from August 2005 to March 2007.
INTERVENTION: BNP testing (n = 306) or no testing (n = 306).
MEASUREMENTS: Admission rates, length of stay, and emergency department medications (primary outcomes); mortality and readmission rates (secondary outcomes).
RESULTS: There were no between-group differences in hospital admission rates (85.6% [BNP group] vs. 86.6% [control group]; difference, -1.0 percentage point [95% CI, -6.5 to 4.5 percentage points]; P = 0.73), length of admission (median, 4.4 days [interquartile range, 2 to 9 days] vs. 5.0 days [interquartile range, 2 to 9 days]; P = 0.94), or management of patients in the emergency department. Test discrimination was good (area under the receiver-operating characteristic curve, 0.87 [CI, 0.83 to 0.91]). Adverse events were not measured.
LIMITATION: Most patients were very short of breath and required hospitalization; the findings might not apply for evaluating patients with milder degrees of breathlessness.
CONCLUSION: Measurement of BNP in all emergency department patients with severe shortness of breath had no apparent effects on clinical outcomes or use of health services. The findings do not support routine use of BNP testing in all severely dyspneic patients in the emergency department.
PRIMARY FUNDING SOURCE: Janssen-Cilag.

PMID 19293069  Ann Intern Med. 2009 Mar 17;150(6):365-71.
著者: R Davison, R Cannon
雑誌名: Am Heart J. 1974 Mar;87(3):279-82.
Abstract/Text
PMID 4812363  Am Heart J. 1974 Mar;87(3):279-82.
著者: J Fisher
雑誌名: Chest. 1984 May;85(5):685-6.
Abstract/Text The presence of venous valves in the internal jugular and subclavian veins at the thoracic inlet has been well documented. Their presence helps explain several physical signs and hemodynamic findings. This lost page in the history of medicine should be returned to the book.

PMID 6713978  Chest. 1984 May;85(5):685-6.
著者: J A Kline, D M Courtney, C Kabrhel, C L Moore, H A Smithline, M C Plewa, P B Richman, B J O'Neil, K Nordenholz
雑誌名: J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.1538-7836.2008.02944.x. Epub 2008 Mar 3.
Abstract/Text BACKGROUND: Over-investigation of low-risk patients with suspected pulmonary embolism (PE) represents a growing problem. The combination of gestalt estimate of low suspicion for PE, together with the PE rule-out criteria [PERC(-): age < 50 years, pulse < 100 beats min(-1), SaO(2) >or= 95%, no hemoptysis, no estrogen use, no surgery/trauma requiring hospitalization within 4 weeks, no prior venous thromboembolism (VTE), and no unilateral leg swelling], may reduce speculative testing for PE. We hypothesized that low suspicion and PERC(-) would predict a post-test probability of VTE(+) or death below 2.0%.
METHODS: We enrolled outpatients with suspected PE in 13 emergency departments. Clinicians completed a 72-field, web-based data form at the time of test order. Low suspicion required a gestalt pretest probability estimate of <15%. The main outcome was the composite of image-proven VTE(+) or death from any cause within 45 days.
RESULTS: We enrolled 8138 patients, 85% of whom had a chief complaint of either dyspnea or chest pain. Clinicians reported a low suspicion for PE, together with PERC(-), in 1666 patients (20%). At initial testing and within 45 days, 561 patients (6.9%, 95% confidence interval 6.5-7.6) were VTE(+), and 56 others died. Among the low suspicion and PERC(-) patients, 15 were VTE(+) and one other patient died, yielding a false-negative rate of 16/1666 (1.0%, 0.6-1.6%). As a diagnostic test, low suspicion and PERC(-) had a sensitivity of 97.4% (95.8-98.5%) and a specificity of 21.9% (21.0-22.9%).
CONCLUSIONS: The combination of gestalt estimate of low suspicion for PE and PERC(-) reduces the probability of VTE to below 2% in about 20% of outpatients with suspected PE.

PMID 18318689  J Thromb Haemost. 2008 May;6(5):772-80. doi: 10.1111/j.・・・
著者: E E Weinmann, E W Salzman
雑誌名: N Engl J Med. 1994 Dec 15;331(24):1630-41. doi: 10.1056/NEJM199412153312407.
Abstract/Text
PMID 7772110  N Engl J Med. 1994 Dec 15;331(24):1630-41. doi: 10.1056・・・
著者: E Ferrari, A Imbert, T Chevalier, A Mihoubi, P Morand, M Baudouy
雑誌名: Chest. 1997 Mar;111(3):537-43.
Abstract/Text BACKGROUND AND STUDY OBJECTIVE: The value of the ECG for the diagnosis of pulmonary embolism (PE) is debatable. Once the diagnosis of PE has been established, however, the ECG could allow the massive forms to be distinguished. The purpose of our study was to analyze the ECG signs in patients hospitalized for PE in a cardiology unit.
DESIGN: Taking a series of 80 consecutive patients hospitalized for PE, we analyzed the ECGs on admission and then during hospitalization. We sought to evaluate changes in ECG signs compared with angiographic and hemodynamic changes in PE.
RESULTS: T-wave inversion in the precordial leads is the most common abnormality (68%), and represents the ECG sign best correlated to the severity of the PE. Among those patients with anterior T-wave inversion, 90% had a Miller index over 50% (mean, 60 +/- 8%). Eighty-one percent had a mean pulmonary arterial pressure (PAP) over 30 mm Hg (mean, 37 +/- 8%). This subepicardial ischemic pattern is an even stronger marker of severity when it appears as early as the first day (p < 0.01). Its reversibility is correlated to the changes in PE. After thrombolysis in particular, normalization of repolarization systematically indicates mean Miller and PAP indexes of < 20% and < 20 mm Hg, respectively.
CONCLUSIONS: The anterior subepicardial ischemic pattern is the most frequent ECG sign of massive PE. This parameter is easy to obtain and reflects the severity of PE. Its reversibility before the sixth day points to a good outcome or high level of therapeutic efficacy.

PMID 9118684  Chest. 1997 Mar;111(3):537-43.
著者: Kazuhiro Usui, Yoshiaki Tanaka, Hiromichi Noda, Teruo Ishihara
雑誌名: Nihon Kokyuki Gakkai Zasshi. 2009 Sep;47(9):781-5.
Abstract/Text UNLABELLED: Several severity scores have been proposed to predict patient outcome and guide initial management of patients with community acquired pneumonia (CAP). The Japan Respiratory Society (JRS) has proposed new predicting scores, A-DROP system (score 0-5, Age : male 70 years and more, female 75 years and more, BUN > 21 mg/dl, SpO2 < 90% or PaO2 < 60 Torr, confusion, systolic blood pressure < 90 mmHg). We aimed to compare the predictive value of these instruments regarding 30-day mortality.
METHODS: All patients with an admission diagnosis of CAP from April 2002-March 2006 were reviewed. Clinical and laboratory features at presentation on electrical medical records were used to calculate severity scores using the Pneumonia Severity Index (PSI), CURB-65 (2004) and A-DROP (2005). Patients were categorized into PSI risk classes (I-V) and CURB-65 (0-5) and A-DROP (0-5) risk strata.
RESULTS: Consecutive 523 patients (61% male) of mean age 70.5 years were included in the analysis. Thirty-one (5.9%) patients died and 12 (2.2%) patients required ventilatory support. ROC analysis for predicting mortality at 30 days showed that A-DROP score has similar power for short-term mortality to PSI, and slightly more accurate in identifying patients at low risk than the CURB-65 score.

PMID 19827581  Nihon Kokyuki Gakkai Zasshi. 2009 Sep;47(9):781-5.
著者:
雑誌名: N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/NEJM200005043421801.
Abstract/Text BACKGROUND: Traditional approaches to mechanical ventilation use tidal volumes of 10 to 15 ml per kilogram of body weight and may cause stretch-induced lung injury in patients with acute lung injury and the acute respiratory distress syndrome. We therefore conducted a trial to determine whether ventilation with lower tidal volumes would improve the clinical outcomes in these patients.
METHODS: Patients with acute lung injury and the acute respiratory distress syndrome were enrolled in a multicenter, randomized trial. The trial compared traditional ventilation treatment, which involved an initial tidal volume of 12 ml per kilogram of predicted body weight and an airway pressure measured after a 0.5-second pause at the end of inspiration (plateau pressure) of 50 cm of water or less, with ventilation with a lower tidal volume, which involved an initial tidal volume of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less. The primary outcomes were death before a patient was discharged home and was breathing without assistance and the number of days without ventilator use from day 1 to day 28.
RESULTS: The trial was stopped after the enrollment of 861 patients because mortality was lower in the group treated with lower tidal volumes than in the group treated with traditional tidal volumes (31.0 percent vs. 39.8 percent, P=0.007), and the number of days without ventilator use during the first 28 days after randomization was greater in this group (mean [+/-SD], 12+/-11 vs. 10+/-11; P=0.007). The mean tidal volumes on days 1 to 3 were 6.2+/-0.8 and 11.8+/-0.8 ml per kilogram of predicted body weight (P<0.001), respectively, and the mean plateau pressures were 25+/-6 and 33+/-8 cm of water (P<0.001), respectively.
CONCLUSIONS: In patients with acute lung injury and the acute respiratory distress syndrome, mechanical ventilation with a lower tidal volume than is traditionally used results in decreased mortality and increases the number of days without ventilator use.

PMID 10793162  N Engl J Med. 2000 May 4;342(18):1301-8. doi: 10.1056/N・・・
著者: D C McCrory, C Brown, S E Gelfand, P B Bach
雑誌名: Chest. 2001 Apr;119(4):1190-209.
Abstract/Text STUDY OBJECTIVES: To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD.
DESIGN, SETTING, AND PARTICIPANTS: English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed.
MEASUREMENT AND RESULTS: Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients.
CONCLUSIONS: Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.

PMID 11296189  Chest. 2001 Apr;119(4):1190-209.
著者: P B Bach, C Brown, S E Gelfand, D C McCrory, American College of Physicians-American Society of Internal Medicine, American College of Chest Physicians
雑誌名: Ann Intern Med. 2001 Apr 3;134(7):600-20.
Abstract/Text PURPOSE: To review critically the available data on diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).
DATA SOURCES: English-language articles were identified by searching MEDLINE (1966 to 2000, week 5), EMBASE (1974 to 2000, week 18), HealthStar (1975 to June 2000), and the Cochrane Controlled Trials Register (2000, Issue 1).
STUDY SELECTION: The best available evidence on each subtopic was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification.
DATA EXTRACTION: Study design and results were summarized in evidence tables. Individual studies were rated by internal validity, external validity, and quality of design. Statistical analyses of combined data were not performed.
DATA SYNTHESIS: Data on the utility of most diagnostic tests are limited. However, chest radiography and arterial blood gas sampling seem useful while acute spirometry does not. Identifiable clinical variables are associated with risk for relapse and risk for death after hospitalization for an acute exacerbation. Evidence of efficacy was found for bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. On the basis of limited data, mucolytics and chest physiotherapy do not seem to be of benefit, and oxygen supplementation seems to increase the risk for respiratory failure only in an identifiable subgroup of patients.
CONCLUSIONS: Although suggestions for appropriate management can be made on the basis of available evidence, the supporting literature is scarce and further high-quality research is necessary. Such research will require an improved, generally acceptable, and transportable definition of acute exacerbation of COPD, as well as improved methods for observing and measuring outcomes.

PMID 11281745  Ann Intern Med. 2001 Apr 3;134(7):600-20.
著者: O James Ekundayo, Virginia J Howard, Monika M Safford, Leslie A McClure, Donna Arnett, Richard M Allman, George Howard, Ali Ahmed
雑誌名: Am J Cardiol. 2009 Jul 15;104(2):259-64. doi: 10.1016/j.amjcard.2009.03.025. Epub 2009 May 14.
Abstract/Text Prospective population studies of incident heart failure (HF) are often limited by difficulties in assembling HF-free cohorts. In this study, public-use copies of the Cardiovascular Health Study (CHS) data sets were used to determine the sensitivity, specificity, and positive and negative predictive values of orthopnea and paroxysmal nocturnal dyspnea (PND), with and without the use of medications used in CHS HF criteria (diuretics plus digoxin or vasodilators), in the diagnosis of prevalent HF and in the assembly of a relatively HF-free population. Of the 5,771 community-dwelling older adults aged > or =65 years, 803 had orthopnea, 660 had PND, 1,075 had either symptom, 388 had both symptoms, 547 were using HF medications, and 4,315 had neither symptom and were not using HF medications. Definite HF was centrally adjudicated in 272 participants. The sensitivity, specificity, and positive and negative predictive values for either orthopnea or PND were 52% (95% confidence interval [CI] 46% to 58%), 83% (95% CI 82% to 84%), 13% (95% CI 11% to 15%), and 97% (95% CI 97% to 98%), respectively, and those for either orthopnea or PND or the use of HF medications were 77% (95% CI 72% to 82%), 77% (95% CI 76% to 79%), 14% (95% CI 13% to 16%), and 99% (95% CI 98% to 99%), respectively. In conclusion, only <20% of those with either orthopnea or PND had definite HF, which limits their usefulness in the diagnosis of prevalent HF in the community. However, nearly 99% (negative predictive value) of those with neither symptom nor using HF medications also did not have HF, which may be useful as a simple and inexpensive tool in assembling relatively HF-free cohorts for prospective population studies of incident HF.

PMID 19576357  Am J Cardiol. 2009 Jul 15;104(2):259-64. doi: 10.1016/j・・・
著者: Mervyn Singer, Clifford S Deutschman, Christopher Warren Seymour, Manu Shankar-Hari, Djillali Annane, Michael Bauer, Rinaldo Bellomo, Gordon R Bernard, Jean-Daniel Chiche, Craig M Coopersmith, Richard S Hotchkiss, Mitchell M Levy, John C Marshall, Greg S Martin, Steven M Opal, Gordon D Rubenfeld, Tom van der Poll, Jean-Louis Vincent, Derek C Angus
雑誌名: JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
Abstract/Text IMPORTANCE: Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination.
OBJECTIVE: To evaluate and, as needed, update definitions for sepsis and septic shock.
PROCESS: A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment).
KEY FINDINGS FROM EVIDENCE SYNTHESIS: Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant.
RECOMMENDATIONS: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.
CONCLUSIONS AND RELEVANCE: These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

PMID 26903338  JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016・・・
著者: Ruth Stalnikowicz, Shaden Salama, Nurit Hiller
雑誌名: Am J Emerg Med. 2006 Mar;24(2):252-3. doi: 10.1016/j.ajem.2005.08.022.
Abstract/Text
PMID 16490664  Am J Emerg Med. 2006 Mar;24(2):252-3. doi: 10.1016/j.aj・・・
著者: David J Brenner, Eric J Hall
雑誌名: N Engl J Med. 2007 Nov 29;357(22):2277-84. doi: 10.1056/NEJMra072149.
Abstract/Text
PMID 18046031  N Engl J Med. 2007 Nov 29;357(22):2277-84. doi: 10.1056・・・
著者: Eyal Fuchs, Suwar Asakly, Amir Karban, Inna Tzoran
雑誌名: Am J Med. 2016 Aug;129(8):872-8. doi: 10.1016/j.amjmed.2016.02.043. Epub 2016 Apr 1.
Abstract/Text BACKGROUND: The diagnosis of pulmonary embolism in the Emergency Room setting is challenging. Multiple patients have to undergo radiologic assessment with its inherent shortcomings. The D-dimer test with accepted cutoff level of 500 μg/L is associated with a high proportion of false-positive results. The present study aimed to validate the advantages of using an age-adjusted D-dimer cutoff level, compared with 500-μg/L value in the diagnosis of acute pulmonary embolism.
METHODS: This study evaluated patients admitted to the Rambam Emergency Room between 2011 and 2014 with a suspected diagnosis of pulmonary embolism. Patient data, D-dimer plasma levels, and imaging results were collected. The study cohort was subdivided according to the D-dimer levels below and above 500 μg/L. The group with levels above 500 μg/L was further assessed using the newly suggested age-adjusted D-dimer cutoff level, defined as age multiplied by 10.
RESULTS: Files of 1241 patients were reviewed; 654 patients with low or intermediate risk for pulmonary embolism had a D-dimer level above 500 μg/L. Two hundred eight (208) patients had a D-dimer level above 500 μg/L but below the age-adjusted cutoff value; one of them was diagnosed with pulmonary embolism (0.48% [95% confidence interval 0%-2.6%]). Four hundred forty-six (446) patients had a D-dimer level above the age-adjusted cutoff value, and 28 of them were diagnosed with pulmonary embolism (6.28% [95% confidence interval 4.2%-8.9%]), representing a negative predictive value of 99.5% for the age-adjusted cutoff level.
CONCLUSIONS: An age-adjusted D-dimer cutoff level may be safely used to exclude pulmonary embolism in patients with a low or intermediate probability for acute pulmonary embolism, alleviating the need to perform unnecessary imaging evaluations.

Copyright © 2016 Elsevier Inc. All rights reserved.
PMID 27046241  Am J Med. 2016 Aug;129(8):872-8. doi: 10.1016/j.amjmed.・・・

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