ABI踝臂指数检查.pptx

动脉粥样硬化的病理进程动脉粥样硬化的病理进程Stable angina 稳定型心绞痛稳定型心绞痛/intermittent claudication 间歇性跛间歇性跛行行ThrombosisThrombosis血栓血栓血栓血栓AtherosclerosisAtherosclerosis动脉粥样硬化动脉粥样硬化动脉粥样硬化动脉粥样硬化 unstable anginaunstable angina不稳定型心不稳定型心绞痛绞痛 MI MI 心梗心梗 ischemic stroke/TIA ischemic stroke/TIA 中风中风 critical limb ischemia critical limb ischemia 下肢缺下肢缺血血 CV death CV death 心血管死亡心血管死亡Pathologic progression to atherosclerosis动脉粥样硬化的主要临床表现动脉粥样硬化的主要临床表现Cerebrovascular disease Cerebrovascular disease 脑血管病脑血管病脑血管病脑血管病Coronary artery disease Coronary artery disease 冠状动脉疾病冠状动脉疾病冠状动脉疾病冠状动脉疾病Renal artery stenosis Renal artery stenosis 肾动脉狭窄肾动脉狭窄肾动脉狭窄肾动脉狭窄Visceral arterial disease Visceral arterial disease 内脏动脉内脏动脉内脏动脉内脏动脉Peripheral arterial disease Peripheral arterial disease 周围动脉疾病周围动脉疾病周围动脉疾病周围动脉疾病 Intermittent claudication Intermittent claudication 间歇性跛行间歇性跛行间歇性跛行间歇性跛行 Critical limb ischemia Critical limb ischemia 下肢严重缺血下肢严重缺血下肢严重缺血下肢严重缺血Major manifestations of atherosclerosis定义定义 PAD是动脉粥样硬化的一种类型,脂肪沿动脉管壁沉积,导致管腔的狭窄和阻塞性病变，主要损伤下肢和足部的动脉。流行病学流行病学 有症状的PAD患者占55-74岁年龄段人群的4.5%，大约20%的老年人患有症状的或无症状的PAD。德国血管学协会和血管医学协会 周围动脉疾病（周围动脉疾病（PADPAD）危险因素糖尿病高血压高脂血症Level ILevel IILevel IIILevel IV血流减少血流减少功能降低功能降低溃疡和坏死溃疡和坏死无症状麻木冷感雷诺氏综合征间歇性跛行静息痛溃疡坏死PAD颈动脉主动脉肠系膜上动脉&腹动脉肾动脉髂总动脉缺血：缺血：血供减少引起疼痛和功能障碍动脉狭窄血小板血小板50%的直径狭窄75%的面积狭窄60%的直径狭窄84%的面积狭窄主要动脉狭窄狭窄进展闭塞周围动脉疾病（周围动脉疾病（PADPAD）最容易的方法最容易的方法.多普勒多普勒+外周动脉血压外周动脉血压血管功能无创检查ABI(踝臂指数踝臂指数)检查检查ABI AssessmentA.B.I.定义定义:狭窄部位以下的动脉压狭窄部位以下的动脉压狭窄部位以上的动脉压狭窄部位以上的动脉压踝部动脉收缩压踝部动脉收缩压肱部动脉收缩压肱部动脉收缩压ABI:=踝部动脉收缩压踝部动脉收缩压肱部动脉收缩压肱部动脉收缩压哪些人需要进行哪些人需要进行ABI检查？检查？50岁以上或病史超过10年以上的糖尿病患者。有高血压、吸烟、高血脂症的患者。有冠心病（或有家族病史）、缺血性卒中史的高危患者。有慢性肾功能不全血液透析的患者。不能活动，卧床、肥胖的病人。哪些人需要哪些人需要ABI 检查检查?解释检查程序 Explain and reassure patient of the procedure保持室温舒适Ensure ambient temperature of the room is comfortable,(Moffatt 1990)松解上下肢体衣裤 Remove any tight clothing from both arms and stockings socks etc.from legs保护溃疡伤口 Remove any dressings from current ulcers and cover with a clear film,(Kenny 1997)患者保持安静休息1520分钟Rest the patient for 15-20 minutes,(Yao 1993;Williams 1993)患者仰卧 Position the patient supine,(Stubbing 1996)患者准备患者准备 Preparation of the Patient Vascular Assessment Training Session-Introductory正常静脉血流音 Sounds of normal vein血流声音血流声音Vascular Assessment Training Session-Introductory正常动脉血流声 Sound of normal arteryThe posterior tibial pulse is located in the hollow behind the medial malleolus,and the dorsalis pedis pulse is felt between the first and second metatarsals.(K.R Vowden,1996)足部动脉足部动脉 Arteries of the Foot Vascular Assessment Training Session-Introductory足動脈前面後脛骨動脈後腓骨動脈貫通枝腓骨動脈前脛骨動脈弓状動脈 外側内側足根動脈 足背動脈 外側内側足底動脈 足底動脈弓 貫通枝（深足底枝）後脛骨動脈内果後方部流、触診検査行適前腓骨動脈貫通枝足足踝踝血血压压 Ankle Pressures Vascular Assessment Training Session-Introductory 右足背右足背动脉收缩压动脉收缩压 Right DP Systolic Pressure足足踝踝血血压压 Ankle Pressures Vascular Assessment Training Session-Introductory 右胫后动脉收缩血压压 Right PT Systolic PressureABI检查检查 How to examine the ABI Vascular Assessment Training Session-IntroductoryABI计算计算 How to Calculate the ABI Vascular Assessment Training Session-Introductory8580145150120115足背動脈 Dorsalis Pedis後脛骨動脈 Posterior Tibial上臂 Brachial右右ABI Right ABI左左ABI Left ABI Normal ABI ratio is equal or greater than 0.90 but not greater than 1.3(check local policy)=85150=0.57=120150=0.80ABI計算法計算法 ABI calculations足関節収縮期血圧最大測定値(両足)Highest ankle systolic pressure上腕収縮期血圧最大測定値 Highest brachial systolic pressure上臂 Brachial後脛骨動脈 Posterior TibialABI结果解释结果解释 How to interpret the ABI Vascular Assessment Training Session-IntroductoryABI 1.0-1.3ABI=0.8-1.0ABI=0.5-0.8ABI 1.3 动脉正常 Unlikely to be arterial in origin轻度动脉疾病 Mild peripheral disease显著动脉疾病 Significant of arterial disease严重动脉疾病Severe arterial disease检测足趾血压Measure toe pressures or refer to specialistApply compression therapyApply compression therapy with caution Do not compress refer to specialist Do not compress refer urgently to vascular specialist may vary according to local protocolsABI检查周期检查周期 Repeat ABI checks Vascular Assessment Training Session-Introductory每12周一次 It is recommended that the ABI is checked every 12 weeks(Simon 1994)however;if the patients condition changes during that time i.e.pain,the procedure should be repeated as necessary If an ulcer re-occurs,repeat the Doppler assessment Do not presume it is of the same origin影响影响ABI结果的因素结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Session-Introductory心律不齐 Cardiac Arrhythmias(Vowden,K.P.1996).More difficult to assess the sound 准备不足 Inadequate preparation i.e.room temperature血管收缩 Vaso constriction 患者焦虑 Patient and clinician anxious and unrelaxed血压升高 Resulting into increased blood pressure 患者体位不舒服 Incorrect positioning of patientFalsely elevated ankle pressures 超声耦合剂不足 Inappropriate Gel空气气泡 Interference due to air bubbles 血压袖带不合适Incorrect size of sphyg cuff血压测量不准 Incorrect pressure measurements 多普勒探头不对 Inappropriate Doppler probe Ultrasound cannot penetrate to depth of vessel 探头位置不正确 Incorrect position of Doppler probe over vessel血压测量不正确 Incorrect pressure measurements 对血管施压过大 Excessive pressure on vessel during procedure血管挤压Collapses vessels 血圧袖带放气过快Releasing sphyg cuff too rapidly Risk of missing systolic pressure point 血管加压时间过长Prolonged inflation of the cuff/re-inflation Hyperemic effect on limb 血管反复加压Mid procedure/repeated inflation (Vowden K.P.1996)Hyperemic effect on limb 检测过程中探头移动Moving Doppler during measurementIncorrect pressure measurement 检测经验不足Inexperience of the procedure(Anderson 1995)practical skill requiring assessment by peers影响影响ABI结果的因素结果的因素 Factors Affecting the Accuracy of the ABI Vascular Assessment Training Session-Introductory多普勒波形和声音多普勒波形和声音Doppler waveforms and sounds心脏收缩期迅速升高的血流速心脏舒张期前期血液回流心脏舒张期后期血液顺流下肢动脉血流波形图多普勒波形和声音多普勒波形和声音 Doppler Waveforms&Sounds多普勒波形和声音多普勒波形和声音 Doppler Waveforms&Sounds 正常三时相波形Triphasic Waveform-NormalVideo clip of Triphasic waveform 单相波形异常Monophasic Waveform2-Abnormal 多普勒波形和声音多普勒波形和声音 Doppler Waveforms&Sounds失去多相波单失去多相波单元元单向波单向波波峰圆钝波峰圆钝NormalNormal正常正常坚锐的上升支坚锐的上升支三相波单元三相波单元Mildobstruction轻度梗阻轻度梗阻Moderate obstructionModerate obstruction中度梗阻中度梗阻Severe ObstructionSevere Obstruction严重梗阻严重梗阻波峰消失波峰消失多普勒波形和声音多普勒波形和声音 Doppler Waveforms&Sounds足趾动脉足趾动脉PPGPPG检查检查Measuring Toe pressures and TBPI光电容积光电容积PPG原理原理 PPG Shift Explained Vascular Assessment Training Session-Introductory光电容积描记仪发射并接收红外线，红外线遇到组织时出现散射，遇到红细胞时则被其吸收。肢体的皮下微循环内血容量增加时被反射的红外线密度减少；反之则增大。影响影响PPG检查的因素检查的因素 Factors affecting APPG measurements 室内温度应保持在2024摄氏度。The room temperature should be between 20-24C 检查前足趾不应裸露在外。Always keep toes covered until tests are started 患者检查局部的温度会影响波形（如凉手、凉足）Patient temperature-cold hands and feet will alter the waveform 吸烟-尼古丁会影响波形。Smoking-nicotine will distort the waveform 患者肢体运动检测过程中应保持不动。Patient movement-patients should remain still during the examinationPPG波形解释波形解释 APPG Waveform Interpretation正常Normal异常Abnormal下降坡重搏切迹尖峰基线重搏切迹消失，下降支轻度上弓上升支轻度下弓上升支延迟波峰园钝波幅减小足趾血压和足趾血压和TBITBI检查检查TBI using Arterial PPG足趾血压足趾血压 Diabetics and Toe PressuresABPI1.3时需进行足趾血压测定和时，需进行足趾血压测定和TBPI检查。检查。Undertake toe pressures and TBPI when ABPI1.3 (Brooks,2001)动脉血管中层钙化很少发生在趾端动脉动脉血管中层钙化很少发生在趾端动脉 Calcification rarely extends to digital arteries (Vowden,1999)对于糖尿病患者应给予更加关注，需进行特殊的动脉检查，如足趾血压检查。对于糖尿病患者应给予更加关注，需进行特殊的动脉检查，如足趾血压检查。“In patients with Diabetes Mellitus additional care should be taken and further arterial investigations undertaken such as toe pressures”(ETRS guideline 2003)足趾血压足趾血压 Diabetics and Toe Pressures 动脉PPG是检查足趾血压的最佳手段。Arterial PPG is the preferred technique to measure toe pressures(Vowden,2002)检测脚趾血压比多普勒操作简单得多Easier than Doppler to measure toe pressures 消除通过声音探测脉搏恢复Eliminates the need to audibly detect the return of the pulse 探头容易连接手指和脚趾Sensors easily attach to fingers&toes血压测定时，充气袖带放气速度应为23mmHg/秒Cuffs should be deflated at 2-3mmHg/sec(BHS,2000)足趾血压足趾血压 Diabetics and Toe Pressures PPG检测足趾血压Toe Pressures using PPG135140上臂BrachialTBI計算法計算法 TBPI calculations足趾収縮期血圧Toe systolic pressure上臂収縮期血圧最大測定値Highest brachial systolic pressure14014075115足趾Toe=75=0.54=115=0.82右右TBIRight TBPI左左TBILeft TBI 上臂Brachial足趾血压足趾血压 Diabetics and Toe Pressures足趾血压足趾血压 Diabetics and Toe Pressures正常TBI 0.7临界值TBI 0.65-0.7病变TBI 0.65总结总结Summary总结总结 Summary针对高危人群需进行血管检查。针对高危人群需进行血管检查。Undertake vascular assessment for higher risk patients (NICE No.10,2004)ABIABI是诊断外周动脉病症是诊断外周动脉病症PADPAD（甚至在未出现症状之前），评估其预后的简单、（甚至在未出现症状之前），评估其预后的简单、有效、无创的方法。有效、无创的方法。ABIABI测量可以用听诊器、光传感器或带血管探头的多普勒（测量可以用听诊器、光传感器或带血管探头的多普勒（DopplerDoppler）超声探测仪超声探测仪等多种仪器测量，但以等多种仪器测量，但以DopplerDoppler法最为简便和准确，是测量法最为简便和准确，是测量ABIABI的金标准。的金标准。针对血管中层钙化的患者进行足趾血压及针对血管中层钙化的患者进行足趾血压及TBITBI测定。测定。Measure toe pressures in patients with calcification(Vowden 1999)北京迪美德尔科技有限公司