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1、最新呼吸机相关性肺炎诊断与预防策略探讨(黎毅敏)_-药学医学精品资料医院获得性肺炎和呼吸机相关肺炎(VAP)医院获得性肺炎指住院48小时以后发生的肺炎,呼吸机相关性肺炎(VAP)指接受机械通气(MV)48小时或以后发生的肺炎早发VAP:指机械通气后4天内发生晚发VAP:认为5天或者更后发生VAP(Langer,1987;ATS,1995)气管插管(ET)跨越了上咽部的防御机制,并且影响咳嗽反射及粘膜纤毛的清除能力。聚集在气管插管套囊上方的分泌物可以进入下呼吸道,同时将致病菌也带入下呼吸道。因此,接受机械通气的患者发生肺炎的风险增加6—21倍VAP发病机制机体呼吸道与全身防御机制受损机械通气时病
2、原菌侵入和定植呼吸道的方式口咽部定植菌的“误吸”胃肠内细菌的逆行吸入带菌气溶胶气管导管和医疗操作如吸痰高强度致病菌RiskFactorsforVAPSerumalbumin<2.2Age>60yrsARDS,COPD,comaBurns,traumaMulti-organfailureLargevolumegastricaspirationGastric&trachealcolonizationChastreJ,FagonJ-YAJRCCM2002Paralysis,continuoussedation>4unitsbloodproductsMV(?intubation)>2dFrequent
3、ventilatorcircuitchangesReintubationNasogastrictubeSupinepositionPriorornoabxRx宿主方面的因素干预因素VAP的诊断临床诊断的VAP常常只有50%左右得到细菌学的证实FagonAmRevRespirDis139,1989TejadaCritCareMed28,2000And8otherstudiesBacteriologicalconfirmationofclinicallysuspectedVAPAuthorClinicallyBacteriologicalSuspectedVAPconfirmation(n)(n
4、)%Fagon842732Croce1364634Rodriguez1104541Luna1326549Bonten1387252Kollef1306046Sanchez513671Ruiz764255Fagon2049044Tejada1032322ThediagnosisofVAPisusuallybasedonthreecomponents:systemicsignsofinfection,neworworseninginfiltratesseenonthechestroentgenogram,andbacteriologicalevidenceofpulmonaryparenchyma
5、linfection.AndrewsCP,Chest1981;80t°>38,3°CWBC>12X109/ml脓性气管分泌物影像学异常表现敏感性69%,特异性75%(尸检病理)TorresA.AmJRespirCritCareMed1994;149临床诊断标准24个ARDS机械通气病人回顾性研究病理证实肺炎:14病人临床诊断肺炎:敏感性:64%特异性:80%Andrewsetal.Chest81临床诊断标准问题临床肺部感染评分ClinicalPulmonaryInfectionScore(CPIS)*temperature°C>36.5and<38.4:0point>38.5and<38.9:
6、1point>39or<36:2points*WBC,mm-3>4,000and<11,000:0point<4,000or>11,000:1point+bandforms>500=+1point*trachealsecretionsabsenceoftrachealsecretions=0pointpresenceoftrachealsecretions=1point+purulentsecretions=+1point*PaO2/FiO2,mmHg>240orARDS=1point<240andnoevidenceofARDS=0point*pulmonaryradiographynoin
7、filtrate=0pointdiffused(orpatchy)infiltrate=1pointlocalizedinfiltrate=2points*cultureofTA(semiquantitative:0,1,2or3+)pathogenicbacteriacultured<1+ornogrowth=0pointpathogenicbacteriacultured>1=1point+s