呼吸機(jī)相關(guān)性肺炎診斷和治療進(jìn)展

畢業(yè)論文

摘要:

       呼吸機(jī)相關(guān)性肺炎是1類特殊類型的院內(nèi)感染，尤其對(duì)于危重患者，其患病率和死亡率較高，早期診斷和規(guī)范化治療非常重要。目前在診斷方面尚有1些爭(zhēng)議，治療上尚無(wú)統(tǒng)1流程，本文就近幾年呼吸機(jī)相關(guān)肺炎診治和預(yù)防策略研究進(jìn)展作簡(jiǎn)要綜述，以期為呼吸機(jī)相關(guān)性肺炎的臨床規(guī)范性治療提供依據(jù)，最終降低呼吸機(jī)相關(guān)性肺炎的死亡率。
       關(guān)鍵詞: 呼吸機(jī)相關(guān)性肺炎；機(jī)械通氣；診斷；治療

       Advance in Diagnosis and treatment of Ventilator-associated pneumonia
       Cong-shan YANG, Hai-bo QIU.
       Department of Critical Care Medicine, Zhong-Da Hospital and School of Clinical Medicine, Southeast University, Nanjing 210009, China

       ABSTRACT
       Ventilator-associated pneumonia is a special type of nosocomial infection. Because of high morbidity and mortality, it is very important，especially for critically ill patients. Early diagnosis and normalization treatment is very necessary. At present, there still has some argument in diagnosis and without united flowsheet in treatment. This review is about the advance in diagnosis, treatment and prophylaxis of ventilator-associated pneumonia, according to the recent articles. We want to provide more evidence to guide our clinical work，finally decrease the mortality of ventilator-associated pneumonia.
       Key words: Ventilator-associated pneumonia; mechanical ventilation; diagnosis; treatment


       呼吸機(jī)相關(guān)性肺炎(Ventilator-associated pneumonia，VAP)是指經(jīng)氣管插管或氣管切開管行機(jī)械通氣48小時(shí)后至撤機(jī)拔管48小時(shí)內(nèi)發(fā)生的新的肺實(shí)質(zhì)感染，是醫(yī)院獲得性肺炎(Hospital-acquired pneumonia，HAP)中最重要的類型之1。根據(jù)發(fā)病時(shí)間，可分為早發(fā)性VAP(機(jī)械通氣≤4天) 和晚發(fā)性VAP(機(jī)械通氣≥5天) [1]。因患者人群不同，VAP患病率在6%～52%不等。并發(fā)VAP的患者ICU住院時(shí)間和總住院時(shí)間明顯延長(zhǎng)，住院費(fèi)用明顯增加，死亡率增加。有研究表明ICU患者合并VAP的死亡率(crude mortality)為24%～76% [2]。因此，提高對(duì)VAP的認(rèn)識(shí)，早期診斷、積極治療和預(yù)防非常重要。
       1、診斷
       VAP的診斷要綜合考慮兩個(gè)方面：1是判斷是否存在肺炎；2是明確感染的病原微生物。
       目前診斷VAP的金標(biāo)準(zhǔn)仍然是組織病理學(xué)有炎癥反應(yīng)和肺活組織培養(yǎng)微生物陽(yáng)性，但此標(biāo)準(zhǔn)臨床難以實(shí)施，1般多采用臨床診斷標(biāo)準(zhǔn)和臨床肺部感染評(píng)分(clinical pulmonary infection score，CPIS)。臨床診斷標(biāo)準(zhǔn)為 X線 胸片出現(xiàn)新的浸潤(rùn)陰影或原有浸潤(rùn)陰影擴(kuò)大，同時(shí)具有下列3項(xiàng)中的兩項(xiàng)或兩項(xiàng)以上：①發(fā)熱；②白細(xì)胞計(jì)數(shù)增高或降低；③膿性痰。此診斷標(biāo)準(zhǔn)的敏感性為69%，特異性為75%。其中 X線 胸片是診斷VAP最敏感的指標(biāo)，但有較高的假陽(yáng)性率，應(yīng)與肺水腫、肺泡出血、肺不張、肺栓塞以及肺纖維化等相鑒別。

摘要:

       呼吸機(jī)相關(guān)性肺炎是1類特殊類型的院內(nèi)感染，尤其對(duì)于危重患者，其患病率和死亡率較高，早期診斷和規(guī)范化治療非常重要。目前在診斷方面尚有1些爭(zhēng)議，治療上尚無(wú)統(tǒng)1流程，本文就近幾年呼吸機(jī)相關(guān)肺炎診治和預(yù)防策略研究進(jìn)展作簡(jiǎn)要綜述，以期為呼吸機(jī)相關(guān)性肺炎的臨床規(guī)范性治療提供依據(jù)，最終降低呼吸機(jī)相關(guān)性肺炎的死亡率。
       關(guān)鍵詞: 呼吸機(jī)相關(guān)性肺炎；機(jī)械通氣；診斷；治療

       Advance in Diagnosis and treatment of Ventilator-associated pneumonia
       Cong-shan YANG, Hai-bo QIU.
       Department of Critical Care Medicine, Zhong-Da Hospital and School of Clinical Medicine, Southeast University, Nanjing 210009, China

       ABSTRACT
       Ventilator-associated pneumonia is a special type of nosocomial infection. Because of high morbidity and mortality, it is very important，especially for critically ill patients. Early diagnosis and normalization treatment is very necessary. At present, there still has some argument in diagnosis and w

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