呼吸机相关性肺炎诊断和治疗进展

摘要:

       呼吸机相关性肺炎是1类特殊类型的院内感染，尤其对于危重患者，其患病率和死亡率较高，早期诊断和规范化治疗非常重要。目前在诊断方面尚有1些争议，治疗上尚无统1流程，本文就近几年呼吸机相关肺炎诊治和预防策略研究进展作简要综述，以期为呼吸机相关性肺炎的临床规范性治疗提供依据，最终降低呼吸机相关性肺炎的死亡率。
       关键词: 呼吸机相关性肺炎；机械通气；诊断；治疗

       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


       呼吸机相关性肺炎(Ventilator-associated pneumonia，VAP)是指经气管插管或气管切开管行机械通气48小时后至撤机拔管48小时内发生的新的肺实质感染，是医院获得性肺炎(Hospital-acquired pneumonia，HAP)中最重要的类型之1。根据发病时间，可分为早发性VAP(机械通气≤4天) 和晚发性VAP(机械通气≥5天) [1]。因患者人群不同，VAP患病率在6%～52%不等。并发VAP的患者ICU住院时间和总住院时间明显延长，住院费用明显增加，死亡率增加。有研究表明ICU患者合并VAP的死亡率(crude mortality)为24%～76% [2]。因此，提高对VAP的认识，早期诊断、积极治疗和预防非常重要。
       1、诊断
       VAP的诊断要综合考虑两个方面：1是判断是否存在肺炎；2是明确感染的`病原微生物。
       目前诊断VAP的金标准仍然是组织病理学有炎症反应和肺活组织培养微生物阳性，但此标准临床难以实施，1般多采用临床诊断标准和临床肺部感染评分(clinical pulmonary infection score，CPIS)。临床诊断标准为 X线 胸片出现新的浸润阴影或原有浸润阴影扩大，同时具有下列3项中的两项或两项以上：①发热；②白细胞计数增高或降低；③脓性痰。此诊断标准的敏感性为69%，特异性为75%。其中 X线 胸片是诊断VAP最敏感的指标，但有较高的假阳性率，应与肺水肿、肺泡出血、肺不张、肺栓塞以及肺纤维化等相鉴别。

       呼吸机相关性肺炎是1类特殊类型的院内感染，尤其对于危重患者，其患病率和死亡率较高，早期诊断和规范化治疗非常重要。目前在诊断方面尚有1些争议，治疗上尚无统1流程，本文就近几年呼吸机相关肺炎诊治和预防策略研究进展作简要综述，以期为呼吸机相关性肺炎的临床规范性治疗提供依据，最终降低呼吸机相关性肺炎的死亡率。
       关键词: 呼吸机相关性肺炎；机械通气；诊断；治疗

       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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