本文選題：重癥肺炎 + 不明原因肺炎　； 參考：《北京協(xié)和醫(yī)學(xué)院》2013年碩士論文

【摘要】：目的：對成人重癥“不明原因”社區(qū)獲得性肺炎的臨床表現(xiàn)、病原體檢測、病情嚴(yán)重程度等方面進(jìn)行綜合分析,探討其病原學(xué)及臨床特點。采集患者血清進(jìn)行細(xì)胞因子測定,初步分析治療前后其細(xì)胞因子水平的變化規(guī)律。 方法：收集2012年4月至2013年4月,北京協(xié)和醫(yī)院急診科重癥監(jiān)護(hù)病房收治的符合重癥“不明原因”社區(qū)獲得性肺炎診斷標(biāo)準(zhǔn)的患者。記錄人口統(tǒng)計學(xué)資料、病史資料、病情評分、治療用藥等。采集患者入院后第1、3、5、7天血液標(biāo)本,分離血清測定TNF-α、IL-1β、IL-6、IL-8、IL-10、可溶性細(xì)胞間黏附分子、可溶性E-選擇素濃度,分析患者治療前后其血清細(xì)胞因子的變化。 結(jié)果：①最終入選重癥“不明原因”社區(qū)獲得性肺炎20例,男性11例,女性9例,平均年齡為(41.9±15.1)歲,所有病例均出現(xiàn)發(fā)熱及咳嗽,病例高發(fā)時間為1月至4月。②所有入選病例均符合急性呼吸窘迫綜合征柏林診斷標(biāo)準(zhǔn),重度ARDS患者(9例)與輕、中度ARDS患者相比,LIS、SOFA評分更高、氧合指數(shù)更低、需要更高的PEEP水平,使用機(jī)械通氣時間更長,差異有統(tǒng)計學(xué)意義(P0.05)。③入選病例中8例明確病原體,均為病毒感染,其中7例為腺病毒,1例為鼻病毒。腺病毒感染患者以男性多見,但差異無統(tǒng)計學(xué)意義(P=0.20)。病毒性肺炎患者與不明原因肺炎患者入院時各項評分及臨床表現(xiàn)無顯著差異。④20例患者病程初期均無細(xì)菌及真菌感染證據(jù),病程后期13例病例合并細(xì)菌感染,均出現(xiàn)在機(jī)械通氣患者中,其中2例合并真菌感染。⑤20例病例中累及兩個或兩個以上肺葉者占55%,影像學(xué)表現(xiàn)為實變影、散在團(tuán)塊影、廣泛磨玻璃影,病毒性肺炎與不明原因肺炎患者的影像學(xué)表現(xiàn)無顯著差異。⑥入院后第1、3、5、7天患者體內(nèi)TNF-α呈上升趨勢；IL-6于第3天出現(xiàn)顯著下降,差異有統(tǒng)計學(xué)意義(P0.05)：IL-8、IL-10第3天達(dá)高峰,后期逐漸下降；可溶性E-選擇素及sIC AM-1持續(xù)處于較高水平。 結(jié)論：①病毒成為重癥“不明原因”社區(qū)獲得性肺炎的主要病原體之一,冬春季節(jié)需高度警惕病毒性肺炎。②根據(jù)臨床特征、病情嚴(yán)重程度及影像學(xué)表現(xiàn)不能區(qū)分病毒性肺炎和不明原因肺炎。③對重癥“不明原因”肺炎患者進(jìn)行病毒篩查尤為重要,確診依靠病原學(xué)證據(jù)。④序貫器官衰竭評分有助于判斷病情嚴(yán)重程度。⑤IL-6對治療反應(yīng)較好,在早期對預(yù)后判評有一定價值。IL-1β、IL-8與病情變化相一致。⑥在疾病嚴(yán)重情況下,TNF-α持續(xù)升高與病情嚴(yán)重程度相關(guān)。
[Abstract]:Objective: to analyze the clinical manifestation, pathogen detection and severity of adult severe "unknown cause" community acquired pneumonia, and to explore its etiology and clinical features. The changes of cytokine levels before and after treatment were preliminarily analyzed. Methods: from April 2012 to April 2013, the patients in the intensive care unit of emergency department of Beijing Union Union Hospital who met the criteria for the diagnosis of severe "unknown cause" community-acquired pneumonia (CPAP) were collected. Record demographic data, medical history, disease score, medication and so on. The blood samples were collected on the 1st day of admission, and the serum levels of TNF- 偽, IL-1 尾, IL-6, IL-8 and IL-10, soluble intercellular adhesion molecules and soluble E- selectin were measured, and the changes of serum cytokines before and after treatment were analyzed. Results Twenty patients with severe "unknown cause" community-acquired pneumonia, 11 males and 9 females, with an average age of (41.9 鹵15.1) years, had fever and cough. The time of high incidence was from January to April .2 all the selected cases were in accordance with the Berlin diagnostic criteria for acute respiratory distress syndrome. The patients with severe ARDS (9 cases) had higher score and lower oxygenation index than those with mild and moderate ARDS. The need for higher peep level, the use of mechanical ventilation time longer, the difference was statistically significant (P0.05) in the selected cases 8 cases identified pathogens, all of them were viral infection, 7 cases were adenovirus 1 case is rhinovirus. Male patients with adenovirus infection were more common, but the difference was not statistically significant (P0. 20). There was no significant difference in scores and clinical manifestations between patients with viral pneumonia and those with unexplained pneumonia at admission. There was no evidence of bacterial and fungal infection in 420 patients at the beginning of the disease course, and 13 cases were complicated with bacterial infection in the late stage of the disease. All of them appeared in mechanical ventilation patients, of which 2 cases were complicated by fungal infection. 55 cases were involved in two or more lobes of lung. The imaging manifestations were solid change, scattered mass shadow, and widely ground glass shadow. There was no significant difference between the imaging manifestations of viral pneumonia and unexplained pneumonia. 6 the TNF- 偽 in patients with viral pneumonia showed an increasing trend on the 7th day after admission, and IL-6 decreased significantly on the 3rd day, and the difference was statistically significant (P0.05). The TNF- 偽 level reached the peak on the 3rd day after admission (P0.05). The content of soluble E- selectin and sIC AM-1 remained at high level. Conclusion the virus of 1 is one of the main pathogens of severe "unknown cause" community-acquired pneumonia. In winter and spring, it is necessary to be on high alert for viral pneumonia .2 according to the clinical characteristics. It is particularly important that the severity of the disease and the imaging findings can not distinguish viral pneumonia from unexplained pneumonia. 3. It is particularly important for patients with severe "unknown cause" pneumonia to be screened for viruses. Depending on the etiological evidence, the score of Sequential Organ failure was helpful to judge the severity of the disease, and the response of IL-6 to the treatment was better. Early prognostic evaluation. IL-1 尾 -IL-8 is consistent with the changes of the disease. 6 in the case of serious disease, the sustained increase of TNF- 偽 is related to the severity of the disease.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R563.1

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