纖維支氣管鏡肺泡灌洗對(duì)機(jī)械通氣下卒中相關(guān)性肺炎患者的療效觀察
發(fā)布時(shí)間：2018-07-31 10:16
【摘要】：目的:近年來(lái),隨著人們生活水平的提高和飲食結(jié)構(gòu)的改變,腦卒中的發(fā)生率逐年增高。肺炎是卒中后最常見(jiàn)的內(nèi)科并發(fā)癥,有研究表明,肺炎的發(fā)生直接影響卒中患者后期的神經(jīng)功能恢復(fù),其甚至與死亡率的發(fā)生有一定的關(guān)聯(lián)。對(duì)于SAP的治療方面,目前尚無(wú)實(shí)質(zhì)性的進(jìn)展,現(xiàn)階段僅停留在吸氧、痰液引流、營(yíng)養(yǎng)支持等對(duì)癥治療方法上,而抗生素的預(yù)防性使用被認(rèn)為可加重感染,惡化患者預(yù)后。本研究旨在探究纖維支氣管鏡肺泡灌洗技術(shù)對(duì)機(jī)械通氣下SAP患者肺部感染的控制及治療情況,為此類患者確定最積極有效的治療方法提供新的思路,從而達(dá)到早期控制感染,改善患者預(yù)后及避免不良結(jié)局發(fā)生的目的。方法:本研究屬回顧性研究,選取2014年12月-2016年12月在延安大學(xué)附屬醫(yī)院東關(guān)分院重癥醫(yī)學(xué)科被確診為卒中相關(guān)性肺炎并行機(jī)械通氣治療(包括氣管插管或氣管切開(kāi))的80例危重癥患者為主要研究對(duì)象。將80例患者按其治療方法及基礎(chǔ)疾病類型歸入兩組:A組(吸痰組)和B組(灌洗組)。兩組患者均給予鎮(zhèn)痛、鎮(zhèn)靜、抗感染、霧化吸入、支氣管擴(kuò)張及支持對(duì)癥等常規(guī)治療,同時(shí)勤翻身拍背、鼓勵(lì)無(wú)意識(shí)障礙的患者自主咳痰。在此基礎(chǔ)治療上,A組采用開(kāi)放式改良吸痰法吸痰并取痰標(biāo)本做病原菌培養(yǎng),B組在采用A組吸痰法的基礎(chǔ)上,在心電血氧全程監(jiān)測(cè)下行纖維支氣管鏡鏡下吸痰、灌洗、留痰培養(yǎng)。收集兩組患者治療前后炎癥控制情況的指標(biāo),包括3d后血?dú)庵笜?biāo):酸堿度(PH)、動(dòng)脈血氧分壓(PaO_2)、動(dòng)脈二氧化碳分壓(PaCO_2)、動(dòng)脈血氧飽和度(SaO_2),7d后炎癥指標(biāo):白細(xì)胞計(jì)數(shù)(WBC)、降鈣素原(PCT)、C-反應(yīng)蛋白(CRP)、簡(jiǎn)化CPIS評(píng)分的變化;治療情況(住院時(shí)間、機(jī)械通氣時(shí)間、抗生素使用時(shí)間)及治療效果(病原菌檢出率、病死率、插管改切開(kāi)比率),以及通過(guò)上述指標(biāo)分析得出與病死率相關(guān)的影響因素等,對(duì)比分析兩組患者肺部炎癥的改善情況及治療效果。結(jié)果:本研究共納入80例卒中后肺炎危重患者,其中A組、B組各40例。兩組患者治療前性別、年齡、基礎(chǔ)疾病、簡(jiǎn)化CPIS評(píng)分均無(wú)明顯差異(P0.05)。炎癥控制情況比較:治療前A、B兩組的血?dú)庵笜?biāo)PH、PaO_2、PaCO_2、SaO_2,炎癥指標(biāo)WBC、PCT、CRP、簡(jiǎn)化CPIS評(píng)分進(jìn)行組間比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。治療3d后,B組患者各項(xiàng)血?dú)庵笜?biāo)PH、PaO_2、PaCO_2、SaO_2較治療前有明顯改善,且具有統(tǒng)計(jì)學(xué)意義(P0.05),A組不明顯,B組治療效果較A組明顯(P0.05)。治療7d后對(duì)比指標(biāo)的變化,A、B兩組患者的CRP、WBC水平較前均有改善,且具有統(tǒng)計(jì)學(xué)意義(P0.05),B組下降幅度較A組明顯(P0.05);A組簡(jiǎn)化CPIS評(píng)分、PCT指標(biāo)前后無(wú)明顯差異,B組治療后較前明顯下降(P0.05),且比A組改善更明顯,具統(tǒng)計(jì)學(xué)意義(P0.05),且對(duì)比治療前后兩組患者的臨床癥狀、體征、影像學(xué)表現(xiàn)等均有相應(yīng)的改變。治療情況比較:本研究中,B組的住院時(shí)間(14.18±3.18d)、機(jī)械通氣時(shí)間(25.59h)及抗生素使用時(shí)間(7.05±1.20d)均比A組(20.30±4.59d、55.42h、12.83±2.72d)縮短,且具有統(tǒng)計(jì)學(xué)意義(P0.05)。治療效果比較:B組病原體檢出率56.9%,高于A組(43.1%),且兩者具有顯著差異性(P0.05)。而B(niǎo)組的改切率(37.1%)、病死率(40.0%)均低于相應(yīng)A組的比率(62.9%、62.5%),具有統(tǒng)計(jì)學(xué)意義(P0.05)。病死率的影響因素分析:通過(guò)對(duì)本研究中所有因素進(jìn)行分析發(fā)現(xiàn),影響A、B兩組病死率的主要因素是治療前后的血?dú)庵笜?biāo)以及炎癥指標(biāo)。如:治療后PH、PaO_2、PaCO_2、PCT、簡(jiǎn)化CPIS評(píng)分以及治療前后均有意義的SaO_2、WBC、CRP等指標(biāo)(P0.05),各指標(biāo)均有實(shí)指意義。結(jié)論:1.纖維支氣管鏡灌洗法可明顯改善血?dú)庵笜?biāo)和炎癥指標(biāo),有效緩解患者的肺部感染癥狀;可間接降低患者的病死率、改切率,提高病原體的檢出率,利于患者的遠(yuǎn)期神經(jīng)功能恢復(fù)及卒中后生活質(zhì)量的保障;同時(shí)縮短住院時(shí)間、機(jī)械通氣時(shí)間及抗生素使用時(shí)間,減輕患者的經(jīng)濟(jì)負(fù)擔(dān),節(jié)約醫(yī)療資源。2.影響病死率的主要因素是治療前后的血?dú)庵笜?biāo)以及炎癥指標(biāo)。治療后PH、PaO_2、PaCO_2、PCT、簡(jiǎn)化CPIS評(píng)分等指標(biāo)在判斷肺炎治療效果方面有積極意義。而對(duì)于治療前后均有意義的SaO_2、WBC、CRP等指標(biāo),可以認(rèn)為其在反映肺部治療效果的同時(shí),還可以評(píng)價(jià)患者入院的嚴(yán)重程度及預(yù)測(cè)患者的結(jié)局與預(yù)后。3.簡(jiǎn)化CPIS評(píng)分系統(tǒng)可以作為SAP危重患者的治療效果和預(yù)后評(píng)估指標(biāo)發(fā)揮作用,為今后的評(píng)價(jià)標(biāo)準(zhǔn)提供新的思路。
[Abstract]:Objective: in recent years, with the improvement of people's living standard and the change of dietary structure, the incidence of stroke is increasing year by year. Pneumonia is the most common complication after stroke. Research shows that the occurrence of pneumonia has a direct effect on the recovery of neural function in the later stage of stroke, and it is even associated with the occurrence of mortality. For SAP There is no substantial progress in the treatment, at the present stage, only oxygen inhalation, sputum drainage, nutritional support and other symptomatic treatment, and the preventive use of antibiotics is considered to aggravate the infection and deteriorate the prognosis of the patients. The purpose of this study is to explore the control of bronchoalveolar lavage by fiberoptic bronchoscopy for pulmonary infection in SAP patients under mechanical ventilation. This study is a retrospective study. This study belongs to a retrospective study and was selected in the Department of intensive medicine of the Affiliated Hospital of Yan'an University in December 2014, -2016, in December, December 2014. 80 critically ill patients diagnosed as stroke associated pneumonia in parallel mechanical ventilation (including tracheal intubation or tracheotomy) were the main research subjects. 80 patients were classified into two groups according to their treatment methods and basic disease types: group A (sputum suction group) and group B (irrigation group). The two groups were given analgesia, sedative, anti infection, atomization, inhalation, and bronchogram In this basic treatment, the A group used the open improved phlegm absorption and sputum specimen for the cultivation of pathogenic bacteria in the A group. On the basis of the A group absorption method, the B group was under the whole process of ECG blood oxygen monitoring under the fiberoptic bronchoscopy. Absorption of sputum, lavage, and sputum culture. Collect the index of inflammation control in two groups of patients before and after treatment, including the index of blood gas after 3D: acidity alkalinity (PH), arterial oxygen partial pressure (PaO_2), arterial carbon dioxide partial pressure (PaCO_2), arterial oxygen saturation (SaO_2), and 7d inflammation index: leukocyte count (WBC), calcitonin (PCT), C- reactive protein (CRP), and CPIS CPIS The change of score, treatment situation (hospitalization time, mechanical ventilation time, antibiotic use time) and treatment effect (pathogenic bacteria detection rate, mortality, intubation and incision ratio), and the factors related to mortality through the above indexes were analyzed, and the improvement and treatment effect of two groups of patients with pulmonary inflammation were compared and analyzed. In this study, 80 patients with severe post stroke pneumonia were included, including group A and 40 cases in group B. There was no significant difference in gender, age, basic disease, and simplified CPIS score (P0.05) before treatment in two groups. The blood gas indexes of group A, B two before treatment were PH, PaO_2, PaCO_2, SaO_2, WBC, PCT, There was no significant difference in the difference (P0.05). After the treatment of 3D, the blood gas indexes of group B patients PH, PaO_2, PaCO_2, SaO_2 were significantly improved, and had statistical significance (P0.05), the A group was not obvious, the therapeutic effect of the B group was more obvious than that of the A group (P0.05). And with statistical significance (P0.05), the decrease of group B was more obvious than that of group A (P0.05), and A group simplified CPIS score, there was no significant difference between before and after PCT index, B group was significantly lower than before (P0.05), and more obvious than the A group (P0.05), with statistical significance (P0.05), and the clinical symptoms, physical signs and imaging manifestations of the two groups of patients before and after treatment were corresponding. In this study, in this study, the hospitalization time of B group (14.18 + 3.18d), mechanical ventilation time (25.59h) and antibiotic use time (7.05 + 1.20d) were shorter than those in the A group (20.30 + 4.59d, 55.42h, 12.83 + 2.72d), and had statistical significance (P0.05). The curative effect of the B group was 56.9%, higher than the A group (43.1%). There were significant differences (P0.05), and the rate of cutting in group B (37.1%), the mortality rate (40%) was lower than that of the corresponding A group (62.9%, 62.5%), and had statistical significance (P0.05). Analysis of the influencing factors of the fatality rate: through the analysis of all factors in this study, the main factors affecting the mortality of A and B two were the blood gas index before and after treatment and Inflammation index, such as PH, PaO_2, PaCO_2, PCT, simplified CPIS score and the significance of SaO_2, WBC, CRP and other indicators (P0.05) before and after treatment, all indexes have real meaning. Conclusion: 1. bronchoscopic lavage can obviously improve the blood gas index and inflammation index, effectively relieve the symptoms of pulmonary infection in the patients, and can indirectly reduce the patient's disease. The death rate, the cutting rate, the detection rate of the pathogen, the recovery of the long-term nerve function and the guarantee of the quality of life after the stroke, shorten the time of hospitalization, the time of mechanical ventilation and the time of antibiotic use, and reduce the economic burden of the patients, and the main factor of saving the death rate of the medical resources.2. is the blood gas index before and after the treatment. After treatment, PH, PaO_2, PaCO_2, PCT, simplified CPIS score and other indicators have positive significance in judging the effect of pneumonia. The indicators such as SaO_2, WBC and CRP before and after treatment can be considered to reflect the effect of lung treatment, and also evaluate the severity of hospitalization and predict the outcome of the patients. Prognosis. 3. Simplified CPIS scoring system can be used as a therapeutic effect and prognostic evaluation index in critically ill patients with SAP, providing new ideas for future evaluation criteria.
【學(xué)位授予單位】：延安大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.1;R743.3
本文編號(hào)：2155277
[Abstract]:Objective: in recent years, with the improvement of people's living standard and the change of dietary structure, the incidence of stroke is increasing year by year. Pneumonia is the most common complication after stroke. Research shows that the occurrence of pneumonia has a direct effect on the recovery of neural function in the later stage of stroke, and it is even associated with the occurrence of mortality. For SAP There is no substantial progress in the treatment, at the present stage, only oxygen inhalation, sputum drainage, nutritional support and other symptomatic treatment, and the preventive use of antibiotics is considered to aggravate the infection and deteriorate the prognosis of the patients. The purpose of this study is to explore the control of bronchoalveolar lavage by fiberoptic bronchoscopy for pulmonary infection in SAP patients under mechanical ventilation. This study is a retrospective study. This study belongs to a retrospective study and was selected in the Department of intensive medicine of the Affiliated Hospital of Yan'an University in December 2014, -2016, in December, December 2014. 80 critically ill patients diagnosed as stroke associated pneumonia in parallel mechanical ventilation (including tracheal intubation or tracheotomy) were the main research subjects. 80 patients were classified into two groups according to their treatment methods and basic disease types: group A (sputum suction group) and group B (irrigation group). The two groups were given analgesia, sedative, anti infection, atomization, inhalation, and bronchogram In this basic treatment, the A group used the open improved phlegm absorption and sputum specimen for the cultivation of pathogenic bacteria in the A group. On the basis of the A group absorption method, the B group was under the whole process of ECG blood oxygen monitoring under the fiberoptic bronchoscopy. Absorption of sputum, lavage, and sputum culture. Collect the index of inflammation control in two groups of patients before and after treatment, including the index of blood gas after 3D: acidity alkalinity (PH), arterial oxygen partial pressure (PaO_2), arterial carbon dioxide partial pressure (PaCO_2), arterial oxygen saturation (SaO_2), and 7d inflammation index: leukocyte count (WBC), calcitonin (PCT), C- reactive protein (CRP), and CPIS CPIS The change of score, treatment situation (hospitalization time, mechanical ventilation time, antibiotic use time) and treatment effect (pathogenic bacteria detection rate, mortality, intubation and incision ratio), and the factors related to mortality through the above indexes were analyzed, and the improvement and treatment effect of two groups of patients with pulmonary inflammation were compared and analyzed. In this study, 80 patients with severe post stroke pneumonia were included, including group A and 40 cases in group B. There was no significant difference in gender, age, basic disease, and simplified CPIS score (P0.05) before treatment in two groups. The blood gas indexes of group A, B two before treatment were PH, PaO_2, PaCO_2, SaO_2, WBC, PCT, There was no significant difference in the difference (P0.05). After the treatment of 3D, the blood gas indexes of group B patients PH, PaO_2, PaCO_2, SaO_2 were significantly improved, and had statistical significance (P0.05), the A group was not obvious, the therapeutic effect of the B group was more obvious than that of the A group (P0.05). And with statistical significance (P0.05), the decrease of group B was more obvious than that of group A (P0.05), and A group simplified CPIS score, there was no significant difference between before and after PCT index, B group was significantly lower than before (P0.05), and more obvious than the A group (P0.05), with statistical significance (P0.05), and the clinical symptoms, physical signs and imaging manifestations of the two groups of patients before and after treatment were corresponding. In this study, in this study, the hospitalization time of B group (14.18 + 3.18d), mechanical ventilation time (25.59h) and antibiotic use time (7.05 + 1.20d) were shorter than those in the A group (20.30 + 4.59d, 55.42h, 12.83 + 2.72d), and had statistical significance (P0.05). The curative effect of the B group was 56.9%, higher than the A group (43.1%). There were significant differences (P0.05), and the rate of cutting in group B (37.1%), the mortality rate (40%) was lower than that of the corresponding A group (62.9%, 62.5%), and had statistical significance (P0.05). Analysis of the influencing factors of the fatality rate: through the analysis of all factors in this study, the main factors affecting the mortality of A and B two were the blood gas index before and after treatment and Inflammation index, such as PH, PaO_2, PaCO_2, PCT, simplified CPIS score and the significance of SaO_2, WBC, CRP and other indicators (P0.05) before and after treatment, all indexes have real meaning. Conclusion: 1. bronchoscopic lavage can obviously improve the blood gas index and inflammation index, effectively relieve the symptoms of pulmonary infection in the patients, and can indirectly reduce the patient's disease. The death rate, the cutting rate, the detection rate of the pathogen, the recovery of the long-term nerve function and the guarantee of the quality of life after the stroke, shorten the time of hospitalization, the time of mechanical ventilation and the time of antibiotic use, and reduce the economic burden of the patients, and the main factor of saving the death rate of the medical resources.2. is the blood gas index before and after the treatment. After treatment, PH, PaO_2, PaCO_2, PCT, simplified CPIS score and other indicators have positive significance in judging the effect of pneumonia. The indicators such as SaO_2, WBC and CRP before and after treatment can be considered to reflect the effect of lung treatment, and also evaluate the severity of hospitalization and predict the outcome of the patients. Prognosis. 3. Simplified CPIS scoring system can be used as a therapeutic effect and prognostic evaluation index in critically ill patients with SAP, providing new ideas for future evaluation criteria.
【學(xué)位授予單位】：延安大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R563.1;R743.3
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