本文選題：呼吸機(jī)相關(guān)性肺炎 + 流行病學(xué)研究�。� 參考：《第三軍醫(yī)大學(xué)》2010年碩士論文

【摘要】： 背景上世紀(jì)50年代以來(lái),機(jī)械通氣(mechanical ventilation,MV)已在臨床上廣泛應(yīng)用,成為ICU的主要治療方式之一,是搶救伴有呼吸衰竭之危重患者的重要生命支持手段。但在取得明顯治療成果的同時(shí),機(jī)械通氣也帶來(lái)了一些嚴(yán)重的并發(fā)癥,如呼吸機(jī)相關(guān)性肺炎(ventilator associated pneumonia,VAP)。呼吸機(jī)相關(guān)性肺炎(VAP)是ICU最主要的醫(yī)院內(nèi)獲得性肺炎(Hospital Acquired Pneumonia, HAP),占ICU所有HAP的85%左右[1]。國(guó)外流行病學(xué)調(diào)查結(jié)果顯示,機(jī)械通氣患者中VAP發(fā)生率約10-30%[1-3],年齡、食道返流、機(jī)械通氣時(shí)間等為VAP的高危因素[1-4]�，F(xiàn)有臨床研究證實(shí),VAP的發(fā)生將導(dǎo)致機(jī)械通氣時(shí)間以及ICU住院天數(shù)延長(zhǎng),增加醫(yī)療花費(fèi),并影響預(yù)后[6-9]。因此,有效預(yù)防VAP發(fā)生具有重要的臨床意義。 美國(guó)醫(yī)療衛(wèi)生質(zhì)量改進(jìn)委員會(huì)(Institute of Healthcare Improvement, IHI)2004年提出,接受機(jī)械通氣患者應(yīng)實(shí)施呼吸機(jī)集束化治療(Ventilator Bundle)[10],措施包括:1.床頭抬高30度以上;2.每日撤離鎮(zhèn)靜劑喚醒病人(Daily wake-up)并評(píng)估呼吸機(jī)撤離可能性(SBT);3.預(yù)防消化道潰瘍;4.預(yù)防深靜脈血栓。通過(guò)呼吸機(jī)Bundle的整體實(shí)施,有效降低了VAP發(fā)生率,證實(shí)了呼吸機(jī)Bundle是有效預(yù)防預(yù)防VAP發(fā)生的臨床措施。然而,后續(xù)的研究結(jié)果存在較大的差異性[11-14]。其中,重要的問(wèn)題之一是呼吸機(jī)Bundle臨床依從性較差,影響其臨床有效性。解放軍309醫(yī)院的一個(gè)單中心的實(shí)施機(jī)械通氣Bundle前后對(duì)照研究表明,由于呼吸機(jī)Bundle臨床依從性較差,在呼吸機(jī)Bundle實(shí)施前后對(duì)VAP發(fā)生率未發(fā)現(xiàn)顯著影響[15]。 因此,通過(guò)教育培訓(xùn)加強(qiáng)呼吸機(jī)Bundle概念的推廣,同時(shí)實(shí)時(shí)檢查與監(jiān)督呼吸機(jī)Bundle的臨床執(zhí)行情況,對(duì)提高呼吸機(jī)Bundle的臨床依從性,有效降低VAP發(fā)生率具有重要意義。 目的了解目前國(guó)內(nèi)ICU內(nèi)VAP發(fā)生的整體情況、預(yù)防VAP基本措施的執(zhí)行情況及臨床效果,為能夠摸索出一個(gè)適合于中國(guó)國(guó)情、臨床依從性好并且切實(shí)有效的呼吸機(jī)Bundle方案并推廣執(zhí)行提供實(shí)踐基礎(chǔ),探索合理的執(zhí)行方法,為降低國(guó)內(nèi)VAP發(fā)生率做出貢獻(xiàn)。 研究對(duì)象于2009年6月11日至2009年7月31日在全國(guó)33家3級(jí)甲等醫(yī)院ICU連續(xù)選擇氣管插管機(jī)械通氣患者共314例。 方法對(duì)各研究中心目前機(jī)械通氣治療方法不進(jìn)行任何干預(yù),沿用各中心經(jīng)驗(yàn)性治療。實(shí)驗(yàn)開(kāi)始前分地域分批次對(duì)各研究中心指定項(xiàng)目負(fù)責(zé)人進(jìn)行研究目的、觀察指標(biāo)、CRF表格填寫要求的集中培訓(xùn),各研究中心指定項(xiàng)目負(fù)責(zé)人負(fù)責(zé)對(duì)所在中心項(xiàng)目參與者進(jìn)行后續(xù)培訓(xùn),研究過(guò)程全程專人負(fù)責(zé)對(duì)各研究中心進(jìn)行相關(guān)問(wèn)題指導(dǎo)。以CRF表格形式采集臨床資料。各研究中心每日填寫研究日志,如實(shí)記錄當(dāng)天該研究中心內(nèi)機(jī)械通氣總病例數(shù)、入選病例數(shù)、未入選病例數(shù)及未入選原因。臨床資料用Epidata軟件盲法雙錄入方法錄入、檢查,確認(rèn)實(shí)驗(yàn)數(shù)據(jù)無(wú)誤后進(jìn)行數(shù)據(jù)導(dǎo)出,應(yīng)用SAS統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析。 結(jié)果本研究共入選患者314例。平均年齡60.85±15.97歲,最小年齡18歲,最大年齡80歲;入選患者中男性209例(66.56%);機(jī)械通氣原因?yàn)閮?nèi)科疾病者184例(58.60%),外科疾病者130例(41.40%);平均APACHEⅡ評(píng)分為19.19±6.63分;所有入選病例的平均床頭抬高角度為23.46±6.99度;發(fā)生VAP病例數(shù)為125例,VAP發(fā)生率為39.81%;總的機(jī)械通氣日為2482天,每千機(jī)械通氣日VAP例數(shù)為50.36/千機(jī)械通氣日;28天隨訪結(jié)果死亡病例為105例,28天病死率為33.44%;ICU內(nèi)死亡病例為59例,占28天死亡病例比例56.19%;與VAP相關(guān)死亡病例為27例,占28天死亡病例比例為25.71%。 發(fā)生VAP組與未發(fā)生VAP組間各指標(biāo)比較分析,平均APACHEⅡ評(píng)分、ICU住院天數(shù)、機(jī)械通氣時(shí)間、平均床頭抬高角度、ICU內(nèi)死亡率等5個(gè)變量間明顯差異。根據(jù)機(jī)械通氣時(shí)間不同將入選病例分為機(jī)械通氣時(shí)間≤3天、4-7天、7天3組,組間VAP發(fā)生率分別為18.03%、42.53%、57.30%,差異有統(tǒng)計(jì)學(xué)意義,提示隨機(jī)械通氣時(shí)間延長(zhǎng),VAP發(fā)生率增高。對(duì)預(yù)防VAP基本措施的臨床執(zhí)行情況進(jìn)行了分組分析,其中,床頭抬高角度完全在30°以上組的VAP發(fā)生率要低于床頭高角度完全在30°以下組,床頭抬高角度完成情況并沒(méi)有隨著機(jī)械通氣時(shí)間的延長(zhǎng)而顯著下降。根據(jù)入ICU時(shí)間先后,以7月10日為分組時(shí)間點(diǎn),將入選病例分為前后兩組。兩組間數(shù)據(jù)比較,平均床頭抬高角度和VAP發(fā)生率2個(gè)變量組間統(tǒng)計(jì)分析有顯著差異。 結(jié)論(1)本研究通過(guò)采用多中心的流行病學(xué)研究,對(duì)國(guó)內(nèi)33家三甲醫(yī)院ICU的VAP進(jìn)行了流行病學(xué)研究,從一定程度上反映了目前國(guó)內(nèi)大型醫(yī)院ICU內(nèi)VAP的發(fā)生情況。研究表明,參研中心整體的VAP發(fā)生率(39.81%)略高于國(guó)外發(fā)達(dá)國(guó)家水平。需要采取有效地干預(yù)措施預(yù)防VAP的發(fā)生。(2) VAP的發(fā)生可以延長(zhǎng)患者的ICU住院天數(shù)和機(jī)械通氣時(shí)間,同時(shí)對(duì)ICU內(nèi)病死率有明顯影響。(3)接受機(jī)械通氣治療的患者入ICU時(shí)整體狀況越差,其發(fā)生VAP的可能性越大;接受機(jī)械通氣治療時(shí)間越長(zhǎng),VAP的發(fā)生率越高。(4)床頭抬高≥30°是有效預(yù)防VAP發(fā)生的影響因素之一。(5)床頭抬高角度≥30°還沒(méi)有被廣泛實(shí)施,其臨床執(zhí)行率非常低。通過(guò)加強(qiáng)對(duì)醫(yī)護(hù)人員的教育培訓(xùn),其臨床依從性可以得到改善。
[Abstract]:Since 50s, mechanical ventilation (MV) has been widely used in clinical practice. It has become one of the main treatment methods of ICU. It is an important means of life support for rescuing critically ill patients with respiratory failure. However, mechanical ventilation has also brought some serious complications, such as call, at the same time. Ventilator associated pneumonia (VAP). Ventilator associated pneumonia (VAP) is the most important hospital acquired pneumonia of ICU (Hospital Acquired Pneumonia, HAP), accounting for about 85% of ICU HAP. Current clinical studies of high risk factors for VAP, such as flow, mechanical ventilation time, and so on, confirm that the occurrence of VAP will lead to prolonged mechanical ventilation and prolonged hospitalization of ICU, increase the cost of medical treatment, and affect the prognosis of [6-9]., therefore, the effective prevention of the occurrence of VAP has important clinical significance.
In 2004, the Institute of Healthcare Improvement (IHI) proposed that patients receiving mechanical ventilation should carry out respirator cluster therapy (Ventilator Bundle) [10], including 1. heads raised above 30 degrees, 2. evacuating sedatives every day to wake up patients (Daily wake-up) and assess the possibility of ventilator evacuation. SBT); 3. prevention of digestive tract ulcers; 4. to prevent deep venous thrombosis. Through the overall implementation of the ventilator Bundle, the incidence of VAP was effectively reduced. It was confirmed that the ventilator Bundle was a effective preventive measure to prevent the occurrence of VAP. However, the follow-up results were quite different [11-14]., one of the important problems was the Bundle presence in the ventilator. The bed compliance was poor and its clinical effectiveness was affected. A single center Bundle control study before and after the implementation of mechanical ventilation in the PLA 309 Hospital showed that the incidence of VAP was not significantly affected by the incidence of VAP before and after the implementation of the ventilator Bundle, because of the poor clinical compliance of the ventilator Bundle.
Therefore, it is of great significance to strengthen the promotion of the concept of ventilator Bundle through education and training, and to inspect and supervise the clinical implementation of the ventilator Bundle in real time. It is of great significance to improve the clinical compliance of the ventilator Bundle and effectively reduce the incidence of VAP.
Objective to understand the overall situation of VAP in ICU in China, to prevent the implementation and clinical effect of VAP basic measures, and to provide a practical basis for the implementation of Bundle scheme suitable for China, good clinical compliance and effective ventilation, and to explore a reasonable implementation method, in order to reduce the occurrence of VAP in China. The rate makes a contribution.
A total of 314 patients with mechanical ventilation from trachea cannula were selected from ICU, grade 33 and grade 3 hospitals in China from June 11, 2009 to July 31, 2009.
Methods no intervention was carried out on the current mechanical ventilation treatment methods of each research center, and the empirical treatment was used in each center. Before the start of the experiment, the purpose of the research was divided by the regional division to the designated project leaders of the research centers, the indexes, the centralized training of the CRF form filling requirements, and the responsible person in charge of the designated project in each research center. The participants of the central project were trained for follow-up. The whole person was responsible for the guidance of the research centers. Clinical data were collected in the form of CRF form. Each research center filled out the journal daily, and recorded the total number of cases of mechanical ventilation, the number of selected cases, the number of non selected cases, and the non admission. The clinical data were recorded by double entry method of Epidata software blind method, and the data were exported after confirming the experimental data, and the statistical analysis was carried out by using the SAS statistical software.
Results 314 patients were enrolled in this study, the average age of 60.85 + 15.97 years, the minimum age of 18 years, and the maximum age of 80 years, 209 male (66.56%) in the selected patients, 184 (58.60%) and 130 patients (41.40%) for mechanical ventilation, and 130 (41.40%) of the surgical disease. The average APACHE II score was 19.19 + 6.63, and the average head elevation angle of all the selected cases. The number of cases was 23.46 + 6.99 degrees; the number of VAP cases was 125, the incidence of VAP was 39.81%, the total mechanical ventilation day was 2482 days, and the number of VAP cases per thousand mechanical ventilation days was 50.36/ 1000 mechanical ventilation day; 105 cases were killed in 28 days, 28 days were 33.44%, 59 cases in ICU and 28 days of death cases, and associated death with VAP. 27 cases died, accounting for 28 days mortality rate was 25.71%.
The comparison and analysis of the indexes between the VAP group and the non VAP group, the average APACHE II score, the number of ICU hospitalization days, the mechanical ventilation time, the average head elevation angle and the mortality rate in ICU were obviously different. According to the mechanical ventilation time, the selected cases were divided into mechanical ventilation time less than 3 days, 4-7 days, 7 days and 3 groups, and the incidence of VAP among the groups was respectively. 18.03%, 42.53%, 57.30%, the difference was statistically significant, suggesting that the incidence of VAP increased with the extension of mechanical ventilation time. The clinical implementation of the basic measures to prevent VAP was divided into groups. Among them, the incidence of VAP in the group with the head elevation angle above 30 degrees was lower than the head height of the bed at less than 30 degrees, and the head elevation angle was finished. The situation did not decrease significantly with the extension of mechanical ventilation time. According to the time of entering ICU, the selected cases were divided into two groups in July 10th. The data of the two groups were compared, and the statistical analysis between the 2 variables of the average bed elevation angle and the incidence of VAP had significant differences.
Conclusion (1) by using multi center epidemiological study, the epidemiological study on VAP of ICU in 33 domestic three a hospital was carried out. To a certain extent, the occurrence of VAP in the domestic large hospital was reflected in ICU. The study showed that the incidence of VAP (39.81%) was slightly higher than that of the developed countries. Effective intervention measures were taken to prevent the occurrence of VAP. (2) the occurrence of VAP could prolong the patient's duration of hospitalization and the duration of mechanical ventilation, and had a significant influence on the mortality rate within ICU. (3) the worse the overall status of the patients receiving mechanical ventilation in ICU, the greater the likelihood of the occurrence of VAP; the longer the mechanical ventilation treatment was accepted, the more VAP was found. (2) The higher the rate of birth. (4) the elevation of the head of the bed is more than 30 degrees. (5) the elevation of the head of the bed is not widely implemented, and the clinical execution rate is very low. The clinical compliance of the medical staff can be improved by strengthening the education and training of the medical staff.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2010
【分類號(hào)】：R181.3

【引證文獻(xiàn)】

相關(guān)碩士學(xué)位論文 前1條

1 楊瀅;清肺化痰湯霧化治療呼吸機(jī)相關(guān)性肺炎療效及血清PCT水平變化的研究[D];黑龍江中醫(yī)藥大學(xué);2012年

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