纤维支气管镜肺泡灌洗对机械通气下卒中相关性肺炎患者的疗效观察

发布时间：2018-07-31 10:16

【摘要】：目的:近年来,随着人们生活水平的提高和饮食结构的改变,脑卒中的发生率逐年增高。肺炎是卒中后最常见的内科并发症,有研究表明,肺炎的发生直接影响卒中患者后期的神经功能恢复,其甚至与死亡率的发生有一定的关联。对于SAP的治疗方面,目前尚无实质性的进展,现阶段仅停留在吸氧、痰液引流、营养支持等对症治疗方法上,而抗生素的预防性使用被认为可加重感染,恶化患者预后。本研究旨在探究纤维支气管镜肺泡灌洗技术对机械通气下SAP患者肺部感染的控制及治疗情况,为此类患者确定最积极有效的治疗方法提供新的思路,从而达到早期控制感染,改善患者预后及避免不良结局发生的目的。方法:本研究属回顾性研究,选取2014年12月-2016年12月在延安大学附属医院东关分院重症医学科被确诊为卒中相关性肺炎并行机械通气治疗(包括气管插管或气管切开)的80例危重症患者为主要研究对象。将80例患者按其治疗方法及基础疾病类型归入两组:A组(吸痰组)和B组(灌洗组)。两组患者均给予镇痛、镇静、抗感染、雾化吸入、支气管扩张及支持对症等常规治疗,同时勤翻身拍背、鼓励无意识障碍的患者自主咳痰。在此基础治疗上,A组采用开放式改良吸痰法吸痰并取痰标本做病原菌培养,B组在采用A组吸痰法的基础上,在心电血氧全程监测下行纤维支气管镜镜下吸痰、灌洗、留痰培养。收集两组患者治疗前后炎症控制情况的指标,包括3d后血气指标:酸碱度(PH)、动脉血氧分压(PaO_2)、动脉二氧化碳分压(PaCO_2)、动脉血氧饱和度(SaO_2),7d后炎症指标:白细胞计数(WBC)、降钙素原(PCT)、C-反应蛋白(CRP)、简化CPIS评分的变化;治疗情况(住院时间、机械通气时间、抗生素使用时间)及治疗效果(病原菌检出率、病死率、插管改切开比率),以及通过上述指标分析得出与病死率相关的影响因素等,对比分析两组患者肺部炎症的改善情况及治疗效果。结果:本研究共纳入80例卒中后肺炎危重患者,其中A组、B组各40例。两组患者治疗前性别、年龄、基础疾病、简化CPIS评分均无明显差异(P0.05)。炎症控制情况比较:治疗前A、B两组的血气指标PH、PaO_2、PaCO_2、SaO_2,炎症指标WBC、PCT、CRP、简化CPIS评分进行组间比较,差异均无统计学意义(P0.05)。治疗3d后,B组患者各项血气指标PH、PaO_2、PaCO_2、SaO_2较治疗前有明显改善,且具有统计学意义(P0.05),A组不明显,B组治疗效果较A组明显(P0.05)。治疗7d后对比指标的变化,A、B两组患者的CRP、WBC水平较前均有改善,且具有统计学意义(P0.05),B组下降幅度较A组明显(P0.05);A组简化CPIS评分、PCT指标前后无明显差异,B组治疗后较前明显下降(P0.05),且比A组改善更明显,具统计学意义(P0.05),且对比治疗前后两组患者的临床症状、体征、影像学表现等均有相应的改变。治疗情况比较:本研究中,B组的住院时间(14.18±3.18d)、机械通气时间(25.59h)及抗生素使用时间(7.05±1.20d)均比A组(20.30±4.59d、55.42h、12.83±2.72d)缩短,且具有统计学意义(P0.05)。治疗效果比较:B组病原体检出率56.9%,高于A组(43.1%),且两者具有显著差异性(P0.05)。而B组的改切率(37.1%)、病死率(40.0%)均低于相应A组的比率(62.9%、62.5%),具有统计学意义(P0.05)。病死率的影响因素分析:通过对本研究中所有因素进行分析发现,影响A、B两组病死率的主要因素是治疗前后的血气指标以及炎症指标。如:治疗后PH、PaO_2、PaCO_2、PCT、简化CPIS评分以及治疗前后均有意义的SaO_2、WBC、CRP等指标(P0.05),各指标均有实指意义。结论:1.纤维支气管镜灌洗法可明显改善血气指标和炎症指标,有效缓解患者的肺部感染症状;可间接降低患者的病死率、改切率,提高病原体的检出率,利于患者的远期神经功能恢复及卒中后生活质量的保障;同时缩短住院时间、机械通气时间及抗生素使用时间,减轻患者的经济负担,节约医疗资源。2.影响病死率的主要因素是治疗前后的血气指标以及炎症指标。治疗后PH、PaO_2、PaCO_2、PCT、简化CPIS评分等指标在判断肺炎治疗效果方面有积极意义。而对于治疗前后均有意义的SaO_2、WBC、CRP等指标,可以认为其在反映肺部治疗效果的同时,还可以评价患者入院的严重程度及预测患者的结局与预后。3.简化CPIS评分系统可以作为SAP危重患者的治疗效果和预后评估指标发挥作用,为今后的评价标准提供新的思路。
[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.
【学位授予单位】：延安大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R563.1;R743.3

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