国内33家三甲医院ICU呼吸机相关性肺炎的流行病学研究

发布时间：2018-07-08 21:27

本文选题：呼吸机相关性肺炎 + 流行病学研究　；参考：《第三军医大学》2010年硕士论文

【摘要】： 背景上世纪50年代以来,机械通气(mechanical ventilation,MV)已在临床上广泛应用,成为ICU的主要治疗方式之一,是抢救伴有呼吸衰竭之危重患者的重要生命支持手段。但在取得明显治疗成果的同时,机械通气也带来了一些严重的并发症,如呼吸机相关性肺炎(ventilator associated pneumonia,VAP)。呼吸机相关性肺炎(VAP)是ICU最主要的医院内获得性肺炎(Hospital Acquired Pneumonia, HAP),占ICU所有HAP的85%左右[1]。国外流行病学调查结果显示,机械通气患者中VAP发生率约10-30%[1-3],年龄、食道返流、机械通气时间等为VAP的高危因素[1-4]。现有临床研究证实,VAP的发生将导致机械通气时间以及ICU住院天数延长,增加医疗花费,并影响预后[6-9]。因此,有效预防VAP发生具有重要的临床意义。美国医疗卫生质量改进委员会(Institute of Healthcare Improvement, IHI)2004年提出,接受机械通气患者应实施呼吸机集束化治疗(Ventilator Bundle)[10],措施包括:1.床头抬高30度以上;2.每日撤离镇静剂唤醒病人(Daily wake-up)并评估呼吸机撤离可能性(SBT);3.预防消化道溃疡;4.预防深静脉血栓。通过呼吸机Bundle的整体实施,有效降低了VAP发生率,证实了呼吸机Bundle是有效预防预防VAP发生的临床措施。然而,后续的研究结果存在较大的差异性[11-14]。其中,重要的问题之一是呼吸机Bundle临床依从性较差,影响其临床有效性。解放军309医院的一个单中心的实施机械通气Bundle前后对照研究表明,由于呼吸机Bundle临床依从性较差,在呼吸机Bundle实施前后对VAP发生率未发现显著影响[15]。因此,通过教育培训加强呼吸机Bundle概念的推广,同时实时检查与监督呼吸机Bundle的临床执行情况,对提高呼吸机Bundle的临床依从性,有效降低VAP发生率具有重要意义。目的了解目前国内ICU内VAP发生的整体情况、预防VAP基本措施的执行情况及临床效果,为能够摸索出一个适合于中国国情、临床依从性好并且切实有效的呼吸机Bundle方案并推广执行提供实践基础,探索合理的执行方法,为降低国内VAP发生率做出贡献。研究对象于2009年6月11日至2009年7月31日在全国33家3级甲等医院ICU连续选择气管插管机械通气患者共314例。方法对各研究中心目前机械通气治疗方法不进行任何干预,沿用各中心经验性治疗。实验开始前分地域分批次对各研究中心指定项目负责人进行研究目的、观察指标、CRF表格填写要求的集中培训,各研究中心指定项目负责人负责对所在中心项目参与者进行后续培训,研究过程全程专人负责对各研究中心进行相关问题指导。以CRF表格形式采集临床资料。各研究中心每日填写研究日志,如实记录当天该研究中心内机械通气总病例数、入选病例数、未入选病例数及未入选原因。临床资料用Epidata软件盲法双录入方法录入、检查,确认实验数据无误后进行数据导出,应用SAS统计软件进行统计分析。结果本研究共入选患者314例。平均年龄60.85±15.97岁,最小年龄18岁,最大年龄80岁;入选患者中男性209例(66.56%);机械通气原因为内科疾病者184例(58.60%),外科疾病者130例(41.40%);平均APACHEⅡ评分为19.19±6.63分;所有入选病例的平均床头抬高角度为23.46±6.99度;发生VAP病例数为125例,VAP发生率为39.81%;总的机械通气日为2482天,每千机械通气日VAP例数为50.36/千机械通气日;28天随访结果死亡病例为105例,28天病死率为33.44%;ICU内死亡病例为59例,占28天死亡病例比例56.19%;与VAP相关死亡病例为27例,占28天死亡病例比例为25.71%。发生VAP组与未发生VAP组间各指标比较分析,平均APACHEⅡ评分、ICU住院天数、机械通气时间、平均床头抬高角度、ICU内死亡率等5个变量间明显差异。根据机械通气时间不同将入选病例分为机械通气时间≤3天、4-7天、7天3组,组间VAP发生率分别为18.03%、42.53%、57.30%,差异有统计学意义,提示随机械通气时间延长,VAP发生率增高。对预防VAP基本措施的临床执行情况进行了分组分析,其中,床头抬高角度完全在30°以上组的VAP发生率要低于床头高角度完全在30°以下组,床头抬高角度完成情况并没有随着机械通气时间的延长而显著下降。根据入ICU时间先后,以7月10日为分组时间点,将入选病例分为前后两组。两组间数据比较,平均床头抬高角度和VAP发生率2个变量组间统计分析有显著差异。结论(1)本研究通过采用多中心的流行病学研究,对国内33家三甲医院ICU的VAP进行了流行病学研究,从一定程度上反映了目前国内大型医院ICU内VAP的发生情况。研究表明,参研中心整体的VAP发生率(39.81%)略高于国外发达国家水平。需要采取有效地干预措施预防VAP的发生。(2) VAP的发生可以延长患者的ICU住院天数和机械通气时间,同时对ICU内病死率有明显影响。(3)接受机械通气治疗的患者入ICU时整体状况越差,其发生VAP的可能性越大;接受机械通气治疗时间越长,VAP的发生率越高。(4)床头抬高≥30°是有效预防VAP发生的影响因素之一。(5)床头抬高角度≥30°还没有被广泛实施,其临床执行率非常低。通过加强对医护人员的教育培训,其临床依从性可以得到改善。
[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.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R181.3

【引证文献】