老年吸入性肺炎患者早期纤维支气管镜吸痰的临床观察

目的观察早期纤维支气管镜吸痰用于老年吸入性肺炎的临床疗效,评价其实际应用价值。方法选择80例老年吸入性肺炎患者,随机分为观察组与对照组各40例,观察组采用早期纤维支气管镜吸痰进行治疗,对照组采用传统疗法进行治疗,对两组治疗后呼吸频率、心率、肺部湿罗音、影像学检查结果进行比较分析,观察组间是否存在统计学差异。结果应用早期纤维支气管镜吸痰治疗的观察组疗效明显优于使用传统疗法进行治疗的对照组,组间比较差异具有统计学意义(P<0.05)。结论早期纤维支气管镜吸痰治疗老年吸入性肺炎,疗效显著,值得临床推广应用。     

Predicting ICU admission in community-acquired pneumonia: clinical scores and biomarkers

Community-acquired pneumonia (CAP) remains a common and serious worldwide health problem. Despite all the advances in therapy, significant interest has focused on the identification of patients with CAP who require intensive care unit admission to improve their outcomes. The severity assessment of CAP provides an important guide to clinicians in deciding the site of care and the use of empiric antibiotics and adjuvant therapy. For years, several clinical assessment scores have been suggested and validated to achieve this goal. The recent introduction of biomarkers as prognostic indicators of severe CAP, whether used alone or in conjunction with other clinical severity of illness scores, has been investigated. An objective scoring system with a high level of sensitivity and specificity to predict the severity of CAP and the need for high levels of care do not exist. Today, the addition of clinical scores and biomarkers to clinical judgment is the best approach to optimize the care of severe CAP. Future research will allow validation of these and newer tools to improve the prognosis of patients with CAP.     

灸法配合中药辨证治疗婴幼儿肺炎后期57例

目的:观察灸法配合中药辨证治疗婴幼儿肺炎后期(包括迁延性肺炎)啰音久不消失的疗效.方法:取背部肩胛下区或腋下啰音最明显处以及肺俞、百劳、膏肓、定喘等为主穴,用艾条灸,配合中药辨证治疗.结果:病程在9～20 d的肺炎后期患儿,治愈时间平均3.6 d;病程在31～37 d的迁延性肺炎患儿,治愈时间平均5.8 d.结论:灸法配合中药辨证治疗婴幼儿肺炎后期疗效好,宜在临床推广应用.     

Genotyping of Mycoplasma pneumoniae isolates using real-time PCR and high-resolution melt analysis

Mycoplasma pneumoniae is an important respiratory pathogen, accounting for up to 25% of community-acquired pneumonia, and is a common cause of hospitalized pneumonia in otherwise healthy adults and children. Mycoplasma pneumoniae isolates can be classified into two main genomic groups (type 1 and type 2) based on sequence variation within the gene encoding the major adhesion molecule P1. Although numerous publications have described real-time PCR assays for the detection of M. pneumoniae , none has been able to discriminate the two genomic types. Here, a real-time PCR assay that can distinguish each type of M. pneumoniae utilizing high-resolution melt-curve analysis is reported. Using this method, 102 isolates obtained from patients from 1965 to the present, including those from recent outbreaks, were typed along with reference strains M129 (type 1) and FH (type 2). The results show that 55 isolates (54%) can be classified as type 1 and 47 isolates (46%) as type 2, and 100% correlation was demonstrated when compared with a standard PCR-restriction fragment length polymorphism typing procedure. Typing of isolates obtained from recent outbreaks in the USA has revealed the presence of both types. This assay provides a rapid, reliable and convenient method for typing M. pneumoniae isolates and may be useful for surveillance purposes and epidemiological investigations, and may provide insight into the biology of M. pneumoniae distribution within populations.     

Monitoring of herpes simplex virus in the lower respiratory tract of critically ill patients using real-time PCR: a prospective study

Herpes simplex virus (HSV) has increasingly been associated with pulmonary disease in critically ill patients. However, the clinical relevance of HSV is still a topic of debate. Monitoring of HSV in a quantitative way could potentially give relevant information on its role in the pathogenesis of lower respiratory tract infection. A fast and reliable quantitative real-time PCR (Q-PCR) for the quantitative detection of HSV-1 and HSV-2 DNA was developed. A prospective observational study was performed in an intensive-care unit (ICU) to monitor the HSV viral load in lower respiratory tract aspirates of long-term mechanically ventilated patients. HSV was common in the lower respiratory tract (LRT) of critically ill patients with mechanical ventilation for at least 48 h (62%, n  = 65/105). Detection of HSV was significantly associated with prolonged mechanical ventilation (p <0.01), prolonged ICU stay (p <0.01), and development of ventilator-associated pneumonia (p = 0.02). Corticosteroid administration (p <0.01) in the ICU and anti-HSV IgG seropositivity (p <0.01) were risk factors for the occurrence of HSV in the LRT. The fact that no HSV-seronegative patient became positive suggests that all HSV DNA-positive patients had HSV reactivations. Monitoring the HSV viral load in the LRT of critically ill patients showed a typical homogeneous pattern of HSV kinetics. HSV emerged in tracheal and bronchial aspirates after a median of 7 days of intubation (5–11 days), and this was followed by an exponential increase ( c. 1 log copies/mL/day) to reach very high HSV peaks (10⁶–10¹⁰ copies/mL) in 78% of the HSV DNA-positive patients.     

Memory B cell response to a PCV-13 booster in 3.5 year old children primed with either PCV-7 or PCV-13

Pneumococcal protein-polysaccharide conjugate vaccines provide direct protection against Streptococcus pneumoniae through the induction of persistent anti-polysaccharide antibodies, and by priming for a rapid secondary antibody response. Memory B cells (B_MEM) generated during an initial immune response are responsible for both the more rapid and quantitatively greater secondary antibody response and are also thought to contribute to the ongoing production of plasma cells providing long-term antibody persistence. We recruited 3.5-year-old children who had participated in a previous clinical trial comparing infant immunization with either a 7-valent (PCV-7) or a 13-valent pneumococcal conjugate vaccine (PCV-13) to investigate whether prior priming with pneumococcal antigens influences B_MEM responses. Blood was taken before and 1 month after a PCV-13 booster. B_MEM were quantified using a cultured ELISpot assay for pneumococcal serotypes 1, 3, 4, 14, 19A, 23F, and with diphtheria and tetanus toxoid as controls, and then correlated with serotype-specific IgG concentrations and opsonophagocytic activity (OPA) titers. In total, blood samples from 62 participants were available for analysis. Serotype-specific B_MEM frequencies were generally low at baseline (before boost) although for serotypes 14 and 3, they were significantly higher in children primed with PCV-13 than PCV-7 primed children. Following the PCV-13 booster, B_MEM frequencies increased and were not different between the groups for all serotypes. A strong inverse correlation was found between antibody concentrations and OPA titers at baseline and B_MEM following booster vaccination for serotype 3 but not for other serotypes suggesting that, for this serotype, pre-existing serotype-specific antibodies may inhibit B_MEM formation in response to vaccination.Clinicaltrials.gov registration number: NCT01095471.     

优质护理对COPD气管插管患者预防呼吸机相关性肺炎的效果分析

目的探究优质护理对COPD气管插管患者预防呼吸机相关性肺炎的应用效果。方法选取120例COPD气管插管患者,采用随机数字表法随机均分为研究组与对照组各60例,对照组采用常规护理方法,研究组在常规护理方法的基础上采用优质护理,主要包括合理应用抗生素、有效排痰、消化系统交叉感染预防、降低医源性感染概率等措施。分析2组患者治疗前后的血气指数变化情况,以及2组患者的机械通气时间、住院时间、呼吸机相关肺炎发生例数。结果 2组患者治疗后血气分析指数均有较大改善;研究组患者的平均总通气时间为(8±3.5)d,对照组患者的平均总通气时间为(14±4.0)d;研究组发生呼吸机相关肺炎的患者例数为3例(5.0%),对照组发生呼吸机相关肺炎的患者例数为10例(16.67%),差异有统计学意义(P0.05)。结论优质护理与常规护理均能有效改善患者呼吸状况,但是在对呼吸机相关性肺炎的预防以及缩短患者治疗时间的改善上,优质护理具有更好的应用效果。     

社区获得性肺炎结局的现状与思考

基于社区获得性肺炎结局研究的思路转变,即强调具有临床意义的结局而不是简单依赖于生理或生物结局,应从短期的生物学终点朝向于远期终点的变化,着重从实验室检查结局(致病菌的清除和肺部病变吸收)、临床结局(死亡率、再住院率、住院的并发症、病情稳定时间、症状与体征、功能或生活质量等)和卫生经济学指标的结局(直接医疗和间接医疗方面等)等方面介绍社会获得性肺炎患者结局的现状,并对有关问题进行讨论.     

Care of the Intubated Emergency Department Patient

Background: Emergency physicians perform tracheal intubation and initiate mechanical ventilation for critically ill patients on a daily basis. With the current national challenges of intensive care unit bed availability, intubated patients now often remain in the emergency department (ED) for exceedingly long periods of time. As a result, care of the intubated patient falls to the emergency physician (EP). Given the potential for significant morbidity and mortality, it is crucial for the EP to possess the most current, up-to-date information pertaining to the care of intubated patients. Discussion: This article discusses critical aspects in the ED management of intubated and mechanically ventilated patients. Specifically, emphasis is placed on providing adequate sedation and analgesia, limiting the use of neuromuscular blocking agents, correctly setting and adjusting the mechanical ventilator, utilizing appropriate monitoring modalities, and providing key supportive measures. Despite these measures, inevitably, some patients deteriorate while receiving mechanical ventilation. The article concludes with a discussion outlining a step-wise approach to evaluating the intubated patient who develops respiratory distress or circulatory compromise. With this information, the EP can more effectively care for ventilated patients while minimizing morbidity, and ultimately, improving outcome. Conclusion: Essential components of the care of intubated ED patients includes administering adequate sedative and analgesic medications, using lung-protective ventilator settings with attention to minimizing ventilator-induced lung injury, elevating the head of the bed in the absence of contraindications, early placement of an orogastric tube, and providing prophylaxis for stress-related mucosal injury and deep venous thrombosis when indicated.     

重症甲型H1N1流感合并两肺弥漫性肺炎的抢救体会

目的：分析22例重症甲型H1N1流感合并两肺弥漫性肺炎患者的临床资料,总结临床抢救体会。方法：回顾分析收治的22例重症甲型H1N1合并两肺弥漫性肺炎患者的临床资料进行。结果：22例患者年龄39.9±12.7岁,临床症状以发热、咳嗽、胸痛、呼吸困难及低氧血症为主要特征,部分患者出现消化道症状、休克;外周血白细胞计数较正常值偏低,X线胸片或胸部CT提示双侧广泛性或多肺叶性的弥漫性病变;22例患者均给予抗病毒治疗（奥司他韦75mg或150mg,每日2次口服）,全部患者均应用激素治疗,甲基强的松龙80~240mg.d-1,平均治疗剂量为136.4±58.8mg.d-1,14例患者采用无创机械通气治疗,2例患者经气管插管行机械通气治疗,2例患者死亡。结论：重症甲型H1N1流感合并两肺弥漫性肺炎患者临床症状进展快、病情重,需尽早应用抗病毒药物、合理地应用全身性糖皮质激素等治疗,同时予积极合理地氧疗,机械通气能增强氧疗的效果、迅速改善病情、改善预后。