呼吸机相关性肺炎预防护理新进展

呼吸机相关性肺炎(Ventilator-associated pneumonia,VAP)是机械通气患者最常见的医院内感染,其发病率和病死率高,本文对国内外VAP的预防和护理进展做一综述,旨在找出有效的、实用的措施来预防VAP的发生.     

预见性气道局麻后吸痰对重型颅脑损伤术后患者高原波的影响

目的：探讨重型颅脑损伤（ sTBI）术后患者预见性使用利多卡因气道给药后吸痰对颅内压（ ICP）、高原波Lundberg－A波和B波、呼吸机相关性肺炎（ VAP）的影响。方法50例行ICP监测和人工气道开放的重型颅脑损伤术后患者随机分为治疗组和对照组，每组各25例。治疗组在吸痰前ICP≥20 mm Hg，则预见性使用利多卡因气道麻醉，ICP＜20 mm Hg时与对照组一样均行常规吸痰。记录术后5 d吸痰前后每天4个时点ICP变化、Lundberg－A和B波发生频次及其吸痰前后ICP变化和7 d内VAP发生率。结果两组常规吸痰ICP均升高。治疗组预见性气道局麻后吸痰，Lundberg－A波频次低，峰值低，VAP发生率26．09％；对照组Lundberg－A波频次高，峰值高，VAP发生率29．17％；未证实气道麻醉吸痰与否和Lundberg－B波形成有关。结论预见性利多卡因气道给药后吸痰，能提高sTBI患者术后Lundberg－A波发生阈值，降低频次及峰值。     

ICU中呼吸机相关性肺炎的护理体会

目的：探讨ICU病房中呼吸机相关性肺炎的护理体会。方法：选择我院ICU病房2008年5月至2010年3月收治的66例行机械通气治疗的患者,进行全方面的护理,对护理效果进行评价,并与对照组66例患者进行比较。结果：实验组有12例发生呼吸机相关性肺炎,发病率为18.9%,显著对于对照组。实验组17例为混合细菌感染,8例为单一细菌感染,2例为真菌感染。细菌感染中,铜绿假单胞菌12例,大肠埃希氏菌9例,不动杆菌7例,MRSA 5例,肺炎克雷伯菌3例,肺炎链球菌2例。两组患者的病原菌株分布差异无统计学意义。结论：对ICU病房VAP患者进行综合的护理,可以取得较好的效果。     

呼吸机相关性肺炎的预防与管理

随着诊疗监护技术的发展,机械通气的临床应用逐渐增多。在危重患者抢救成功率不断提高的同时,机械通气所带来的并发症对医护工作者是一大挑战,尤其是呼吸机相关性肺炎（VAP）的发生越来越受到关注,控制和减少VAP的高发率、高死亡率,重点在于加强预防。采取有效措施预防VAP的发生,对于降低病死率、减少住院时间和医疗费用,节约医疗资源具有重要意义,其中护理干预在预防VAP的发生起着举足轻重的作用。     

Endotracheal tube biofilm inoculation of oral flora and subsequent colonization of opportunistic pathogens

Endotracheal (ET) tubes accumulate a biofilm during use, which can harbor potentially pathogenic microorganisms. The enrichment of pathogenic strains in the biofilm may lead to ventilator-associated pneumonia (VAP) with an increased morbidity rate in intensive care units. We used quantitative PCR (qPCR) and gene surveys targeting 16S rRNA genes to quantify and identify the bacterial community to detect fastidious/nonculturable organisms present among extubated ET tubes. We collected eight ET tubes with intubation periods between 12 h and 23 d from different patients in a surgical and a medical intensive care unit. Our qPCR data showed that ET tubes were colonized within 24 h. However, the variation between patients was too high to find a positive correlation between the bacterial load and intubation period. We obtained 1263 near full-length 16S rRNA gene sequences from the diverse bacterial communities. Over 70% of these sequences were associated with genera of typical oral flora, while only 6% were associated with gastrointestinal flora. The most common genus identified was Streptococcus (348/1263), followed by Prevotella (179/1263), and Neisseria (143/1263) with the highest relative concentrations for ET tubes with short intubation periods, indicating oral inoculation of the ET tubes. Our study also shows that even though potentially pathogenic bacteria existed in ET tube biofilms within 24 h of intubation, a longer intubation period increases the opportunity for these organisms to proliferate. In the ET tube that was in place for 23 d, 95% of the sequences belonged to Pseudomonas aeruginosa, which is a bacterial pathogen that is known to out compete commensal bacteria in biofilms, especially during periods of antibiotic treatment. Harboring such pathogens in ET biofilms may increase the chance of VAP, and should be aggressively monitored and prevented.     

重症监护病房呼吸机相关性肺炎的危险因素分析

目的探讨重症监护病房呼吸机相关性肺炎（VAP）的危险因素。方法将158例患者分为VAP组和非VAP组,并对患者的基本情况、原发疾病、APACHEⅡ评分、意识状态、通气方式等因素进行比较分析。结果 VAP的发生与患者的年龄、APACHEⅡ评分、意识状态、口咽部或是呼吸机部件生物污染、机械通气方式和时间以及抗生素联合应用种类等因素有相关性（P〈0.05）。结论在呼吸机的使用过程中,加强对各危险因素的监测,能降低VAP的并发率。     

急诊EICU病房呼吸机相关性肺炎98例流行病学分析

目的分析急诊重症监护病房呼吸机相关肺炎（ventilator associated pneumonia简称VAP）的致病菌,探讨VAP的发病机制及预防措施。方法对本院急诊重症监护病房行气管插管或气管切开98例患者为对象,分为感染组和对照组,分析VAP患者的临床资料、病原菌构成。同时抽取两组血清,比较TNF-A、IL-2的浓度值。结果 VAP发生率42.86%。革兰阴性杆菌占81.43%,前3位致病菌分别是铜绿假单胞菌（28.57%）、鲍曼不动杆菌（18.57%）和肺炎克雷伯杆菌（15.71%）。细菌耐药率较高。与对照组相比较,感染组患者的死亡率显著高于对照组。与对照组相比,感染组患者的TNF-Α、IL-1的含量明显上升P（〈0.05）。结论重症监护病房VAP的致病菌以革兰阴性杆菌为主且呈多重耐药现象,通过内毒素或外毒素刺激细胞免疫系统,分泌致炎细胞因子,同时激活凝血途径,加重病情。     

术后监护室呼吸机相关性肺炎病原菌的分布及耐药情况分析

目的探讨我院胸外科术后监护室呼吸机相关性肺炎（VAP）病原菌分布及耐药情况,指导临床合理用药。方法对气管插管或气管切开机械通气超过48h的16例患者的下呼吸道分泌物,进行细菌培养及对抗菌药物敏感性测定。结果16例VAP患者下呼吸道分泌物培养检出病原菌61株,革兰阴性杆菌占49.2％,革兰阳性球菌占19．7％,真菌占31．1％。革兰阳性球菌对青霉素、头孢菌素、碳青酶烯类、氨基糖甙类抗生素均耐药;对万古霉素、利奈唑胺敏感,敏感率为100％;对利福平较为敏感,敏感率为83.3％;鲍曼不动杆菌对阿米卡星敏感,对碳青酶烯类较为敏感;肺炎克雷伯菌对阿米卡星、碳青酶烯类、哌拉西林／他唑巴坦敏感;铜绿假单胞菌对环丙沙星、左氧氟沙星、阿米卡星、碳青酶烯类、哌拉西林／他唑巴坦敏感;大肠埃希菌对阿米卡星、碳青酶烯类敏感;对于培养出的真菌对抗真菌药物耐药率不高。结论VAP的主要病原菌包括杆菌、球菌和真菌。杆菌和球菌存在较严重的耐药现象,进行细菌培养和药物敏感性分析,对合理选用抗菌药物治疗VAP患者具有重要意义。而在培养及药敏试验结果出来之前,可以根据痰细菌涂片的结果进行经验性用药。