复方氯己定含漱液声门下冲洗引流对呼吸机相关性肺炎及其致病菌的影响研究

背景　人工气道的建立损害了口咽部及下呼吸道的生理保护屏障，使含有大量细菌的口咽分泌物及胃内容物积聚在声门下和气管套管气囊之间，成为呼吸机相关性肺炎（VAP）病原菌的重要来源。复方氯己定含漱液可抑制口腔内细菌的黏附和生长，杀灭多种致病菌。目的　研究复方氯己定含漱液进行声门下冲洗引流对VAP及其致病菌的影响。方法　采用前瞻性随机对照研究方法，选取2016年1月-2018年8月入住南昌大学第二附属医院急诊重症监护病房（ICU）及综合ICU需行经口人工气道建立和机械通气的患者120例，采用随机数字表法将其分为0.9%氯化钠溶液冲洗引流组（A组）60例和复方氯己定含漱液冲洗引流组（B组）60例。在常规护理基础下，A组每隔6 h使用0.9%氯化钠溶液冲洗并持续负压吸引，B组每隔6 h使用复方氯己定含漱液冲洗并持续负压吸引。观察终点为机械通气开始后第14天。分析两组患者VAP发生率、机械通气时间、ICU住院时间、限制级抗生素使用时间、声门下滞留物细菌培养菌落数、VAP患者下呼吸道分泌物中致病菌及耐药性。结果　B组VAP发生率低于A组，机械通气时间、ICU住院时间、限制级抗生素使用时间短于A组（P<0.05）。第3、6、9、12天，B组声门下滞留物细菌培养菌落数均少于A组（P<0.05）。B组VAP患者革兰阴性菌检出率低于A组，鲍曼不动杆菌多重耐药（MDR）、泛耐药（XDR）发生率低于A组（P<0.05）。结论　复方氯己定含漱液进行声门下冲洗引流可以明显减少机械通气患者VAP发生率、机械通气时间、ICU停留时间、限制级抗生素使用时间、声门下滞留物中的菌落数，还能明显减少VAP的主要革兰阴性菌致病菌及耐药性，可作为VAP的预防和治疗措施。

The Effect of Subglottic Secretion Drainage with Compound Chlorhexidine Gargle on Ventilator-associated Pneumonia

Background The establishment of artificial airway damages the physiological protective barrier of oropharynx and lower respiratory tract.A large number of bacteria accumulating between subglottic and tracheal cannula balloon is an important source of pathogenic bacteria of ventilator-associated pneumonia(VAP).Compound chlorhexidine gargle could inhibit bacterial adhesion and growth in oral cavity and kill many pathogenic bacteria.Objective To evaluate the effect of subglottic secretion drainage with compound chlorhexidine gargle on VAP.Methods It was a prospective randomized controlled study.From January 2016 to August 2018,120 patients receiving mechanical ventilation in EICU and ICU of the Second Affiliated Hospital of Nanchang University were randomly divided into A group and B group(60 patients in each group).Patients in B group was rinsed with compound chlorhexidine gargle every 6 hours and continuous negative pressure aspiration while patients in A group rinsed with normal saline.The end point of observation was the 14 th day after the beginning of mechanical ventilation.Incidence of VAP,lengths of mechanical ventilation,ICU stay,time of using antibiotics,colonies of pathogenic bacteria in subglottic secretion,bacteria and drug resistance in lower respiratory tract of VAP patients between two groups were compared.Results The incidence of VAP,lengths of mechanical ventilation time,ICU stay and time of using antibiotics in B group were significantly lower than those in A group(P<0.05).The subglottic secretion bacterial colonies in B group were significantly lower than that in A group on 3,6,9,12 d(P<0.05).The rate of Gram-negative bacilli of VAP patients in B group was significantly lower than that in A group(P<0.05),in which the MDR,XDR rate of Acinetobacter baumannii was significantly lower(P<0.05).Conclusion Subglottic secretion drainage with compound chlorhexidine gargle in patients with mechanical ventilation could significantly reduce the incidence of VAP,lengths of mechanical ventilation,ICU stay,time of using antibiotics,the number of colonies of subglottic secretion and Gram-negative pathogenic bacteria and drug resistance of VAP.It could be used as a preventive and therapeutic measure for VAP.