摘要
目的对比行有创机械通气(MV)的慢性阻塞性肺病(COPD)患者使用持续气囊上滞留物引流(CSSD)与间断气囊上引流(ISSD)方法对下呼吸道分泌物细菌种类、数量的影响,研究其耐药趋势,为临床抗生素治疗提供参考,同时为气囊上滞留物冲洗在此类患者中的临床应用提供理论基础。方法连续性纳入2007年11月至2010年5月武汉市中心医院呼吸内科重症监护病房(RICU)114例进行有创机械通气治疗的COPD患者,随机分成对照组(A组,n=38)、间断气囊上冲洗组(B组,n=38)、持续气囊上引流组(C组,n=38)。于机械通气48h起,每隔3d留取气囊上滞留物及下呼吸道分泌物进行细菌分离、培养、鉴定及药敏测定,观察各组间细菌的差异、耐药情况及呼吸机相关性肺炎(VAP)的发病情况。结果 MV患者上、下呼吸道细菌培养以革兰阴性菌为主,主要为铜绿假单胞菌(24.8%),鲍曼不动杆菌(19.7%),大肠埃希菌(14.7%),肺炎克雷伯菌(11.1%)为主,革兰阳性菌则以金黄色葡萄球菌(13.1%)为主。各菌株对阿莫西林的耐药率均达到90%以上,耐药性严重。B组和C组下呼吸道细菌菌株总数与A组相比,有明显减少(P<0.01),主要以金黄色葡萄球菌数减少为主(P<0.05),其细菌总数、金黄色葡萄球菌菌株数与气囊上滞留物相比也有明显减少(P<0.05或P<0.01)。各组气囊上滞留物之间,B组与C组之间细菌菌株数没有显著差异(均P>0.05)。B、C两组早发性VAP发病率较A组减少,发病时间延缓(均P<0.05)。结论气管插管患者下气道分泌物以革兰阴性菌为主,耐药率有上升趋势。使用气囊上滞留物冲洗可减少气囊上细菌下移,特别是金黄色葡萄球菌,减少下呼吸道细菌感染,有助于合理使用抗生素,减少细菌耐药,并可减少早发性VAP发病率,具有较大的临床应用价值。
Objective To compare the effect of continuous subglottic secretion drainage（CSSD） and intermittent subglottic secretion drainage（ISSD） on species and amount of bacteria from the secretion of lower respiratory tracts in mechanically venti- lated COPD patients,and to research the trend of drug resistance for the purpose of guiding clinical treatment and providing the theoretic basis for the clinical application of SSD to COPD patients. Methods From Nov,2007 to May,2010,114 consecutive mechanically ventilated COPD patients in RICU were randomly divided into control group（n= 38）, ISSD group（n= 38） and CSSD group（n=38）. Forty-eight hours after mechanical ventilation, subglottic secretion and lower respiratory tracts secretion were isolated for bacterial culture and identification every three days. Antimicrobial susceptibility tests were performed. The drug resistance of bacteria and the incidence of ventilator-associated pneumonia（VAP） among the three groups were exam- ined. Results Bacterial culture in mechanically ventilated patients showed that the Gram-negative bacteria were predominant, including Pseudomonas aeruginosa （ 24.8 %）, Acinetobacter baumannii （ 19.7 % ） , Escherichia coli （ 14.7 % ） and Klebsiella pneumoniae （11.1%）. Staphylococcus aureus was the main Gram-positive bacteria（13.1%）. The resistance rates of amoxicillin in the bacteria reached 90 %. Bacterial strains from the secretion of lower respiratory tracts were markedly reduced in ISSD and CSSD groups compared with the control group（P〈0.01）. The Staphylococcus aureus occupied the first place in ISSD and CSSD groups（P〈0.05）. The total bacterial count and the amount of Staphylococcus aureus were obviously decreased from the lower respiratory secretion compared with the subglottic secretion（P〈0. 05 or P〈0.01）. There was no significant different in the total bacterial count between ISSD and CSSD groups（P〉0.05）. The incidence of early-onset VAP was lower in ISSD and CSSD groups than that in control group,and the onset of VAP was significantly delayed in the former two groups（P〈0.05）. Conclusion Gram-negative bacteria are the main bacteria in the secretion from the lower respiratory tracts of mechanically ven tilated COPD patients. The drug resistance of the bacteria tends to increase. SSD can reduce the bacteria, especially Staphylococ cus aureus, moving downward to the lower respiratory tract,and can reduce the lower respiratory infections. It facilitates reason able antibiotic therapy and reduces the incidence of early-onset VAP. It is of great value for clinical application.
出处
《华中科技大学学报（医学版）》
CAS
CSCD
北大核心
2013年第2期215-218,共4页
Acta Medicinae Universitatis Scientiae et Technologiae Huazhong
基金
武汉市卫生局临床医学科研项目(No.WX09B05)
关键词
气囊上滞留物冲洗
呼吸机相关性肺炎
细菌
耐药性
subglottic secretion drainage
ventilator-associated pneumonia
bacteria
drug resistance
