医院获得性肺炎的预防

医院获得性肺炎的预防,北京协和医院杜斌,医院获得性肺炎 现状,ICU患者医院获得性肺炎罹患率10 65%影响预后的重要因素ICU住院时间延长4.3天 (95% CI, 1.5 7.0天)死亡危险增加5.8% (95%CI, 2.4 14.0%),医院获得性肺炎 危险因素,明确误吸COPD应用抗酸药物或H2受体阻滞剂平卧位昏迷胃肠营养经鼻胃管,再次插管气管切开患者转运ARDS既往应用抗生素年龄 60岁颅脑损伤颅内压监测装置,医院获得性肺炎 发病机制,改变胃排空及胃液pH值的药物,有生物膜的装置(气管插管, 鼻胃管),既往应用抗生素,宿主因素(免疫抑制, 烧伤),消化道细菌定植,细菌误吸,细菌吸入,医院获得性肺炎,水, 药物溶液及呼吸治疗装置污染,感染控制措施不够(洗手, 隔离衣, 手套),医务人员不足,经胸种植原发性菌血症胃肠道细菌移位,医院获得性肺炎 发病机制,医院获得性肺炎 预防措施,细菌定植(口咽, 胃, 鼻窦),污染分泌物误吸/呼吸机管路冷凝物/气雾剂,医院获得性肺炎,医院获得性肺炎发病机制,医院获得性肺炎预防措施,避免不必要的抗生素使用避免不必要的应激性溃疡预防硫醣铝预防应激性溃疡经口气管插管洗必太口腔清洗选择性胃肠道去污染短疗程胃肠外抗生素使用适当洗手,避免气管插管/无创通气缩短机械通气时间半卧位避免胃过度膨胀声门下分泌物引流避免频繁更换呼吸机管路/操作引流呼吸机管路中的冷凝水避免患者转运避免意外拔管,医院获得性肺炎 预防措施,细菌定植(口咽, 胃, 鼻窦),污染分泌物误吸/呼吸机管路冷凝物/气雾剂,医院获得性肺炎,医院获得性肺炎发病机制,医院获得性肺炎预防措施,避免不必要的抗生素使用避免不必要的应激性溃疡预防硫醣铝预防应激性溃疡经口气管插管洗必太口腔清洗选择性胃肠道去污染短疗程胃肠外抗生素使用适当洗手,避免气管插管/无创通气缩短机械通气时间半卧位避免胃过度膨胀声门下分泌物引流避免频繁更换呼吸机管路/操作引流呼吸机管路中的冷凝水避免患者转运避免意外拔管,医院获得性肺炎的预防措施,避免或缩短机械通气避免气管插管(NPPV)缩短机械通气时间减少误吸引发的肺炎避免鼻窦炎减少胃肠道潴留减少胃肠道细菌定植减少误吸减少吸入引发的肺炎减少呼吸道操作物理治疗与气道管理其他措施人力资源配备预防性抗生素,医院获得性肺炎的预防措施,避免或缩短机械通气避免气管插管(NPPV)缩短机械通气时间减少误吸引发的肺炎避免鼻窦炎减少胃肠道潴留减少胃肠道细菌定植减少误吸减少吸入引发的肺炎减少呼吸道操作物理治疗与气道管理其他措施人力资源配备预防性抗生素,避免气管插管 无创通气与COPD,避免气管插管 无创通气与COPD,避免气管插管 无创通气与CHF,避免气管插管 无创通气与CHF,缩短机械通气时间 计划脱机,Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol Weaning of Mechanical Ventilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses: Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia. Chest 2000; 118: 459-467,缩短机械通气时间 计划脱机,Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol Weaning of Mechanical Ventilation in Medical and Surgical Patients by Respiratory Care Practitioners and Nurses: Effect on Weaning Time and Incidence of Ventilator-Associated Pneumonia. Chest 2000; 118: 459-467,缩短机械通气时间 每日中断镇静,Kress JP, Pohlman AS, OConnon MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477,医院获得性肺炎的预防措施,避免或缩短机械通气避免气管插管(NPPV)缩短机械通气时间减少误吸引发的肺炎避免鼻窦炎减少胃肠道潴留减少胃肠道细菌定植减少误吸减少吸入引发的肺炎减少呼吸道操作物理治疗与气道管理其他措施人力资源配备预防性抗生素,避免鼻窦炎 经口气管插管,经口气管插管患者VAP患病率低鼻窦炎患病率低没有鼻窦炎的患者VAP患病率低推荐意见: 需要插管时应采取经口气管插管途径,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,鼻窦炎与医院获得性肺炎,医院获得性肺炎的预防 鼻窦炎,P 3天)机械通气患者最有效,医院获得性肺炎的预防 声门下分泌物,声门下分泌物引流可降低VAP的发生率特别是早发性VAP推荐意见: 推荐应考虑进行声门下分泌物引流,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,医院获得性肺炎的预防措施,避免或缩短机械通气避免气管插管(NPPV)缩短机械通气时间减少误吸引发的肺炎避免鼻窦炎减少胃肠道潴留减少胃肠道细菌定植减少误吸减少吸入引发的肺炎减少呼吸道操作物理治疗与气道管理其他措施人力资源配备预防性抗生素,洗手/消毒措施,减少吸入 减少管路更换频率,减少吸入 减少管路更换频率,呼吸机管路的更换频率不影响VAP发生率较少更换呼吸机管路没有明显危害频繁更换呼吸机管路增加医疗费用推荐意见: 推荐对每名新患者应用新的呼吸机管路, 如果管路有污染则进行更换, 但无需常规更换呼吸机管路,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,减少吸入 警惕湿化装置,常规加热湿化装置冷凝水产生量20 40ml/hr培养2.0 x 105 cfu/ml从患者痰液中培养的52株GNB有73%随后也可从冷凝水中培养出来,减少吸入 警惕湿化装置,清除呼吸机管路中的冷凝水并进行适当的处理污染的冷凝水可以经收集系统在病房之间传播, 造成耐药细菌感染的爆发流行人工鼻(HME)能够在很大程度上减少冷凝水的聚集降低VAP的危险常规检查所有呼吸机管路是否有冷凝水聚集, 并迅速加以清除,湿化装置的选择 人工鼻 vs. 加热湿化器,人工鼻(HME) vs. 湿化器(n = 5)OR 0.41 (0.20 0.86)OR 0.34 (p 0.05)OR 0.66 (p 0.05)OR 0.68 (p 0.05)OR 0.86 (p 0.05),减少吸入 减少人工鼻的更换频率,减少人工鼻(HME)的更换频率5天 vs. 2天OR 0.83 (p 0.05),医院获得性肺炎的预防 湿化装置,较少更换呼吸机管路不增加VAP发病率推荐级别: I较少更换人工鼻不增加VAP发病率推荐级别: IIa降低医疗费用, 可以考虑用于所有机械通气患者人工鼻 vs. 湿化器临床试验结果存在差异,医院获得性肺炎的预防 湿化装置,湿化器种类使用人工鼻(HME)可以轻度降低VAP发生率新型人工鼻不增加气管插管阻塞的副作用人工鼻的费用较低推荐意见: 推荐没有禁忌症(咯血或需要高分钟通气量)的患者应用人工鼻更换湿化器频率较少更换人工鼻可能轻度降低VAP发生率减少更换湿化器的频率可以降低医疗费用推荐意见: 推荐每周更换人工鼻,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,医院获得性肺炎的预防 吸痰系统,吸痰系统的种类(开放式或密闭式)不影响VAP发生率每日更换或无规律更换密闭式吸痰系统不影响VAP发生率应用密闭式吸痰系统, 且仅在必要时更换, 能够降低医疗费用推荐意见: 推荐使用密闭式吸痰系统, 用于新患者或临床必要时方予更换,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,物理治疗与气道管理 俯卧位,俯卧位能够降低VAP发生率研究存在方法学缺陷普遍推广的可行性推荐意见: 没有任何推荐意见,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,物理治疗与气道管理 翻身床,物理治疗与气道管理 翻身床,翻身床对内科患者并无益处现有证据表明, 翻身床对外科或神经系统疾病的患者非常有效推荐级别: I在上述患者应考虑使用翻身床,医院获得性肺炎的预防 翻身床,使用翻身床可以减少VAP发生率可行性医疗费用推荐意见: 推荐临床医生应考虑使用翻身床,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,胸部物理治疗,胸部物理治疗可以减少VAP发生率研究存在方法学缺陷推广缺乏可行性推荐意见: 没有任何推荐意见,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,气管切开时机与患者预后,机械通气天数r = 0.690,ICU住院日r = 0.610,Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med 2005; 33: 2513-2520,气管切开时机与患者预后,住院病死率,医院获得性肺炎,Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ,气管切开时机与患者预后,机械通气时间,ICU住院日,Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ,物理治疗与气道管理 气管切开时机,早期及晚期气管切开患者VAP发生率没有差异方法学存在严重错误推荐意见: 由于缺乏证据, 没有任何推荐意见,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,医院获得性肺炎的预防措施,避免或缩短机械通气避免气管插管(NPPV)缩短机械通气时间减少误吸引发的肺炎避免鼻窦炎减少胃肠道潴留减少胃肠道细菌定植减少误吸减少吸入引发的肺炎减少呼吸道操作物理治疗与气道管理其他措施人力资源配备预防性抗生素,其他措施 人力资源配置,增加总护理时间内科患者住院日- 3.5 (1.5 5.7).01泌尿系感染- 9.0 (6.1 11.9) 72 h(n = 100),插管后静脉头孢呋肟1.5 g x 2(n = 50),对照组(n = 50),预防性抗生素(n = 17),未用抗生素(n = 33),12 (24%),4 (23%),21 (64%),Sirvent JM, Torres A, El-Ebiary M, et al: Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 1997; 155: 17291734,P = 0.016,P = 0.007,早发性肺炎70% (26/37),预防性抗生素: 迟发性肺炎,Hoth JJ, Franklin GA, Stassen NA, et al: Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients. J Trauma 2003; 55: 249254,预防性抗生素,早发性肺炎高危患者(颅脑创伤, 昏迷, 高危手术后)24小时内迟发性肺炎不能减少肺炎发生肺炎发生时间推迟耐药细菌比例增加,输血与医院获得性肺炎,Shorr AF, Duh M-S, Kelly KM, et al: Red blood cell transfusion and ventilator-associated pneumonia. A potential link? Crit Care Med 2004; 32(3):666-674,输血与医院获得性肺炎,Shorr AF, Duh M-S, Kelly KM, et al: Red blood cell transfusion and ventilator-associated pneumonia. A potential link? Crit Care Med 2004; 32(3):666-674,医院获得性肺炎的预防,预防措施的实施,医院获得性肺炎的预防 国家间的差异,7项措施法国ICU 64% vs. 加拿大ICU 30% (p = 0.002),Cook D, Ricard JD, Reeve B, et al: Ventilator circuit and secretion management strategies: A Franco-Canadian survey. Crit Care Med 2000; 28:35473554,医院获得性肺炎的预防,不依从率37.0%,推荐临床使用的措施不依从率: 25.2%,效果不太显著的措施不依从率: 45.6%,Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661,OR 1.80,医院获得性肺炎的预防,不依从率37.0%,药物措施不依从率: 57.4%,非药物措施不依从率: 19.6%,Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661,推荐临床使用的措施不依从率: 78.9%,效果不太显著的措施不依从率: 38.9%,推荐临床使用的措施不依从率: 16.4%,效果不太显著的措施不依从率: 23.4%,医院获得性肺炎的预防,Rello J, Lorente C, Bodi M, et al: Why physicians do not follow evidence-based guidelines for preventing ventilator-associated pneumonia? A survey based on the opinions of an international panel of intensivists. Chest 2002; 122:656661,专家组对预防措施的评价(n = 10),完全不同意,完全同意,1,9,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,9.0,8.2,8.9,8.5,8.6,7.9,7.2,8.6,8.8,专家组对预防措施的评价(n = 10),完全不同意,完全同意,1,9,Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, Muscedere J, Foster D, Mehta N, Hall R, Brun-Buisson C, for the Canadian Critical Care Trials Group and the Canadian Critical Care Society. Evidence-Based Clinical Practice Guideline for the Prevention of Ventilator-Associated Pneumonia. Ann Intern Med 2004; 141: 305-313,8.0,8.5,8.3,8.3,8.2,医院获得性肺炎 非药物预防措施,医院获得性肺炎 药物预防措施,医院获得性肺炎 非药物预防措施,医院获得性肺炎 非药物预防措施,医院获得性肺炎 非药物预防措施,医院获得性肺炎 药物预防措施,医院获得性肺炎 药物预防措施,医院获得性肺炎的预防 半卧位,患者采取半卧位的决定因素护士: 医嘱特别说明医生: 护士的喜好,患者采取半卧位的主要障碍其他可以选择的体位禁忌症可能的危险安全性缺乏相关资源,Cook DJ, Meade MO, Hand LE, et al: Toward understanding evidence uptake: Semirecumbency for pneumonia prevention. Crit Care Med 2002; 30:14721477,医院获得性肺炎的预防 宣教,Babcock HM, Zack JE, Garrison T, et al: An educational interventi