重症社区获得性肺炎诊断治疗进展

1、 重症社区获得性肺炎（重症社区获得性肺炎（SCAP）研究热点）研究热点 病情严重性的评估病情严重性的评估 病原学病原学 诊断实验诊断实验 治疗方法治疗方法 需要机械通气需要机械通气 48h 内肺部浸润扩大内肺部浸润扩大50% 脓毒性休克脓毒性休克 急性肾功能损害急性肾功能损害 呼吸频率呼吸频率30 次次/m in PaO 2/FiO2250 病变累及双肺或多肺叶病变累及双肺或多肺叶 收缩压收缩压90mmHg 舒张压舒张压 60mmHg 符合符合1 条主要标准或者条主要标准或者2 条次要标准条次要标准 方可诊断方可诊断 有无或有无脱水 30/ 分 20/ 分呼吸频率 130/ 分 100/ 分脉

2、搏 38. 6 30次次/min +20 SBP 90 mm Hg +20 T 40C +15 P 125/min +10 实验室和实验室和X线发现线发现 pH 30 mg/dl +20 Na 250 mg/dl +10 血细胞压积血细胞压积 30% +10 PaO2 60 mm Hg +10 胸腔积液胸腔积液 +10 PORT积分系统分组积分系统分组(IDSA) 死亡危险分级死亡危险分级 死亡率死亡率 I- II: 130 27.0% Copyright 2003 BMJ Publishing Group Ltd. Lim, W S et al. Thorax 2003;58:377-382

3、 Figure 3 Clinical severity assessment in the community setting: the CRB-65 score. Strategy for stratifying patients with CAP into risk groups in the community using only clinical observations (when blood urea results not available). Copyright 2003 BMJ Publishing Group Ltd. Lim, W S et al. Thorax 20

4、03;58:377-382 Figure 2 Severity assessment in a hospital setting: the CURB-65 score. One step strategy for stratifying patients with CAP into risk groups according to risk of mortality at 30 days when the results of blood urea are available. Internal Medicine 2003,42(8):676 Risk Classifications Usin

5、g the IDSA Guidelines and the Number of Deaths Risk classNumber of patients (%)Numberof deaths (%) Low10 (10.3)0 (0) I3 (3.1)0 (0) II7 (7.2)0 (0) Intermediate50 (5 1.5)2 (4.0) III12 (12.4)0 (0) IV38 (39.2)2 (5.3) High V37 (38.1)7 (18.9) Total97 (100)9 (9.3) Internal Medicine 2003,42(8):676 Severity

6、Classifications Using the JRS Guidelines SeventyNumber of patients (%)Number of deaths (%) Mild5 (5.2)0 (0) Moderate 25 (25.8) 0 (0) Severe 67 (69.1) 9 (13.4) Total 97 (100)9 (9.3) Internal Medicine 2003,42(8):676 Relationship between the Risk Class in the IDSA Guidelines and the Severity Class in t

7、he JRS Guidelines Internal Medicine 2003,42(8):676 Severity(JRS) Risk class(IDSA) Total number of patients (%) Low number of patients (%) Intermediate number of patients (%) High number of patients (%) Mild5(50)0(0)0(0)5(5.2) Moderate2(20)17(34)6(16.2)25(25.8) Severe3(30)33(66)31(83.8)67(69.1) Total

8、10(100)50(100)37(100)97(100) CURB category 0121+2343+4 Admission to ICU 7/229 (3%) 44/231 (19%) 24/91 (26%) 68/332 (21%) 20/33 (61%) 3/8 (38%) 23/41 (56%) Mortality 3/229 (1%) 17/231 (7%) 7/91 (8%) 24/322 (8%) 13/33 (39%) 1/8 (13%) 14/41 (34%) Predictive potential of the CURB criteria Am J Respir Cr

9、it Care Med 2002;166:1038 Am J Respir Crit Care Med 2001;163:645 Waterer GW Clin Chest Med 2005;26:29 Disposition of patients in a study of high-dose, short- course levofloxacin for treatment of community- acquired pneumonia. ITT( intent-to-treat) Patient category n/N (%)a 95% CId 750-mg groupb (n =

10、 198) 500-mg groupc (n = 192) Evaluable patients183/198 (92.4)175/192 (91.1)-7.0 to 4.4 Stratum Ie Total69/76 (90.8)73/86 (84.9)-16.5 to 4.7 PSI class IIIf44/49 (89.8)44/51 (86.3)-17.2 to 10.2 PSI class IVg25/27 (92.6)27/32 (84.4)-26.1 to 9.6 PSI class Vh0/0 (0.0)2/3 (66.7) Not applicable Stratum II

11、i114/122 (93.4)102/106 (96.2)-3.4 to 9.0 Pathogen class, species n/N (%)a 750-mg groupb500-mg groupc Typical pathogend Haemophilus influenzae12/13 (92.3)13/14 (92.9) Haemophilus parainfluenzae12/12 (100.0)9/10 (90.0) Streptococcus pneumoniae20/22 (90.9)18/20 (90.0) Atypical pathogene Chlamydia pneum

12、oniae20/22 (90.9)16/16 (100.0) Legionella pneumophila11/11 (100.0)3/3 (100.0) Mycoplasma pneumoniae41/43 (95.3)34/36 (94.4) 晚发性或有晚发性或有MDR感染风险的感染风险的HAP包括包括VAP及及HCAP初始静脉使用经验性抗生素治疗的成人剂量初始静脉使用经验性抗生素治疗的成人剂量 Group 1Group 1 Group 2Group 2） Group 3Group 3） Outcomes Primary Study Group (n = 409) Group 1 (n =

13、 222) Group 2 (n = 136) Group 3 (n = 51)p Value Time to Antibiotics, min 280.51 (241.17) 131.46 (5.42) 335.52 (65.88) 783.98 (79.52) TCS, d3.19 (4.33)3.19 (4.27)3.16 (4.48)3.29 (4.31)0.98 LOS, d9.50 (6.47)9.01 (6.00) 10.21 (7.18) 9.75 (6.41)0.22 PSI 116.26 (32.98) 116.21 (33.56) 115.98 (32.15) 117.3

14、9 (33.25)0.96 time to clinical stability (TCS) length of stay (LOS) Houck PM, Bratzler DW, Nsa W, et al. Arch Intern Med 2004, 164:637644 结果结果 v 此结果提示此结果提示Mechan(JAMA.1997;278:2080)提出的提出的8小时法小时法 则可能要变成则可能要变成4小时法则小时法则 Dudzevicius V et al. Medicina (Kaunas,立陶宛) 2003, 39:260265 v结论：早期治疗失败与高病死率相关（结论：早期治

15、疗失败与高病死率相关（27%比比4%），最常见原因是宿主），最常见原因是宿主 不适当的反应，治疗不适当可用遵循指南的方法来避免不适当的反应，治疗不适当可用遵循指南的方法来避免 Roson B , Arch Intern Med 2004;164:502 入住入住ICU的重症的重症SCAP病人的经验治疗病人的经验治疗 Clin Chest Med 2005;26:65-73 Leroy O, et al. Impact of positive microbiological diagnosis of severe community-acquired pneumonia 存活率机械通气时间 Ou

16、tcome VariablePlaceboHydrocortisonep Value ICU mortality mortality* 7 (30%)0 (0%)0.009 Hospital mortality* 7 (30%)0 (0%)0.009 60-d mortality* 8 (38%)0 (0%)0.001 Length of ICU or RICU stay18 (345)10 (433)0.01 Length of hospital stay21 (372)13 (1053)0.03 Duration of mechanical ventilation10 (244)4 (12

17、7)0.007 Peter C. Minneci, et al. MetaAnalysis:J Ann Intern Med 2004,141: 47 肺炎肺炎 肺部炎症肺部炎症 机械通气机械通气 通气诱导肺损伤通气诱导肺损伤表面活性物质破坏和灭活表面活性物质破坏和灭活微血管损伤微血管损伤 肺泡肺泡-毛细血管膜完整性减低毛细血管膜完整性减低 细菌和前炎症因子易位细菌和前炎症因子易位肺水肿增加和淋巴回流增加肺水肿增加和淋巴回流增加 循环细菌和前炎症因子增加循环细菌和前炎症因子增加 全身炎症反应增加全身炎症反应增加 Sepsis and /or MOD 肺炎机械通气病人放大全身炎症反应图解肺炎机械

18、通气病人放大全身炎症反应图解 Clin Chest Med 2005;26:19 ACIP推荐肺炎球菌疫苗使用概况推荐肺炎球菌疫苗使用概况 ACIP推荐的流感疫苗使用概况推荐的流感疫苗使用概况 呼吸频率呼吸频率30 次次/m in PaO 2/FiO2250 病变累及双肺或多肺叶病变累及双肺或多肺叶 收缩压收缩压90mmHg 舒张压舒张压 60mmHg 符合符合1 条主要标准或者条主要标准或者2 条次要标准条次要标准 方可诊断方可诊断 Am J Respir Crit Care Med 2001;163:645 Houck PM, Bratzler DW, Nsa W, et al. Arch Intern Med 2004, 164:637644 Outcome VariablePlaceboH