如何合理理解重症社区获得性肺炎课件

1、 Crit Care Med 2011; 37:214-223. (Germany+UK+Spain)Towards a sensible comprehension of severecommunity-acquired pneumonia如何合理理解重症社区获得性肺炎肺 炎 诊 断 咳嗽、咳痰、发热、胸膜性胸痛胸片显示肺内浸润影如果临床高度怀疑肺炎，CXR正常，可行CT 检查，或24-48小时后复查胸片IntroductionCAP患者中40-80%是轻度肺炎，死亡率低（1-3%），门诊可治愈 20-30%需要住院治疗，住院治疗中10%需要入住ICU，而这部分人群的死亡率则高达30-40%

2、两大评分系统：PSI和CURB-65PSI对预测轻中度肺炎更敏感，而CURB-65则预测重症肺炎更敏感二者对判断何时入住ICU均不太敏感SCAP定义的演进1993ATS首次提出十个标准诊断和预测需要ICU治疗的SCAP1998发现虽然敏感性98%，但特异性仅32%2001modified ATS rule:敏感性78%，特异性仅94%，阳性预测值75%，阴性预测值95%SCAP的诊断标准Am J Respir Crit Care Med 2001;163:645 651PSI评分系统N Engl J Med 1997;336:243-50.Thorax 2003;58:377382CURB-6

3、5评分系统该评分系统直接与肺炎严重程度相关，2分以上需要住院治疗3分以上需要入住ICU两种评分系统与患者死亡率得分分级死亡率%130V26.7 CURB-65 PSI 得分死亡率%00.712.129.2314.5440557几大预后评估系统的比较危重度评估四大因素 Methods of derivation: the reference outcome used1 Populations evaluated2 Variables included3 Time course of pneumonia severity4admission to the ICU is biased by loca

4、l admission policieslimit the applicability of predictive rules in other treatment settingsNPV In non-ICU ward (intermediate care unit)admission to the ICU can be replaced by its inflation to admission to the ICU or intermediate care unit.Methods of derivation: the reference outcome used最重要的混杂因素潜在的治

5、疗限制因素: elderly, multiple Comorbidities, severe disabilityPopulations evaluatedVariables included三大类: reflecting acute respiratory failure severe sepsis/septic shock radiographic spreadTime course of pneumonia severity none of the predictive rules accounts appropriately for the time course of pneumon

6、ia severitymixes patients who meet the criteria at admission with those who meet them during follow-up patients with severe CAP during follow-up not requiring mechanical ventilation or not having septic shock are not identifiedSCAP的再思考 what is SCAP? What are the specific needs of the clinician in or

7、derto recognize patients with SCAP?What is SCAP?肺炎进展恶化的两大因素 alveolar infectious inflammation may result in serious ventilationperfusion mismatches e.g：acute respiratory failure （呼吸） infection might induce a systemic inflammatory response syndrome with severe hypoperfusion and multiorgan failure, i.e

8、., severe sepsis and/or septic shock （血流动力学）What are the specific needs of the clinician in orderto recognize patients with SCAP?筛选那些可能受益于ICU加强治疗的病人鲜有研究针对进展到SCAP的预测因素 研究未发现SIRS能预测CAP患者进展至severe sepsis 无相关数据：关于合并症在肺炎进展衰竭中的相对风险性评估How should we assess the presence of SCAP?当前所有评分系统的弊端：All severity rules

9、 have a failure in sensitivityfocused on vital sign abnormalities and do not specifically weigh the contribution of complications or decompensated comorbidityNone of the severity scores is sensitive for the lower extreme in the spectrum of severe pneumonia, i.e., patients at risk of SCAPAll criteria reflecting acute respiratory failure and hemodynamic compromise may be used to assess severityThe first 2472