呼吸器相關肺炎的適當診治

Optimizing Management of Ventilator-Associated Pneumonia

吳杰亮(Chieh-Liang Wu) ； 曾政森(Jeng-Sen Tseng)

《重症醫學雜誌》 9卷2期 (2008/06) Pp. 110-116

https://doi.org/10.30035/TCCM.200806.0005

摘要

呼吸器相關肺炎(ventilator-associated pneumonia, VAP)是發生在使用呼吸器48小時以後產生的院內感染肺炎(hospital-acquired pneumonia, HAP)。根據過往研究顯示，VAP會增加病患死亡率、延長住院天數及增加醫療費用的支出。多重抗藥性菌種的盛行，使VAP的診治更加困難，適當的VAP診治必需結合三種策略：首先是診斷策略，病人臨床的表徵仍是大部分醫師診斷VAP的主要依據，應用侵襲性的方法診斷肺炎，如肺部灌洗(bronchoalveolar lavage, BAL)及保護性支氣管刷拭(protected specimen brush, PSB)，雖然不能直接降低病患死亡率，但是可以提供更精準調整抗生素的依據，不管選用侵襲性或非侵襲性的檢查，必須在抗生素給予前採集氣道檢體進行培養。其次是抗生素選用策略，建立自己的流行病學資料與參考病患得到多重抗藥細菌感染的風險因子，選用最可能有效的抗生素進行治療，以降低病患死亡率。最後是應用療效評估方法進行抗生素調整與停藥的策略，充分了解VAP的自然病程，透過臨床肺炎指數(clinical pulmonary infection score, CPIS)綜合臨床表徵與簡單的實驗室診斷，可作爲評估治療反應的參考，結合先前檢體培養的結果，進行抗生素降階治療，另外建立停藥的機制，有效縮短治療的天數，減少抗生素的使用量，進而減少抗生素對加護病房引起多重抗藥菌種的壓力，及產生多重抗藥菌種院內感染的惡性循環。透過這三個層面的策略結合，才能提供適當的VAP診治，兼顧病人治療結果的改善與有效的管控加護病房多重抗藥菌種的產生。

關鍵字

呼吸器相關肺炎 ； 臨床肺炎指數 ； 氣管內抽吸 ； 肺部灌洗 ； 保護性支氣管刷拭

並列摘要

Ventilator-associated pneumonia (VAP) is one kind of hospital-acquired pneumonia (HAP), developed in a patient mechanically ventilated for more than 48 hours. It is associated with a higher mortality, longer hospital-stay, and increased medical cost. In order to optimize management of VAP, at least three strategies should be done. At first, diagnostic strategy should be established. VAP is usually diagnosed based on clinical features. Invasive diagnostic methods, for example bronchoalveolar lavage (BAL) or protected specimen brush (PSB), have been advocated for high sensitivity and specificity. Though invasive methods do not reduce the mortality, they provide specific data to de-escalate antibiotics. The second step is to establish an antibiotic strategy based on the microbiological epidemiology and risk factors of VAP caused by multiple drug resistant organisms. Initial appropriate antibiotics should be administered immediately after collecting specimens for cultures. Finally, we need a strategy to evaluate the response of VAP therapy, de-escalation of antibiotics and stopping antibiotic therapy. We are ought to be familiar with the nature course of VAP. Clinical pulmonary infection score (CPIS), including 6 clinical and laboratory items, provides comprehensive information to monitor the response of VAP therapy. Antibiotics could be de-escalated based on the data of CPIS and the results of previous cultures. Short course of antibiotic therapy for VAP could be achieved by the initial adequate antibiotics, delicate treatment assessment, and the criteria of stopping antibiotics. If the three strategies are organized in the management of VAP, we could improve the outcome of VAP therapy and down-regulate the risk of nococomial infection due to multiple drug resistant organisms.

並列關鍵字

Ventilator-associated pneumonia VAP ； Clinical pulmonary infection score CPIS ； Endotracheal aspirate ； Bronchoalveolar lavage BAL ； Protected specimen brush PSB