肺膿瘍預測膿胸病人手術治療之預後

膿胸是肺炎的嚴重併發症之ㄧ，並且會增加肺炎的死亡率及致病率。在先前的文獻報告指出，膿胸的病人死亡率甚至有高達20%，而且會增加醫療費用及住院天數。膿胸是肋膜腔內有感染及膿液聚積，而肺膿瘍是在肺實質中出現，內含膿液的厚壁空腔，並伴有周圍之肺組織炎性病變。在以往的文獻報告認為，肺膿瘍在膿胸或肋膜積液的病人身上是少見的。我們比較了肺膿瘍併發膿胸及膿胸沒有併發肺膿瘍的病人的臨床表現及手術結果。從2004年一月到2006年十二月，總共收集了259個被診斷出膿胸的病人，並在本部門施行手術。我們記錄並比較了以下資料：年齡、性別、臨床資料、初步的表現及診斷、肋膜液的生化檢驗及細菌培養資料、影像學發現及手術中發現的結果，以探討膿胸與肺膿瘍的相關性及預測其預後關係。這些膿胸病人的誘發病因包括：肺炎或肺膿瘍（239人），肺癌（9人），深頸部的感染（1人），創傷後引發的膿胸（6人）及開胸手術後併發的膿胸（4人）。其中有22個病人在影像學上或是手術中被診斷出有肺膿瘍。所有病人的手術都嘗試以胸腔內視鏡完成所有步驟，只有兩位病人（0.77％）因為臟層肋膜上的表殼太厚，所以改為迷你開胸手術。而在肺膿瘍併發膿胸組及膿胸未併發肺膿瘍組兩組病人的比較中，手術前的血液中白血球增生（95.45％ and 63.29％， P＜0.05）、需要住入加護病房接受照護（63.64％ and 40.08％， P＜0.05）、手術後三十日內死亡率（18.18％ and 2.95％， P＜0.05）及總死亡率（22.73％ and 5.91％， P＜0.05）都有明顯的統計學上的差異。此外，膿胸併發肺膿瘍組的病人有可能需要接受較多次手術治療（40％ and 1.7％， P＞0.05）。在膿胸的病人中，併有肺膿瘍及診斷後未能盡快引流膿胸都有可能增加膿胸病人的死亡率。肺膿瘍併有膿胸的病人臨床上較常出現有白血球增加的情形，也較可能需要住入加護病房照護。整體或是三十天存活率都以肺膿瘍併有膿胸的病人較低，死亡比率是膿胸未併有肺膿瘍病人的4.685倍，而且可能需要較多次的手術治療。對於肺膿瘍併有膿胸的病人，需要臨床上更細心的觀察及照護。

關鍵字

肺膿瘍；膿胸

並列摘要

Pleural empyema is one of the serious complications of pneumonia, which increases morbidity and mortality. The mortality of patients with pleural empyema is up to 20% and leads to a higher hospital cost and longer hospital stay. Lung abscess has previously been thought to be a rare condition of empyema and parapneumonic effusions. We compared the clinical presentations and surgical results of patients with pleural empyema with and without lung abscesses. From January 2004 to December 2006, 259 patients with pleural empyema were diagnosed and received operation in our department. We recorded the following data: age, gender, clinical findings, chronology of initial signs, diagnoses, bacteriological and biochemical studies of pleural fluid, and radiologic and intra-operative findings. The outcomes were compared to evaluate the correlationships exists between pleural empyema and lung abscess. All early and late deaths were attributed to progressive uncontrolled sepsis in patients with pleural empyema. The causes of pleural empyema included pneumonia or lung abscess (n = 239), lung cancer (n = 9), deep neck infection induced (n=1), post-traumatic empyema (n = 6) and post-operation complications (n = 4). 22 patients with lung abscess were diagnosed by the pre-operative image study or by the finding during operation. All these patients received video-assisted thoracic surgery, but two operations（0.77％）were converted to mini-thoracotomy due to thick peel. There are statistic significant difference between abscess group and non-abscess group in pre-operative leukocytosis（95.45％ and 63.29％, P< 0.05）, transferred into intensive care unit（63.64％ and 40.08％, P<0.05）, mortality during 30 days after operation（18.18％ and 2.95％, P<0.05）and overall mortality（22.73％ and 5.91％, P<0.05）. Patients with lung abscess and pleural empyema may need more operations（40％ and 1.7％， P>0.05）. The mortality is higher in pleural empyema patients with lung abscess, or without adequate drainage in time. Patients with lung abscess and pleural empyema may need more operation procedures and need careful clinical observation and care.

並列關鍵字

lung abscess ； empyema

參考文獻

Yen CC, Tang RB, Chen SJ, Chin TW, Pediatric lung abscess: a retrospective review of 23 cases. J Microbiol Immunol Infect 2004; 37:45–49.

Neild JE, Eykyn SJ, Phillips I, Lung abscess and empyema. Quart J Med 1985, 224:875–882

Maskell NA, Davies CW, Jones E, Davies RJO, The characteristics of 300 patients participating in the MRC/BTS multicenter intrapleural streptokinase vs. placebo trial (ISRCTN-39138989). American Thoracic Society Meeting, Atlanta, 2002

Agrenius V et al., Pleural fibrinolytic activity is decreased in inflammation as demonstrated in quinacrine pleurodesis treatment of malignant pleural effusion. Am Rev Respir Dis, 1989. 140(5): p. 1381-5.

Allewelt M, Schuler P, Bolcskei PL, et al, Ampicillin t sulbactam vs. clindamycin_cephalosporin for the treatment of aspiration pneumonia and primary lung abscess. Clin Microbiol Infect 2004; 10:163–170.

國際替代計量

肺膿瘍預測膿胸病人手術治療之預後

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