如何合理理解重癥社區(qū)獲得性肺炎課件

1、 Crit Care Med 2011; 37:214-223. (Germany+UK+Spain)Towards a sensible comprehension of severecommunity-acquired pneumonia如何合理理解重癥社區(qū)獲得性肺炎肺 炎 診 斷 咳嗽、咳痰、發(fā)熱、胸膜性胸痛胸片顯示肺內(nèi)浸潤影如果臨床高度懷疑肺炎，CXR正常，可行CT 檢查，或24-48小時(shí)后復(fù)查胸片IntroductionCAP患者中40-80%是輕度肺炎，死亡率低（1-3%），門診可治愈 20-30%需要住院治療，住院治療中10%需要入住ICU，而這部分人群的死亡率則高達(dá)30-40%

2、兩大評分系統(tǒng)：PSI和CURB-65PSI對預(yù)測輕中度肺炎更敏感，而CURB-65則預(yù)測重癥肺炎更敏感二者對判斷何時(shí)入住ICU均不太敏感SCAP定義的演進(jìn)1993ATS首次提出十個(gè)標(biāo)準(zhǔn)診斷和預(yù)測需要ICU治療的SCAP1998發(fā)現(xiàn)雖然敏感性98%，但特異性僅32%2001modified ATS rule:敏感性78%，特異性僅94%，陽性預(yù)測值75%，陰性預(yù)測值95%SCAP的診斷標(biāo)準(zhǔn)Am J Respir Crit Care Med 2001;163:645 651PSI評分系統(tǒng)N Engl J Med 1997;336:243-50.Thorax 2003;58:377382CURB-6

3、5評分系統(tǒng)該評分系統(tǒng)直接與肺炎嚴(yán)重程度相關(guān)，2分以上需要住院治療3分以上需要入住ICU兩種評分系統(tǒng)與患者死亡率得分分級(jí)死亡率%130V26.7 CURB-65 PSI 得分死亡率%00.712.129.2314.5440557幾大預(yù)后評估系統(tǒng)的比較危重度評估四大因素 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最重要的混雜因素潛在的治

5、療限制因素: elderly, multiple Comorbidities, severe disabilityPopulations evaluatedVariables included三大類: 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?肺炎進(jìn)展惡化的兩大因素 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 （血流動(dòng)力學(xué)）What are the specific needs of the clinician in orderto recognize patients with SCAP?篩選那些可能受益于ICU加強(qiáng)治療的病人鮮有研究針對進(jìn)展到SCAP的預(yù)測因素 研究未發(fā)現(xiàn)SIRS能預(yù)測CAP患者進(jìn)展至severe sepsis 無相關(guān)數(shù)據(jù)：關(guān)于合并癥在肺炎進(jìn)展衰竭中的相對風(fēng)險(xiǎn)性評估How should we assess the presence of SCAP?當(dāng)前所有評分系統(tǒng)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