呼吸性相关性肺炎的预防

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,呼吸机相关性肺炎,的预防与控制,AACN VAP Practice Alert(,美国护士协会,VAP,操作警戒,),内容,呼吸机相关性肺炎的流行病学,预防策略,抬高床头,不要常规更换呼吸设备,持续声门下吸引分泌物,洗手,AACN VAP Practice Alert,呼吸机相关性肺炎（,VAP,）的流行病学,AACN VAP Practice Alert,医院内肺炎,占医院感染的,15%,占内科,ICU,医院感染的,27%,主要危险因素是机械通气（是非机械通气患者的,6,21,倍）,CDC Guideline for Prevention of Healthcare Associated Pneumonias 2003,Cook et al,Ann Intern Med 1998;129:433,AACN VAP Practice Alert,重症护理干预增加了医院内肺炎的易感性,气管定植,改变了宿主的防御机制,医院感染肺炎增加,插管,AACN VAP Practice Alert,呼吸机相关性肺炎的病因学,大多数是细菌，以革兰阴性杆菌最常见,:,铜绿假单孢菌,变形杆菌属,不动杆菌属,金黄色葡萄球菌,早发的,VAP,主要是非多重耐药菌,迟发,VAP,为多重耐药菌,AACN VAP Practice Alert,医院内肺炎的意义,病死率为,20,41,，主要取决于感染的病原体、预先使用的抗微生物药物治疗，基础疾病。,是医院感染病死率的首要原因,CDC Guideline for Prevention of Healthcare Associated Pneumonias 2003,Heyland et al,Am J Respir Crit Care Med 1999;159:1249,Bercault et al,Crit Care Med 2001;29:2303,AACN VAP Practice Alert,医院内肺炎的意义,增加呼吸机的使用和,ICU,入住时间,4.3,天,增加住院日,4,9,天,增加费用,每例增加,$20,000 to 40,000,估计美国每年,VAP,支付,12,亿美元,Heyland et al,Am J Respir Crit Care Med 1999;159:1249,Craven D.Chest 2000;117:186-187S,Rello et al,Chest 2002;122:2115,AACN VAP Practice Alert,呼吸机相关性肺炎的预防,AACN VAP Practice Alert,持续的声门下分泌物吸引,应用气囊上方背侧有附加管腔的气管插管进行持续的吸引,CDC Guideline for Prevention of Healthcare Associated Pneumonias 2003,Kollef et al,Chest 1999;116;1339,AACN VAP Practice Alert,患者的卧位,抬高床头,30-45,o,CDC Guideline for Prevention of Healthcare Associated Pneumonias 2003,Drakulovic et al,Lancet 1999;354:1851,AACN VAP Practice Alert,呼吸设备更换的频率,呼吸机管路,气管内套管,呼吸机内部,机械装置,不要常规更换,没有足够的资料,患者间,CDC Guideline for,Prevention of Healthcare Associated Pneumonias 2003,AACN VAP Practice Alert,洗手,洗手在预防控制医院内肺炎中起重要作用。,Albert,NEJM 1981;Preston,AJM 1981;Tablan,1994,AACN VAP Practice Alert,VAP,的预防,CDC Guideline for Prevention of Healthcare Associated Pneumonias 2003,AACN Practice Alert for VAP,2004,吸痰前后、接触呼吸设备前后、与病人呼吸道分泌物接触前后要洗手,.,IA,类,AACN VAP Practice Alert,气管插管超过,24,小时的患者采用持续声门下吸引,如无禁忌症，将床头抬高至少,30,度,VAP,预防,II,类,CDC Guideline for,Prevention of Healthcare Associated Pneumonias 2003,AACN Practice Alert for VAP,2004,AACN VAP Practice Alert,没有资料支持以下措施,应用小口径的胃管代替大口径的胃管,持续代替间断喂养,胃管代替小肠管,闭合式吸引代替开放式吸引,应用特殊的可以侧翻的动力床,CDC Guideline for,Prevention of Healthcare Associated Pneumonias 2003,AACN VAP Practice Alert,口腔护理,口腔护理、口咽部定植与,VAP,的关系尚不清楚。牙菌斑可能是细菌的储主,严格的口腔护理能降低,VAP,的研究很少,调查表明大多数护士使用泡沫拭子而不是牙刷给气管插管病人进行口腔护理,CDC Guideline for,Prevention of Healthcare Associated Pneumonias 2003,Grap M.Amer J of Critical Care 2003;12:113-119.,AACN VAP Practice Alert,