摘要
目的探讨痰涂片与简化临床肺部感染评分（clinical pulmonary infection score，CPIS）对呼吸机相关性肺炎（ventilator associated pneumonia，VAP）的早期诊断价值。方法前瞻性观察研究，病例组入选沈阳市第四人民医院重症监护病房2014年6月至2016年6月连续收治的59例患者，所有患者均符合VAP诊断标准，以同期入住重症监护病房非肺部感染且机械通气〉48h的59例患者为对照组；排除肺部恶性肿瘤、自身免疫性疾病、免疫缺陷的患者；所有患者均计算急性生理与慢性健康状况Ⅱ（APACHEⅡ）评分。患者诊断VAP当天及同时期留取痰标本，采用一次性无菌吸痰管从人工气道内吸痰，取合格痰标本（镜检：每个低倍视野下的多形核白细胞〉25个及鳞状上皮细胞〈10个为合格痰标本）进行革兰染色及培养，同时进行简化CPIS评分。统计学方法应用SPSS15．0进行数据处理，计数资料采用χ^2检验，计量资料以均数±标准差（x^-±s）表示，组问比较采用成组t检验，以P〈0．05为差异有统计学意义。比较两组患者痰涂片结果构成情况。设定痰涂片阳性、简化CPIS≥5分为阳性筛选标准，分析单独、联合诊断VAP时的灵敏度、特异度、阳性预测值和阴性预测值。结果VAP组与非VAP组患者的基线资料（年龄、性别，APACHEⅡ评分）差异无统计学意义（P〉0．05）；VAP组G。菌[44．1％（26／59）]、G^＋菌[40．6％（24／59）]、未检出菌[10．2％（6／59）]、两者均检出[5．1％（3／59）]，非VAP组G^-菌[39．0％（23／59）]、G^＋菌[30．5％（18／59）]、未检出菌[27．1％（16／59）]、两者均检出[3．4％（／2／59）]。两组患者构成比差异无统计学意义（P〉0．05）。痰涂片单独、联合简化CPIS≥5分诊断VAP的灵敏度分别为89．8％、84．7％；特异度分别为27．1％、79．7％；阳性预测值分别为55．2％、80．6％；阴性预测值分别为72．7％、83．9％。结论机械通气患者无论是否发生VAP，下呼吸道均能检出病原菌，痰涂片不能单独作为诊断依据；痰涂片联合简化CPIS评分能提高VAP诊断效能，并能早期指导抗菌药物的选择具有一定临床意义。
Objective To explore the diagnostic value of sputum smear coupled with simplified clinical pulmonary infection score （CPIS） of ventilator associated pneumonia （VAP） in the early stage. Methods A cohort of 59 consecutive patients with VAP admitted in Intensive Care Unit from June, 2014 to June, 2016 were enrolled for a prospective and observational study. Concurrently, another 59 patients without pulmonary infection undergone mechanical ventilation over 48 hrs, were assigned into the control group. The criteria of exclusion were patients with pulmonary malignancies, autoimmune diseases and immunodeficiency. APACHE Ⅱ scores of all patients were recorded. All patients ＇ inferior airway sputum which met the criteria was taken to make a validated sputum smear （ i. e. polymorphonuclear leukocyte 〉 25 and squamous epithelial cell 〈 10 per low-power field） for Gram stain and culture on the admission day.Meanwhile, simplified CPIS were calculated. Data were statistically processed by SPSS 15.0, enumeration data were statistically analyzed by Chi-Square test, and measurement data were represented as Mean ± SD. The significant differences in characteristics between two groups were analyzed by independent t test, and P 〈 0. 05 was considered statistically significant. As positive sputum smear and simplified CPIS≥5 were set respectively as a positive screening criterion, sensitivity, specificity, positive predictive value and negative predictive value of each marker and combined markers were calculated. Results There were no significant differences in demographics and clinical features （ including age, sex, APACHE Ⅱ scores） of patients in VAP and non-VAP patients （P 〉 0. 05）. The rates of bacteria detected were Gram-negative [ 44. 1% （26/ 59） ], Gram-positive [40. 6% （24/59） ], none [10. 2% （6/59） ] and both [5.1% （3/59） ] bacteria in VAP group, while [39.0% （23/59） ], [30. 5% （18/59） ], [27.1% （16/59） ] and [3.4% （2/59） ] were found in non-VAP group correspondingly. There were no significant differences in the percentages of different bacteria in sputum smear between two groups （ P 〉 0. 05 ）. The values of diagnostic sensitivity of sputum smear and sputum smear coupled with simplified CPIS were 89. 8% and 84. 7% ; the specificity were 27. 1% and 79. 7% ; the positive predictive values were 55.2% and 80. 6% ; and the negative predictive values were 72. 7% and 83.9%, respectively. Conclusions No matter the ventilated patients suffered VAP or not, bacteria might be detected from their lower respiratory tracts. Sputum smear could not be taken as an exclusively diagnostic evidence. While sputum smear coupled with simplified CPIS might improve the diagnostic efficacy of VAP, and provide the guildlines of appropriate choice of antibiotics employed in the early stage.
作者
支琳琳
冯伟
郭轶男
Zhi Linlin Feng Wei Guo Yinan(Department of Intensive Care Unit, the Fourth People＇s Hospital of Shenyang, Shenyang 110031, China)
出处
《中华急诊医学杂志》
CAS
CSCD
北大核心
2017年第11期1296-1299,共4页
Chinese Journal of Emergency Medicine
基金
沈阳市卫生和计划生育委员会科研项目（201506）
关键词
痰涂片革兰染色
临床肺部感染评分
呼吸机相关性肺炎
Sputum smear and gram stain
Clinical pulmonary infection score
Ventilator associated pneumonia
