声门下分泌物引流预防呼吸机相关性肺炎的临床研究

A clinical study of subglottic secretion drainage for prevention of ventilation associated pneumonia

目的观察声门下分泌物引流（SSD）预防呼吸机相关性肺炎（VAP）的临床效果。方法采用前瞻性随机对照研究，选择2005年1月-2006年6月收住本院重症加强治疗病房（ICU）、年龄〉18岁、机械通气〉48h的患者，按随机原则分为SSD组和对照组，记录两组患者年龄、性别、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分、人工气道内径、鼻饲时间、机械通气时间、VAP发生率和发生时间、ICU住院时间和病死率，以及SSD组每日引流量等指标。结果符合条件的61例患者中SSD组30例，对照组31例，两组患者年龄、性别、APACHEⅡ评分、人工气道内径、鼻饲时间差异均无统计学意义。与对照组比较，SSD组VAP发生率明显降低（30．0％比51．6％，P〈0．05）；机械通气时间[（7．9±2．6）d比（10．4±0．9）d]和ICU住院时间（9．3±2．9）d比（12．3±5．7）d]均明显缩短（P均〈0．05）；但VAP发生时间[（6．5±1．3）d比（5．5±0．6）d]及ICU病死率（26．7％比38．7％）差异均无统计学意义（P均〉0．05）。SSD组以第1日引流量〉20ml作为有效标准，23例引流有效的患者VAP发生率为8．7％，引流无效的7例患者VAP发生率高达57．1％，差异有统计学意义（P〈0．01）。发生VAP患者平均每日引流量明显少于未发生VAP患者[（13．3±3．3）ml比（37．8±11．2）ml，P〈0．01]。纳入研究的61例患者中发生VAP患者的机械通气时间[（12．1±4．5）d比（6．9±2．5）d]、ICU住院时间[（14．0±5．3）d比（8．4±2．5）d]及ICU病死率（52．0％比22．2％）均明显长于或高于未发生VAP患者（P均〈0．01）。结论有效的SSD是预防VAP的重要措施。

Objective To study the effect of subglottic secretion drainage （SSD） on the incidence of the ventilator associated pneumonia （VAP） in patients receiving mechanical ventilation. Methods A retrospective randomly controlled trial was adopted. From January 2005 to June 2006, patients with an expected duration of mechanical ventilation 〉48 hours and age 〉18 years were randomly enrolled as SSD group or control group. The following data were analyzed： age, sex, acute physiology and chronic health evaluation Ⅱ（APACHE Ⅱ） score, internal diameter （ID） of artificial airway, duration of enteral nutrition （EN）, incidence of VAP, duration of mechanical ventilation, length of intensive care unit （ICU） stay, and the mortality in ICU. In SSD group, the amount of secretion was recorded everyday. Results Sixty-one patients were enrolled in the study, 30 patients were randomized to SSD group, and 31 patients were randomized to control group. The two groups were similar in age, sex, APACHEⅡ score, ID of artificial airway, and duration of EN. Compared with control group, the incidence of VAP was significantly lower （30.0% vs. 51.6% , P〈0.05）, and the duration of mechanical ventilation [（7.9±2.6） days vs. （10.4± 0.9 ） days] and length of ICU stay [（9.3±2.9） days vs. （12.3±5.7） days] were significantly shorter in SSD group （both P〈0.05）, but the time of onset of VAP [（6.5±1.3） days vs. （5.5±0.6） days] and mortality （26.7% vs. 38.7%） showed no significant difference between two groups （both P〉0.05）. In SSD group, if 20 ml was supposed to be regarded as an effective criterion for effective drainage on the first day, the incidence of VAP was 8.7% in 23 patients in whom the criterion was reached, and it was 57.1% in 7 patients in whom the amount of drainage was not up to the criterion （P〈0.01）. The average daily drainage in patients who developed VAP was significantly lower than those who did not develop VAP [（13.3±3.3） ml vs. （37.8±11.2） ml, P〈0.01]. Among all 61 patients, the duration of mechanical ventilation [（12.1±4.5） days vs. （6.9±2. 5） days], length of ICU stay [（14. 0±5.3） days vs. （8.4±2.5） days], and mortality （52.0% vs. 22.2%） were significantly different between VAP patients and patients without VAP （all P〈0.01）. Conclusion Effective SSD is one of the important measures to prevent VAP.