乙酰半胱氨酸雾化吸入联合支气管镜治疗老年重症呼吸机相关性肺炎的临床效果

Clinical effect of nebulized acetylcysteine inhalation combined with bronchoscopy in the treatment of elderly patients with severe ventilator-associated pneumonia

目的探讨乙酰半胱氨酸雾化吸入联合支气管镜治疗老年重症呼吸机相关性肺炎(VAP)的临床效果。方法2016年1月—2017年12月,浙江医院收治80例住院老年重症VAP患者,按随机数字表法分为乙酰半胱氨酸+支气管镜组[男24例、女16例,年龄(78±7)岁]和单纯支气管镜组[男26例、女14例,年龄(80±7)岁],对其进行前瞻性队列研究。单纯支气管镜组患者除进行常规对症支持治疗外,采用支气管镜治疗;乙酰半胱氨酸+支气管镜组患者在单纯支气管镜组治疗基础上行乙酰半胱氨酸雾化吸入治疗。2组患者均持续治疗7 d。2组患者治疗前以及治疗后,行简化临床肺部感染评分(CPIS);取静脉血10 mL,检测白细胞计数、血清C反应蛋白和降钙素原;取动脉血1 mL,检测动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)及氧合指数。记录2组患者治疗前、后吸气平台压(Pplat)、动态肺顺应性(Cdyn)、气道阻力与呼吸做功及抗生素使用时间、机械通气时间。对数据行χ^2检验、t检验。结果(1)乙酰半胱氨酸+支气管镜组患者治疗后简化CPIS、白细胞计数、血清C反应蛋白和降钙素原明显低于单纯支气管镜组(t=2.32、2.15、6.08、7.12,P<0.05或P<0.01)。乙酰半胱氨酸+支气管镜组、单纯支气管镜组患者治疗后简化CPIS、白细胞计数、血清C反应蛋白和降钙素原均明显低于治疗前(t=13.76、13.60、12.70、8.32,11.44、14.28、9.48、9.50,P<0.01)。(2)乙酰半胱氨酸+支气管镜组患者治疗后PaO2、氧合指数明显高于单纯支气管镜组(t=4.14、2.55,P<0.05或P<0.01),PaCO2明显低于单纯支气管镜组(t=4.36,P<0.01)。乙酰半胱氨酸+支气管镜组患者治疗后PaO2、氧合指数明显高于治疗前(t=10.90、43.72,P<0.01),单纯支气管镜组患者治疗后PaO2、氧合指数明显高于治疗前(t=6.55、43.03,P<0.01);乙酰半胱氨酸+支气管镜组、单纯支气管镜组患者治疗后PaCO2明显低于治疗前(t=21.54、21.92,P<0.01)。(3)乙酰半胱氨酸+支气管镜组患者治疗后Cdyn明显高于单纯支气管镜组(t=5.41,P<0.01),Pplat、气道阻力、呼吸做功明显低于单纯支气管镜组(t=2.18、5.46、2.49,P<0.05或P<0.01)。乙酰半胱氨酸+支气管镜组、单纯支气管镜组患者治疗后Cdyn明显高于治疗前(t=16.10、10.90,P<0.01),Pplat、气道阻力、呼吸做功明显低于治疗前(t=21.18、11.13、9.32,15.50、5.17、5.97,P<0.01)。(4)乙酰半胱氨酸+支气管镜组患者机械通气时间、抗生素使用时间分别为(6.9±1.9)、(8.7±2.8)d,明显短于单纯支气管镜组的(10.1±2.2)、(11.6±3.5)d,t=6.85、4.09,P<0.01。结论乙酰半胱氨酸雾化吸入联合支气管镜治疗能够明显控制老年重症VAP患者的肺部感染程度,改善患者的呼吸力学指标、血气分析指标,缩短机械通气时间、抗生素使用时间。

Objective To explore the clinical effect of nebulized acetylcysteine inhalation combined with bronchoscopy in treating elderly patients with severe ventilator-associated pneumonia(VAP).Methods From January 2016 to December 2017,80 elderly patients with severe VAP who were hospitalized in Zhejiang Hospital were divided into acetylcysteine+bronchoscopy group[24 males and 16 females,aged(78±7)years]and bronchoscopy group[26 males and 14 females,aged(80±7)years]using random number table for a prospective cohort study.Patients in bronchoscopy group were treated with bronchoscopy in addition to conventional supportive care of symptoms.Patients in acetylcysteine+bronchoscopy group received nebulized acetylcysteine inhalation therapy on the basis of the treatment given to patients in bronchoscopy group.Patients in both groups received treatment continuously for 7 days.The simplified clinical pulmonary infection score(CPIS)in both groups was assessed before and after treatment.Venous blood of 10 mL was collected before and after treatment to detect leukocyte count,serum C-reactive protein,and procalcitonin.Arterial blood of 1 mL was collected before and after treatment to detect partial arterial oxygen pressure(PaO2),partial arterial carbon dioxide pressure(PaCO2),oxygenation index.The inhalation platform pressure(Pplat),dynamic lung compliance(Cdyn),airway resistance,work of breathing,time of antibiotic use,and time of mechanical ventilation of patients in two groups were recorded before and after treatment.Data were statistically analyzed with chi-square test and t test.Results(1)The simplified CPIS,leukocyte count,serum C-reactive protein,and procalcitonin of patients in acetylcysteine+bronchoscopy group were significantly lower than those in bronchoscopy group after treatment(t=2.32,2.15,6.08,7.12,P<0.05 or P<0.01).The simplified CPIS,leukocyte count,serum C-reactive protein,and procalcitonin of patients in acetylcysteine+bronchoscopy group and bronchoscopy group after treatment were significantly lower than those before treatment(t=13.76,13.60,12.70,8.32,11.44,14.28,9.48,9.50,P<0.01).(2)Compared with bronchoscopy group,patients in acetylcysteine+bronchoscopy group had significantly higher PaO2 and oxygenation index(t=4.14,2.55,P<0.05 or P<0.01)but significantly lower PaCO2(t=4.36,P<0.01)after treatment.The PaO2 and oxygenation index of patients in acetylcysteine+bronchoscopy group after treatment were significantly higher than those before treatment(t=10.90,43.72,P<0.01).The PaO2 and oxygenation index of patients in bronchoscopy group after treatment were also significantly higher than those before treatment(t=6.55,43.03,P<0.01).The PaCO2 of patients in both groups after treatment were significantly lower than those before treatment(t=21.54,21.92,P<0.01).(3)The Cdyn of patients in acetylcysteine+bronchoscopy group after treatment was significantly higher than that in bronchoscopy group(t=5.41,P<0.01),and Pplat,airway resistance,and work of breathing were significantly lower than those in bronchoscopy group(t=2.18,5.46,2.49,P<0.05 or P<0.01).The Cdyn of patients in both groups after treatment were significantly higher than those before treatment(t=16.10,10.90,P<0.01),and Pplat,airway resistance,and work of breathing were significantly lower than those before treatment(t=21.18,11.13,9.32,15.50,5.17,5.97,P<0.01).(4)The time of mechanical ventilation and antibiotic usage of patients in acetylcysteine+bronchoscopy group were(6.9±1.9)and(8.7±2.8)d,respectively,which were significantly shorter than(10.1±2.2)and(11.6±3.5)d in bronchoscopy group(t=6.85,4.09,P<0.01).Conclusions Nebulized acetylcysteine inhalation combined with bronchoscopy can significantly control the degree of lung infection in elderly patients with severe VAP,improve patients′respiratory mechanics parameter and blood gas analysis indicator,and shorten the time for mechanical ventilation and antibiotic usage.