院内获得性肺炎的诊断与治疗.ppt

院内获得性肺炎的诊断与治疗

院内获得性肺炎的定义社区获得性肺炎（CAP)是指在医院外罹患的感染性肺实质炎症，包括具有明确潜伏期的病原体感染而在入院后平均潜伏期内发病的肺炎。医院获得性肺炎（HAP)患者入院时不存在，也不处于潜伏期，而于入院48小时后在医院（包括老年护理院、康复院等）内发生的肺炎。内科学第七版

院内获得性肺炎的诊断社区获得性肺炎（CAP)医院获得性肺炎（HAP)注意与肺不张、心衰、肺水肿、基础疾病肺侵犯、药物性肺损伤、肺栓塞等鉴别临床诊断依据：X线检查出现新的或进展的肺部浸润影或间质性改变加上以下三个临床征候中的两个或以上发热超过38度血白细胞增多或减少脓性气道分泌物临床诊断依据：（以下1-4项中任何1项加第5项，除外非感染性疾病）新近出现的咳嗽、咳痰或原有呼吸道疾病症状加重，并出现脓性痰，伴或不伴胸痛发热肺实变体征和（或）闻及湿性啰音WBC＞10×109/L或＜4×109/L，伴或不伴中性粒细胞核左移胸部X线检查显示片状、斑片状浸润阴影或间质性改变，伴或不伴胸腔积液

Howisventilatorassociatedpneumonia

diagnosed?Ventilatorassociatedpneumoniaisahospitalacquiredpneumoniathatoccurs48hoursormoreaftertrachealintubation.Despitethelackofauniversallyagreeddefinition,ICUphysiciansgenerallyagreethatpneumoniashouldbesuspectedwhentherearenewinfiltratesonchestradiographyplustwoormoreofthefollowing:?Purulenttrachealsecretions?Bloodleucocytosis(12×109whitebloodcells/L)orleucopenia(4×109whitebloodcells/L)?Temperaturegreaterthan38.3°C.

Howisventilatorassociatedpneumonia

diagnosed?Postmortemstudiesofpatientssuspectedofhavingventilatorassociatedpneumoniasuggestthatusingclinicalcriteriaalonefordiagnosisproduces30-35%falsenegativeresultsand20-25%falsepositiveresults.Becauseofthislackofsensitivityandspecificity,itisgoodpracticetoobtainmicrobiologicalsamplesoflowerrespiratorytractsecretionsbeforeantibioticsarestarted.Samplescanbeobtainedinvasivelyornon-invasively.Invasivesamplingmethodsincludebronchoalveolarlavage(BAL),protectedspecimenbrushing,andincreasinglyblind“mini-BAL.”Mini-BAL,whichisalsoreferredtoasnon-bronchoscopicBALorblindBAL,isperformedusingspeciallydesignedcathetersthatallowsamplingofthedistalairwaysviathetrachealtube.Becauseabronchoscopeisnotneededitisquickandtechnicallysimple,withcultureresultsthatarecomparabletootherlavagemethods.

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