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目的评价综合性干预措施对老年人呼吸机相关性肺炎(VAP)的预防价值,初步探讨VAP 的发病机制。方法采用前瞻性、随机、对照设计,将年龄>60岁、接受人工气道和机械通气者分为综合干预组(半卧位+持续声门下分泌物引流+促胃动力药——莫沙必利,A 组)和普通气管导管组(B 组),比较2组患者的住院时间、ICU 内住院时间、机械通气时间、VAP 发生率、病死率、归因病死率及相对危险度、VAP 致病菌与不同部位菌群一致率、2组口咽和下呼吸道美蓝发现情况。结果入组86例,A 组41例,B 组45例。B 组患者住院时间、ICU 内住院时间、机械通气天数均长于 A 组,A 组与 B 组 VAP 发生率(34.1%比66.7%)、早发性 VAP 发生率(4.9%比20.0%)差异有统计学意义,2组病死率、归因病死率差异无统计学意义(P>0.05)。2组 VAP 总发生率 RR 为0.259,95%CI为0.106～0.634,P<0.05。VAP 致病菌与消化道存在一致菌群,以晚发性 VAP 为主(P<0.05)。A组美蓝发现率和发现时间迟于 B 组。结论实施综合干预措施可降低 VAP 发生率;胃→下呼吸道感染途径是 VAP 发病机制之一。
Objective To evaluate the value of comprehensive interventions in the prevention of ventilator-associated pneumonia (VAP) in the elderly and to explore the pathogenesis of VAP. Methods A prospective, randomized, controlled design was adopted. Patients aged> 60 years, receiving artificial airway and mechanical ventilation were divided into comprehensive intervention group (semi-recumbent + sustained subglottic drainage + gastric motility drug- A group) and general tracheal tube group (B group). The hospitalization duration, hospital stay time, mechanical ventilation time, incidence of VAP, mortality, attributable fatality and relative risk in two groups were compared. VAP induced Bacteria and different parts of the flora consistent rate, two groups of oropharyngeal and lower respiratory tract methylene blue found. Results Into the group of 86 cases, 41 cases in group A, 45 cases in group B. The hospital stay time, hospital stay time and mechanical ventilation days in group B were longer than those in group A, the incidence of VAP in group A and group B was 34.1% vs 66.7%, and the incidence of early-onset VAP was 4.9% vs 20.0% Statistical significance, two groups of fatality rates, attributed to the difference in mortality was not statistically significant (P> 0.05). The overall incidence of VAP in 2 groups was 0.259, 95% CI 0.106 ~ 0.634, P <0.05. VAP pathogens and digestive tract consistent flora, with late-onset VAP-based (P <0.05). A group of methylene blue detection rate and the discovery of time later than the B group. Conclusion The implementation of comprehensive interventions can reduce the incidence of VAP; stomach → lower respiratory tract infection is one of the pathogenesis of VAP.