目的: 研究探讨双导管进行改良支气管肺泡灌洗法在诊断呼吸机相关性肺炎(ventilator associated pneumonia,VAP)上的临床运用价值。方法: 选取经确诊为VAP的患者60名,通过对三种呼吸道标本留取方法留取的痰液进行微生物学诊断,将入选的60名VAP患者按随机原则进行分组,采取普通吸痰管或密闭式吸痰管法的A组(n=20)、采取改良支气管肺泡灌洗术(RBAL)的B组(n=20)及采取纤维支气管镜下作支气管肺泡灌洗术(BAL)的C组(n=20),比较三种方法的诊断敏感性、特异性、阳性预测值、阴性预测值以及各项临床费用指标。结果: B组的诊断敏感性、特异性、阳性预测值、阴性预测值均优于A组与C组(P＜0.05);A组与C组敏感性、阳性预测值、阴性预测值特异性比较差异均无统计学意义(P＞0.05)。三种方法在平均材料费、平均药品费、平均监护费以及其他费用上比较差异无统计学意义(P＞0.05)。结论: 双导管进行改良支气管肺泡灌洗法在对呼吸机相关性肺炎上具有较高的诊断价值,且临床费用不高,在患者可接受范围内,具有一定推广价值。
Objective: To investigate the clinical value of double catheter modified bronchoalveolar lavage (BAL) in the diagnosis of ventilator associated pneumonia.Methods: 60 cases of the patients diagnosed with VAP were selected and grouped according to the random principle. Microbiological diagnosis was made on the sputum obtained from 3 respiratory specimens methods. The common suction tube or closed suction tube method was adopted in group A (n=20), the modified bronchoalveolar lavage was adopted in group B (n=20) and the fiberoptic bronchoscopy bronchoalveolar lavage was adopted in group C (n=20). The diagnostic sensitivity, specificity, positive predictive value, negative predictive value and other clinical cost index were compared between the three groups.Results: The diagnostic sensitivity, specificity and positive predictive value in group A were better than those in group B and group C (P＜0.05); the negative predictive value in group A was higher than that in group B and group C (P＜0.05); there was no significant difference of the four indicators in group B and C (P＞0.05). There was no significant difference in average material cost, average drug fee, average monitoring fee and other expenses between the three groups (P＞0.05).Conclusion: Double catheter modified bronchoalveolar lavage is of high diagnostic value for ventilator-associated pneumonia, and the clinical cost is not high. It is worth popularizing in the acceptable range.
[1] Haley RW,Hooton TM,Culver DH,et al.Nosocomial infections in US hospitals,1975(R)C1976:estimated frequency by selected characteristics of patients[J].Am J Med,1981,70(4):947-959.
[2] Pennington JE.Nosocomial respiratory infection.In: Mandell GL, Douglas RG Jr, Bennet JE,editors.Principles and practice of infectious diseases.St.Louis, MO:Churchill Livingstone;1990.p.2199(R)C2205.
[3] Chastre J,Fagon JY.Pneumonia in the ventilator-dependent patient.In:Tobin MJ, editor.Principles and practice of mechanical ventilation. New York:McGraw-Hill; 1994.p.857(R)C890.
[4] Celis R,Torres A,Gatell JM.Nosocomial pneumonia.A multivariate analysis of risk and prognosis[J].Chest,1988,93(2):318-324.
[5] Torres A, Aznar R, Gatell JM.Incidence risk and prognosis factors of nosocomial pneumonia in mechanically ventilated patients[J].Am Rev Respir Dis,1990,142(3):523-528.
[6] Johanson WG Jr,Pierce AK,Sanford JP,et al.Nosocomial respiratory infections with gram-negative bacilli.The significance of colonization of the respiratory tract[J].Ann Intern Med,1972,77(5):701-706.
[7] 中华医学会重症医学分会.机械通气临床应用指南(2006)[J].中国危重病急救医学,2007,19(2):65-72.
[8] 刘长庭.纤维支气管镜诊断治疗学[M].北京:北京大学医学出版,2003:43-45.
[9] Pugin J,Auckenthaler R,Mili N,et al.Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lvage fluid[J].Am Rev Respir Dis,1991,143(1):1121-1129.
[10] Salata RA,Lederman MM, Shlaes DM, et al.Diagnosis of nosocomial pneumonia in intubated,intensive care unit patients[J].Am Rev Respir Dis,1987,135(2):426-432.
