1、暨南大学附属第一医院呼吸科骆文志主要内容 目前肺炎诊治现状目前肺炎诊治现状 各种评分系统介绍各种评分系统介绍 文献回顾和文献回顾和meta分析分析 总结总结1.由于社会人口老龄化、罹患慢性病人群增加、免疫损害宿主增加、病原体变由于社会人口老龄化、罹患慢性病人群增加、免疫损害宿主增加、病原体变迁和抗生素耐药率上升迁和抗生素耐药率上升,CAP成为威胁人群健康的重要疾病之一成为威胁人群健康的重要疾病之一,病死率高病死率高,治疗治疗费用昂贵费用昂贵,值得深入研究。值得深入研究。2.在美国每年约有在美国每年约有CAP患者患者300万一万一560万例万例,住院患者超过住院患者超过100万例次万例次,平均病
2、平均病死率死率8.8-15.8,直接医疗费用直接医疗费用84亿一亿一97亿美元亿美元,而重症监护病房而重症监护病房(ICU)的重症的重症CAP患者死亡率高达患者死亡率高达50%。目前现状3.在中国在中国,CAP死亡原因中排在死亡原因中排在第五位第五位,带来极大的经济负担。在中国带来极大的经济负担。在中国,患者和医患者和医生可能对肺炎的严重程度生可能对肺炎的严重程度过分高估过分高估,导致不必要的或过长的住院治疗导致不必要的或过长的住院治疗,带来极大带来极大的医疗资源和经济的浪费。的医疗资源和经济的浪费。4.研究发现不同国家和地区，肺炎的住院率、住院时间、诊治措施及死亡率存研究发现不同国家和地区，
3、肺炎的住院率、住院时间、诊治措施及死亡率存在很大的在很大的差异差异,医生在决定患者是否住院治疗及采用何种治疗措施时存在很大的医生在决定患者是否住院治疗及采用何种治疗措施时存在很大的主观性主观性。普遍存在高估普遍存在高估病人的严重程度而导致不必要的住院治疗及过度医疗现病人的严重程度而导致不必要的住院治疗及过度医疗现象象,浪费医疗资源。浪费医疗资源。目前现状5.PSI、CURB-65评分在西方国家已经通过大样本的回顾性分析评分在西方国家已经通过大样本的回顾性分析,被认为是有效被认为是有效的的,能够准确地对能够准确地对CAP患者进行患者进行危险分层危险分层,帮助临床医生做出帮助临床医生做出临床决策临
4、床决策。6.准确地对准确地对CAP患者进行患者进行严重度评分严重度评分,可以规范医生行为可以规范医生行为,减少医疗行为的随意减少医疗行为的随意性性,按最佳方式开展诊治工作按最佳方式开展诊治工作,提高医院的医疗水平提高医院的医疗水平,识别和清除过度的医疗行为识别和清除过度的医疗行为,减少资源浪费减少资源浪费,降低医疗费用降低医疗费用,提高医疗工作效率提高医疗工作效率,降低平均住院日及死亡率降低平均住院日及死亡率。目前现状HOW? WHEN? WHERE? WHAT?主要内容 目前肺炎诊治现状目前肺炎诊治现状 各种评分系统介绍各种评分系统介绍 文献回顾和文献回顾和meta分析分析 总结总结1987
5、年年BTS（英国）（英国）1997年年PORT评分（美国评分（美国 ） CURB评分（英国）评分（英国） 2003年年CURB-65评分（英国）评分（英国） 2009年年SMATR-COP评分（澳大利亚）评分（澳大利亚） CURB评分：评分：Confusion、Uremia、Respiratory rate、舒张压、舒张压60mmHgBTS标准：标准：Uremia尿素氮尿素氮7mmol/l、Respiratory rate30次次/分、舒张压分、舒张压60mmHgPORT评分：评分：Fine分分层（略）层（略）CURB-65评分评分 ：Confusion、Uremia7mmol/l、R30次次
6、/分、分、收缩压收缩压90mmHg或舒张压或舒张压38C or 90 beats/min3 、RR20 breaths/min or PaCO212000/ L or 10% immature forms脓毒症休克非特异性损伤引起的临非特异性损伤引起的临床反应床反应, 满足满足 2条标准条标准SIRS = systemic inflammatory response syndrome SIRS及可疑或及可疑或明确的感染明确的感染Chest 1992;101:1644. 全身性感染全身性感染伴器官衰竭伴器官衰竭顽固性低血压顽固性低血压SIRSSepsisSevere SepsisSeptic S
7、hock1993年ATS2001年ATS修订2007年IDSA/ATS存在以下任何一项指标：存在以下任何一项指标：R30次次/分分,Pa02/FIO2250,双肺双肺/多叶肺炎多叶肺炎,SBP90mmHg，DBP60mmHg,需要机械通气需要机械通气,在在48h内肺部浸润内肺部浸润50%,脓毒症休克或需要血管活脓毒症休克或需要血管活 性药物支持性药物支持4h,急性肾衰竭。急性肾衰竭。（敏感性极高敏感性极高,特异性很低特异性很低）符合一个以上主要指标主要指标:需要机械通气;脓毒症休克;在48h内肺部浸润扩大50%;急性肾功能衰竭。或者两个以上次要指标：R30次/分;Pa02/FIO2250;双肺
8、或多肺叶肺炎;SBP90mmHg；DBP60mmHg。具备1项主要指标：气管插管需机械通气,脓毒症休克需要血管活性药物。或者至少3项次要指标：T36,R30次/分,低血压需要积极的液体复苏,多肺叶浸润,意识障碍和/或定向障碍,U7mml/L,WBC4000个/mm3,PLT100,000/mm3,Pa02/FIO2250。中国社区获得性肺炎诊断和治疗指南主要内容 目前肺炎诊治现状目前肺炎诊治现状 各种评分系统介绍各种评分系统介绍 文献回顾和文献回顾和meta分析分析 总结总结文章文章1.Risk Prediction Models for Mortality in Community-Acqu
9、ired Pneumonia: A Systematic Review（1）数据来源：1.MEDLINE results: 768 potential abstracts2.EMBASE results: 879 potential abstracts3.Cochrane library results:300 potential abstract（2）剔除：75 articles were excluded because they were not:1) derivation studies ;2) initial validation studies（3）纳入：18 articles w
10、ere included in review which evaluated 20 pneumonia scoresSearch results and study selection.共纳入19篇文章Frequency of variables used in prognostic or severity scores in community-acquired pneumonia.年龄-性别-免疫抑制-肾病-脉搏-血压-呼吸-体温-休克-神智-尿素氮-白细胞-氧合指数-HCT-钠-ph-胸水-多肺叶炎症-机械通气结果1：Balanced accuracy and area under RO
11、C of pneumonia severity scores versus number of variables. 结果2：Sensitivity and specificity of pneumonia severity scores by a number of variables.结论1.不考虑各种肺炎评分系统的复杂性和纳入因子的多少，在平衡精确性 和AUC方面，各评分系统表现相似。2.虽然有众多肺炎危险预测模型，但只有一些模型经得起正确的评价； 并没有明确证据表明其他新采用的评分系统优于临床采用已久的 CURB-65和PSI系统。3.仍需要高质量的随机对照研究以更准确地评价其临床价值
12、。文章文章2：Prediction of severe community-acquiredpneumonia: a systematic review and meta-analysis1.采用系统回顾和Meta分析对各种CAP严重性评分系统进行分析，评估预测入住ICU和强化治疗的价值。2.数据来源：searched Medline, Embase, and the Cochrane Controlled Trials registry for clinical trials。Components of the main severity scores机械通气-休克-年龄-性别-共病-神智-
13、心率-血压-呼吸-体温-氧合指数-ph-多肺叶渗出-HCT-钠-高血糖-Urea-ALB-中性粒- 血小板Operative characteristics of the principal scores to predict ICU admission at their usual cut-off (95% CI)SROC curve and area under the curve (AUC) of Pneumonia Severity Index (PSI) and CURB-65 to predict ICU admissionIndividual studies are repres
14、ented by a number indicating the cut-off used. Their place on the diagram represents the sensitivity and specificity of the individual study. Diamonds represent meta-analytic test statistics for each cut-off.Pooled discriminative performance of the principal scores for severe CAP compared with Pneum
15、onia Severity Index (PSI) and CURB-65 ROC curve.Conclusions1.New severity scores for predicting the need for ICU or intensive treatment in patients with CAP, such as ATS/IDSA 2007 minor criteria, SCAP score, and SMART-COP, have better discriminative performances compared with PSI and CURB-65. 2.High
16、 negative predictive value is the most consistent finding among the different prediction rules. 3.These rules should be considered an aid to clinical judgment to guide ICU admission in CAP patients.不同肺炎严重度评分系统在社区获得性肺炎病人管理中的应用不同肺炎严重度评分系统在社区获得性肺炎病人管理中的应用浙江大学2009年文章文章:3：CRP, PCT, CPIS AND PNEUMONIA SEV
17、ERITY SCORES IN NURSING HOME ACQUIRED PNEUMONIA1.目的：评价目的：评价CRP, PCT, CPIS（临床肺部感染评分）（临床肺部感染评分） 和各种肺炎严重性评分和各种肺炎严重性评分（CURB-65, PSI,NHAP index, SMART-COP, SOAR)在预测（诊断）护理院在预测（诊断）护理院居住者获得性肺炎的能力。居住者获得性肺炎的能力。2.方法：采用观察性研究，因急性呼吸系统疾病住院的护理院居住者被纳入。方法：采用观察性研究，因急性呼吸系统疾病住院的护理院居住者被纳入。A组：护理院获得性肺炎组：护理院获得性肺炎B组：其他肺部疾病。收
18、集组：其他肺部疾病。收集CPIS（临床肺部感染评分）和肺炎评分（临床肺部感染评分）和肺炎评分 系统的临床、影像学、实验室数据，并检测系统的临床、影像学、实验室数据，并检测CRP和和PCT浓度。浓度。RESPIRATORY CARE Paper in Press. Published on October 08, 2013 as DOI: 10.4187/respcare.02741结果结果1： 因子分组 nCRPmg/dl PCTng/ml CPIS(group A)NHAP5816.388.61.522.755.41.2（group B）其他肺病295.25.60.240.212.31.5P
19、 0.001=0.0010.001结果2：At cut-off value of 0.475ng/ml, PCT had sensitivity 83% and specificity 72%. At cut-off value of 8.05mg/dl, CRP had sensitivity 81% and specificity 79%. The inpatient mortality was 17.2% in group A.结果3：PCT and CURB-65 were significantly greater among non-survivors (p0.001 and p=
20、 0.034 respectively).PCT levels were4.675.4ng/ml in non-survivors and 0.860.9ng/ml in survivors (p0.001).Area under the curve (AUC) for PCT in predicting inpatient mortality was 0.84(95%CI 0.70-0.98, p=0.001). A PCT level on admission above 1.1ng/ml was an independent predictor of inpatient mortalit
21、y.（A survival analysis, using Kaplan-Meier curves and the log-rank test）AUC:in predicting inpatient mortality AUCCIP PSI 0.650.49-0.820.12NHAPindex0.580.41-0.750.41SMART-COP0.570.36-0.780.45SOAR0.620.42-0.820.23CURB-650.680.53-0.840.06Conclusion: The CPIS, PCT and CRP are reliable for the diagnosis
22、of NHAP. PCT and CURB-65 were accurate in predicting inpatient mortality in NHAP.文章文章4：Predictive Values of Semi-Quantitative Procalcitonin Test and Common Biomarkers for the Clinical Outcomes of Community-Acquired Pneumonia1.回顾性分析，纳入回顾性分析，纳入2010年年8月月-2012年年10月因月因CAP住院，住院，且检测了半定量且检测了半定量PCT的患者，共的患者，共
23、213例。例。2.收集人口背景学特征、实验室生物标记物收集人口背景学特征、实验室生物标记物、微生物学检验、微生物学检验结果，并计算结果，并计算PSI, CURB-65, 和和 A-DROP评评分值。分值。3.观察终点：住院观察终点：住院28天死亡率、入住天死亡率、入住ICU率率。结果1.213例患者被纳入，20例死亡，32例入住ICU。2.Mortality did not differ significantly among subjects with different semi-quantitative serum PCT levels; however, subjects with s
24、erum PCT levels 10.0 ng/mL were more likely to require intensive care than those with lower levels (p 0.001)。3.PCT水平有一定的预示致病菌作用，特别是肺炎链球菌。Distribution of subjects with different semi-quantitative serum procalcitonin levels. (A) Relation with mortality. Significant differences were not observed betwee
25、n any 2 concentration groups. (B) Relation with the requirement for intensive care. Subjects with serum procalcitonin levels 10.0 ng/mL were significantly more likely to require intensive care than those with levels 10.0 ng/mL (p 0.001).Analysis of the receiver-operating characteristics curves. (A)
26、For predicting mortality. The area under the curve values were 0.86 for the PSI class, 0.81 for the B/A ratio, 0.80 for the CURB-65, and 0.57 for the semi-quantitative PCT test. (B) For predicting the requirement for intensive care. The area under the curve values were 0.87 for the PSI class, 0.86 f
27、or the CURB-65, 0.85 for the B/A ratio, and 0.72 for the semiquantitative PCT test. PSI: pneumonia severity index; B/A ratio: blood urea nitrogen to serum albumin ratio;PCT: procalcitonin.Conclusion 1.The semi-quantitative serum PCT level on admission was less predictive of mortality from CAP as com
28、pared to the B/A ratio. 2.The subjects with serum PCT levels 10.0 ng/mL were more likely to require intensive care than those with lower levels.文章文章5：Usefulness of CURB-65 and pneumonia severity index for influenza A H1N1v pneumonia. CONCLUSIONS: Use of CURB-65 and PSI in the emergency department ma
29、y underestimate the risk of patients with Influenza A H1N1v pneumonia. Based in our results, the ability of these scales to predict ICU admissions for Influenza A H1N1v pneumonia is questioned.Monaldi Arch Chest Dis. 2012 Sep-Dec;77(3-4):118-21.文章文章6：Severity of Influenza A 2009 (H1N1) Pneumonia Is
30、Underestimated by Routine Prediction Rules. Very recently the Influenza A(H1N1) pandemic in 2009, provided the opportunity to check the lowest predictive value and usefulness of the different scores in patients with viral pneumonia.Bjarnason A, Thorleifsdottir G, Lve A, Gudnason JF,Asgeirsson H, Hal
31、lgrimsson KL, et al. Results from a Prospective. Population Based Study PLOS ONE Public Library of Science. 2012;7:e46816EP文章文章7：医生因素不可忽视！：医生因素不可忽视！ 1.A survey conducted in Australia found that only 12% of respiratory physicians and 35% of emergency physicians reported using the PSI always or freque
32、ntly even though it is recommended by the AustralasianTherapeutic Guidelines。 2.the majority of physicians were unable to accurately approximate the PSI scores and calculations of the simpler CURB-65 were more accurate。D. J. Serisier, S.Williams, and S.D.Bowler, “Australasian respiratory and emergen
33、cy physicians do not use the pneumonia severity index in community-acquired pneumonia,” Respirology,vol. 18, no. 2, pp. 291296, 2013.文章文章8：PSI, CURB-65, SMART-COP or SCAP? And the winner is. SMART DOCTORS！葡萄牙肺科杂志社论Rev Port Pneumol. 2013;19(6):243-244主要内容 目前肺炎诊治现状目前肺炎诊治现状 各种评分系统介绍各种评分系统介绍 文献回顾和文献回顾和m
34、eta分析分析 总结总结总总 结结PSICURB-65SMATR-COP总总 结结1.CURB-65和和CRB-65、CURB评分操作简单评分操作简单,容易掌握容易掌握,适合在门急诊或社区适合在门急诊或社区就诊患者的评估就诊患者的评估;2.中国标准和中国标准和PORT评分均是很好的风险预测指标评分均是很好的风险预测指标,但操作较复杂但操作较复杂,涉及相关危涉及相关危险因素较多险因素较多,计算分值较繁琐计算分值较繁琐,不便于在门急诊及社区开展不便于在门急诊及社区开展;且不适用于死亡和人且不适用于死亡和人住住ICU的预测的预测,比较适用于需要住院的非比较适用于需要住院的非SCAP患者评估患者评估;总总 结结3.SMATR-COP评分、评分、Sepsis评分、评分、IDSA/ATS标准可能更适用于标准可能更适用于SCAP患者的评估。患者的评估。4.PCT检测对死亡率、入住检测对死亡率、入住ICU率有预测意义。率有预测意义。5.SMART DOCTORS 不可忽视。有意识去采用、可以熟练运用不可忽视。有意识去采用、可以熟练运用最恰当的评分系统，高危患者收入住最恰当的评分系统，高危患者收入住ICU和强化治疗。和强化治疗。
