1、预防预防VAP:Bundle 的作用的作用内容提要内容提要VAP流行病学流行病学1VAP预防预防Bundle2研究结果的启示研究结果的启示3Am J Respir Crit Care Med Vol 165.pp 867903,2002确切的发生率尚未可知确切的发生率尚未可知 Clinical practice guidelines for HAP and VAP in adults(Canada).Rotstein C,Can J Infect Dis Med Microbiol 2008;19(1):19-53.ICU VAP:32.3%时间时间19971997-2003 2003 数据分
2、析数据分析 Incidence of VAP Incidence of VAP：16.9%of Patients 16.9%of Patients 15.9/1000 MV-days 15.9/1000 MV-days法国法国11个个ICU VAP监测数据库监测数据库Crit Care Med 2009;37:2545-2551Ventilator-associated pneumonia in adults in developing countries:a systematic review.InterJ Infect Dis(2008)12,505512Outcomes Attribut
3、able to VAPCrit Care Med 2005;33:21842193Clinical and economic consequences of VAP:A systematic review.CCM 2005Patients who develop VAP incur$10,019in additional hospital costs.Am J Respir Crit Care Med 165.pp 867903,2002 ICU ventilated patients with VAP have a 2-to 10-fold higher risk of death comp
4、ared with patients without pneumonia.Mortality:VAPChastre J and Fagon JYCrit Care Med 2009;37:2709-291852项研究包含项研究包含4882个个VAP患者患者12465个非个非VAP对照者对照者VAP导致死亡相对风险度（导致死亡相对风险度（RR）1.27(95%CI:1.15-1.39,P0.01)Publication BiasI 2=69%研究的差异性分析研究的差异性分析For trauma patients N=9For ARDS patients N=4I 2=1.3%I 2=0%病源微生
5、物相关吗？病源微生物相关吗？Am J Respir Crit Care Med 165.pp 867903,2002Impact of MRSA VAP on mortality:a systematic reviewEur Respir J 2008;31:625632Critical Care 2008,12:R142Determinants and impact of MDR in pathogens causing VAP高危因素：病人群体高危因素：病人群体病人性别病人性别Gender and sex hormone specific risk of ventilatorassocia
6、ted pneumonia after critical illness or injuryDossett LA,S42 Surgical Forum Abstracts .J Am Coll Surg718 of 2,290 patients developed VAP(31%).Males were more likely to develop VAP(34%vs25%,p0.001),and this association remained after adjusting for age and illness severity(OR1.5,95%CI1.2-1.8,p0.001).V
7、entilator-Associated PneumoniaInsights From Recent Clinical Trials Kollef MH,CHEST 2005,128(5 suppl 2)583S-591S VariablesAdj OR(95%CI)p ValueTrauma admission1.68(1.152.47)0.0079Male gender1.54(1.152.07)0.0042Duration of MV.d 1.50(1.331.70)0.0001Continuous sedation1.43(1.071.92)0.0158EN within 48 h o
8、f MV2.65(1.933.63)0.0001Parenteral nutrition3.27(2.244.75)0.0001病人年龄是问题吗？病人年龄是问题吗？Postgrad Med J 2006;82:172178.多器官功能障碍综合征患者呼吸机相关多器官功能障碍综合征患者呼吸机相关性肺炎的危险因素分析性肺炎的危险因素分析ChinJ Emerg Med,November 2006,l115(111):1010A Prospective Study of Ventilator-Associated Pneumonia in ChildrenPediatrics 2009;123:1108
9、-1115机械通气时间机械通气时间VariablesAdj OR(95%CI)p ValueTrauma admission1.68(1.152.47)0.0079Male gender1.54(1.152.07)0.0042Duration of MV.d 1.50(1.331.70)0.0001Continuous sedation1.43(1.071.92)0.0158EN within 48 h of MV2.65(1.933.63)0.0001Parenteral nutrition3.27(2.244.75)24 hours)VAP:mean rate of 23%;5%:MV f
10、or 1 day 69%:MV for 30 days Am Rev Respir Dis 1989;140:302305.Respiratory Medicine(2007)101,762767Epidemiology of VAP in a Long-Term Acute Care HospitalA total of 23 CDC-defined cases of VAP occurred in 19 patients during 13,746 ventilator days.The cumulative VAP incidence was 14.6%(23 of 157 admiss
11、ions),and the incidence rate was 1.67 cases/1,000 ventilator-days,which was a 56%reduction from theVAP rate of 3.8 cases per 1,000 ventilator-days before the implementation of a VAP-bundle approach.Infect Control Hosp Epidemiol 2009;30:319-324MV 时间时间VAP发生率并非线性相关发生率并非线性相关Day 3:2.2%increaseDay 7:3.3%i
12、ncreaseDay:15:1.5%decreaseVAP higher risk days:4-7 MV days Crit Care Med 2009;37:2545-2551VAP 高危因素高危因素Crit Care Med 2009;37:2545-2551Continuous Aspiration of Subglottic Secretions in the Prevention of VAP in the Postoperative Period of Major Heart Surgery CHEST 2008;134:938946医源性因素医源性因素宿主因素宿主因素操作污染操
13、作污染创伤患者创伤患者胃液胃液PH升高，返流升高，返流存在基础疾病老年患者存在基础疾病老年患者镇静过度镇静过度 男性男性患者患者MV 高危时间高危时间高高SOFA患者患者VAP 高危因素分析高危因素分析机体抗感染能力低下机体抗感染能力低下不恰当操作不恰当操作Story from Current VAP Epidemiological Analysisv一双不干净的手，对一群缺乏抵抗能力的患者实施不规范的操作，导致呼吸机相关性肺炎的发生。v结果：花了大把的钱！增加了死亡风险！结果：花了大把的钱！增加了死亡风险！内容提要内容提要VAP流行病学流行病学1VAP 预防预防Bundle2研究结果的启示研
14、究结果的启示3Prevention measures of VAPCrit Care Med 2009IHI呼吸机呼吸机Bundle内容内容 1、床头抬高、床头抬高 2、每日唤醒、每日唤醒+脱机试验脱机试验 3、消化性溃疡预防、消化性溃疡预防 4、深静脉血栓预防、深静脉血栓预防Institute of healthcare Improvement 2004捆绑是捆绑是 有有”或或 无无”的策略的策略,要麽不要麽不用用,要麽全部应用以取得治疗的成功。要麽全部应用以取得治疗的成功。每个病人每个病人,每项措施均要落实每项措施均要落实Bundle 策略策略Reports from Lady of Lo
15、urdes Hospital,Binghampton,New York,USA290 Days With a VAP Rate of ZeroBundle 降低降低VAP的报道的报道(www.ihi.org)1.Dominican Hospital：97 days2.St.Vincents Hospital 255 days3.Virginia Mason Center 180 days4.University of Texas 50%reduction5.Naval Medical Center 150 days6.Our Lady of Lourdes 290 days7.Universi
16、ty of Rochester 300 days VAP in a Military Deployed Setting:The Impact of an Aggressive Infection Control Program（J Trauma.2008;64:S123S128）Shorr A F,Kollef M H Chest 2005;128:583S-591SVAP 预防预防Bundle 研究结果研究结果Implementing quality improvements in the intensive care unit:Ventilator bundle as an example
17、.Crit Care Med 2009;37:305309Potential for publication biasFirst,all of the peer-reviewed papers reported positive results and none reported negative ones.A recent story in a nonpeer-reviewed trade publication questioned the effectiveness of bundle implementation in a trauma ICU,where the VAP rate a
18、ctually increased directionally from 10 cases/1000 MV days in the period before to 11.9 cases/1000MV days in the period after implementation of the bundle.Conclusion:Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundles effectiveness or cost-effecti
19、veness.呼吸机呼吸机 Bundle临床依从性分析（临床依从性分析（N=166N=166）2005.6-2008.62005.6-2008.6 总数总数达达 标标（例（例/%）未达标（例未达标（例/%）措施措施1 措施措施2 措施措施3 措施措施43 天天5635/62.519（33.9）0（0）0（0）5（8.9）4-7天天9521/22.161（64.2）8（8.4）12（12.6）18（18.9）7天天151/6.714（93.3）5（33.3）8（53.3）5（33.3）总体总体16657/34.394（56.6）13（7.8）20（12.0）28（16.9）措施措施1：床头抬高：
20、床头抬高30；措施；措施2：每日唤醒：每日唤醒+脱机试验；脱机试验；措施措施3：溃疡性溃疡预防；措施：溃疡性溃疡预防；措施4：深静脉血栓预防：深静脉血栓预防 Bundle 应用前后对照研究对照组干预组例数例数71166男性例数（男性例数（%）48(67.6)114(68.6)年龄（年龄（XS）58.7916.8654.4818.32APACHEAPACHE评分评分（XS）13.54.7512.65.56MV时间（时间（XSD，天），天）5.925.65.156.13 天（例数天（例数/%）20（28.2）56（33.7）4-7天（例数天（例数/%）43（60.6）95（57.2）7天（例数天（
21、例数/%）8（11.2）15（9.1）VAP例数（例数（%）15（21.1）34（20.5）VAP例数例数/1000MV日日33.739.528天病死率（例数天病死率（例数/%）12（16.9）33（19.8）内容提要内容提要VAP流行病学流行病学1VAP 预防预防Bundle2研究结果的启示研究结果的启示3Bundle 内容的间的逻辑联系VAPSedation误吸误吸营养营养SBT血栓血栓MV timeMortalityBundle内容中确切有效措施内容中确切有效措施 1、床头抬高、床头抬高 2、每日唤醒、每日唤醒+脱机试验脱机试验 3、消化性溃疡预防、消化性溃疡预防 4、深静脉血栓预防、深
22、静脉血栓预防Institute of healthcare Improvement 20041、床头抬高问题u 简单的操作，但高度差的依从性简单的操作，但高度差的依从性原因：不能保持原因：不能保持30-4530-45度位置度位置Factors impacting on patient positionv Nurse preference with average angle 23v Negative correlation between angle and severity of illnessv Specific groups e.g.raised ICP and spinal injur
23、yv Procedures requiring supine positionv Patient preference2.每日唤醒每日唤醒-脱机脱机仅强调仅强调Wake-up不够不够 计划镇静计划镇静u提高MV患者的舒适性u 提高MV有效性u 避免过度镇静 Depth of Sedation assessed by Motor Activity LevelCrit Care Med 2007;35:393401A total of 111 subjects(40%)received one or more ratings of oversedation,and 211(76.2%)receiv
24、ed one or more ratings of undersedation计划镇静内容计划镇静内容v 设计方案与目标设计方案与目标v 监测、调整、目标维持监测、调整、目标维持v 每日唤醒每日唤醒v 镇静撤离镇静撤离 缩短机械通气天数缩短机械通气天数Changes in sedation management in German intensive care units between 2002 and 2006:A national follow-up surveyCritical Care 2007,11:R124Wake-up plus SBTu 每日一次可能不够每日一次可能不够Lancet 2008;371:12634总结1：VAPu VAP是ICU 最主要的HAP 发生率：10-30例/1000MV天 高危因素：MV时间、食道返流、年龄、机体免疫状态、不规范的与MV相关的医护操作。u VAP对预后影响：增加MV时间和医疗费用，可能增加死亡风险。总结2：呼吸机Bundlev 是预防VAP有效的手段之一v IHI呼吸机Bundle临床依从性、措施间的逻辑联系以及临床有效性存在争议。v 优化呼吸机Bundle将具有重要的临床意义。Thank you for your attention
