Nair Shalini, Sen Nagamani, Peter John Victor, Raj John Prakash, Brahmadathan K N
Medical Intensive Care Unit, Christian Medical College and Hospital, Vellore, India.
Indian J Med Sci. 2008 Aug;62(8):304-13.
Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting.
We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP.
Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India.
Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3+/-5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 5 colony forming units/ml (cfu/ml) for ETA and 10 4 cfu/ml for BAL.
The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures.
VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA.
Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP.
准确诊断并恰当治疗呼吸机相关性肺炎（VAP）对于取得良好预后至关重要。气管内吸痰是机械通气患者常规护理及气管清洁的一部分。
我们评估了对于疑似VAP，定量气管内吸出物（ETA）是否是支气管肺泡灌洗（BAL）的合适替代方法。此外，我们评估了监测ETA是否能指导后续VAP的抗生素选择。
在印度一家三级医院的外科重症监护病房（ICU）进行的前瞻性研究。
连续200例平均（标准差）急性生理与慢性健康状况评分系统（APACHE II）评分为12.3±5且机械通气超过48小时的患者接受了监测ETA培养。如果患者出现VAP特征，则进行第二次ETA和BAL。VAP微生物学诊断的阈值，ETA为10⁵菌落形成单位/毫升（cfu/ml），BAL为10⁴ cfu/ml。
将监测和同期ETA吸出物培养的敏感性和特异性与BAL培养进行比较。
27/177例患者（15.3%）临床怀疑VAP并经影像学证实。虽然19例患者通过ETA获得了VAP的微生物学支持，但仅13例患者可行支气管镜检查，其中8例分离菌达到显著阈值。从BAL分离出的16种微生物中，11种达到显著阈值，9/11（82%）的BAL分离菌与同期ETA具有相似的抗菌谱。仅1例（9%）达到显著阈值的BAL分离菌在同期ETA中未分离出。另一方面，仅6/11（55%）的BAL分离菌与监测ETA具有相同的抗菌谱。BAL有另外3例（27%）达到显著阈值的分离菌在监测ETA中未分离出。
同期定量ETA可替代BAL用于VAP培养。通气48小时时的监测ETA似乎无助于后续VAP的抗生素选择。
