Lipovy B, Rihová H, Gregorova N, Hanslianova M, Zaloudikova Z, Kaloudova Y, Brychta P
Department of Burns and Reconstructive Surgery, Brno University Hospital, Brno, Czech Republic.
Ann Burns Fire Disasters. 2011 Sep 30;24(3):120-5.
Aim. The aim of this work is to determine the incidence of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) and to define the define the most important respiratory pathogens in patients with inhalation injury. Introduction. Infectious complications in severely burned patients present serious problems. Patients with inhalation injuries are exposed to greater risk owing to the possible development of infectious complications in the lower respiratory tract. VAP is the predominant cause of death in these patients. This is due to the increasing resistance of strains of Gram-negative bacteria such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae. Design. Retrospective, monocentric. Setting. A five-bed burn intensive care unit. Material and methods. Between 2004 and 2009, 348 adult patients were hospitalized in the intensive care unit of the Department of Burns and Reconstructive Surgery, Brno University Hospital, Czech Republic. Of these, 127 (36.49%) were diagnosed by bronchoscopy as having inhalation injury. The prerequisite for inclusion in the cohort was an inhalation injury requiring artificial ventilation for at least 48 h. The lower airway microbiological condition was monitored regularly by sampling biological material for cultures (sputum, tracheobronchial aspirates, etc.). For the diagnosis of VAP and VAT we used the Centers for Disease Control and Prevention criteria and the Clinical Pulmonary Infection Score. Results. The average age of the 127 patients (31 women/96 men) included in the study was 38.4 yr (range, 21-69 yr) and the average total body surface area (TBSA) burned was 29.3% (range, 2-75%). The average length of hospital stay was 49.4 days (range, 4-150 days) and the duration of mechanical ventilation 8.7 days; 18 patients (14.2%) died. In patients with inhalation injury, 309 strains of bacteria were cultivated from the lower respiratory tract, of which 234 were Gram-negative. All of these bacterial strains were isolated in significant quantities for lower respiratory tract infection. The most common bacteria isolated from the lower respiratory tract was Klebsiella pneumoniae (78 times), followed by Pseudomonas aeruginosa (49x), and Acinetobacter baumannii (28x). VAT was diagnosed in 109 patients (85.8%) in the cohort. The incidence of VAT was calculated to be 98.8 per 1000 days of mechanical ventilation. VAP was diagnosed in 34 patients in the cohort (26.8%). The incidence of VAP was calculated as being 30.8 cases per 1,000 days of mechanical ventilation. In eight patients (23.5%), VAP was diagnosed within 5 days of initiation of mechanical ventilation (early onset) and in 26 patients (76.5%) after a longer period (late onset). The most common aetiological agent of VAT and VAP was Klebsiella pneumoniae (respectively 41.3% and 35.3%). Conclusion. In this study we were able to determine the incidence of VAP and VAT in patients with inhalation injury. In spite of the advances in diagnostics and therapy, inhalation injury is still burdened with disappointingly high morbidity and mortality rates. For this reason, the treatment of VAP remains a major challenge for all physicians caring for patients with inhalation injury.
目的。本研究旨在确定呼吸机相关性气管支气管炎（VAT）和呼吸机相关性肺炎（VAP）的发病率，并明确吸入性损伤患者中最重要的呼吸道病原体。引言。严重烧伤患者的感染性并发症是严重问题。吸入性损伤患者因下呼吸道可能发生感染性并发症而面临更大风险。VAP是这些患者死亡的主要原因。这是由于铜绿假单胞菌、鲍曼不动杆菌和肺炎克雷伯菌等革兰氏阴性菌菌株的耐药性增加。设计。回顾性、单中心研究。地点。一个拥有五张床位的烧伤重症监护病房。材料与方法。2004年至2009年期间，348名成年患者在捷克布尔诺大学医院烧伤与重建外科重症监护病房住院。其中，127名（36.49%）经支气管镜诊断为吸入性损伤。纳入该队列的前提条件是吸入性损伤需要人工通气至少48小时。通过采集生物材料进行培养（痰液、气管支气管吸出物等）定期监测下呼吸道微生物状况。对于VAP和VAT的诊断，我们采用了疾病控制与预防中心标准和临床肺部感染评分。结果。纳入研究的127名患者（31名女性/96名男性）的平均年龄为38.4岁（范围21 - 69岁），平均烧伤总面积（TBSA）为29.3%（范围2 - 75%）。平均住院时间为49.4天（范围4 - 150天），机械通气时间为8.7天；18名患者（14.2%）死亡。在吸入性损伤患者中，从下呼吸道培养出309株细菌，其中234株为革兰氏阴性菌。所有这些菌株均大量分离自下呼吸道感染。从下呼吸道分离出的最常见细菌是肺炎克雷伯菌（78次），其次是铜绿假单胞菌（49次）和鲍曼不动杆菌（28次）。该队列中有109名患者（85.8%）被诊断为VAT。VAT的发病率经计算为每1000天机械通气98.8例。该队列中有34名患者（26.8%）被诊断为VAP。VAP的发病率经计算为每1000天机械通气30.8例。8名患者（23.5%）在机械通气开始后5天内被诊断为VAP（早发），26名患者（76.5%）在较长时间后被诊断为VAP（晚发）。VAT和VAP最常见的病原体是肺炎克雷伯菌（分别为41.3%和35.3%）。结论。在本研究中，我们能够确定吸入性损伤患者中VAP和VAT的发病率。尽管在诊断和治疗方面取得了进展，但吸入性损伤的发病率和死亡率仍然高得令人失望。因此，VAP的治疗仍然是所有照顾吸入性损伤患者的医生面临的重大挑战。
