Wu L, Yu Y H, Li L, Xu L Y, Ruan X X, Lin C B, Zhao J P
Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou 310013, China.
Zhonghua Shao Shang Za Zhi. 2020 Apr 20;36(4):267-272. doi: 10.3760/cma.j.cn501120-20200229-00107.
To explore the clinical effect of nebulized acetylcysteine inhalation combined with bronchoscopy in treating elderly patients with severe ventilator-associated pneumonia (VAP). From January 2016 to December 2017, 80 elderly patients with severe VAP who were hospitalized in Zhejiang Hospital were divided into acetylcysteine+ bronchoscopy group [24 males and 16 females, aged (78±7) years] and bronchoscopy group [26 males and 14 females, aged (80±7) years]using random number table for a prospective cohort study. Patients in bronchoscopy group were treated with bronchoscopy in addition to conventional supportive care of symptoms. Patients in acetylcysteine+ bronchoscopy group received nebulized acetylcysteine inhalation therapy on the basis of the treatment given to patients in bronchoscopy group. Patients in both groups received treatment continuously for 7 days. The simplified clinical pulmonary infection score (CPIS) in both groups was assessed before and after treatment. Venous blood of 10 mL was collected before and after treatment to detect leukocyte count, serum C-reactive protein, and procalcitonin. Arterial blood of 1 mL was collected before and after treatment to detect partial arterial oxygen pressure (PaO(2)), partial arterial carbon dioxide pressure (PaCO(2)), oxygenation index. The inhalation platform pressure (Pplat), dynamic lung compliance (Cdyn), airway resistance, work of breathing, time of antibiotic use, and time of mechanical ventilation of patients in two groups were recorded before and after treatment. Data were statistically analyzed with chi-square test and test. (1) The simplified CPIS, leukocyte count, serum C-reactive protein, and procalcitonin of patients in acetylcysteine+ bronchoscopy group were significantly lower than those in bronchoscopy group after treatment (=2.32, 2.15, 6.08, 7.12, <0.05 or <0.01). The simplified CPIS, leukocyte count, serum C-reactive protein, and procalcitonin of patients in acetylcysteine+ bronchoscopy group and bronchoscopy group after treatment were significantly lower than those before treatment (=13.76, 13.60, 12.70, 8.32, 11.44, 14.28, 9.48, 9.50, <0.01). (2) Compared with bronchoscopy group, patients in acetylcysteine+ bronchoscopy group had significantly higher PaO(2) and oxygenation index (=4.14, 2.55, <0.05 or <0.01) but significantly lower PaCO(2) (=4.36, <0.01) after treatment. The PaO(2) and oxygenation index of patients in acetylcysteine+ bronchoscopy group after treatment were significantly higher than those before treatment (=10.90, 43.72, <0.01). The PaO(2) and oxygenation index of patients in bronchoscopy group after treatment were also significantly higher than those before treatment (=6.55, 43.03, <0.01). The PaCO(2) of patients in both groups after treatment were significantly lower than those before treatment (=21.54, 21.92, <0.01). (3) The Cdyn of patients in acetylcysteine+ bronchoscopy group after treatment was significantly higher than that in bronchoscopy group (=5.41, <0.01), and Pplat, airway resistance, and work of breathing were significantly lower than those in bronchoscopy group (=2.18, 5.46, 2.49, <0.05 or <0.01). The Cdyn of patients in both groups after treatment were significantly higher than those before treatment (=16.10, 10.90, <0.01), and Pplat, airway resistance, and work of breathing were significantly lower than those before treatment (=21.18, 11.13, 9.32, 15.50, 5.17, 5.97, <0.01). (4)The time of mechanical ventilation and antibiotic usage of patients in acetylcysteine+ bronchoscopy group were (6.9±1.9)and (8.7±2.8) d, respectively, which were significantly shorter than (10.1±2.2) and (11.6±3.5) d in bronchoscopy group (=6.85, 4.09, <0.01). Nebulized acetylcysteine inhalation combined with bronchoscopy can significantly control the degree of lung infection in elderly patients with severe VAP, improve patients' respiratory mechanics parameter and blood gas analysis indicator, and shorten the time for mechanical ventilation and antibiotic usage.
探讨雾化吸入乙酰半胱氨酸联合支气管镜治疗老年重症呼吸机相关性肺炎（VAP）的临床效果。选取2016年1月至2017年12月在浙江医院住院的80例老年重症VAP患者，采用随机数字表法分为乙酰半胱氨酸+支气管镜组[男24例，女16例，年龄（78±7）岁]和支气管镜组[男26例，女14例，年龄（80±7）岁]，进行前瞻性队列研究。支气管镜组患者在给予常规对症支持治疗的基础上进行支气管镜治疗。乙酰半胱氨酸+支气管镜组患者在支气管镜组治疗的基础上接受雾化吸入乙酰半胱氨酸治疗。两组患者均连续治疗7天。分别在治疗前后评估两组患者的简化临床肺部感染评分（CPIS）。治疗前后采集10 mL静脉血检测白细胞计数、血清C反应蛋白及降钙素原。治疗前后采集1 mL动脉血检测动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）、氧合指数。记录两组患者治疗前后的吸气平台压（Pplat）、动态肺顺应性（Cdyn）、气道阻力、呼吸功、抗生素使用时间及机械通气时间。采用卡方检验和t检验进行统计学分析。（1）治疗后，乙酰半胱氨酸+支气管镜组患者的简化CPIS、白细胞计数、血清C反应蛋白及降钙素原均显著低于支气管镜组（t=2.32、2.15、6.08、7.12，P<0.05或P<0.01）。乙酰半胱氨酸+支气管镜组和支气管镜组患者治疗后的简化CPIS、白细胞计数、血清C反应蛋白及降钙素原均显著低于治疗前（t=13.76、13.60、12.70、8.32、11.44、14.28、9.48、9.50，P<0.01）。（2）治疗后，乙酰半胱氨酸+支气管镜组患者的PaO₂及氧合指数显著高于支气管镜组（t=4.14、2.55，P<0.05或P<0.01），而PaCO₂显著低于支气管镜组（t=4.36，P<0.01）。乙酰半胱氨酸+支气管镜组患者治疗后的PaO₂及氧合指数显著高于治疗前（t=10.90、43.72，P<0.01）。支气管镜组患者治疗后的PaO₂及氧合指数也显著高于治疗前（t=6.55、43.03，P<0.01）。两组患者治疗后的PaCO₂均显著低于治疗前（t=21.54、21.92，P<0.01）。（3）治疗后，乙酰半胱氨酸+支气管镜组患者的Cdyn显著高于支气管镜组（t=5.41，P<0.01），Pplat、气道阻力及呼吸功显著低于支气管镜组（t=2.18、5.46、2.49，P<0.05或P<0.01）。两组患者治疗后的Cdyn均显著高于治疗前（t=16.10、10.90，P<0.01），Pplat、气道阻力及呼吸功显著低于治疗前（t=21.18、11.13、9.32、15.50、5.17、5.97，P<0.01）。（4）乙酰半胱氨酸+支气管镜组患者的机械通气时间及抗生素使用时间分别为（6.9±1.9）天和（8.7±2.8）天，显著短于支气管镜组的（10.1±2.2）天和（11.6±3.5）天（t=6.85、4.09，P<0.01）。雾化吸入乙酰半胱氨酸联合支气管镜可显著控制老年重症VAP患者的肺部感染程度，改善患者的呼吸力学参数及血气分析指标，缩短机械通气时间及抗生素使用时间。
