Harrell Kevin N, Lee William B, Rooks Hunter J, Briscoe W Eric, Capote Walter, Dart Benjamin W, Hunt Darren J, Maxwell Robert A
From the Department of Surgery, University of Tennessee Health Science Center College of Medicine Chattanooga, Chattanooga, Tennessee.
J Trauma Acute Care Surg. 2023 Jan 1;94(1):30-35. doi: 10.1097/TA.0000000000003808. Epub 2022 Oct 17.
Ventilator-associated pneumonia (VAP) is a source of morbidity and mortality for trauma patients. Aspiration events are also common because of traumatic brain injury, altered mental status, or facial trauma. In patients requiring mechanical ventilation, early pneumonias (EPs) may be erroneously classified as ventilator associated.
A prospective early bronchoscopy protocol was implemented from January 2020 to January 2022. Trauma patients intubated before arrival or within 48 hours of admission underwent bronchoalveolar lavage (BAL) within 24 hours of intubation. Patients with more than 100,000 colony-forming units on BAL were considered to have EP.
A total of 117 patients underwent early BAL. Ninety-three (79.5%) had some growth on BAL with 36 (30.8%) meeting criteria for EP. For the total study population, 29 patients (24.8%) were diagnosed with VAP later in their hospital course, 12 of which had previously been diagnosed with EP. Of EP patients (n = 36), 21 (58.3%) were treated with antibiotics based on clinical signs of infection. Of EP patients who had a later pneumonia diagnosed by BAL (n = 12), seven (58.3%) grew the same organism from their initial BAL. When these patients were excluded from VAP calculation, the rate was reduced by 27.6%. Patients with EP had a higher rate of smoking history (41.7% vs. 19.8%, p < 0.001) compared with patients without EP. There was no difference in median hospital length of stay, intensive care unit length of stay, ventilator days, or mortality between the two cohorts.
Early pneumonia is common in trauma patients intubated within the first 48 hours of admission and screening with early BAL identifies patients with aspiration or pretraumatic indicators of pneumonia. Accounting for these patients with early BAL significantly reduces reported VAP rates.
Therapeutic/Care Management; Level IV.
呼吸机相关性肺炎（VAP）是创伤患者发病和死亡的一个原因。由于创伤性脑损伤、精神状态改变或面部创伤，误吸事件也很常见。在需要机械通气的患者中，早期肺炎（EP）可能被错误地归类为呼吸机相关性肺炎。
从2020年1月至2022年1月实施了一项前瞻性早期支气管镜检查方案。在到达前或入院后48小时内插管的创伤患者在插管后24小时内接受支气管肺泡灌洗（BAL）。BAL培养出超过100,000个菌落形成单位的患者被认为患有EP。
共有117例患者接受了早期BAL。93例（79.5%）BAL有某种程度的细菌生长，其中36例（30.8%）符合EP标准。在整个研究人群中，29例（24.8%）患者在住院过程中后来被诊断为VAP，其中12例之前被诊断为EP。在EP患者（n = 36）中，21例（58.3%）根据感染的临床症状接受了抗生素治疗。在后来通过BAL诊断为肺炎的EP患者（n = 12）中，7例（58.3%）最初BAL培养出相同的病原体。当这些患者被排除在VAP计算之外时，VAP发生率降低了27.6%。与无EP的患者相比，EP患者有吸烟史的比例更高（41.7%对19.8%，p < 0.001）。两组患者的中位住院时间、重症监护病房住院时间、呼吸机使用天数或死亡率没有差异。
早期肺炎在入院后48小时内插管的创伤患者中很常见，早期BAL筛查可识别有误吸或肺炎创伤前指标的患者。将这些患者纳入早期BAL显著降低了报告的VAP发生率。
治疗/护理管理；四级。
