NGHIEN CUfU MOT SO Y E U TO NGUY C d HOI CHUTNG SUY HO HAP CAP TIEN TRIEN T R E N BENH NHAN BONG NANG
Nguyln Nhij> Lam, Trtn Cinh Hung, Ngd Tuin Hu'ng, Nguyen Thai Ngpc Minh, L@ Quang Thdo, Nguyln Hai An Vi$n Bdng Quic gia
T6IVI TAT
Ngtiiin c(fu tiin cOv xic 6inii cic yiu td nguy co tiiin nt)i6n dii vdi biin ctiCtng suy ti6 tiip cip tiin triin (ARDS) trin 159 b$nti nhin bdng n^ng, bdng lid tiip. Kit qui ngliiin ciru cho thiy 28,3% si binh nhin bi biin chCmg ARDS. Cic yiu td nguy ca tim thiy bao gdm bdng a 40%
diin tich CO thi, bdng siu a 10% di$n ticii co thi, bdng hd hip vi bdng siu vCtng li/ng/ngirc.
Tin suit xuit hi$n ARDS ting cao cung vdi sw c6 m^t cua so lu^ng cic yiu td nguy co: 7,29%
khi cd mdt yiu td nguy co, 15,56% khi cd hai yiu ti nguy co, 24,6% khi cd ba yiu td nguy co vi 62,29% khi cd aO 4 yiu td nguy ca.
Tir khda: ARDS, bdng n^ng, bdng hd hip.
A prospective study conducted on 159 severe burn patients to find out obviously risk factors contributing to development of Acute Respiratory Distress Syndrome-ARDS. Result showed that, 28.3% of patients developed ARDS. Found risk factors for ARDS including: burn surface area s 40%, fullthickness bum area £ 10% Total body surface area, inhalation injury and deep bum at chest or back region. The development of ARDS significantly increased along with number of mentioned risk factors: 7.29% for 1 risk factor, 15.56% for 2 risk factors, up to 24.6%
with 3 factors and reaching 62.29% when all 4 factors presented.
Key words: ARDS, severe bum, inhalation injury
1. DAT VAN D£' vl tinh chat b^nh n^ng cung nhu' 19 i$ tCf vong HOi chijpng suy hS hap tien trien (Acute '=^°- '^'°"^ ''°"9' " i ™ ' ^ '''*"9 ^^' 'J '* ' * Respiratory Distress Syndrome -ARDS) \i ™ g <io ARDS ICf 40 - 90% v6i nguySn nhSn tinh tr?ng suy he hip clp nSng tiin tnen, tro * ' " ^ ihuimg do nhiSm l<huin huylt hoSc suy vdi ii«u ph^p tho oxy, giam id din hoi cua ^^ ' ' " 9 ' ^^ '''^' ° ^"'^ "^^" *^''S ^'> *^P- ph6i vi trSn phim XQuang \i hinh anh t6n '^9*''^" '''"' "^^ "^^'" ' " " ^ ' * " -"*' ^ V^" ^ thu-ong thSm nhiem Ian toa hai bSn phoi. Ti§u "^"^ "^ "="= '^'^°® 1-*" f"*-"^ "•'*-' *>°"9 chuJn chin doin ARDS da ducjc dua ra t?i "^"9 nhSm tiln tdi de xult cSc bi$n phip hOi nghi th6ng nhlt Au iViy nam 1994 gin dSy ^'^^ ' " " " "^^^"^ "^ " ' " '^*'^ ' ' * " <l"a ^Oi da d u w b6 sung va thing nhlt tgi Hoi nghi "'"''"^ " * " ' ' '> "^"9 "^^•
^lTu°2' w "J;'''.° f 1 ? ^ ' ' ° ^ 2.£)6iTl«?NGVAPHUONGPHAPNGHlENClh;
van ia thaoh thuc ton doi vcS-i cac nha hoi sue •••!;« v,uu B l i tu-cng nghiSn ci>u gom 159 bjnh Phin biin khoa hoc: TS. L« Buc Min "f'S" " 9 " * ' ' * " '-*"9 "^"9 " ^ ' ' i * ^ trj t?i khoa
TCYHTH&B s6 4-2014
H6i SCFC c4p ci>u, Vi#n Bong L6 HO-u Tr^c tCr thdng 5/2013 d4n thdng 9/2014, thoa mSn cac y6u clu sau: Tu6i tCr 16 den 60; vdo vi^n trong 48h sau bong; di$n tich bong chung >
20% Di0n tich ca thi ho$c c6 bong h6 hap;
khGng bj cic b§nh vh phfii ph4 quan tru-d-c khi bj bdng.
B$nh nhan via vi$n tJu-gc chan 6oin vj tr( bong, di$n tich bdng, dO sdu t6n thu-ang bdng, 6\iu trj theo phdc d6 chung tgi Vt$n B6ng L6 HOu Trdc bao g6m ch6ng s6c, nu6i du-O-ng, thay bdng hdng ngdy, phau thu^t cdt hogi tO" gh6p da theo chf djnh. Bdng hO hip du-p-c chin dodn theo tiSu chuIn cua HOi Bdng Hoa Ky ndm 2007 dya trfin cdc diu hi$u Idm sdng, vd nOi soi khf phi quan trong 3 ngdy diu sau bdng. Chin dodn hOi chu-ng ARDS dya theo tiSu chuIn cOa h$i nghj Berlin ndm 2012 nhu-sau [3]:
- Khdi phdt dOt ngOt diln biln xlu trong vdng mOt tuIn
- Xquang c6 hlnh thdm nhilm ph6i 2 b6n Ian tda, logi trO do trdn djch, khIi u ho|c x$p thuy phli.
- Suy hd hip clp khdng phai do thira djch, suy tim
- MO-c dO oxy hda mdu:
+ Nhe: 200 mmHg < Pa02/Fi02 ^ 300 mmHg vdi PEEP hodc CPAP a ScmHzO
+ Ndng: 100 mmHg < PaOj/FiOz s 200 mmHg vdi PEEP a ScmHzO
+ Rlt ndng: PaOj/FiOz £ 100 mmHg vdi PEEP aScmHzO
Phdn tich mli lien quan giO-a cdc yeu t l bao gdm: tuoi, gidi, di§n tich bdng chung, di^n tich bdng sdu, cht so bdng, chi s6 ti§n lu-g'ng bdng, bdng hd hip, vj tri bdng sdu lu-ng/ngg-c, soc nhiem khuan, ndng dd du-dng mdu vdo vign, mdu vd cdc chl phim mdu tnjyIn vd sy xult hi0n ARDS trong bdng.
Phan tich tong hg-p sy ket hg-p cua cdc ylu td nguy co- hiln nhi^n vd sy xult hi0n ARDS trong bdng. Xu- ly so li$u trdn phIn mIm thong ke Stata Intecool 11.0. Gid trj p < 0,05 du-gc coi Id cd y nghTa thong kd.
3. K£T QUA NGHIEN Cl>U
Bang 1. Dae diem b#nh nhan nghien cu-u D9C diem
Tuoi (nim) Di?n tich bong (%) Dl^n tich bong sSu (%) Thai gian vao vion sau bong (h) Bong ho hap n, % Ty 1^ nam/nu ARDS
Trung binh 34,39±11,7 49,08 ± 20,05 20 ±18,04 7,54 ± 7,94
Min- Max 16-59 20-95 0-90 3-70 56 (35,22%)
126/33 45 (28,3%)
Nhdn x6t: Tuoi tmng binh cua 159 b$nh nhdn nghien ci>u Id 34 tuoi, bgnh nhdn nam chiem u-u the han so vdi benh nhdn nQ-. Tit ca bfenh nhdn diu bdng ndng vd rlt ndng, cd 35,22% benh nhdn bdng hd hip. Thdi gian den vi$n b'ong khoang 8h sau bdng. 45 b$nh nhdn bj bien chu-ng ARDS chiem ty 1$ 28,3%.
Bang 2. Lien quan giu-a gidi tJnh, tac nhin bdng vdi ARDS
Gidi tinh Nam NS Tu6i
TSc nhan bing Nh«t I<h6 Nhi$t uin Di$n H6a chit
ARDS n 38 7
30,16
%
21,2 36,8 ± 12,27 37
4 4 0
28.03 50 25 0
Khong ARDS n
88 69,84
%
26 1 78,8 33,43 ±11,39 95
4 12 3
71,97 50 75 100
P 0,31 0,10
0,37
46
fJhin xit Nam gidi C(5 ty 1$ ARDS nhieu quan gitta tao nhan gSy bdng va tuli v*i biln hen nu gi*i, tuy nhiSn su' l<hac biet I(h6ng co chung ARDS vdi p > 0,06.
y nghTa thong kS vdi p=0,31. Kh6ng c6 sir Ii6n
Bang 3. Uen quan giija di#n tich bdng, bong hd hip v6i ARDS
Bong ho hap Bong sSu viing
li/ng,ngi^c
Dl$n bong chung
D[$n bong sau
Co Khong
Co Khbng
<20%
20-39%
40-69%
260%
Bong n6ng 1-9%
10-19%
£20%
ARDS n 25 31 33 12 0 4 19 22 2 2 9 32
55,56
%
27,19 38,37 16,44 0 9,76 31,15 44,90 9,1 7,14 23,08 45,71
Khong ARDS n 20 63 53 61 8 37 42 27 20 26 30 38
44,44
%
72,81 61.63 83,56 100 90,24 68,85 55,1 90,9 92,86 76,92 54,29
P 0,001 0,002
0,001
< 0,001
Nhdn xit: Ty 10 biln chCrng ARDS tdng cao cCing vdi sy gia tdng di$n tich bdng, di0n tich bdng sdu, sy khdc bi$t cd y nghTa thdng kd vdi p =0,001. Cdc gid trj trung binh cua di$n tich bdng, di^n tich bdng sdu vd cao han cd y nghTa thdng kd d nhdm ARDS so vdi
nhdm b^nh nhdn khdng bj ARDS. T^ 1$ ARDS tdng cao ddng k l d nhdm b0nh nhdn cd bdng hd hip (55,56% so vdi 27,19%) cQng nhu- d nhdm cd bdng sdu vOng lyng/ngyc. Sy khdc bi$t cd y nghTa thdng kd vdi p < 0,01.
100 100
9 0 80 70 60 50 40 30 20 10 0
• 1
• •
•
.M
Khdng YTNC1
9271
^ ^ H &a 44
m U m
• • 1
H • H
• • •
1 1 ^H H^^liH
iliW
1 YTNC 2 YTNC 3 YTNC• ARDS (%) • Khdng ARDS (%) 6129
^^
| 3 8 71
s
4 YTNC X'
Bieu do 1. LiSn quan giipa s6 lipp^g y l u to nguy ca hien nhidn v^ ARDS
* YTNC: yiu ti nguy ca
TCYHTH&B s6 4-2014
Nh$n xdt: Phdn tich tdng hp-p 4 y l u td nguy c a hien nhien bao gdm bdng hd hap, di$n tich bdng £ 4 0 % di$n tich ca t h i , bdng sdu > 10% di$n tich c a t h i vd bong sdu vdng lu-ng/ngyc cho t h i y ty 10 ARDS tdng cao ciing vdi s y x u l t hi^n ciing IGc cua cac yeu to nguy ca. Ty 10 ndy tu- 0% neu khdng cd yeu td nguy ca ndo tdng Idn 7,29% khi cd mdt y l u t l nguy ca, 15,56% khi cd hai y l u td nguy c a , 24,6%
khi cd ba y l u t l nguy c a vd 62,29% khi cd du 4 y l u to nguy ca.
Bdng 4. Kdt qud d i l u trj ARDS
C6 Kh6n9
T6ng
Ciru sdng n 9 80 89
%
20 70,16 55.97
Tu* vong n 36 34 70
%
80 29.82 44.03
T6ng 45 114 159 Nh$n xdt Ty 10 tii- vong cua nhom b$nh nhdn nghidn ci>u Id 44,03%. Ty 10 tu- vong tdng cao d nhdm b0nh nhdn cd b i l n chi>ng ARDS vdi 80% so vdi nhdm khdng ARDS (29,82%).
4. BAN U)^U
Trong bdng, ARDS Id b i l n chCrng ndng, ty 10 x u l t hi0n cao trdn nhu-ng BN cd bdng hd h i p k i t hp'p. Ty 10 ARDS trong bdng dyp-c cdng bd khdc nhau trong n h i l u cdng trinh nghidn c d u , n6 phy thudc vdo mu-c dd ndng cua b0nh bdng [1], [2], [3]. Dancey D.R.
(1999) nhdn thay ty 10 A R D S sau bong Id khd cao, vdi ty 10 53,6% [6]. Theo Steinvall I.
(2008), t } 10 ARDS d b0nh nhdn bdng ndng Id 56,25% [8]. Nhu-ng nhin chung, cdc tdc gia deu thdng nhat ty 10 A R D S trong bdng dao ddng ti> 20 - 5 6 % tOy theo mu-c dd ndng cua b0nh bdng [5], [7]. Ty 10 A R D S d b0nh nhan bdng trong nghidn cu-u cua chiing tdi Id 28,3%.
Tdn t h y a n g bong Id nguydn uy cua cdc rdi logn b0nh ly d b0nh nhdn bdng. Di0n tfch bong chung vd bdng sdu cdng tdng thi mu-c
dd tidn l u v n g b0nh bong cdng ndng, ty Id xuat hi0n bien chdng cdng cao. Cdc cdng trinh nghidn c d u dd n h i n m?nh, ty 10 ARDS tdng cao cung v d i tdng di0n tich bdng chung vd bdng sdu trong bdng. Trong nghidn c d u cua chCing tdi cung cho ket ludn tu-ang ty: Khdng c6 b0nh nhdn ndo cd bien chdng ARDS neu di0n tich bdng chung du-di 20% di0n tich ca t h i , ty 10 ARDS Id 9,76% vdi di0n tich bong Chung 20-39%, tdng cao d i n 31,15% vdi di0n t i d i bdng ti> 40-59%, 44,9% vdi di0n tich bdng t d 60% di0n tich c a the tra Idn. Ty 10 ndy Id 7,14% vdi di0n tich bdng sdu t d 1-9% di0n tich c a the, tdng Idn 23,08% vdi di0n tich bdng sdu tir 10-19% vd 4 5 , 7 1 % vdi di0n tich bdng sdu t d 20% di0n tich c a t h i trd Idn. khdc bi0t cd y nghTa thdng kd vdi p < 0,001.
Bdng hd h i p Id b0nh ly bdng cd ty 10 t d vong cao. Ty 10 bdng hd h i p theo cdc tdc gid bdo cdo khdc nhau, tuy thudc vdo tdc nhdn, hodn canh bi bdng, cung nhu- c d mdu nghidn cdu. Nhin chung, ^ 10 bdng hd h i p trong cdc nghidn cdu khoang 2,5 - 56%. Bdng hd h i p cd lien quan den s y x u l t hi0n ARDS vd Idm tdng ty 10 ARDS tnang bdng. Trong dd, roi logn tuIn hodn p h i qudn trong bdng hd hap Id nguydn nhdn Idm tdng shunt phli, d i n tdi ton thu-ang phdi. CCing vdi sdn pham ddc peroxynitrite dyp-c hlnh thdnh t d nitric oxide sau bong hd h i p gdy ton thyang mdng mao mgch p h i nang Id ca c h l b0nh sinh chinh ARDS bdng [7]. K i t qua nghidn cdu cua chLing tdi cho t h i y , ty Id ARDS d nhdm BN bdng hd h i p Id 55,56%, cao han d nhdm khdng bdng hd h i p Id 27,19%, s y khdc bi0t cd y nghTa thdng kd vdi p < 0,001.
Vj tri bong Id mOt trong nhdng gp-i y giOp nhd Idm sdng tidn lyp-ng b0nh bdng phyc vy cho cdng tdc dieu trj. Vi tr! bdng vCing d i u mdt cd Id mdt trong cdc gp-i y nghT d i n bong hd hap, d i l n b i l n b0nh t h y d n g n$ng han. Bdng sdu vung lu-ng, ngyc, hogi t d chu vi ngyc, lu-ng gdy can t r d hd hap, can rgch hogi t d giai phdng chdn 6p, dong thdi bong sdu cung Id ngudn goc gdy n h i l m khuln.Trong nghidn c d u cua chung tdi, h l u h i t cdc b0nh nhdn bdng sdu lu-ng/ngyc thu-dng kdm theo bdng
48
hd h i p . D i l u ndy c6 t h i du-p-c gidi thich Id do tdc nhdn gdy bdng d cdc tru-dng hp-p ndy chu y l u Id nhi0t khd gdy chdy q u i n do. I^Ot sd b0nh nhdn bj bdng trong cdc budng kin. Tuy nhidn, chya cd nghidn c d u ndo d l cdp d i n mdi lidn quan gida bdng sdu lu-ng ngyc vd ARDS. ChOng tdi nhdn thay, ty 10 ARDS tdng cao han g I p 2,33 Ian d nhdm b0nh nhdn cd bdng sdu lu-ng/ngyc so vdi nhdm khdng bdng sdu d lu-ng/ngyc, vdi p = 0,002. Da sd cdc tdc gia deu di den thdng nhat cdng nhieu y l u td nguy co thi ty 10 xuat hi0n ARDS cdng cao [5], [8]. Trong nghien c d u , chung tdi phdn tich mdi lidn quan gida 4 yeu td nguy c a h i l n nhidn bao gdm: di0n tich bdng chung trdn 40%, di0n tich bdng sdu tren 10% di0n tich ca t h i , bdng hd h i p , bong sdu lu-ng/ngyc vd s y x u l t hi0n ARDS. Ket qua cho t h i y , t^ 10 x u l t hi0n ARDS tdng theo sd cdc y l u td nguy ca.
TJ 10 ndy Id 7,29% neu cd mdt yeu td nguy c a vd tdng tdi 61,29% khi cd 4 y l u td nguy ca, 5 . K £ T L U A N
Di0n tich bdng chung £ 40%, di0n tich bdng sdu £ 10% di0n tich c a the, bdng hd h i p , bdng sdu vOng lu-ng ngyc cd lidn quan d i n s y gia tdng ddng k l bien chdng ARDS, Cdng n h i l u yeu to nguy c a thi ty 10 x u l t hi0n b i l n chdng ARDS cdng cao. Ty 10 ndy Id 7,29% khi cd mdt y l u td, 15,56% khi cd hai y l u td , 24,6% khi cd ba yeu td vd tdng cao tdi 61,29% khi cd du 4 y l u td nguy ca.
T A I L I $ U T H A M K H A O
1. VO van Dinh (2004). "Hpi chu-ng suy h6 hap cip tiln triln", Hdi s&c cip cO-u loan tap, Nhi xuit bin Vhpc, trang78-95.
2 Tr^n Thj Oanh (2006), 'Nghien ciru 69c diem ISm siing. c^n Idm s^ng va ket qua dieu trj ARDS t^i khoa l-t6i si>c cap ciru va trung lam ch6ng d$c b$nh vi§n b9ch mai", Lu$n vin thac s^ y ApcDgi hgc Y HaN$i
3. ARDS Definition Task Force (2012), "Acute respiratoiy distress syndrome. The Berlin deRnition", JAMA, 307 (23), pp. 2526 - 2533
t . Ashbaugh DG, Bigelow, Petty TL et al. (1967),
"Acute respiratory distress in adults". Lancet, vol 2, pp. 319-323.
5 Bhadade RR, Souza RA de, Harde MJ et al.
(2011), "Clinical characteristics and outcome of patients with acute lung injury and ARDS", J Postgrad Med; Vol 57, pp. 286 - 290.
6. Dancey DR, Hayes J, Gomez M, et al. (1999),
"Acute respiratory distress syndrome in patients with thermal injury". Intensive care Med; vol 25, pp 1231-1236.
7. Nugent N, Herndon D.N, (2007), "Diagnosis and treatment of inhalation injury" Edited by Hemdon DN. Third edition; pp. 262 - 272
8. Steinvall I, Bak Z, Sjot>erg F (2008), "acute respiratoiy distress syndrome is as Important as intialation injuiy for the devetopment of respiratory dysftjndion HI major bums".eums; vol 34, No (4), pp. 441 - 451.
