Y HOC V l f r NAM THANG 5 . SO 1/2014
TAI UEU T H A M KHAO
1. Naoya Yoshida, Masayuki Watanabe, Yoshifumi Baba, Shiro I w a g a m i e t a l . Risk factors for pulmonary complications al^er esopiiagectomy for esophageal cancer. Surg
70^5/(2014) 44:526-532
2. Ferguson MK, Celauro AD, Prachand V.
Prediction of major pulmonary complications after esophagectomy. Ann ThoracSurg. 2011;91:1494- 500.
3. Ph^m Dure Huan. Nghien cuU dieu tri phiu thuat ung thu" thu'c quan ngu'c. Luan an TS Y hoc, Tru'dng Dai iioc Y Ha Ngi, 2003
4. Paul DJ, Jamieson GG, Watson D I , Devitt PG, Game PA. Perioperative risk analysis for acute respiratory distress syndrome after elective oesophagectomy. ANZJSurg. 2011;81:700-6.
Zingg U, Smithers BM, Gotley DC, Smith G, Aly A, Clough A, e t a l . Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer. Ann Su/g Oncot 2011;18: 1460-8.
Bakhos CT, Fabian T, Oyasiji TO, Gautam S^
Gangadharan SP, Kent MS, et a l . Impact of the surgical technique on pulmonary morbidity after esophagectomy. Ann Thorac Surg. 2012;93:
221-6.
Surya S A Y Biere, Mark Z van Berge Henegouwen, Kirsten W Maas e t a l . Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open- label, randomised controlled trial, lancet, (2012), 379: 1887-92
DAC DIEM LAM S A N G CIJA BENH NHAN VIEM PHOI DO CUM A / H I N I vA A / H 5 N 1 NANG CO BIEN CHU'NG SUY HO HAP CAP TIEN TRIEN
D 5 Thi Phirorng Mai*, Ngo Trong To^n**, Bui Nam Phong***, Nguyen Gia Binh****, Bao Xuan Cff****
T O M TAT
Nghien culi nay thi/c hi#n nhSm mo ta cac dac diem lam sang va hinh anh x-quang phoi cua benh nhan ciim A/ H l N l va H5N1 nang. Nghien CLTU hoi ciJtJ, thu'c hien tren 21 benh nhan cum A n3ng theo tieu chuan cua Bp Y Te Viet Nam gom 17 ca cum A/HINI va 4 ca cCim A/H5N1, cac benh nhSn nay nhap vl@n va dieu trj tai khoa hoi sij"c tich cUc - Benh vien Bach Mai trong Wioang thcfi gian tOr thang 1/2007 den 12/2011. Lam sang: 17/17 (100%) c^c benh nhan co sot va kho thd, tiep den la dau ngu'c 14/17 (82,4%) cf nhom H l N l va % (75%) is nhom HSNl. 6 nhom benh nhan mSc^ciim A/H5N1 co xuat hien trieu diiJtig iam sang khac ma nhom benh nhan mac cum A/HINI khong co nhU; ban xuat huyet du'di da, d6m CO mau, non, ia long. 0 | c diem lam sang khi nhap khoa: Khi vao vien cac benh nhan deu co suy ho hap.
Nhjp thd, Sp02, mach cua nhom H l N l la 29±5;
74±1,8; 104±12 con cua nhom HSNl la 35±6;
65±1,5; 129±12.
* Benh vien GTVT
** Benh vi$n Lao khoa
*** Bgnh vi$n 198
**** Benh vien Bach Mai
Phan bign khoa hgc: GS.TS Vu Van Dinh
S U M M A R Y
TO STUDY C L I N I C A L MANIFESTATIONS OF S E R I O U S A / H I N I A N D A / H 5 N 1 I N F L U E N Z A I N V I E T N A M Our retrospective study recruited 21 serious influenza patients (Criteria of Vietnamese Healthcare I^inlstry) includes 17 patients with A/HINI and 4 patients v/lth A/H5N1. Our remarks:
- Mean age of patients in our study is young (HlNl influenza A group is 27±15,2 year; HSNl influenza A group is 26±3,4 year).
- All patients in our study are fever and dysnea.
Frequency of chest pain, dry cough, headache are 8 1 % ; 71,4%; 57% respectively. Frequency of myalgias, sore throat, rhinorrhea, sputum ough are 47,6%; 42,9%; 19%; 28,6% respectively.
- In HSNl influenza A group appears spedal symptoms: Petechia, hemoptysis, diarrhea, vomiting
I. OAT V A N OE
Nhiem virut cum la mot benh truyen nhiem thu'dng gap. Trong Ijch sii', virut cum da gay ra nhieu vu dai djch ldn tren the gidi lam chet h^ng trieu ngu'di.
142
Y HOC VlfT NAM THANG 5 - SO 1/2014 Virut^cum A co gidi han vat chu rat rpng, lutj
hanh pho bien tren gia ram va mot so dpng vat CO vu. Nguyen nhan gay cac vy dai dich cum d ngu'di do vi rut cum A [6].
Virut cum A la loai dac biet nhat trong cac vims du'dng ho hap cd kha nang bien doi khang nguyen nhanh chdng [2], [6].
Co nhieu thay doi trong bieu hien iam sang cua benh cum A d ngu'di. Tinh trang suy ho hap CO the tien den rat nhanh kem theo cac ton thu'dng ngoai phoi nhi/ ia Idng, hon me suy than lam nguy cd tu* vong tang len [3],[5]. Benh tien trien nSng dac biet d nhu'ng benh nhan tre tuoi khoe manh khong mic benh ngn, day la dieu rat khac biet so vdi nhuTig ddt dai dich tru'dc day [3],[7].
Viet Nam la nu'dc cd so ca mac cum A/H5N1 cao dCrng thu" 3 tren the gidi va ty le tu" vong cao thu" 2 sau In-do-ne-sia [1],[2].
Khoa hoi sii'c ti'ch cifc benh vien Bach Mai la ndi tiep nhan nhieu benh nhan nliiem cum A/HINI va HSNl nang tijr cac benh vien tuyen du'di thuoc khu vifc mien Bac va mien Trung.
Trong nu'dc cd nhieu de tai ve benh nhan cum noi chung nhuHg chu'a cd nghien CLTU ve b^nh nhan cum nang. Tren the gidl cd nhieu de
tai ve benh nhan cum nang nhutig benh canh lam sang cd nhieu khac biet gitta cac vung dja ly khac nhau [1].
Vdi mong muon phai hieu biet day du hdn ve cac trieu chiTng lam sang benh cum A/HINI va HSNl nang, chung toi tien hanh de tai "Nghien cu'u_ dac diem I3m sang cua benh nhan nhilm cum A / H I N I va HSNl nang" vdi muc tieu: Mo ta dac diem lam sang benh nhan nhiim cum A/HlNl va HSNl nang.
II. OOI TyONG VA PHUaNG PHAP NGHIEN
cCru
2.1. Ooi tu'dng nghien cu'u:
Bao gom tat ca cac benh nhan du'dc chan doan xac djnh la nhiem cum A/HINI va HSNl xep vao loai nang theo tieu chuan chan doan cua Bo Y te Viet Nam. Cac benh nhan nay nhap vien va dieu tn tai khoa hoi sii'c tich cut - Benh vien Bach Mai trong khoang thdi gian tCt thang 1/2007 den 12/2011.
2.2. Phu'dng phap nghien cu'u - Nghien CLTU mo ta hoi ciiu.
- Chpn cd mau thuan tien,
I. K^QUA NGHIEN CCrU
3.1. D^c di€m Chung cua nhom nghiSn ct^u:
Tong so benh nhan la 21 ca. Trong do 17 ca cum A/HINI va 4 ca cum A/HSNl.
3.1.1. B^cdii'm vegidi.
Binq3.1, Dac diem ve Nff Nam Tonq so
gidi
CumA/HlNl 5 12 17
CumA/HSNl 2 2 4
Tong 7 14 21 3.1.2. D$cdiem vetuoi.
Bang 3.2. Dac diem ve tuoi TuSi Tuoi trung binh (nam) (cao nliSt - thap nhat)
CumA/HlNl n=17 27±15,2
(59-6)
Ciim A/H5N1 n=4 26±3,4 (30-22) 3.2. D$c diSm 13m sdng
3.2.1. dc dSu hi$u lam sang thong thu'dng cua benh cum:
Bang 3.3, CAc dau hieu lam sang thong thu'dng cua benh cum DKu hieu iam sanq
Sot Khothi Dau ngu'c
Cum A / H I N I 17 (100%) 17 (100%) 14 (82%)
Cum A/H5N1 4 (100%) 4 (100%) 3 (75%)
Tan xuat (%) 100%
100%
81%
Y HOC VI$T NAM THANG 5 • SO 1/2014 Ho ithan
Dau dau Daucd Dau hong Chay nu'dc mui Ho CO ddm Dau i<hdp Tong so
13 (76%) 10 (59%) 9 (53%) 8 (47%) 4 (23,5%) 4 (23,5%) 2 (11,8)
17
2 (50%) 2 (50%) 1 (25%) 1 (25%)
0 2 (50%)
0 4
71,4%
57%
47,6%
42,9%
19%
28,6%
9,5%
Nhin xet: 17/17 (100%) cac Ijenh nhan c6 sot va l<hd thd, tiep sau ia dau ngiTc 14/17 (82,4%) d nhom HlNl va Vt (75%) d nhom HSNl.
3.2.2, Cic di'u hieu lim sang d$c biit:
Dau iiieu iam sang Ban XHDD Ddm cd mau ia Idng Non Nhip cham xoang Tonqsd
Cum A / H I N I 0 0 0 0 2 17
Cum A/H5N1 2 2 1 1 2 4 NhanxSt:
- O nhom benh nhan mac aim A/HSNl cd xuat hien trieu chuhg lam sang khac ma nhdm benh nhan mac cum A/HINI khong cd nhu": ban xuat huyet du'di da, ddm cd mau, non, la Idng.
- Nhjp cham xoang gap d ca hai nhdm.
3,2.3. B0C diem lim sing khi vio khoa Bing 3,5, Cac dau hieu lam sang l(hi vao l<hoa
Dau iiieu i3m s^ng Nhip thd (chu l(y/phut) SpOj(%) Mach (chu l(y/phut) Huyet ap trung binh (mmHg) CVP (cmHjO)
C u m A / H l N l 29 ± 5 74 ± 1,8 104 ± 12 58 ± 5,2 10,5 ± 1,20
Cum A/H5N1 35 ± 6 64 ± 1,5 129 ± 12 58 ± 6,7 11,3 ± 2,12 Nhin xit: Khi vao vien cac benh nhan deu co bieu hien suy h6 hap. Nhip thd, Sp02, mach vS HA trung binh ciia nhom HlNl la 29±5; 74±1,8; 104±12 cdn cua nhom HSNl 1^ 35±6; 65±1,5; 129±12.
iV. BAN LUgN
4.1. DSc diSm ciiung cCia niiom ngiiien cu'u
Tong so benh nhan la 21 ca. Trong dd 17 ca cum A/HINI va 4 ca cum A/HSNl.
Giong nhff Viet Nam, d Thai Lan nSm 2004- 2006 theo tong l<et cua Vivel< Shinde cd 2074 ca cum A/HINI thi aim A/HSNl chi cd 25 ca. Lffdng benh nhan cum A/HSNl thap hdn nhieu so vdi cum A/HINI [6]. Nhieu nha l<hoa hoc cho rang CO tinh trang nay la do hien tai vl rut cum /VHSNl mdi chi cd kha nSng lan truyen tff gia cam sang ngffdi nhffng trong tffdng lai chung cd
the bien doi glen va se cd kha nang lay tff ngu6l sang ngffdi [7].
4,1,2, Bicdlem vi tudi:
Trong nghien cffu ciJa chung toi, tuSi trung binh cua benh nhan cum A/HINI la 27±15,2, cao nhat la S9 tuoi. Tuoi trung binh la 27±15,2 iJffl vdi nhdm cum A/HSNl, cao nhat la 30 tuoi.
Trong nghien cffu cila chiing toi, tuoi tmng binh cua benh nhan cum A/HINI. 6 Ai-Cap lip tuoi trung binh cua benh nhan chi co 15,5 tuS trong do so benh nhan dffdi 18 tuoi chiem 62%
[7]. a Viet l^am nam 2004 do tuoi cila b^nli nhan cnn thap hdn chi cd 13,7 tuoi (nho nhSt la S, Idn nhat la 24 tuoi) [1]. 6 Thai Lan con s5 nS(
Y HOC VlfT NAM THANG 5 - SO 1Q014
la 18 tuoi .Oieu nay cang khang dinh gia thuyet vS cd che benh ^nh ctia b§nh aim, dac biet benh nhan nang. NhuTig trenh nhan tre tuoi co he mien dich khoe manh thi "cdn bao cytokine"
cang manh [2].
4.2. Dac diem lam sang:
4.2.1. Cac dau hieu lam sang thong Otifdng cua benh cum:
0 nhdm benh nhan mac aim nang trong nghien cu'u cua chiing toi cung thay xuat hien hau het cac trieu chiJng cua benh aim thong thu'dng nhutig cd Sn suat cao hdn. Tinh trang sot va khd thd xuat hien d tat ca cac benh nhan trong hai nhdm chiem 100%. Tiep theo dd la dau ngu'c (82,4%) va ho khan (76,S%) roi den cac dau hieu khac. So vdi nhdm aim A/HINI thong thu'dng ddt djch 2009-2010 tgi benh vien benh nhiet ddi trung u'dng, theo tong ket ciia Pham Thanh Binh tinh trang sot chl xuat hien tren 9S%
benh nhan, dac biet tinh trang khd thd chi cd ty le 3,1% [1].
Khong phai liic nao dau hieu sdt cung xuat hifn va khdng phai nhiing b?nh nhan khdng sdt thi b^nh se nhe hdn. Nghien ciiXi ciia Sopirala cho thSy trong so 135 benh nhan aim A/HlNl/2009 d 6-hai-o cd 56 benh nhan khdng c6 bleu hien sdt nhuing 31 (32%) trong so S6 b$nh nhan nay van cd chuyen benh nang phai chuyen dieu trj tai khoa HSTC, tham chi 9 (16%) b?nh nhan trong so nay da tii" vong [3].
Tu'dng tu" nhu" nghien ciiU ciia chiing toi, Estenssoro va dong nghiSp ciia dng d Ac-hen-tl-na cljng CO dau hieu sdt va khd thd xuat hien vdi ty le cao nhat d nhdm benh nhan nhiem aim A/HINI nang (sot: 96,2% va khd thd: 8S,9%) [S].
Trong nghien cu'u ciia chting tdi, nhdm aim A/HSNl cd tinh trang ho cd ddm nhieu la 50%, nhom aim A/HINI chi cd 23,5% va chu yeu la ho khan chiem 76,5%. 0(ft djch aim A/HSNl 2004-2009 d Thai Lan co 25 benh nhan, ty le sot cung rat cao chiem 23/25 (96%), tiep theo la khd thd 81% nhuhg ho cd ddm chi chiem 38% [7].
4.2.2. Cac dS'u hl$u lim sing dac biet:
Trong nghien cufu ciia chiing tdl, cac benh nhSn mSc aim A/HSNl nSng cd xuat hien mot sd dSu hl?u 13m sang bat thudng nhu'; ho cd ddm lan mdu 2/4 benh nhan chiem ty le 50%, ban xuSt huyet du'di da 2/4 benh nhan chiem ty le
S0%, ndn va ia long 'A benh nhan ty le 25%. Cd 02 ca benh nhan xuat hien tinh trang nhip cham xoang gay tut huyet ap phai lap may tao nhjp ngoai cd the de theo ddi va cap CUIJ kjp thdi. Day cung chinh la diem khac biet tuyet doi giO^ hai nhdm benh nhan aim nang bdi vi cac benh nhan nhdm aim /VHlNl trong nghien ciiu ciia chiing tdi khdng he cd cac bieu hien tu'dng ttf.
Khdng gidng vdi nghien cu'u cua chiing tdi, d My ddt djch aim A/HINI nam 2009 dau hieu lam sang nhtf ndn, ia Idng cd xuat hien trong nhom benh nhan nay vdi ty te la 25%. 6 My, trong ddt djch aim A/HINI 2005-2009, cd xuat hien dong thdi tinh trang ndn, ia Idng, ho ra ddm co mau [7], Cac dau hieu lam sang cua benh nhan nhiem dim A/HSNl trong nghien di'u ciia chung tdl ttfdng ddi giong vdi benh aim A/HINI nang d cac ntfdc My, Ca-na-da, Ac-hen-ti-na, Tay ban nha [3], [4], [7],
Trong nghien ciilj ciia Vivek Shinde va cac cong stf ve benh nhan mac aim A/HSNl d Thai Lan ddt dich 2004-2006 cung xuat hien trieu chiihg non, ia Idng nhutig khdng thay xuat hien ban xuat huyet dudi da va khdng thay ho cd ddm lln mau, tuy nhien dau hl?u non va ia Idng xuat hien nhieu hdn d nhdm aim A/HSNl so vdi nhdm dim A/HINI trong ding nghien ai\j nay [15]. O Viet Nam, ddt dich 2004 cd 10 benh nhan tiii chi thay cd 1 benh nhan ho ra mau, con lai tat ca dSu sot va ho trong dd 50% ho cd ddm, 50% ho khan.
Tinh trang ho ra ddm lan mau xuat hl^n d nhdm 18 benh nhan aim A/HlNinang d Me -hi- ed vdi ty le 33% trong khi dau hiSu chay ntfdc mui chi CO 18% [7].
Nhtf vay cac dau hieu lam sang dSc biet trong nghien cinj ciia chiing toi va nhieu nghien etfu d cac ntfdc khac hau nhtf chi xuat hien d nhdm benh nhan nang. Cac dau hieu cua benh dim thtfdng 6\iac ghi nhan lai vdi ty le thap trong nhdm benh nang. Cac nha lam sang nen het SLTC Itfu y vdi cac trtfdng hdp benh nhan nghi mac ciim kem cac trieu chiitig bat thtfdng nhtf ho ra mau, ia Idng, dau ngtfc, khd thd...Khi benh nhan nghi mac aim cd them cac bieu hien dSc biet thi cac nha lam sang nen het sii'c can th?n de phdng tinh trang viem phoi do ciirn, va tii do cd the phat Wen the aim nSng.
J^S
Y HOC VIET NAM THANG 5 - S01/2014
4.2.3, Bac diem lam sang Idti vao vien:
Khi vao khoa HSTC benh vien Bach mai, cac benh nhan fiting nhdm nghien di'u deu d trong tinh trang suy hd hap nSng nen cac dau hieu lam sang (^u phan anh tinh trang suy hd hap ndi tren.
Benh nhan cS hai nhdm deu m nhip thd nhanh, nhdm tiim A/HINI cd nhip thd la 29 ± Sfan/phiit, nhdm ciim A/HSNl cd nhjp thd la 35 ± 6 lan/phiit.
SpOz ciia nhdm aim A/HINI la 74 ± 1,8% nhdm aim A/HINI la 64 ± 1,5%. Huyet ap trung binh ciia ca hai nhdm cung d mtfc thap, nhdm ciim A/HINI la 58 ± S,2mmHg va nhdm aim A/H5N1 la 58 ± 6,7mmHg. 03 hien UTdng nay vi khi vao khoa mpt so benh nhan ciim A/HINI da rdi vao tinh trang sdc v& suy hd hap nang.
V. KET LUAN
Qua nghien ciiXi hdi oilj tren 21 benh nhan aim A nang (theo tieu chuan ciia Bd Y Te Viet Nam), gom 17 benh nhan ciim A/HINI va 4 benh nhan aim A/H5N1 chiing tdi nhan thay:
- Op tudi trung binh ciia cac benh nhan aim trong nghien etfu ciia chiing tdi rat tre: trang nhdm aim A/HINI la 27±15,2 (cao nhat la 59 tudi, thap nhat 6 tuoi), trong nhdm ciim A/HSNl la 26±3,4 (cao nhat 30 tudi, that nhat 22 tuoi).
- Tat ca bSnh nhan aim deu cd bieu hien sdt va khd thd. Cac trieu chtfng dau ngu'c, ho khan, dau dSu g3p vdi tan xuat cao tren 50%, Cac trieu chtihg dau cd, dau hong, chay ntfdc mui, ho cd ddm xuat hien vdi tan xuat thap dtfdi 50%.
- Trong nhdm aim A/H5N1 xuat hien them cac tri^u chiitig dac biet nhtf ban xuat huyet dtfdi da,
ddm cd mau, ndn, ia Idng. Trong ca hai nhom xuat hien mdt sd tjfnh nhan cb nhjp cham xoang.
VL KIEN NGHj
Sd Itfdng benh nhan trong nghien ciiXi ciia chiing tdi cdn ft, cac ket luan dtfa ra cdn han che.
Can tiep tuc nghien di'u, tdng ket tren sd Itfdng benh nhan Idn hdn.
TAI Ll|U THAM KHAO
1. Pham Thanh Binh (2011): "Nghien cull dSc diem lam sang can lam sang d benh nhan ngiM ldn nhiem cum A/HlNl/20(^ te/ t^nh vien benh nhiet ddi irung u'dng (2(m-2010T, Luin van th?c sy y hpc, dai hoc y Ha Npi - nam 2011.
2. Joseph PiMizgerd.Sc.D.(2008): Mo/A? Lovm Respirator/ Tract Infec^on". N Engl J Med; 358:
716-727.
3. Estenssoro E, Rios FG, Apezteguia C, et at (2010); "Pandemic 2009 Influenza A in AtgenOna:
A study of 337 Patients on Mechanical Ventilaaon". Am J Respir Crit Care Med; 182(1):
41-48.
4. Ewbster R6, Bean WJ, Gorman OT.
Chambers TM, Kawaoka Y (1992): "Evolution and ecology of influenza viruses". Microbiol Rev;
56(10): 152-179.
5. Ghazi Kayali, Richard 3. Webby et al (2011);
"The Epidemiological and Molecular Aspects of Influenza HSNl Viruses at the Human-Animal Internee in Egypt". Plos One; 6(3).
6. Michael T.Osterholm,Ph.D,M.P.H. (2005):
^Pieparing fyr the Next Pandemic". N Eng! J M;
352; 1839-1842.
/ . Rogelio Perez-Padilla, M.D. et al (2009):
"^Pneumonia and Respiratory Failure from Swin- Origin Influenza A(H1N1) in Mexico". N Engl J Med; 361:680-689
