DAC DIEM LAM SANG. CAN LAM S A N G
CUA VIEM PH6\ MAC PHAI TAI CONG D 6 N G
TOM T A T
Di danh gid eae dde diim lam sdng vd edn Idm sang tmng Vidm phii mie phii tgi dng ding (VPMPCB) chOng tdi tien hanh nghiin cdij 75 bdnh nhan mie VPMPCD diiu tri tai Binh vidn BSnh Nhidt ddi Tmng uang td thdng 2/2011 din thang 7/2012.
Bdnh nhan duac chin doan VPMPCD thudng va n^ng theo tieu chuin ding thuan giOa Hdi Ling nguc Mp vd H& Benh Nhiim trung My ndm 2007.
Kit qui: Tridu chdng thudng gdp eda VPMPCD Id sit (98.6%), ho (90.6%). khae ddrn (74.6%,). dau nggc (68%). Trong vidm phdi ndng, tp Id bdnh nhdn d khd thd va cim gidc khd thd, rdi loan p thdc vd dau ea cao han cd p nghTa thdng ke so vdi vidm phii thudng (p<0,001) (khd thd 95,2% so vdi 46.3%o; rdi loan p thdc 42.9%, so vdi 1.9%,; dau ea 57.9%, so vdi 27,8%).
90,5%, dnh nhdn vidm phii ndng d tin thuang lan td d phii; so lugng tiiu du va bach du mau giam d p nghTa thing ki(p<0,001), nhungmenAST. ALT, ure.
CRP tmng mdu tdng cao cd y nghTa so vdi vidm phii thudng {p<0,001). Nguy cO mic vidm phii ndng d de bdnh nhan nghidn rugu Id 9,55 lan so vdi bdnh nhdn kiidg nghien njgu (95%oCI: 2,36-57,9; p=0,003).
Tdkhda: Vidm phii mie phii tai cdng ddng, viem ph&ndng.
SUMMARY
To Study clinical and pamdinical manifestations of community acquird pneumonia (CAP), 75 patients hospitalized at National Hospital for Tmpical Diseases were recmited fmm February 2011 to July 2012. All of patients were diagnosed CAP and severe CAP according to the criteria of the Infectious Diseases Society of America and American Thomcic Society Consensus Guidelines on the Management of Ckxnmunity-Acquired Pneumonia in Adults, 2007.
Results: The most common symptoms of CAP were fever (98.6%,). cough (90.6%,), sputum (74.6%,) and chest pain (68%,). The mte of dyspnea and dyspnea feeling, confusing and myalgia in the severe CAP was significantly higher than those in non-severe CAP (dyspnea/dyspnea feeling 95.2%, versus 46.3%,;
confi/s/on 42.9%, versus 1.9%; myalgia 57.9%, versus 27.8%,). 90.5%o of severe CAP patients had multilobed infiHrations. Thmmbocyte and white blod cellls wem significantly decreased but the levels of AST, ALT, Urea, CRP in blod were significantly increased in comparision with non-sevem CAP. Alcohol dependence was a risk factor for sevem CAP (0R=9.55; 95%CI=2.36-57.9).
Keyvmrds: CAP, sevem CAP
TA THj^Dieu N G A N , NGUYEN V A N KtNH, N G U Y £ N V U TRUNG
Trudng Oai hgc Y Hd N^
QATVAND^
Viem phdi mac phii tai cfing dfing (VPMPCD) la mdt bfinh thudng gap va hien tai v i n l i mdt trong nhCfng can nguySn chfnh gay tCf vong tren thd gidi. Tai My, viem phdi diifng hang thif 6 trong sd cac can nguyen ^gay til vong va la nguyen nhan tCf vong sd 1 trang sfi c i c benh truyin nhilm [1]. Phin Idn c i c tiiidng hpp VPMPCO dupe theo ddi dieu hi ngoai tm, nhung efi khoing 20% sd bdnh nhan can phii nhap vifin dieu tri. 10% benh nhan dieu tri npi tni cd bieu hien viem phdi nang va c i n phii dieu tri tal Khoa Hdi sUc tfch cue. Ty la tCf vong ciia vidm ph^i nang cd t h i len tdi 50% [2], Oac biet, ty Id vidm phdi ngiy cang tang d ngudi gia va tren mdt sfi cd dia dac biet nhu nghien rUOu, tieu dudng, benh gan-thin man ti'nh. 6 cac benh nhan nay, trifiu chUng lam sing cfi t h i khong diln hinh va thudng diln bien thanh vidm phdi nang.
Ty le mac viem phdi nang tang len ^ e o tudi va tuoi cing cao cang gay ra nhilu tac dfing bat ldi den kdt q u i dieu tri [1]. Benh canh lam sang da dang l i m cho viec chin doin va dilu trj VPMPCO gap nhieu khd khan. 6 Viet Nam, hien chu^ cd nhieu nghien cifu iam sing v l VPMPCO. C i c nghien ciiu trudc day thudng chi tap tmng tim hieu can nguyen gay VPMPCO.
Chiing tdi tien hanh nghien eiifu nay vfii mue tieu: Nhan xet dac diem lam sing, can lam sang eua VPMPCO d dc benh nhan dieu tri ndi trii tal Benh vien Benh Nhiet ddi Trung Udng (BVBNOti;).
D6\ T U Q N G V A PHUONG P H A P NGHIEN CQU 1. Doi tuong nghien cUu.
- C i c benh nhan tren 18 tudi mdi nhap vien dieu trj trong vdng 36h dau, cd c i c bieu hien cua viem phdi va dong y ky b i n thoa tiiuin Uiam gia nghien eiiiu.
VPMPCD dUde chin d o i n theo tieu ehuan sau [3]:
Mdt tdn thuong mdi xuat hien tren phim chup XQ nguc (mdt hoac hai ben phdi).
Kdm theo co mfit hoac nhilu bieu hien cap tfnh eda dudng hd hap nhii: ho. khae ddm, khd thd, sfit tren 38"C hoae co the ha nhiet dp (36''C), kham phdi cfi hfii ehifng ddng dae hoac cd ran am hoac ran no d phdi.
- l i e u chuin loai tiiT. Bfinh nhan da ti^g nam vien trong thdi gian 14 ngiy tnide khi bj VPMPCD hoae da dilu tn d mdt bdnh vien khae trong vong 48h tn/dc khi ehuyen den BVBNDTU; benh nhan nhifim HIV hoac nghi ngd mac lao phfii.
2. Thdi gian nghien cdu: TU thing 2/2011 den thing 7/2012
3. Phuong phap nghien cufu:
Y HOC THVC HANH (881) - S6 10/2013
- Nghien cCfu t i l n cifu, mfi ta c i t ngang. Thfing tin ciia bfinh nhin dupc thu t h i p theo mfit mSu bdnh i n efi s i n . Bfinh nhin nghifin ciifu duoc chia thinh 2 nhdm VPMPCD thudng v i nang di so s i n h .
- Chin doan VPMPCD nSng \d dc bfinh nhSn cfi eac tieu chf gidng nhu VPMPCD thuOng nhu da nfiu ci ti^n v i cfi thfim ft nhit 3 tidu chuin phu va/ho^c ft nhit mfit tidu ehuin chfnh sau [3]
TiSu chuin chfnh:
Cfi thfing khf hS trp xfim nhSp
Sfie nhilm khuin c i n phii diing thufic van mach Tidu ehuIn phu:
Nhip thd tr^n 30 lln/phut Pab2/Fi02 <250 T i n thuong cl nhilu thuy phfii Rfii loan p thdc
Urd m'au >20mg/dL (>7,14mmol/L)
Giam bach elu m i u (sd lupng bach e l u <4000 t l bao/mm^)
Giim tilu e l u m i u (sfi lupng tilu c l u <100,000 t l bao/mm^)
Ha nhiSt dp (nhidt dd eo t h i < 36°C)
Ha huylt i p c i n phii hdi site tfeh cue bing djch truyen
- Mpt sd yeu tfi nhU tudi, tinh ti^ng nghien nJOu, hdt thufic la se duoc phSn tfch de tim ra yeu tfi nguy cd gay viem phoi nang.
- C i c xet nghidm trong nghien cifU dUpe thuc hien tai khoa xet nghiem BVBNOTLTtheo thudng quy.
4. Xur ly ket q u a : S f i lieu tiiu thap dupe xi!r ly bang phan mem STATA 10.
K £ t QUA NGHIEN CCaj
Trong sfi 75 benh nhan dO tieu c h u i n chon v i o nghien cUu c d 54 bfinh nhan V P M P C D thudng v i 21 VPMPCD nang, tudi trung binh l i 55,4 + 19,3 ( t h i p n h i t l i 18, cao nhat la 92 tudi), 48 nam (64%) va 27 niJ (36%).
B i n g 1. Trieu ehirng iam sang khi nhap vien
Nhan x i t : Trong nhfim vifim phoi nang ty |g benh nhfin c d rfii loan p thdc, khd t h d va dau ed cao hdn c6 y nghTa thfing ke so vdi nhdm vifim phdi thudng (p<0,01)
B i n g 2. Mfit s d thay ddi v e xet nghidm can lam s i n g trong vifim phdi
Tri^u chumg
sa
Ho Khac ddmHo mdu KhathdIcSmgiSc
khiW Dau nguc
R^tmn VamShS i ^ ioan y t h ^
Dau^u Dau hong Dau CO Ndn Dau bung
Chung d 2nh6m
n(%) 74 (98,6) 68 (90,6) 56(74,6) 5(6,6) 45(60) 51(68) 44 (56,6) 18(24) 10(13,3) 32 (42,6) 31 (41,3) 26(34,6) 7(9,3)
3(4) VPMPCD
thudng (n=54)(1)
n(%) 54(100)_
48 (88,9) 41 (75,9) 4(7,4) 25 (46,3) 35(64,8) 32160,4) 14 (26,4) 1(1,9) 23 (42,6)
20 (37) 15(27,8) 5(9,2) 3(5,5)
VPMPCD nSng (n=21)(2)
n(%) 20(95,2) 20(95,2) 15(71,4) 1(5) 20(95,2)
16(80) 12(57,1) 4(21,1) 9142,9) 9 (42,9) 11(57,9) 11 (57,9) 2(9,5)
0(0) P(1)(2)
p>0,05 p>0,05 p>0,05 1»0,06 p<0,001 p>0,05 p>0,05 p>0,05 p<0,001 p>0,05 p>0,05 p<0,05 p>0,05 P>D,05
X6t nghiam
HUng oau (10°/l) Bachc8u(10"/1) TiSucau(10'/i) Ur6 mdu (mmol/L) Crealjnino (^moUL) AST(U/L,37<C) AI.T(U/L-37'C) CRP (mg/l)
VPMPCO t h u ^ (n=54)(1)
4 , 5 * 0 , 8 12,3 * 5,9 227,2* 115,6
5 , 1 * 2 , 4 98^*23,3
36*23,6 33,3 • 29,1 113±75,1
VPMPCO ning (n=21)(2) 4,1*0,53 7,3*7,1 117,9*116,9
11,6*15,8 • 106,1*32,3 145,8*112,6 77,8*56,1 218,4*128,8
mn
p<0,01 P<0,001 p<0,001 1X0*1
|»0,OS p<0,l)01 p<0,001 pO,01
N h i n xfit: Trong vifim phfii nang, sfi lupng tieu cau v i bach c l u t h i p hdn cfi p nghta thdng k d so vdi wem phdi thudng (p<0,001). Men AST, A L T va CRP trong vifim phdi nang tang eao hon rd rfit so vdi viem phdi thudng (p<0.01).
Bang 3. Thay ddi v l hinh i n h X Q trong viem phfii
TfinthitongtrfenXQ
MUcddl&l thuong Ti^djch mdng phd
T6n thuang khu tn) T6n thuonq lan t6a
CO Khtng
VPMPCO IhuOng (n= 54)
n 23 31 6 49
42,6
%
57,4 13 87
VPMPCO n;ng (n=21|
n 2 19 5 16
9,5
%
90,5 2J« 76? Nhan xet: Trong vidm phdi nang, t i n thUdng phdi lan toa c h i l m 90,5%, tp ie benh nhan cfi tran djch mang phoi trong viem phoi nang ia 23.8%, wem phoi 0 i u d n g l i 1 3 % ,
Bang 4, Yeu tfi nguy co mac vifim phdi nang Ddcdi^m
Nlidm ludi 19,<25lu(S 25<45tuS 45-<65tu6i
>65tulii HutHlu&li
Khdng Cd Nglti^n n/t?u
Khdng Cd
01^
1 0,505 0,124 0,230 1 1,45
1 9,55
P
0,525 0,098 0,203
0,633
0,003 l95%Ci|
0,06-4,14 0,01-1,47 0,02-2,20
0,31-6,84
2,36-57,9 Nhan xet: Phan tfch hdi quy d a bien logistic vdi mOt so ydu t d lien quan d e n vifim phoi cho U i l y cae fcienh nhan nghien afpu cfi nguy c d mae vifim phdi nSng gIp 9,55 lan so vdi cae bfinh n h i n khfing ufing niou
Y HOC THVC HANH (881) - S6 10/2013
BAN LUAN
Trong nghidn cClU cCia chiing tdi, ty le bdnh nhan ed cae trieu ehUng ciia viem phdi la sfit (98,6%), ho (90,6%), khac ddm (74,6%) va dau ngiic (68%), Kdt qui niy eung tUOng tii nhu ket qua ciia Sopena N.
(1998) [4] vdi ty le cac trieu chifng la sot (93,6%), ho (89,6%), khae ddm (69,6%), dau ngiic (42,4%). Trong viem phdi nang, ty le benh nhan cd khd thd, rdi loan y thCfC va dau cd khi d i n b§nh vien eao hon ed p nghTa thdng ke so vfii viem phoi thudng. Bieu hien rdi loan p thifc gap trong 42,9% sd bdnh nhan nang nhUng ehi gap 1,9% d dc benh nhan viem phdi thudng. Neu tinh chung tren e l nhdm bdnh nhan mac viem phdi cdng ddng thi ty le nay ehiem 13,3%, thip hdn so vdi nghiSn cifu eda Sopena N. (20,8%) [4], Nguyin Thanh Hdi (23,7%) [5], RUIZ M. (24%) [6],
Khi phan tfch c i c xet nghiem can lam sang trong viSm phdi, ehiing toi nhan t h i y trong viem phdi nang, sd lupng tieu cau va bach c l u giam hon cfi y nghTa thdng ke so vfii vidm phoi thudng, nhung ngupe lai, men gan, ure, lai tang eao efi y nghTa hdn trong viem phdi nang (Bang 2), H i u h i t c i c benh nhan viem phdi nang ngoai bieu hien tdn thuong nang d phoi cdn cd bieu hien suy da tang kem theo va ed the til vong do suy da tang hdn la do tdn thUdng he hd hap [2]. Protein C phan Ung (CRP) trong viem phdi nang cung cao ro ret hdn so vdi viem phdi thudng (p=6,0049). CRP la mpt dau an viem cd vai trd quan trpng trong chin doan viem phdi do vi khuan va theo doi dap ifng vdi dieu tri khang sinh. Mdt sfi nghien ciiu eho thay CRP la mdt dau an quan trpng de chan doan VPMPCD va duoe sfir dung de danh gia mCfc do nang ciia benh tren lam sang [7,8].
Ket qua nghien cCfU d bang 3 cho thay cd 90,5%
benh nhan viem phfii nang cd tdn thuong phoi lan tda d nhieu hdn mpt thuy phdi. trong khi do ed 57,4% benh nhan viem phoi thudng ed bilu hien dang tdn thuong nay tr§n phim XQ phoi. Tran djeh mang phdi gap 13%
so benh nhan viem phdi thudng va 23,8% viem phdi nang. Hinh anh ton thuong XQ trong VPMPCD thudng da dang va khic nhau d eic nghien eifu. Nguydn Thanh Hdi [5] eho thay ed 52,6% benh nhan cfi tdn thuong d mfit phan thuy phoi va 26,3% benh nhan eo tdn thuong c i hai phdi. Jong G.M va cs (1995) lai cho thay 45,5% cd tdn thuong phdi lan toa [9].
Phan tfch da bien hfii quy logistic de tim ra yeu td nguy cd gay viem phdi nang cho thay cae benh nhan nghien rUou ed nguy cd mac viem phfii nang Id 9,55 lan ('95%CI: 2,36-57,9, p=0,003). Mdt sfi nghien cifU khac cho thiy nguy ed viem phoi nang d bdnh nhan nghien rUpu thay dfii tU 5,2 (95% Cl 1,4-19) [10] den 9 (95%C1 5,1-16,2) [11]. Cac benh nhan nghien n/du thudng CO ton thuong phdi lan toa gay ra tinh trang suy hd hap cap tien trien va fhudng phai dieu tri thdng khi nhantaotaicicKhoaHdisitetfchcUe[12].
K^'T LUAN
Trieu ehUng thudng gap eda VPMPCO la sfit (98,6%), ho (90,6%), khae ddm (74,6%), dau nguc (68%)
Trong viem phdi nang: ty le benh nhan ed khd thd, rdi loan y thdc va dau cO khi den bdnh vien cao hdn ed y nghTa thdng kd so vdi viem phdi thudng (p<0,01), 90,5% benh nhan vidm phoi nang cd ton thuong lan tda d phoi; sd lupng t i l u eau va bach cau thap hOn cfi p nghTa thdng ke, nhung men gan, ure, CRP lai tang eao ed y nghTa so vdi viem phdi thudng.
Nguy ed mac vidm phdi nang 6 eae benh nhan nghidn nidu la 9,55 lan so vdi benh nhan khdng nghidn ruOU (95%CI. 2,36-57,9, p=0,003).
TAI LI$U THAM K H A O
I.American Thoracic Society (2001). Guidelines for the Management of Adults with Community-acquired Pneumonia. Am J Respir Crit Cam Med. Vol 163. pp 1730-1754.
2. Baudouin SV (2002). The pulmonary physician in entical care. Critical care management of community acquired. Thomx 57,267-271,
3. Lionel A. Mandell, Richard G. Wunderink, Antonio Anzueto. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community- Acquired Pneumonia in Adults Clinical Infectious Diseases. 44:327-72.
4. Sopena N, Leal M.S, Botet M.L.P, et al. (1998).
Comparative study of the clinical presentation of legionella pneumonia and other community-acquired pneumonia. Chest volume 113, P. 1195-1200
5. Nguyin Thanh Hdi (2003). Nghien cdu dae diem lam sang va vi khuan hoc cCia viem phdi epng ddng do vi khuan hieu khf dieu tn tai khoa Hd hap, Benh vien Bach Mai Luan van tdt nghiep bac sy ndi tnJ benh vien. OHY Ha Ndi.
6. Ruiz M, Ewig S, Marcos M.A et al. (1999).
Etiology of community-acquired pneumonia: impact of age, comorbidity, and seventy. American joumal of respimtory and critical care medicine, vol 160, P. 397- 405
7. Almirall J, Bolfbar 1, Toran P, et al. (2004), Contribution of C-reactive protein to the diagnosis and assessment of seventy of community-acquired pneumonia. Chest. 125:1335-1342. doi, 101378/chest,125,4.1335.
8. Garcia Vazquez E, Martinez JA, Mensa J, et al.
(2003). C-reaetive protein levels in commuriity- acquired pneumonia. Eur Respir J. 21:702-705.
9. Jong G.M, Hsiue T.R, Chen C R , Chang H.Y, and Chen C W (1995). Rapidly fatal outcome of bacteremic Klebsiella pneumoniae pneumonia in alcoholics. Chest, vol: 107, P, 214-217
10. Femandez-Sola J, Junque A, Estmch R, et al (1995) High alcohol intake as a nsk and prognostic factor for community-acquired pneumonia. Arch Intern Med 155:1649-1654,
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