CHAO MUMS HOI NGHj KHOA HOC THUONG HltN HOI HO HAP VlfT NAM
DAC DIEM LAM SANG, CAN LAM SANG VIEM PHOI TREN BENH NHAN LffXEMI TAI TRUNG TAM HO HAP BENH VIEN BACH MAI
Dang Hung Minh*, Le Hoan*, Pham Hong Ngoc*
T O M TAT
B a t van de; Trong qua trinh dieu t n benh Lflxemi thuSng hay mac viem phoi, va dien bien nSng, ie tim hieu thSm ve viem phoi i benh nhan Ldxemi chung toi nghien ctfti 6e tai nhSm muc tieu; 1. Nhan xet mot so dac diem iam sang va can tam sang cua viem phoi tren iJ<l^ cap tai Trung tam Ho hap benh vien Bach Mai. 2. Danh gia ve mu'c do nang va i<et qua dieu trj cua viem ph6i tren benh nhan LXI^ cap tai Trung tam Ho hap benh vien Bach Mai. Col tu'dng v^ phu'dng phdp; Nghien culj hoi ciru mo ta tren 31 benh nhan viem phoi tir 01/01/2012 den 31/12/2014.
Kel q u i ; Tuoi trung binh 52,3 ± 19,2 tuoi, ty ie nam/nif « 1/1. The U(M cap hay gSp M2 (48,4%) va i2 (19,4%). Trieu chiing toan than;
sot (77,4%). Trieu chiJng cd nang; ho ddm (74,2%). Trieu chu'ng thu'c the; ran am, ran no (61,3%). Thieu mau va giam tieu cau 80,6%, 32,3% tang bach cau, 38,7% co te bao biast trong mau ngoai vl. TSng CRP 91,3%, procaicitonin 100%. Ton thu'dng X-quang phoi:
dam md 5 8 , 1 % , djch mang phoi 19,4%. Mu'c dp nSng theo CURB65; 0 diem 25,8%, 1 diem 29%, 2 diem 32,3%, 3 diem 12,9%. 61,3% benh nhan phai liet hop l<hang sinh i(hi su' dung. Ket qua dieu trj; Ithol 12,9%, da 48,4%, Ithong 63 12,9%, nang xin ve 22,6%, tiJ vong 3,2%. Ket luan; Viem phoi is benh nhan idxemi dien bien nang hdn, thdi gian dieu trj dai, ty le tir vong cao hdn.
• Trung ldm Hd hdp • Bfnh vifn Bgch Mai
• • .Tin/i vien Y6 - Bgi hpc YHd Noi 2009-2015 Chju trach nhifm chinh: BJng Hiing Minh Email: [email protected] Ngiy nhjn bai: 14/9/2015 Ngay phan bien khoa hpc: 14/IO/201S Ngay duy?t bai: 21/10/2015
Tdkhoa; Ldxemi, viem phoi
SUIVIMARY
CLINICAL, PARACLINICAL CHARACTERISTICS OF PNEUMONIA
I N PATIENTS W I T H LEUKEMIA AT T H E RESPIRATORY CENTER - BACH
IVIAI HOSPITAL
Background; During treatment process, patients with leukemia usually suffer from severe pneumonia. I order to get more knowledge about pneumonia in patients with leukemia, we perform this study with two study objectives: 1.
Review some clinical and paradinical characteristics of pneumonia in patients with acute leukemia at the respiratory center - Bach Mai hospital. 2. To assess severity and results of treatment of pneumonia in patients with acute leukemia at the Respiratory center - Bach Mai hospital. Subjects and study method;
Retrospective descriptive study on 31 pneumonia patients from Jan/2012 to Dec/2014. Results;
The mean age was 52,3 ± 19,2 years, the ratio of male and female 1/1. Common acute leukemia types were M2 (48,4%) and 12 (19,4%). Symptoms; fever (77,4%), productive cough (74,2%), crackles (61,3%). Anemia and thrombocytompenia 80,6%, 32,3% leukocytosis, 38,7% have blast cells in peripheral blood.
Increase in CRP 91,3%, and in procalcitonin 100%. Lesions on chest X-ray; mass 58,1%, pleural effusion 19,4%. Severity according to CURB65; 0 point 25,8%, 1 point 29%, 2 points 32,3%, 3 points 12,9%. 61,3% of patients had be treated with combination of anbblotlcs.
Results of treatment: cured 12,9%, responsive 48,4%, unresponsive 12,9%, more severe 22,6%, die 3,2%. Conclusion: Pneumonia In
122
y HOC VIJT NAM THANG 11-5OCHUTENDE-2015
patients with leukemia is more severe and has long treatment duration, higher mortality rate.
Keywords: Leukemia, pneumonia.
I. BAT VAN OE
Viem ph5i la hien tuong nhiem khudn cua nhu mo ph6i bao g6m: viem phe nang, 6ng va tui phi nang, tiSu ph8 quan tan cimg hale viem td chute ke cua phdi. Benh do can nguyen vi Idiuan, virus, ky sinh trimg va nim gay nen khdng phai do true khuan lao [ 1 ].
Oan day, ty 1$ viem phdi tren benh nhan LXM ngay cang tang, viee diju tri van cdn nhiSu khd khan, thai gian diSu trj dai ya phai ket hpp nhiSu loai khing sinh din den tang chi phi didu tri, la ganh nang cho y te va cho gia dinh benh nhan. Vi v^y vi$c nghien citu die diim lam sang, cac rdi loan can lam saiig d b|nh nhan viem phdi - LXM trd thanh vdii dS rat can thidt. Do dd chung tdi tidn hanh dd tai nghien cilu vdi 2 muc tieu sau:
1. Nhgn xet mot sd dgc diem ldm sdng va can lam sang ciia viem phdi tren LXM cdp Igi Trung Idm Hd hdp Bfnh vifn Bgch Mai
2. Bdnh gid vk mice dp ngng vd kit qud diiu Iri cua viem phdi tren bfnh nhdn LXM cip lgi Trung Idm Hd hdp Bfnh vifn Bgch Mai
II. B6| VSqiNG PHirONG PHAP NGHIEN ClJU 2.1. DSI tuyng nghien CBTI
31 benh nhan dupe chin doan viem phdi/LXM cjp didu tri npi trii tEii Trung tam Hd hip bdnh vi$n Beich Mai tit ngay 01
thang 01 nam 2012 den ngay 31 thang 12 nam 2014
2.2. Tieu chuan chon benh nhan Benh nhan viem phdi/LXM cap chan doan xac dinh dua vao:
- Viem phdi: cd cac dau liieu sau:
-t- Ca nang: sdt, ho khac ddm due hay ri sit, cd thd cd dau nguc.
-^ Thuc thd: hdi chiing ddng dac, ran am, rannd.
+ X-quang phoi cd ton thuong nghT tdi viem phoi dien hinh hay khdng didn hinh.
-Chin doan LXM cip bing xet nghidm huydt tuy do vdi ty id td bao Blast tuy > 20%
td bao tuy.
2.3. Tieu chuin lo?i trif b$nh nhSn - U phdi.
- Lao phdi.
- Tic ddng m^ch phdi.
2.4. Phu-oTig phip nghien cuu -Thidt kd nghien cuu: nghien cim hdi ciru mdta
- Thu thap thdng tin nghien citu: thdng tin dupe khai thae theo mau benh an chi tiet III. KET QUA NGHIEN CU'U
3.1.8$c diem chung
Tudi trung binh trong nghien cim 52,3 ± 19,2 tudi. Nhdm 45 - d5 tudi va tren 65 tudi chiem ty id cao nhat 32,3%.
3.2. D^c diim lam sang, can Iam sang 3.2.1. Trtfu chirng toin than va ca nang
Bing 1: Trieu chfag toan than vii co nSng Toin than
Tri?u chung Sdt HC thieu mau HC xuat huyet
Nhip thd 20<NT<30 n 24 21 10 14
%
77,4 67,7
• 32,2 45,2
CHAD MifNG Hdi NGHI KHOA HOC THUdHS NIEN Hpi HO HAP VI$T NAM
Cff nang
Sp02
> 3 0
< 9 0 Ho ddm Dau nguc
Khd thd Ho mau Ho khan Dau dau, co, khdp
16 6 23 22 20 i i 6 1
51,6 19,4 74,2 71,0 64.5 35,5 19,4 3,2
Nhfn xit: Sdt, thieu mau, xuat huyet la nhiing trieu chfag toan than hay gSp nhat. Ho ddm, dau ngvc va khd thd ik nhfag tridu chfag co nang hay gap nhit.
3.2.2. Trl^u chung thuc the Bing 2: Trieu chfag thuc the
Tri|u chung Ran am, ran nd HC 3 giam HC ddng dac Ran rit, ran ngay
n 19 14 3 3
%
61,3 45,2 9,7 9,7 Nhdn xit: Tri^u chumg thirc the khi vao vien chu yeu la ran am va ran no (61,3%)-
3,2.3. Cong thitc mdu
Bdng 3: Xet nghiem cong thuc mau Cong thiVc mau
Hb(s/1)
Bach ciu (G/1)
Blast mau
Tieu ciu (G/1)
< 6 0 6 0 - 9 0 9 0 - 1 1 0
> 1 1 0
< 4 4 - 1 0
> 1 0 Cd Khdng
< 1 0 1 0 - 5 0 5 0 - 1 0 0 100- 150
> 1 5 0
X ± S D 48 ±14,2 78,7 ± 7,9 98,7 ± 6,4 1 2 5 , 5 ± l i
1,9 ± 1 , 2 5,6 ± 1 , 8 36,8 ± 24,2
5,0 ± 0,0 25,6 ± 1 2 , 4 77,9 ±18,0 141,8 ± 9 , 7 267,0 ± 62,7
n 3 15 7 6 12 9 10 12 19 1 13 7 4 6
%
9,7 48,4 22.5 19,4 38,7 29,0 32.3 38,7 61.3 3,2 41,9 22,6 12,9 19,4
X ± S D
89,3 ± 29,1
14,2 ± 2 0 , 8
98,8 ± 97,2
Y HOC VlfT NAM THANG 11 - SO CHUYEU DE - 2015
Nhgn xet:
-Lugng Hb trung binh la: 89,3 ± 24,lg/I, thip nhit la 32g/l. ThiSu mau miic trung binh chiem ty le cao nhdt 48,4%.
-So luong bach cau trung binh la: 14,2 ± 20,8G/1, cao nhdt la 73,8G/1. Co 12 benh nhan giam bach cdu (38,7%), 10 benh nhan tang b^h cdu (32,3%), con lai co s6 luong bach cdu trong gioi hgn binh thucmg (29,0%).
- Co 32,3% benh nhan co s6 luong BCDNTT<1000BC/I.
-Trong xet nghiem cong thuc mau ngoai vi:
CO 38,7% benh nhan co tk bao blast.
-80,6%) benh nhan co giam tiiu cdu, s6 lugng tiiu cdu trung binh cr muc 98,8 ± 97,2G/1. Trong do benh nhan co so lugng tiiu cdu tit 10 - 50G/1 chiem ty le cao nhdt 41,9%.
3.2.4. X- quang phot
Bang 4: Hinti thai ton thuomg tren Xquang ph6i Hinh thai ton thu'omg Tdn thuong dang d t a ma Djch mtog phdi
D t a md hinh tam giac nhu viem phdi thuy Viem ranh lien thu^
Tdn thuong dang chim, ndt md Tdn thuang dang ludi ndt
n 18 6 5 4 3 2
%
58,1 19,4 16,1 12,9 9,7 6,4 Nh^n xit; Hinh thai tdn thuang hay gap nhat tren X-quang la tdn thuang d?mg d t a md 58,1%, tran dich m4ng phdi 19,4%.
3.3. Kit qui diiu trj
3.3.1. Phin lofi mttc dp nfng theo CURB65 Bing 5; Phan lo?ii mirc dp nang theo CURB65
Diem 0 1 2 3 4 - 5
n 8 9 10 4 0
%
25,8 29,0 32,3 12,9 0,0
Nli^n xit: B$nh nhan cd CURB65 2 chiem ty 1? cao 32,3%, cd 4 trudng hpp CL1RB65 3 diim (12,9%) vk khdng cd b?nh nhan nao cd CURB65 > 3 didm.
3.3,2. Khing sinh su dfng Bing 6; Sit d^lng khang sinh
Kh^ng sinh Dimg dan ddc Kdt hpp khang
sinh
2 khang sinh 3 khang sinh 4 khang sinh
n 12 9 9 1
%
38,7 29,0 29,0 3.3
T6ng(%) 38,7 61,3 Nh^n xil: Ty 1$ phai ket hpp khang sinh de dieu tri la 61,3%. Cd 1 truimg hpp ket hop 4 loai khing sinh chidm 3,3%.
CHAO M Q N G H O I NGHj KHOA HOC THUONG NIEN HO! HO HAP VIET NAM
3,3.3. Kit qua dieu tri Bdng 7: Kdt qua dilu tri
Ket quii Khdi
Do Khdng dd Nang xin ve
Chet
n 4 15 4 7 1
%
12,9 48,4 12,9 22,6 3,2
Nhin xil; Trong sd 31 b?nh nhan dupe didu tri bpnh nlian da chidm ty Id cao nhat 48,4%, tidp dd la benh nhan nSng xin vd 22,6% va khdi 12,9%. Ty Id tir vong la 3.2%.
IV. BAN LU$N 4,1, D^c diem chung
Tudi trung binh ciia nhdm benh nhan la 52,3 ± 19,2 tudi, benh nhan trd tuoi nhit la 23, cao tudi nhat la 79. Kdt qua nay thip hon nghidn cfa ciia Thai Thj Nga (2014) tudi trung binh cua bjnh nhan la.59,9 ± 18,3 tudi [2].
4.2.8$c diem Iam sing, c^n lam siing 4,2,1. Trifu chung caning vi toin than Trieu chfag ca nang ciia viem phdi chu ydu ia ho ddm 74,2%, dau nguc 71,0% va khd thd 64,5%. Kdt qua nay phii hpp vdi kit qua nghidn cfa ciia Sopena va cs (1998) cac tridu chfag I t a sang thudng gap cua viem phdi do vi khuan la: ho 89,6%, kh^c ddm 69,6%, dau ng\rc 42,4%, dau diu 13,6%, rdi loan y thirc 9,6% [3].
Tridu chfag toan than hay gSp nhat la sdt 77,4%. Cac trieu chfag thd hipn tinh trang nang cua bpnh gap vdi cac ty Id: khdng cd benh nhan rdi loan y thiic, nhjp thd > 301/p (51,6%), SpOz < 90% (19,4%). Kdt qua nay cd s\i khac bipt vdi nghien cfa ciia Ha Van Ngae (1991) khi tidn hanh tren 310 benh nhan vita phdi cho thiy nhfag bpnh nh&i cd nhjp thd > 301/p chiim 14,1%, rdi loan y thirc (9,6%) [4],
Cd mpt ty le dang kd bpnh nhan cd hdi chfag thieu mau (67.7%) va hdi chfag xuit huydt ( 32,2%) kdm theo.
4.2.2. Trieu chttng thifc the Trong sd 31 benh nhkn vidm phdi thSm khta thuc thd thay chu ydu ran im va ran nd (61,3%). hpi chfag 3 giam (45,2%). cac tri^u chfag khac nhu hdi chfag ddng dac va ran rit. ran ngay gap it han (9,7%). Kdt qua ciia Ha van Ngae (1991) cung cho thiy cac bpnh nhan cd bieu hidn ran nd, ran im gap vdi ty Ip cao han 37%. cac biiu hien khac gjp vdi ty Id it han: hdi chfag ddng dgc 19,6%, bieu hien tran djch 4.3% [4].
4.2.3. Cdng thitc miu
Sd luong bach cau trung binh trong nhdm bpnh nhan nghien cfa la: 14,2 ± 20,8g/l, cao nhit la 73,8g/l, thip nhit la 0,49g/l, trong dd sd iupng bdnh nhan cd bach cau > lOg/l la 32,3%. Kdt qua nay thip hon so vdi kit qua nghien cfa ctia Nguyen Thanh Hdi (2002) ty Id BC > lOG/1 la 76,3% [5]. Trong nghien cfa ciia chfag tdi nh^n thiy cd mdt ty le dang ki benh nhan cd gita bach ciu 38,7%, 10 trufag hpp BCDNTT < 1000 chiim 32,3% day la nhfag trufag hpp cd nguy ca cao mic cac bdnh nhiem khuan trong dd cd viem phdi. Cd 38.7% bpnh nhan cd te bao blast trong mau ngoai vi.
Lupng huyit sac td trung binh ciia cac benh nhSn nghien cfa la 89,3 ± 24,1 g/1. Da sd bpnh nhan vao vipn vol lupng huydt sic td d mirc 60 - 90g/l (48,4%), cd 9,7% bpnh
Y HOC VlgT HAM THANG 11 - SO CHUYEN BE - 2015
nhan thilu mau nang va 19,4% benh nhan khong thieu mau. Ket qua nay phii hgp vai trieu chung lam sang va muc do thieu mau, gap nhieu nhdt la thilu mau 6 muc do trung binh.
Hgi chung xuat huyet va roi loan dong mau la mgt trong nhiJng bieu hien lam sang hay gIp trong LXM cap ma nguyen nhan chinh la do giam so lugng tieu cau. Trong nghi€n cuu ciia chung toi so lugng tieu cau trung binh la 98.8 ± 97,2G/1. Co 25 b?nh nhan co giam tieu cau (80,6%), phan ion co tiiu cdu giam 6 muc 10 - 50 G/1 (41.9%).
Nghien cuu cua Nguyen Thj Dan cho ket qua benh nhan tri?u chimg giam tieu cdu lan lugt la8!,7%[6].
4.2.4. X-quang phoi
Ton thuorng tren X- quang phoi duoi d?ng dam ma gap voi ty 1? cao 58,1%. Cac dang ton thuong khac thuang gkp vai ty Ie tircmg ling la: tran dich mang phoi 19,4%.
d^ng dam mo tam giac 16,1%. viem ranh lien thuy 12,9%, dang chdm mcr 9.7%. Theo Jong G.M va cs (1995) ton thuong nhieu dam mo g3p 6 63.6% cac trudng hgp, TDMP 54,2%. hinh thanh hang 36,4%, t6n thuong phii Ian toa 45,5% [7].
4.2.5. Phan dp mite dg ngng theo CURB6S
Danh gi^ miic do nang cua viem phoi theo thang dilm CURB65 trong nghien cuu cua chiing toi tren 31 benh nhan thi miic 0 dilm 25,8%, 1 dilm 29,0%, 2 dilm 32,3%, 3 diem 12,9% va kh6ng co benh nhan nao 4 diem tra nen. Theo nghien cuu tren 150 benh nhan cua A.S Bashir va CS (2009) co 18%
miic 0 dilm. 20,7% miic 1 diem. 28% miic 2 diem, 14% miic 3 dilm, 15.3% miic 4 diem.
4% miic 5 dilm [8]. Sir sai khac nay c6 thi ly giai la do d6i tucng nghien ciiu ciia cac tac gia nay bao gom toan bg benh nhan toi
kham tai phong kham va dugc chdn doan viem phoi. Con trong nghien ciiu ciia chiing toi, d6i tugng nghien ciiu la benh nhan dugc chan doan la viem phoi ndm dilu tri tai Tnmg tam Ho hap nhu vay co mot so benh nhan viem phoi dugc ke don dieu tri ngoai tni va 1 so benh nhan vao vien voi tinh trang nang dugc chuyen thang vao khoa dilu tri tich cue ma khong vao Trung tam Ho hdp.
4.2.6, Kit hgp kiidng sinh
Trong nghien ciiu cua chung toi 100%
benh nhan co sir dung khang sinh dieu tri, phan Ion la phai ket hgp khang sinh (61,3%), trong do CO 1 benh nhan I;et hgp 4 loai khang sinh (Cefalosporin thi h? Ill + Aminoglycosid -i- Carbapenem + 5-Nitro- imidazol). Ket qua nghien ciiu nay cao hon nghien ciiu viem phoi nghidn nrgu ciia Nguyen Thj Van (2014) voi ty le phoi hgp khang sinh 36,7% [9].
Nhom khang sinh sir dung nhieu nhat la Cefalosporin thi h? Ill; 30.5%. tilp theo la Carbapenem 28.8%.
4.2.7. Kit qua dieu trf
Ty Ie dieu tri thanh cong (khoi va do khi ra vien) chiem phdn 1cm 61.3%. Co 4 trucmg hgp khong d5 (12.9%). 7 truang hgp nang xin vl (22.6%) va dac bi?t co 1 trudng hgp tii vong (3,2%). Theo Nguyen Thanh Hoi (2002) tren 38 benh nhan viem phoi co 17.5%. thdt bai trong dilu tri [5], con theo Doan Hiiu Phuac (2011) khong do va n|ng xin ve ciia viem phoi nghien nrgu la 26,8%
[10]. Co su khac biet nay la do nhung b?nh nhan ciia chiing toi co tien sii mac LXM.
Nhu vay nhftng benh nhan viem phoi/LXM thudng nang hon va kho dieu tri hon.
V. KET LUiSkN
5.1. Dac diem lam sang va c^n lam sang ciia viem phoi
CHAO MONG HQI HGH| KHOA HOC THUONG NIEN HOI HO HAP V | | T NAM
5.1.1. Bdc diem ldm sdng - T y lemac benh nam/nu = 1/1.
- Tuoi trung binh 52,3 ± 19,2 tuoi.
- T h i LXM cdp hay gap M2 (48,4%) va L2 (19,4%).
- Ly do vao vien: ho ddm (51,6%).
- Trieu chiing toan than: sot (77,4%).
- Trieu chiing co nang: ho ddm (74,2%o).
-Trieu chiing th\rc thi: ran dm, ran n l (61,3%).
5.1.2. DSc diim c^n ldm sdng - C o n g thiic mau: thilu mau 80,6%, giam tiiu cdu 80,6%, 32,3% tang bach cdu va 38,7% CO t l bao blast trong mau ngoai vi.
- X e t nghiem hoa sinh: Tang CRP 91,3%, procalcitonin 100%.
-X-quang phoi: dam md 58,1%, dich mang phii 19,4%.
-CT-Scan: 51,9% tran dich mang phoi.
48,1% dam md hinh tam giac, 33,3% cham, not md.
- X e t nghi?m chan doan nguyen nhan: cay mau (+) 9,6%, cdy ddm (+) 3,7%.
5.2. B^nh gi^ miic d$ n^ng va dieu trj viSm phoi
5.2.7. Ddnh gid mttc dd n^ng - M i i c do nang theo CURB65: 0 dilm 25,8%, 1 dilm 29%, 2 dilm 32.3%. 3 dilm 12,9%.
5.2.2. Diiu trf viem phdi
- 61,3% benh nhan phai ket hgp khang sinh khi sii dung.
- T h d i gian ndm vidn trung binh 11,0 ± 6,9 ngay.
- K i t qua dilu tri: khoi 12.9%, dd 48,4%o, khong dd 12,9%. n^ng xin v l 22,6%, tir vong 3,2%.
TAI Ligu THAM KHAO
I. Ng8 Quy Chau (2012), B^nh hgc ngi khoa tgp I, Nha xuat ban Y hpc. Ha Noi.
2. Thai Thi Nga (2014), Ddc diim idm sdng.
cgn ldm sdng vd chi si Procalcitonin viem phii mdc phdi cgng ding tgi benh vi?n Bgch Mai, Luan van th^c sT, Trirong dai hpc Y Ha Noi, Ha Npi.
3. Sopena N., Leal M.S., Tudela P.. (1998).
Comperative and other community acquired pneumonia. Chest, 113, 1195 - 1200
4. Ha Van Ng^c. (1991). Nhan xet vl 106 ca viem phoi cdp dilu trj t^i khoa noi b^nh vi$n quan Y 108. Ngi san lao vd benh phoi, hgi chdng lao vd b^nhphoi Viet Nam, 8, 89 - 96 5. Nguyen Thanh Hoi (2002), Nghien cuu dde diem ldm .sdng vd vi khudn hgc eua viem phdi mdc phdi cgng dong do vi khudn hiiu khi dieu tri tgi khoa hd hdp bfnh vi?n Bgch Mai, Luan vSn tot nghi$p bac sT npi tru c^c b?nh vi?n, Trudng d^i hpc Y Ha Npi, Ha Noi.
6. Nguyen Thj Dan (1994), Chdn dodn va phdn logi LXM cap bdng hinh thdi ti bdo mdu vd tuy xuang nhugm bdng phucmg phdp CO dien bo sung hda hgc te bdo, Luan vSn thae sT. Tru-dng d^i hpc Y Ha Noi, Ha Npi.
7. Jong GM., Hsiue T.R.. Chen C.R., et al.
(1995). Rapidly fatal outcome of bacteremlc kledsiella pneumonia pneumonia in alcoholics. Che.st. 107.214 - 217.
8. Bashir, Ahmed, Shah, Wasim Ahmed, et al. (2009). Validity of pneumonia severity index and CURB65 severity scoring systems in community acquired pneumonia in an Indian setting. Indian J chest dis allied SCI 2010.52,9- 17.
9. Nguyen Thj Van (2014), Nghien ciru ddc diem ldm .sdng, cgn ldm sdng viem phoi nghien nrgu. Lukn vSn tot nghidp bac sT y khoa. Tnrdng dai hpc Y Ha Noi, Ha Noi.
10. Doan Hihi Phu&c (2011), Nghien cihi ddc diem ldm .sdng. cgn ldm .sang viem phdi co nghi$n rugu tgi b?nh vi?n da khoa tinh Trd Finh, Lugn vSn th?c sf, Trudng d?i hpc Y Hk Npi. Ha Npi.
