TAP CHi Y HOC VIJT NAM TAP 459 - THANG 10 - SO 2 - 2017 - Mire dp phuc hoi lao ddng: do I la chii yeu
(chiem 71,91%), do I I (7,87%), dd I I I (4,49%), do IV (3,37%) va dp V (12,36%).
TAI LIEU T H A M KHAO
1. Mark S.Greenberg (2010), Spine injuries, Handbook of Neurosurgery, sevenOi edition, Thiem Medical Publisher New Yori<, New York, pp 930-1002.
2. Hiromi Ataka, Takaaki Tanno, Masashi Yamazaki (2009), "Postenor intrusmented fusion without neural decompression for incomplete neurological deficits following vertebral collapse in the osteporotie thoracolumbar spine", Eur Spine J, 18, pp 69-76.
3 Andrzej Kaminski, Ernst Josef Muiler, Stefan Hankemeier, Gert Muhr (2003), ''Low Lumbar Spine Fracture-Results of Posterior Internal Fixation and Transpedicular Bone Grafting", European Journal of Trauma, 29, pp 23-30.
4. Benjamin Ulmar, Alexander Brunner, Markus Guhring, Traude Schmalzle, Kuno Weise, Andreas Badke (2010); "Inter - and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fracture:
evaluation in lateral X-rays and sagitall computed tomographies", Eur Spine J, 19, pp 558-566.
5. Jen-Chung Liao, Kuo-Fon Fan (2017),
"Postenor short-segment fixation in thoracolumbar unstable burst fractures - Transpedicular grafting or six-screw construct". Clinical Neurology and Neurosurgery, 153, pp 56-63.
6. Bulent Ozdemir, Ayhan Kanat (2017), Restoraton of Anterior Vertebral Height by Short-Segment Pedide Screw Fixation with Screwing of Fractured Vertebra for the Treatment of Unstable Thoracolumbar", W/orld Neurosurgery, 99, pp 409-417.
7. Srivastava R.N., Raj S. (2012) "Motor segmental recovery in spinal cord injury a blessing in disguise", BSS, spineweek, pp. 65.
DAC DIEM LAM SANG/CAN LAM SANG VA GIA TRI CUA THANG DIEM SCAP TRONG PHAN TANG NGUY Ca BENH NHAN
VIEM PHOI CONG DONG TAI BENH VIEN BACH MAI
TOM TAT
De danh gia cac dac diem lam sang, can lam sang va irng dung thang diem SCAP trong tien liTOng benli nhan viem phoi mac phai cong dong, chiing toi thu'c hien nghien ciru tren 146 benh nhan da du'dc chan doan xac dmh viem phoi mae phai cong dong tai benh viei Bach Mai txT 01/2014 6en 12/2016. Ket qua cho thay cac trieu chirtig Oiirdng gap ciia tienh nhan VPMPCO la kho thd (88.4%)^, ho (67.1%), sot (63.7%^. Diem S«P can^ cao ty le benh nhan nhap ICU, thd may, soc nhiem khuan, tir vong cang tang (p<0.01).
Tdkhda: viem phoi cong dong, SCAP SUMMARY
CHARACTERISnCOF CLINICAL/PARACUNICAL AND THE VALUE OF
THE SCAP SCALE I N STRATIFICA'nON FOR PATIENTS WITH COMMUNITY - ACQUIRED
PNEUMONIA I N BACH MAI HOSPITAL To shjdy dinical, paraclinical characteristics and apply SCAP score for patjents diagnosed community acquired pneumonia (CAP), sample size of the study was 146 patients hospitalized at Bach Mai hospital 'Benh vien Quan Y105 - Tong cue Hau Can
^Benh vien Bach Mai
Chiu trach nhiem chinh: Le Hal song Ha Email: [email protected] Ngay nhan bai: 12,7.2017 Ngay phan bien khoa hgc: 28.9.2017 Ngay duyet bai: 4.10.2017
Le Hai Song Ha , Nguyin Van Chi^
Tr4n Huu Thong^, Nguyen Dat Anh^
from January 2014 to December 2016. The main of study showed that, the most common symtoms of CAP were dyspnea feeling (88.4%), cough (67.1%), fever (63.7%), The higher the SCAP score was, the higher the incidence of ICU admission, mechanical ventilation, sepsis, and mortality were.
Keywords: community acquired pneumonia, SCAP I. DAT VAN OE
Viem phoi mac phai cf cong dong (VPMPCO) bao gom cae nhiem khuan phoi xay ra cf ngoaL benh vien, bieu hien bang viem phoi thiiy, viem phoi dom, hoac viem phoi khong dien hinh. Tae nhan gay viem phoi eo the la eac vl khuan, virus, niim nhu'ng khong phai do tru'c khuan lao. Tren the gidi viem phoi mac phai epng dong van la benh ly nang va thu'dng gap, dac biet la d ngu'di cao tuoi, ty le mac cf moi quoc gia khac nhau va tan suat mac d tuoi tir 65 - > 85 la 18,2 - 52,3/1000 dan moi nam [1]. Tai My, viem phoi (Jimg hang thir 6 trong so cae can nguyen gay tir vong va la nguyen nhan tir vong so 1 trong so cac benh truyen nhiem, hang nam co khoang 5,6 tritu tru'dng hop mac va co hOn 1,1 trieu tru'dng hcfp phai nhap vien, khoang 10% trong so nay tien trien thanh viem phoi mae phai eong dong nang can dieu trj tai khoa hoi sire tich eire.
Nhii'ng benh nhan ngoai trii ed ty le tir vong thap tir 1 - 5%, trong khi d benh nhan noi trii trung
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 binh la 12%, ty le nay tang hdn cf benh nhan co
benh ket hcfp va dac biet d benh nhan nam hoi sii'c tfch cdc 40 - 50%, [2]. O Viet Nam, viem phoi mac phai epng dong chiem 12% cae benh phoi. Trong so 3606 benh nhan dieu tri tai khoa Ho hap benh vien Bach' Mai tir 1996 - 2000 ed tdi 345 benh nhan viem phoi mac phai cong dong (9,57%), dimg hang thir tu" [3]. C^n thiet eo mot thang diem ddn gian vdi muTc dp tien lu'dng rong de danh gia mu'c do nang tai thdi diem kham ban dau giup cac bae sT du'a ra quyet dinh cho benh nhan dieu tn npi trii, tien lu'dng eac ket cue xau eiia VPMPCD. Do do nghien eiru nay du'dc thu'c hien vdi hai muc tieu: 1. 1^3 ta mot sd dac diem lam sang va can iam sang cua ngu'di binh VPl^PCD. 2. Danh gia thang dli'm SCAP trong tien iddng mdc do nang ciia binh nhan VPMPCD II. OOI TUONG VA PHUONG PHAP NGHIEN CU'U
2.1 Ooi tu'dng nghien cii'u: Cae benh nhan du'dc chan doan la viem pho'i mac phai eong III. K^T QUA VA BAN LU^N
3.1 Trieu chu>ig lam sang/can lam sang ciia benti nhan VPMPCD 3.1.1 Cac trieu chu'ng ctf nang va thUc the.
Bang 3.1. Trieu chdng lim sang ciia benh nhan VPCBMP khi vao vien.
dong nhap vien tir thang 01/2014 den 12/2016.
2.2 t h d i gian nghien cu'u: tir thaiia 12/2016 den thang 6/2017
2.3 Phu'dng phap nghien cii'u:
a. Thiet ke nghiin cdu: nghien ciTu mo ta cat ngang, hoi eulJ.
b. Cdmau:cd m l u thuan tien e. Thu thap sd lieu: theo benh an nghien euli thu thap tir ho sd benh an lu'u tru" tir benh vien Bach Mai.
d. Bien so: 3 nhdm bien so ve dac diem lam sang, dac diem can lam sang va cac tieu chuan danh gia thang diem SCAP.
2.4 Xir ly va phan tich so lieu: tren phan mem SPSS 16.0.
2.5 Dao dii'e nghien cii'u; Tuan thii eac qui trinh ve dao ddc trong nghien ciru Y hoe, nghien cii'u du'a tren so lieu san co, mpi thong tin ca nhan du'dc dam bao bi mat. Ket qua ehi sir dung cho muc dich nghien ciru.
Trieu chu'ng Tan so Tv le C/o)
SoT Ho khan Cd nang
Dau ngi/c Hpi chu'ng dong dac
Hpi chu'ng 3 giam Ran am, ran no
Rung thanh giam
98.0
Nhan xet: Trieu chu'ng kho thd xuat hien nhieu nhat 88.4%, sau do la sot 63.7%. Qua tham kham cd 98.0% benh nhan co ran am, ran no, t / le benh nhan cd hpi chu'ng 3 giam la 5.5% nhieu hdn benh nhan cd hoi chirng dong dac.
3.1.2 Cac Icet qua can lam sang
Bang 3.2 Kit qui xit nghiem dauanf^an litig viim vi Xquang phoi ciia tyenhnhan VPMPCO Can lam sanq
CRP Bach cau
Xquang phoi
>20mq/dL 5-20mq/dL
>10.000
< 4.000 Phoi phai Phoi trai Ca2ben Khonq thav qi
'ran so 22 34 90 13 29 22 94 1
Tv le ('/o) 24.4 37.8 61.6 8.9 19.9
15 64.4
0.7 Nhan xet: Oanh gia mu'c dp viem theo CRP ed 37.8% benh nhan d mii'c do viem trung binh, 24.4% CO mire tang >20mg/dL. Ty le benh nhan tang bach cau >10.000 la 61.6%, cd 8.9% benh nhan ed bach eau giam mire < 4.000. Hinh anh ton thu'dng phoi 6 2 ben gap nhieu nhat 64.4%, ton thu'dng 1 ben d phoi phai (19.9%) nhieu hdn phoi trai (15%). Chi cd 0.7 (1 benh nhan) khong phat hien hinh anh ton thu'dng phoi tren Xquang.
TAP CHi Y HOC VlgT NAM T ^ P 459 - THANG 10 - S 6 2 - 2017
3.2 Lien quan giu:a thang diem SCAP vdi tien lu'dng mu'c do nang cua benh nhan VPMPCD Bang 3.3: Lien guan giii'a thang diem SCAP theo cac Itet cue xau
— — K g t o i c x a u ( n , % )
Mu'c do ^ Thap (0-1)
Trung binh (2) Cao (3-4)
P
N h a p I C U 3(8.1) 42(60.) 38(97.4)
<0.01
Thd may 0(0.0) 16(22.9) 32(82.1)
<0.01
Soc nhiem l<huan
0(0.0) 3(4.3) 16(41.0)
<0.01
Tu' vong 0(0.0) 16(22.9) 29(74.4)
<0.01 Nhin xet: Co moi lien quan giu^ cae mire dp eiia thang diem SCAP vdi eac tinh trang nhap ICU, thd m^y, soc nhiem khuan va tir von^ cua benh nhan. Trong do: benh nhan mire dp nguy cd cang cao, ty le nhap ICU, thd may, soc nhiem khuan cang cao, tir vong cang eao. Si/ khac biet ed y nghTa thong ke vdi do tin cay dat 95%.
fla/ig 3.4 Dp nhay, dp dac hieu ciia thang diem SCAP vdi tinh trang nhip ICU
Tests I Pi€m cat P o nhay Do dac hieu NPV
Nhin xet Tai diem cat bang 2, thang diem SCAP co do nhay 96.4% va dp dac hieu d mire 54%
du'dc xem la cd y nghTa trong phan loai benh nhan cd kha nang nhap ICU.
Bang 3.5: Binh gia nguy cd nhap ICU cua thang diem SCAP.
Tests
SCAP > 2
< 2 Nhap
icii
80 3
Khong nhap
ICU 29 34
OR ( 9 5 %
C I ) 31.2(6.7-
145.3) Nhin xet: Nhdm benh nhan ed diem SCAP >2 cd nguy ed nhap ICU cao gap 31.2 i n so vdi nhdm benh nhan diem SCAP <2, do tin cay 95%.
SCAP trong tien lu'dng benh nhan tu" vong.
Tests
sc
AP
> 1
> 2
> 3 4
Bo nhay
100 100 64.4 26.7
S o dac liieu
5.9 36.6 90.1 99.0
PPV 32.1 41.3 74.4 92.3
NPV 100 100 85.0 75.2 fllhan xet: tai diem cat bang 3, thang diem SCAP CO do nhay la 64.4% va do dac hieu la 90.1% du'dc xem la diem cat co gia tr| trong tien lu'dng tir vong.
Bang 3.8: Banh gia nguy cd tiy vong ctia cac thang diem SCAP
Tests SCAP
> 3
Tiif 1 Khong tit | O R ( 9 5 % vong vong CI)^
16
2991 10
16.5 (5.5-49.1)
Bieu do 3,8: Bddng cong ROC trong tien litdng nhap ICU.
Bang 3.6: Dien tich dirdng cong cua cac thang diem SCAP trong tien lu'dng nhap ICU.
Nhan xet: Benh nhan co diem SCAP > 3 CO nguy cd tLf vong cao hdn nhdm benh nhan SCAP
< 3 la 16.5 lan, do tin cay 95%.
Test 0.852
9 5 % CI 0.793- 0.912 <0.001
Nhan xet: Dien tich difdi du'dng cong ROC trong tien lUdng benh nhan nhap ICU la 0.852 co gia tri tdt trong tien lu'dng benh nhan nhap ICU vdi p<0.001.Bang 3.7: Bg nhay, do dac hieu, gia tri du'dng tfnh, gia tri am tinh cua thang diem
Bieu do 3.10: Birdng cong ROC trong tien lu'dng tit vong.
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017
Bang 3,9: Bien tich dirdng cong thang diem SCAP trong tien iddng
Test SCAP
AUC 0.848
95''/o C I 0.782- 0.913
cua cac td vong.
P
<0.001 Nhin xet: Dien t'ch du'di du'dng cong ROC ciia thang diem SCAP la 0.848 ed y nghia tot trong ben lu'dng benh nhan tir vong, vcfl p<0.001.
IV. BAN L U A N
4.1 Trieu chu'ng lam sang va can lam sang ciia benh nhan VPMPCD: Trong nghien eiru nay eiia ehung tdi, cae trieu chirng khd thd (88.4%), ho (ho khan: 17.8%, ho cd ddm:
49.3%) va sot (63.7%) la cae trieu chiing ed nang hay gap nhat, tu'dng t i ; nhu' eac nghien eiru tru'dc day eiia Phi Thj Thue Oanh (2013) [4], Nguyen Dang To (2017) [5]. Day la nhii'ng trieu chirng du'a benh nhan den vdi benh vien va co gia tri trong viee hu'dng tdi chan doan viem phoi.
Nhii'ng trieu chirng thdc the ddng vai trd djnh khu ton thu'dng cung nhu' chan doan xae dinh viem phoi. Hdi chirng dong dae la mot hdi chiTng dien hinh trong viem phoi, tuy nhien trong nghien ciiu nay eung nhu' nghien eac eiru gan day, t / le benh nhan cd hpi chirng ddng dac ngay cang giam nhu' ket qua nghien eiru ciia Nguyin Dang Td (2017) [5] la 16.7%, nghien ciru ciia Chung tdi thap nhat lal.4%.
Ket qua nghien ciru d u ^ ra ty Ie ton thu'dng ca 2 phdi la eao nhat chiem 64.4%, ket qua nay cao hdn so vdi 1 sd nghien ciru khae eiia Nguyen Dang To va Phi Thi Thuc Oanh (28-34.1%), dieu nay gop phan giai thich ty le benh nhan khd thd trong nghien eiru nay cting eao hdn eac nghien ciru tren. Ty le ton thu'dng tai 1 ben phoi phai cao hdn ben trai, dieu nay phii hdp vdi eac nghien ciTu tru'dc day ciia Le Chung Thiiy (2012) [6] va Phi thj Thuc Oanh (2013) [6] phoi phai (34-37%), phoi trai ^20-13%). Dieu nay cd the la do eau true giai phau phe quan phai ngan hdn phe quan trai nen cac tru'dng hdp viem nhiem hay di vat thu'dng gap ty le ton thu'dng ben phai cao hdn.
4.2 Thang diem SCAP vdi ti§n lu'dng mu'c dd nang cua benh nhan. Nghien ciru da ehi ra rang, vdi eac mire diem cang cao, t^ le benh nhan phai nhap ICU, thd may, soc nhiem khuan, tCr vong cang cao, so ngay nam vien trung binh eiia benh nhan giam do benh nhan tiT vong sdm.
Ket qua tu'dng dong vdi k€t qua nghien ciru cua Espana ya cdng SLT (2011) [7] khi nghien eiiu phat trien he thdng SCAP trong ben lu'dng thd
may, soc, tir vong. Tai diem cat bang 2 thang diem ed dd nhay va do dae hieu cao, ed y ngiiia trong danh gia ehi djnh nhap ICU, tai diem cat 3 bac sT dieu tri can chii y den kha nang phai th6 may, diln bien soc nhiem khuan, td vong ciia benh nhan.
Thang diem SCAP cd dd nhay, dp dae hieu eao trong tien lu'dng benh nhan nhap ICU va tiy vong; kha nang phan loai benh nhan tot, dien tich du'dng cong ROC ciia thang diem d miTc cao
>80%. Day la mot thang diem danh gia cac mifc dp viem phoi eong dong 1 each ddn gian, bao gom 8 bien so, it hdn thang diem PSI va tien lu'Ong chinh xae hdn he thong CURB-65 vi b6 sung them bien so danh gia tinh trang oxy hoa, la bien sd quan trpng trong viec du'a ra quyet dinh ehuyen benh nhan den dieu trj ICU.
V. KET LUAN
Trieu chu'ng thu'dng gap cua benh nhan VPMPCD la khd thd (88.4%), sdt (63.7), ho (67.1%). Hinh anh td'n thu'dng gap nhieu d ca 2 ben phoi (61.6%).
Diem SCAP cang eao ty le benh nhan nhap ICU, thd may, sde nhiem khuan, tir vong cang tang (p<0.01).
TAI Ll|U T H A M KHAO
1. Jackson ML, Neuzil KM and Thompson WW (2004], 'The burden of community-acquired pneumonia In sensior: results of a population"!^
based study", Clin Infed: Dis 2004, 39, p. 9. -^
2. SV and B. (2002), 'The pulmonary physlriarrw critical care. Critical care management ^iW community acquired". Thorax, 57, p. 5. S 3. Tran Chung va cong sU (2001), Tinh hinh berin
tat khoa Ho hap Benh vien Bach Mai nam 199F 2000, Bao eao hoi nghi khoa hoc tuoi tre sang tao trddng Dai Hoc YHa Noi2001, Ha Noi.
4. Phi Thi thMC Oanh (2013), Nghien ciiVapdm mot so tiiang diem trong danh gia mdc do n$n^ a binh nhan Viem phoi mac phai cong dong tai benii v'len Bach Mai, Luan van tot nghiep chuyen khoa II,' Dai hoc Y Ha Ndi, Ha Noi. ^ , ^ 5. Nguyen Bang t o (2017), "Dac tJlem lam sang/can lam sang va gia tri ciia thang fliem CURB-65 trong phan tang nguy ed benh nhan VPMPCD tai benh vien da khoa tinh Phii Tho", Tap chiY Dddc hoc, 7(2), tr. 44-48.
6. Le Chuiig thuy (2012), Nghien edU dac dm lam sang, can lam sang va chup cat idp vi tinnji benh nhan VPMPCD tai benh vien Bach Mai, Luan van Thac si y hoc, Dai hoc Y Ha Noi, Ha Noi.
/ . Alberto Capelastegui Pedro, P. Espana, Inmacuiada Gorordo, et al (2006), "Development and Validahon of a Clinical Prediction Rule for Severe Community-acquired Pneumonia", Amencan Journal of Respiratory and Cridcal care l^ediane, 174, p. 1249 - 1256.
