JOURNAL OF 108-CUNICAL MEDICINE ANDPHARMACY Voi.12-N°3/2017
Danh gia hieu qua phuang phap hiit dich lien tuc ha thanh mon di du phdng viem ph6i 6" benh nhan tho* may
Evaluate the effectiveness of Hi-Lo evac subglottic suction for preventing ventilator-associated pneumonia
Ngo Diix Ngoc Benh vi$n Bgch Mm
Tom tSt
Muc tieu: Danh gia hieu q u i kT t h u l t hut djch lien tuc ha thanh mon de d u phdng viem phdi 6 bfnti nhan thd may tai Khoa Cap cUu Benh vien Bach Mai. Doi tugng vd phuang phdp: Nghien cUu can thi^p ngau nhien cd nhdm chUng. Ddi tupng: Benh nhan dat dng ndi khi quan thd may tren 48 gid nhip Khoa Cap cUu, Benh vi$n Bach Mai tU 2009 - 2013. Nhdm can thiep: Dat ndi khf q u i n Hi-Lo evac cd dng hut djch ha thanh mon hut li^n tuc vdi ap lUc -20mmHg, nhdm chUng la nhdm dat ndi khi q u I n thudng quy. Kitqud:
Nhom nghien cUu va nhdm chUng Ian lupt la: Tuoi trung binh 58,1 ± 20,1 va 56,1 ± 15,2. Benh 1)/ thudng gap: Tai bien mach nao (28,8% va 30,3%), COPD (20,8% va 21,1 %). Tl le viem phoi lien quan thd may (39,0%
va 56,6%; RR = 0,69, p<0,05). Thdi gian xuat hien viem phdi lien quan thd may (7,7 + 3,3 va 4,3 + 2,3 ngay, p<0,05). Thdi gian thd may (6,2 ± 3,4 va 8,7 ± 5,0 ngay, p<0,05). Thdi gian nhm d Khoa Hdi sUc Cap cilu (12,1 ± 10,0 v l 14,8 ± 11,6 ngay, p<0,05)."ni&tU vong (10; 12,9% va 9; 11,8%; p>0,05)./feif/wan; Trong nghien cUu cua chung tdi, hut djch lien tuc ha thanh mon da chUng minh k h i nang dU phdng viem ph6i li&n quan thd may d benh nhan thd may; Giam ti le viem phdi lien quan thd mIy, g i l m thdi gian thd may, giam thdi gian nam tai Khoa Hdi sUc Cap cUu.
TCfkhoa: Viem phoi lien quan thd may, hut djch ha thanh mon, Hi-Lo evac.
Summary
Objective: To evaluate the effectiveness of subglottic secretion suction for preventing ventilator associated pneumonia (VAP) at intensive care unit (ICU) of Bach Mai Hospital. Subject and method: A randomised control trial included patients w/ere intubated more than 48 hours at ICU of Bach Mai Hospital from 2009 to 2013. We randomized patients into 2 groups. Intervention group: Patients were intubated w/ith Hi-Lo evac and continuously drained by subglottic suction method with -20mmHg pressure. In control group: Patients were intubated without subglottic secretion drainage. Result: We compared between two groups (the study and control): Average age (58.1 + 20.1 and 56.1 ± 15.2). The common disease: Stroke (28.8% and 303%), COPD (20.8% and 21.1%). VAP proportion (39.0% and 56.6%; RR = 0.69, p<0.05). The onset-timing of VAP (7.7 + 3.3 and 4.3 ± 2.3; p<0.05). The duration of mechanical ventilation (6.2 ± 3.4 and 8.7 ± 5.0 days; p<0.05). ICU stay length (12.1 ± 10.0 and 14.8 + 11.6 days; p<0.05). The mortality rate (12.9% and 11.8%; p>0.05). Conclusion: In our study, Hi-Lo evac subglottic secretion suction determined in preventing VAP for mechanical ventilated patient: Reduced VAP rate, duration of mechanical ventilation as well as ICU stay length.
Keywords:\//KP. subglottic secretion suction, Hi-Lo evac.
Ngay nhan bdi: 07/03/2017. ngdy chap nhdn ddng: 23/03/2017
Nguai phan hdi: Ngo Due Ngoc. Email: [email protected] - Benh vien Bach Mai
TAP CHiY DUpc LAM SANG 108 T^pl2-S6 3/2017 I.Datvande
Thd may I I mdt trong nhufng ky thuat quan trpng khdng the thieu trong h6i sUc cap ciJfu. Viem phdi lien quan t h d may (VPLQTIVl) l l m gia tang t i le tCf vong va dang t r d t h i n h van de thdi su trong chuyen n g l n h hdi sUc cap cLifu. 6 cac nUdc phat trien, t i le viem phoi li§n quan t h d may tai cIc khoa hdi sdc cap cUu dao ddng tCr 9% d^n 25% [1 ], [2]. 6 Viet Nam, theo tac gia Pham Van Hien, t i le viem phoi d benh nhan t h d may la 74,2% [31. TCr dau nhUng nam 1990, mot sd khoa cap cUu d My da ap dung phUdng phap hut djch t d khoang ha thanh mdn U dpng tren bdng chen dng ndi khi q u I n ciJa benh nhan thdng qua sCf dung dng ndi khi quan Hi-Lo evac (cd bd phan hut djch ha thanh mdn) trong qua trinh t h d may nham han che ngudn vi khuan co hdi, lam g i l m tl IS VPLQTM. Bay la ky thuat cd nhieu Uu diem, mac du vay van ed mdt sd y kien khdng thdng nhat ve hieu q u i , dae biet vai trd d u phdng viSm phdi mudn [4], [5], [6]. Tai Vi&t Nam, ky thuat nay phat trien cham hdn va chUa pho bien.
Va cung chua cd nghien cufu nao ve van de nay cua cac tac g i l Viet Nam. Chung tdi cho rang vi^c dng dung phUdng phap nay se lam g i l m ti le VPLQTM.
Chinh vi vay, chung tdi tien hanh nghien cu'u nham muc tieu Ddnh gid hieu qua cua phuang phdp hut djch liin tuc hg thanh mdn de du phdng vHm phoi 6 binh nhdn thd mdy.
2. Doi tifdng va phUCng phap
Chung tdi tien hanh nghien cufu 153 benh n h I n t h d may tai Khoa Cap cUu A9, B&nh vien Bach IVlai tU nam 2009 den 2013.
2.1. Doi tttcmg
Tieu chuan lUa chpn binh nhan
Benh nhan 6iiac dat ong ndi khi q u I n t h d may tren 48 gid.
77eu chuan logi trCinhOng binh nhan Cd bang chu'ng viem phdi XiS trudc: Sot, cd tham n h i ^ m p h d i . . .
Bat ndi khi q u I n d tuyen trUdc.
Bang difng hoa tri li^u gay g i l m bach cau.
Cd cae b^nh ly suy g i l m mi^n djch.
Tieu chuSn chan doan VPLQTM
Benh nhan chan doan viem phdi lien quan t h d m I y khi cd d l y du 2 tieu chuan lam sang va vi sinh:
Chan doan lam sang: Dua theo bang diem lam sang viem phdi CPtS cCia Pugin [7]: Benh nhan dUpc ch^n doan la VPLQTM khi ed diem vi^m phdi > 6 sau t h d may it nhat 48 gid (khdng lay tieu chuan vi khuan).
TiSu chu^n Nhiet dp ("0
> 36,5 va <. 38,4
£ 38,5 va 5 38,9 a 39 hoac £ 36 Bach cau trong mau/mm^
4.000 < bach cau £ 11.000
< 4.000 h o a o 11.000
< 4.000 hoac > 11.000 va bach cau dua > 50%
Djch tiet p h e q u i n Khdng cd/cd rat it Djch tiet nhi^u, khdng due Djch tiet nhieu, due hoac ddm md Oxy hda mau: Pa03/Fi02 (mmHg)
> 240 hoac hoi chUng suy hd hap cap tien trien
<, 240 va khong cd hdi chdng suy hd hap cap ti^n trien
XQ phoi
Khdng cd tham nhiem hoac tien trien mdi
Tham nhiem r l i ric hoac Idm ddm Tham nhiem vung hole tien trien
Tong s6 diem
Diem
0 1 2
0 1 2
0 1 2
0 2
0 1 2 0 den 10 Tieu chuan vi sinh: Dich p h e q u i n dUpc lay bang dng hai ndng ed nut b i o ve dau xa qua phUOng p h i p soi phe quan. Benh pham dUpc nudi c^y tai Khoa Vi sinh Benh vien Bach Mai, ket qua dUde coi la dUdng tfnh cd y nghia vdi ngUdng > 10* vi khuan/ml tUdng dUdng 5 10^ vi khuan/ml benh pham.
2.2. Phuang phdp Thiet ki nghiin ciiu
JOURNAL OF 108 - CLINICAL (WEDICINE AND PHARMACY Vol.12-N"3/2017
Nghien eUu ngau nhi&n can thiep cd sd dung nhdm ehUng.
Benh nhan dUpc chia ngau nhien thanh 2 nhdm (bang phan mem m I y tinh):
Nhdm nghiSn eUu (cdn goi la nhdm can thiep):
SCf dung dng ndi khi q u I n Hi-Lo evac ed dng hut djch ha thanh mdn hut lien tuc vdi ap lUc -20mmHg.
Gpi la nhdm 11.
Nhdm chCfng: Sis dung dng ndi khi q u I n thudng.
X& Ij/ so lieu: Bang cac thuat toan thong ke y hpc phu hop, mile y nghia alpha = 0,05. T-test student cho
so sanh t m n g binh, x^ cho so sinh v^f le. Nguy cotuong ddi RR (Relative Risk), g i l m nguy cd tuong doi RRR (Relative Risk Reduction) va NNT (number needed to treat) giufa nhdm chC^ig va nhdm nghien euU.
3. Ket quit
Chung tdi cd 153 benh nhan du tieu chu^n difi vao nghien cu\i.
Nhdm dat ndi khi q u I n Hi-Lo evac (nliom nghien cUu): 77 benh nhan.
Nhdm dat ndi khi quan thdng thudng (niiom chCJng): 76 benh nhan.
Bang 1 . Dac diem chung
~ -^^^^^ Nhom Dac dilm "^ — . ^ Tuoi (trung blnh ± SD)
Gidi
Benh 1^
nguyen nhan (n,%)
Lydodat ong ndi kiii quan (n,%)
Nam (n, %) NCr(n,%) COPD Tai bien mach nao Benh t h i n kinh khac*
Benh iy tim mach Soc nhiem l<huan Honm^
Viem tuy cap Suy than cap Benh l<hac Suy ho h i p Benh t h i n l^inh B^nhlytim mach S6c APACHE II ITB±SD)
Nhom chung (n = 153) 57,1 ±18,7 91 (59,5%) 62 (40,5%) 32(21,0%) 45 (29,4%) 30(19,6%) 19(12,4%) 5 (3,3%) 7 (4,6%) 4 (2,6%) 4 (2,6%) 7 (4,6%) 56 (36,6%) 74 (48,4%) 17(11,1%) 6 (3,9%) 19,4±2,2
Nhom nghien curu (n = 77) 58,1 ± 20,1 45 (58,4%) 32(41,6%) 16(20,8%) 22 (28,8%) 18(23,4%) 10(13,0%) 2 (2,5%) 4 (5,2%) 2 (2,5%) 0(0,0%) 3 (3,8%) 26 (33,8%) 38 (49,4%) 10(13,0%) 3 (3,8%) 20,6 ± 1,9
Nhom chihig (n = 76) 56,1 ±15,2 46 (60,5%) 30 (39,5%) 16(21,1%) 23 (30,3%) 12(15,8%) 9(11,8%) 3 (4,0%) 3 (4,0%) 2 (2,6%) 4 (5,2%) 4 (5,2%) 30 (39,5%) 36 (47,5%) 7 (9,2%) 3 (3,9%) JS,I±I,7
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
<0,05
>0,05
>0,05
>0,05
>0,05
>0,05
<0,05
Benh ly th^n kinh khac gom: NhUdc co, Guillain Barre, trang thai ddng kinh.
Nhdn xet: Tuoi trung binh, gidi giufa 2 nhdm khac biet khdng cd y nghia thdng ke. Khdng cd sU khac biet ve b^nh ly nguyen nhan giUa 2 nhdm
nghien cUu. Biem APACHE II trung binh cCia nhon can thiep cao ban nhdm ehUng (p<0,05).
Tl le viem phdi lien quan thd mIy: Trong 153 b§nli nhan nghien eChj cd 73 benh nhan viem phdi lien qua"
t h d may, ti le VPLQTM d nhdm chung la 47,7%.
TAPCHlY Dl/qc LA|« SANG 108 TSpl2-S6 3/2017
B^ng 2. Ti le VPLQTM 6 n h o m chij:ng va n h o m can t h i e p
VPLQTIW(n,%)
Nhom nghien cihj (n = 77) 30 (39,0%)
Nhom chumg (n = 76) 43 (56,6%)
P
<0,05
RR(95%CI) 0,69(0,49-0,97) Nhdn xit: Sd benh nhan viem phoi lien quan t h d may la 30/77 (39,0%) d nhdm hut lien tuc djch ha thanh mdn va 43/76 (56,6%) d nhdm khdng can thiep, vdi RR = 0,69. G i l m nguy cd tUong ddi (RRR - Relative Risk Reduce) = 0,31 va sd benh nhan can dupe dieu tri can thiep (NNT - Number Needed t o Treat) = 5,6.
Sd ngay t h d may va xac suat viem phoi tich luy.
Kaplan-IVleier survival estimates
So ngay tho may
Bieu do 1. Xac suat b^nh nhan mac viem phdi lien quan den thdi gian thd may d hai nhdm ddi tUpng nghien cUu. Log- rank test (p<0,01) Nhan xet: 6 nhdm can thiep xac suat mac VPLQTIVl
theo thdi gian thap hdn so vdi nhdm chUng.
Thdi gian xuat hien viem phoi
Trdng nghidn cufu, d nhdm chung, thdi gian xuat hien viem phdi trung blnh 5,8 ± 3,3 ngay, nhdm chu'ng la 4,3 ± 2,3 ngay, nhdm can thiep la 7,7 ± 3,3 ngay, t h d i gian xuat hien viem phoi d nhdm can thiep xay ra mudn hdn 3,4 ngay so vdi nhdm chuYig, khac bi&t cd y nghla t h o n g ke (p<0,05), d d tin cay 95% la-4,7;-2,1.
Thdi gian thd mdy
Thdi gian t h d may trung binh 6 nhdm chung la 7,5 ± 4,4 ngay, n h d m chiJng la 8,7 ± 5,0 nhom can thiep la 6,2 ± 3,4, sd ngay g i l m trung blnh la 2,5 ngay (95% CI: -3,9; -1,2), thdi gian t h d may d nhdm
can thiep ngan hdn so vdi nhdm chUng, khie biet cd y nghTa thdng ke (p<0,05).
Thdi gian nam Khoa Hdi sC/c cap cCfu Thdi gian nSm ICU trung binh d nhdm chung la 13,5 ± 10,8 ngay, nhdm chufng la 14,8 + 11,6 ngay, nhdm can thi^p la 12,1 + 1 0 ngay, nhdm can thiep ng^n hdn so vdi nhdm chufng 2,7 ngay, p<0,05.
VtlitCf vong do viim phoi liin quan tbd mdy Trong nghien cUu cd 19 benh nhan tCr vong do VPLQTM, t i le tCf vong do VPLQTM la 12,4% d nhdm chung. T^ le tCf vong do VPLQTM d nhdm ehUng la 9/76 benh nhan (chiem 11,8%), nhdm can thiep la 10/77 benh nhan (chiem 12,9%), khac biet giUa 2 nhdm khdng cd y nghia thdng ke (p>0,05).
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoLl2-N='3/20i?
4. Ban ludn
D i e diem chung vi benh nguyen va mufc dp nang tinh theo APACHE II.
Tai bien mach nao dan den hdn me la benh ly thudng gap nhat chiem 29,4%; deu cho ca hai nhdm (p>0,05). Sau dd den b^nh phdi t i c nghen man tfnh 21,0% v l cung khdng khac biet giufa 2 nhdm (p>0,05) (BIng 1). Benh ly nguyen nhan trong nghien c<iu cua chung tdi khac vdi nghien cUu eCia Valles va Smulders.
B^nh ly nguyen nhIn chiem chCi yeu trong nghien cdu la benh phoi tac nghen man tinh, sau dd la benh ly than kinh [5], [6]. Ly do dat ndi khi q u I n : BIng 1 cho thay cac ly do ehfnh dat ndi khi q u I n t h d m I y bao gdm suy hd hap, benh 1^ than kinh, b6nh \'^ tim mach va sdc. NhIn xet cCia chung tdi cung phu hpp vdi cac t i e g i l khIc nhu Dezfullan [4], Smulders [5], Valles [6].
Diem APACHE II khi nhap vien d nhdm can thiep cao hon cd )/ nghTa thdng ke so vdi nhdm chufng, vdi p<0,05. K^t q u i cila chung tdi tUdng tU so vdi nghien cUu cOa Pham Van Hien [3] va mdt sd t i c g i l tren the gidi khac nhU Valles [6]. Nhung thap hdn so vdi Smulders, di^m APACHE II trung binh trong nghien cCfu cCia Smulders I I 23,1 ± 7,6 d nhdm can thi^p, va 22,3 ± 8,6 d nhdm chUng [5].
77/e viem phoi liin quan thdmdy
Trong nghien cUu chung tdi, t i le vi&m phdi lien quan t h d may chiem 47,7%. Ket qua nay cao hon so vdi mdt sd nghien eUu d nude ngoai, nhUng thap han nghien ciifu eCia Le Bio Huy [8]. Nhdm can thiep (hut lien tuc djch ha thanh mdn) t i le VPLQTM chiem 39%, thap hon cd y nghia so vdi nhdm ehCifng la 56,6% (p<0,05, RR: 0,69; 95% CI: 0,49 - 0,97). NhU vay, cd the ndi, hOt lien tuc djch ha thanh mdn cd hieu q u i lam g i l m nguy c o t u d n g ddi 3 1 % sd b&nh nhan bj viem phdi lien quan t h d may. CU6 benh nhan dat ndi khi q u I n cd bd phan hut lien tuc djch tren bdng ch^n se g i l m dupe 1 trUdng hap vigm phoi lien quan thd may (Number Need to Treat ^ 5,6). Ket q u i cua chung tdi cung gidng vdi cac t i c gia tren the gidi. Vi du nhu trong phan tich gpp cua John va cpng sU nam 2010 tU nhl4u nghien cufu khac nhau, RR la 0,54 (CI 95%: 0,44 - 0,65); NNT = 11 [9].
So ngdy thd may vd xac suat viim phdi tich luy Bieu do Kaplan Meier p h I n tich sdng con (Survival Analysis) cho thay xac suat viem phoi lien quan den thdi gian t h d m I y g i l m dang ke 6 nhom hut lien tuc dich ha thanh mdn (nhdm can thiep)«
vdi nhdm khdng hut dich (nhdm chCi'ng) vdi p<o,Ol (Bleu do 1). Nhan xet cua chung tdi tUOng tU nghien cUu cCia Kess Smulders [5] va Valles [6].
Thdi gian xuat hien viim phoi
Thdi gian xuat hien viem phdi d nhdm chung la 5,8 ± 3,3 ngay, nhdm ehUng la 4,3 + 2,3 ngay va nhom nghien culi la 7,7 ± 3,3 ngay. NhU vay, nhdm nghien cUu phat trien viem phoi cham hdn 3,4 ngay so v6i nhufng benh nhan su" dung dng ndi khi quan thif6ng (p<0,05; 95% CI: -4,7 den -2,1). ChCfng to phUOng phap hut lien tuc djch ha thanh mdn cd tac dung lam cham thdi gian tan cdng viem phoi lien quan thci may, cd y nghTa dac biet tranh VPLQTIVl d cac benh nhan t h d m I y n g i n ngay. Nhan x^t trong nghi§n ciiu eOa chung tdi cung tuang tU vdi ket q u i nghiin oihi cua Dezfullan [4], Kess Smulders [5], Valles [6].
Hieu qua Idm giam thdi gian thd mdy cua phuang phdp hOt dich hg thanh mon: Thdi gian thd may trung binh d nhdm chcing la 8,7 ± 5,0 ngay va ii nhdm can thiep hut lien tuc djch ha thanh mon la 6,2 ± 3,4 ngay. NhU vay phuang phap hut lien tuc dich ha thanh mdn da lam giam thdi gian thd may xudng 2,5 ngay, p<0,05, dp tin cay 95%: -3,9; -1,2.
Nhan xet cOa chung tdi cung tUdng tU nhan xet cOa Dezfullan [4], nhUng benh nhan dUpc hiit lien tuc dich ha thanh mdn ed thdi gian t h d may giam hai n g l y so vdi nhdm chufng (95% CI: 1,5 - 2,1 ng^y).
5. Ket luan
Khi sCr dung dng ndi khi quan Hi-Lo evac hiit tren cuff lien tuc vdi ap lUc -20mmHg cho nhOng benh nhan t h d m I y , phuang phap n l y ed hieu qua lam giam t l le viem phoi lien quan thd may 38% so vdi 56,6% (p<0,05); RR = 0,69; 95% CI: 0,49 - 0,97;
RRR = 3 1 % ; NNT = 5,6. Lam e h l m phat trien viefn phdi lien quan t h d may hdn 3,4 ngay so vdi nhilng benh nhan sCr dung ong ndi khi quan thadng (p<0,05; CI 95%: -4,7 den -2,1). Hieu q u i lam gi^m
TAP CHl Y DUgC LAlVI SANG 108 Tap 12-56 3/2017
thdi gian t h d may xudng 2,5 ngay (p<0,05). Hieu q u i lam g i l m t h d i gian nam ICU xudng 2,7 ngay.
Tai lieu tham khSo
1. Chastre J, Jean-Yves F (2005) Ventilator-associated pneumonia. American journal of respiratory and critical care medicine 165:867-903.
2. Vincent JL, Bihari DJ, Suter PM et al (1997) The prevalence pf nosocomial infection in intensive care unit in Europe Results of the European prevalence of infection in intensr/e care (EPIC) study. EPIC international advisory committee. Ches 112:458-465.
J. Pham Van Hien (1996) SCf dung phuang phdp rCfa phe quan phe nang qua dng soi mem xac dinh nhiem khuan phoi phe quan dbenh nhdn thdmdy. Luan van tot nghiep Thac sy. TrUdng £)ai hoc Y Ha Ndi.
4. Dezfullan C, Shojania K, Collard H et al (2005) Subglottic secretion drainage for preventing ventilator-associated pneumonia: A Meta-Analysis.
The American Journal of Medicine 118:11 -18.
Smulders K (2002) A randomized clinical trial of intermittent subglotic secretion drainge in patiens receiving mechanical ventilation. Ches 121 (3): 858-862.
Valles J, Artigas A, Rello J et al (1995) Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Annals of Internal Medicine 122:179-186.
Pugin J, Auckenthaler R, Mill N et al (1991) Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and non bronchoscopic "blind" bronchoalveolar lavage fluid.
Am Rev Respir Di 143:1121-1129.
Le Bio Huy (2008) Dac diem viem phoi liin quan thd may khdi phdt sdm vd mudn tai Khoa Hdi sCfc cap cCru Binh vien Thong Nhat thanh phd Hd Chi Minh. Hdi t h i o toan qudc ve hdi sUe cap cufu va chdng ddc l l n thU 9, tr. 206.
John M (2010) Epidemiology of methicillin-resistant Staphylococcus aureus infection in adults.
Uptodate. September 23.
