TAP CHi Y HOC VlfeT HAM TAP 455 - THAHG 6 - SO 2 - 2017
NGHIEN CU'U DAC DIEM LAM SANG, CAN LAM SANG a BENH NHAN BOT CAP BENH PHOI TAC NGHEN MAN TINH NAM VIEN D A I NGAY
Vu Quang Diln*, Dinh Van Thinh*, Nguyen Thi Thanh Lieu*
l . D A T V A N D E
Hien tren toan cau cd khoang 329 trieu ngffdi mac benh phdi tae nghen man tinh (BPTNI^), moi nam cd khoang 3 trieu ngffdi tff vong vi can benh nay. Vdi tinh chat pho bien, tien trien keo dai, chi phi dieu trj cao va hau qua tan phe, BPTNMT da thffe sff trd thanh ganh nang ve sffc khde, kinh te va xa hdi cho toan nhan loai. Nam vien bdi ddt cap eiia BPTNI^T la sff kien chinh trong tien sff tff nhien ciia BPTNMT vi nhuYig anh hffdng xau den chffc nang phoi, sff song, nguy cd nhap vien lai va chat Iffdng cudc sdng. Nam vien dai ngay eiJng ehi ra nhffng benh nhan yeu hdn, nhffng benh nhan can sff cham sde nhieu hdn tff phia y te. Nhan biet sdm cac dau hieu de tien Iffdng benh nhan phai nam vien dai ngay bdi ddt eifp tinh eua BPTNMT ed the chu ddng xay dffng ke hoach cham sdc, dieu trj tdi ffu, rut ngan thdi gian nam vien dai ngay, giam nguy ed eiia cae sff ed bat ldi va chi phi dieu tri ddi vdi thay thude va benh nhan [1]. Chfnh vi vay chung tdi tien hanh de tai nham mue tieu:
1. Nghien c&u dac die'm lam sang d benh nhan ddt cap binh phdi tac nghen man tinh nam vien dai ngay.
2. Nghiin c&u dac diem can iam sang d binh nhan ddt cap benh phd'i tac nghen man tfnh nam viin dai ngay.
II. €}6l TU'ONG VA PHU'aNG PHAP NGHIEN COXJ 2 . 1 . Dol tu'dng, dja diem va thdi gian nghien cufu: Benh nhan BPTNI^TT cd dpt bung phat cap tfnh phai nhap vien dieu tri tai Benh vien 74 Trung ffdng, on djnh ra vien. Ttidi gian nghien effu tffthang 1/2015-10/2015.
2.2. Phu'dng phap nghien cuXi.
Thiet ke nghien c&u: Nghien cuXi md ta eat ngang, hdi effu ket hpp vdi tien eiilj. Chpn mau khdng xae suift vdi mdt mau thuan tien.
Cd miu: 445 benh nhan dpt cap BPTNMT, trong dd 98 tienh nhan tien eiilJ. Khdng cd djnh nghTa cho thdi gian nam vien eiia benh nhan BPTNMT nhff the nao dffpe gpi la dai ngay.
Trong nghien eirtj nay chung tdi xac dinh ngudng cho thdi gian nam vien dffdc gpi la dai ngay la sd ngay nam vien ldn hdn bach phan vi 75"* theo cac nghien cffu khac. Bach phan vj 75''' dffdc tinh toan la 18 ngay. Benh nhan nghien T O M TAT
Muc tieu: Md ta dae diem lam sang, can lam sang d benh nhan dpt cap benh phdi tSe nghen man tinh nam vien dai ngay. Phu'dng phap: Nghien cffu hen cull ket hpp vdi hoi cuU, md ta cat ngang tren 445 benh nhan dpt cap benh phoi tac nghen man tinh (BPTNMT) nam dieu tri npi trii tai Benh vien 74 Trung uong. Benh nhan nghien cuff dffpe ehan doan dot cap ciia benh phoi tac nghen man ttnh theo tieu chuan ciia GOLD nam 2015. Thdi gian nghien ciTu tff thang 1 nam 2015 den thang 10 nam 2015. Ket qua va ket luan: Tien sff nam vien bdi BPTNMT > 1 lan, tien sir hoa tn lieu oxy, benh kem theo: suy tim, viem phdi chiem ty le cao hOn d nhom nam vien dai ngay. Pa02 mau dpng mach trung binh va albumin mau trung binh thap^hpn, hjnh anh X.Q ngUcr^^tim hinh giot nffdc, tham nhiem phoi, dpng mach phoi rong chiem ty le cao hon d nhdm nam vien dai ngay so vdi nhom n&m vien khong dai ngay.
T& khda: Dpt cap ciia benh phoi tSc nghen man tfnh, nam vi|n dai ngay
SUIWIVIARY
STUDY CUNZCAL, PARA-CLINICAL CHARACTERISnCS I N PROLONGED LENGTH
OF HOSPITALIZATION EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY
DISEASE PATIENTS
Objectives; To describe the dinical, para-clinical characteristics in prolonged length of hospitalization exacerbation of chronic obstrucb've pulmonary disease patients. Method: A retrospective combined prospective, cross-sectional descriptive study was conducted in 445 exacerbation of chnDnic obsffuedve pulmonary disease inpatients in cmtral 74 hospital. All study patients were diagnosed according t» criterion of GOLD (2015).
Research time from January to October in 2015. Results and condusion: A hospitalized and oxy therapy histery by chronic obstructive pulmonary disease, combined heart failure, pneumonia were higher proportion, PaO^
serum albumin were lower level, chest Xrav: heart was drop of water, oulmonarv intubates, enlarged pulmonary arteries were higher proportion in prolonged length of hospitalization exacerbation of chronic obstructive pulmonary disease patients compared with non- prolonged length of hospitalization group.
Keywords: Exacerbation of chronic obstructive pulmonary disease, prolonged length of hospitalization
*Benh vien 74 Trung i^ng Chju trach nhiem chinh: ViJ Quang Dien Email: [email protected] Ngay nhan bai: 20.2.2017 Ngay phan bien khoa hpc: 3.5.2017 Ngay duyet bill: 17.5.2017
VIETNAM MEDICAL JOURNAL N°2 • JUNE - 2017 eulj ehla lam 2 nhdm de so sanh dac diem lam
sang va can lam sang: Nhdm nam vien dai ngay (>18 ngay) goml99 benh nhan va nhdm nam vien < 18 ngay gom 246 benh nhan.
2.3. Phu'dng phap thu thap thong tin:
Phdng van benh nhan, tham kham, ehup X.quang ngffe, xet nghiem edng thffe mau ngoai vi, sinh hda mau, khi mau ddng mach liie benh
nhan nhap vien. Do ehffe nang hd hap khi benh nhan diidc dieu tri dn djnh.
2.4. Phu'dng phap xu* ly so lieu; Sd lieu dffpe phan tfch tren chffdng trinh SPSS 16.0. C^c so sanh ddn bien dffdc tien hanh bang bang cheo va cac kiem dinh thdng ke Chi-square, Student's t test phu hdp cho tuVig trffdng hdp. Mffe y nghTa thdng ke trong eae kiem dinh nay la 0,05.
III. KET QUA NGHIEN CU'U VA BAN LUAN 3 . 1 . Tfen sir dieu trj
Bang 3.1. Tiin s&nhap vien vi benh phd'i tac nghen man tinh TPen six nhap vien
< l l a n
> l l a n
Tong> 1 8 ngay 134 (67,3%) 65 (32.7%)
199
< 18 ngay 215 (87,4) 31 (12,6%) 246
P
< 0 , 0 5 1 = 4 4 5 Ty le tien sff nhap vien bdi BPTNh'lT > 1 lan d nhdm dieu trj dai ngay eao hdn nhdm cdn lai c6' nghTa thdng ke. Nhieu nghien cffu eho ket qua tffdng tff va tien sff phai nhap vien la mdt tieu chf danh gia mffe dp nang eiia BPTNMT, ty le ddt biing phat nang ngay cang eao va day theo theo thdi gian sau ddt bung phat dau [3],[7].
Bang 3.2. Tien s&hda tri iieu oxy
>1S ngay < 18 ngay Tien su" hoa trj lieu oxy
Sa sff dung
73(36,7%) 49(19,9%)
< 0 , 0 5Chu^ sff dung
20 (10%) 42(17,1)
Khdng rd
106(53,3%) 155(63%)
>0,05Tong
199 246
S = 445Nhdm nam vien dai ngay ed tien sff hda tri lieu oxy eao hdn nhdm cdn lai co y nghla thdng ke.
Theo ATS/ERS, oxy dffPe ehi dinh d nhuliq benh nhan BPTNMT suy hd hap man ed qiam oxy d liic nqhi (PaOj<55mml-lq) hoae PaO? tff 56 - 59mmHq d benh nhan ed dau hieu tam phe man, hematocrit > 55%, vdl suy hd hap cap tronq ddt biinq phat, tuy tinh tranq ma hda tri lieu oxy bang eac phffdnq thffc tff oxy qua sonde mui, thd qua mask den thdng khf khdng xam nhap va thdng khi xam nhap [ 4 ] .
3.2. Trieu chu'ng lam sang ciia 2 nhdm Bang 3.3. Triiu ch&ng lam sang cua 2 nhdm
Trieu chu'ng lam sang Xanh tim Roi loan y thu'c
Ngu ga Sot Tanq ho khac ddm
Tanq kho thd Tong
>1S ngay 46 (23,1%) 15 (7,5%) 42(21,1%) 97(48,7%) 178(89,4%) 187 (93,9%)
199
< 18 n g ^ 38(15,4%)
12(4,8%) 42 (17,1%) 99(40,2%) 203(82,5%) 223(90,7%)
2 4 6
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Z = 445 Ty le benh nhan co bieu hien cae trieu ehffng lam sang d nhdm nam vien dai ngay cao hdn nhom cdn lai, tuy nhien chffa cd sff l<hac biet cd y nghTa thong ke. Theo ATS/ERS: Ddt cap eiia BPTNMT la sff thai^doi cap tinh cac trieu ehffng ed ban ho, khd thd va/hoac khac ddm so viffi hang ngay => phai ttiay ddi trj lieu hang ngay [ 4 ] .
Bang 3.4. Cac dau hi$usinh tdn d 2 nhdm Dau liieu sinli ton
Mach trunq binh Nhip thd trunq binh Huyet ap trunq binh Nhiet do trunq binh
fong
> 1 8 ngay 81 ± 20,2 26±7,3 130/80± 40,2/6,3
37.2± 2,1 199
< 18 ngay 78± 21,4
25± 5,4 135/76± 35,5/7,1
37.25± 1,9 2 4 6
P
>a,05
>0,05
>0,05
>0,05 1 = 445 BSnh nhan nghien cffu ed trung binh eua tan so thd, tan so mach va nhiet do d nhdm nam vien dai ngay cao hdn nhdm < 18 ngay, nhffng sff khac biet chffa ed y nghTa. Tang nhip tim hay nhjp thd
TAP CHi Y HOC VIET HAM TAP 455 - THANG 6 - S6' 2 - 2017
20% so vdi tranq thai binh thffdng la tieu chi danh gia mffe dp nang tiip 3 eiia ddt cap BPTNMT theo NR Anthonlsen [4].
Bang 3.5. M&c dd kho thd theo mMRC Mu'c da mMRC
0 1 2 3 4 Tong
> 18 ngay 3(7,1%) 13 (30,9%) 16 (38,1%) 7(16,7%) 3 (7,1%) 4 2
< 18 ngay 6 (10,7%) 21(37,5%) 17(30,4%) 10(17,9%) 2(3,5%)
56
P
>0,05
>0,05
>0,05
>0,05
>0,05 Z = 98 Benh nhan nghien^ effu cd khd thd chii yeu la d mffc 1,2,3. Mffc 0 va 4 chiem ty le thap, sff khac biet giffa 2 nhdm khdng cd y nghTa thdng ke. Cd mdt sd bd eau hdi khac danh gia mffc dp khd thd ciia benh nhan BPTNMT, theo GOLD thi bd ciiu hdi khd thd eiia Hdi ddng nghien cffu y khoa sffa ddi mMRC v l n cd gia tri hdn ca [ 5 ] ,
Bang 3.6. Cac binh phoi hdp.
Cac bSnh phoi hop Suy tim Loan nhip tim Tang huyet ap Dot quy Tieu du'dnq
Viem phoi Khac Tong
> 18 ngay 92(46,3%)
12(6,1%) 24(12,2%) 2(1%) 8(4,1%) 53(26,6%) 32(16,1%) 199
< 18 ngay 63(25,6%)
10(4,1%) 33(13,4) 2(0,8%) 5(2%) 23(9,3%) 28(11,4%) 2 4 6
P
< 0 , 0 5
>0,05
>0,05
>0,05
>0,05
< 0 , 0 5
>0,05 1 = 4 4 5 Suy tim va viem phoi d nhdm dieu tri dai ngay chiern^ty le cao hdn nhdm < 18 ngay cd y nghTa thdng ke. Nhiem triing dffdng thd ndi ehung va viem phoi ndi rieng la ngdi no ciia dpt cap BPTNMT va lam cho benh canh ciia BPTNMT nang len. Theo GOLD (2015): benh tim thieu mau cue bd, suy tim, nhoi mau phoi, viem phoi hit la nhiJng benh thffdng di kem vdi BPtNMT [7].
3.3. Can lam sang ciia 2 nhdm
Bang 3.7. Bac dii'm cdng th&c mau va sinh hda mau Cong thu'c va sinh hoa mau
Bach cau trunq binh Honq cau trunq binh Albumin trunq binh
Ure trunq binh Creatinin trunq binh
Tong
> 1 8 ngay 11,3± 5,1 4,75 ± 1,1
33,5± 6,4 6,8 ± 2,3 124 ± 12,6
199
< 18 ngay 10,5± 4,2 4,63 ± 1,3
35,6± 7,1 6,6 ± 1,4 123 ± 13,2
246
P
>0,05
>0,05
< 0 , 0 5
>0,05
>0,05 X = 4 4 5 Nhdm nam vien dai ngay cd aibumin mau trunq binh thap hdn cd v nqhla thonq ke so vdi nhdm <
18 nqay. Theo Chen C W (2015) giam aibumin mau ia nguy cd cho suy ho hap cap tinh d benh nhan BPTNi^TT [6],
Bang 3.8. Xet nghiem khi mau dong mach.
Khi mau dong mach pH PaCO,
PaO, HCOr Tong
> 1 8 ngay 7,35 ± 2,2 51,4± 8,1 67,8± 10,3 21,8± 5,6
154
< 18 ngay 7,36± 3,5 50,3± 6,2 70,6± 12,5 2 2 , 3 ± 4 , 1
189
P
>0,05
>0,05
< 0 , 0 5
>0,05 Z = 3 4 3 Benh nhan nghien cii'u cd PaO; d nhdm dieu tn dai ngay thiip hdn nhom < IB ngay co y nghia thong ke. Tlieo GOLD (2015): PaO; < 60mmHg cd hoac khong kem PaCO; > SOmmHg khi thd kh trdi, chan doan suy ho hap [7].
Bang 3.9. Oac diem x.quang ngffc d2 nhom Oac diem x.quang ngu'c
Tim hinh qiot nUdc Khi phe thung Phdi ban/binh thu'dnq
> 1 8 ngay 144(72,3%) 156(78,3%) 43(21,7%)
< 18 ngay 111(45,1%) 173(70,3%) 73(29,7%)
P
< 0 , 0 5
>0,05
>0,05
VIETNAM MEDICAL JOURNAL N°2 - JUNE - 2017 Tham nhiem
Donq mach phdi ronq tong
61(30,7%) 108(54,3%) 199
29(11,8%1_
75(30,5%) 246
<0,05
<0,05 Z = 4 4 5 Benh nhan co hinh anh X.quang tim hmh gipt nffpc, tham nhiem, va ddng maeh phoi rdn^ d nhom nam vien dai ngay chiem ty le cao hdn nhdm cdn lai ed y nghTa thong ke. Hinh anh ehi ra ton thffdng phe quan va phoi ciia BPTNMT la khf phe thting lioac hinh anh viem phe quan man. Tim hinh giot nffdc la hau qua eua khf phe thung va suy dm, ddng mach phdi rdng la hinh anh gian tiep chi ra tang ap Iffc ddng maeh phdi trong BPTNMT. Ty le dffdng kinti dpng maeh phoi/dffdng kinh dpng mach chii d benh nhan BPTNMT > 1 la yeu to nguy eP dpe lap lien quan vdi so ddt cap BFTNMT trong tffdng lai.
Bang 3.10, Phan loai giai doan cua BPTNMT d 2 nhdm Giai doan cua BPTNMT
I II III IV Tong
> 18 ngay 20 (10,0%) 64 (32,2%) 79 (39,7%) 36 (18,1%)
199
< 18 ngay 33 (13,4%) 98i39,8%) 90 (36,6%) 25 (10,2%)
246
P
>0,05
>0,05
>0,05
>0,05 i = 445 Benh nhan ehii yeu la giai doan I I va I I I , ty ie phat hien benh d giai doan sdm la thap, sff khac biet giffa 2 nhom khdng ed y nghTa thdng ke. rjghien eirtj eua Dinh Thi Phffdng Lan (2014), ty le giai doan I ia 0%, I I : 18,1%, I I I : 64,8, IV: 17,1% [2].
IV. KET LUAN
1. Tien sff nam vien bdi BPTNMT > 1 lan, tien sff hda tri lieu oxy, benh suy t'm, viem phdi kem theo chiem t / le cao hdn d nhdm nam vien dai ngay.
2. Pa02 mau ddng mach, albumin mau trung binh thap hdn, tim hinh gipt nffde, tham nhilm phdi, ddng maeh phoi rdng tren X.quang ngffe chiem t^ le cao hdn d nlidm nam vien dai ngay so vdi nhdm nam vien khdng dai ngay.
TAI UEU THAM KHAO
1. Ngo Quy Chau (2011), "Benh ho hap', Nha xuat ban giao due Viet nam, tr 177-189,
2. fiinh Thi Phu'dng Lan va cong sut (2014), " Dac diem lam sang, c|n lam sang va dieu tn benh nhin dot cap COPD tai khoa noi 2 Benh vien Viet Tiep
Hai Phong tff thang 1 den thang 6 nam 2014", Thong tin y dddc Hai Phong, so 1/2015, tx 24-33.
3. ATS (2014), "Exacerbation of COPD", Am J Respir Crit Care Med,Mo\. 189, pp: 11-12.
1. ATS/ERS (2004), "Standard for diagnosis and management of patiens with COPD", Am. J. Respir Crit care Med, 152, pp. 8-222.
5. Claire L., Coralie B., Eric B., at al (2012), "The modified Medical Research Council scale for the assessment of dvsonea in dailv living m obesity: a pilot study", BMC Pulmonary Medicine, 12, pp. 61.
6. Chen CW at al (2015), "Severe hypoalbuminemia is a strong independent risk factor for acute respiratory failure in COPD: a nationwide cohort studv", InternationalJoumal of Chronic Obstmi^ve Pulmonary Disease, 10(1) Pages 1147—1154.
7 GOLD (2015), "Global strategy for the diagnosa^
managemnent and prevention of COPD, chapter 1, R) 2.
MOI LIEN QUAN GIU'A MOT SO DAC DIEM CAN LAM S A N G VA TYP VIRUS (jf BENH NHI SOT XUAT HUYET DENGUE
Lg Minh Dung*, NguySn Duy ThSng**, Nguyin Quang Du^t**^
T O M TAT
Bat van di: Sdt Dengue d tre em cd xuat huyet thu'dng nang va cd nguy cd tff vong cao. Hien nay Viet Nam CO dii ca 4 typ huyet thanh ciia virus Dengue, tuy
*BVsan nhi Tra Vinh
**BVN6ng Nghiep Hi Noi
***Benh vien 103
Chju trach nhiem chinh: Le Minh Dung Email: [email protected] Ngay nhan bai: 17.2.2017 Ngay phan bien khoa hoc: 5.5.2017 Ngay duyet bai: 16.5.2017
nhien mffc dp tac ddng cua tiihg typ len ngffdi benh den nay van chu^ dUde ro. Muc tieu: Nghien ciiXi moi lien quan giii^ mot so dae diem can lam sang va t/p virus trong chan doan, tten Iffpng va dieu trj _s5t Dengue. Bdi tUdng va phitdng phap: Tien hanh dinh typ huyet thanh d nhdm benh nhan nhi co xuat huyet tieu hda va so sanh cac bieu hien can lam sang theo typ virus. Kit qua: Trong eac chi tieu can lam sang mot so chi tieu cd mdi lien quan d^n typ^virus bao gom: sd Iffpng hong cau d typ 3 la thap nhat; so Iffdng bach cau thap nhat d tuyp 1; typ 2 c6 ti le giam tieu cau dudi 3 trieu la cao nhat. Kit luan: Ket qua nghien cii\i co y nghTa gdi y chan doan typ huyet thanh va tien Iffdng dac biet d nhiJng npi Wiong co dieu kien dinh typ huyet thaiih.
