To identify the incidence, proportion, outcome of VAP

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TCNCYH Phu trwong 74 (3) - 2011

Summary

THE INCIDENCE, RISK FACTORS AND OUTCOME OF VENTILATOR ASSOCIATED PNEUMONIA

Objectives: To identify the incidence, proportion, outcome of VAP; To describe some risk factors to VAP in three intensive care unit - NHP. Results: 120 patients under MV fit criteria, there were 1162 ventilators days in total; The proportion was 26.7%); The incidence was 27.5/1000 ventilators days; Mortality rate was 46.7%; Association between VAP and gender (OR = 1.3; p > 0.05); Age < 1 week and > 1 week (OR = 0.65; p > 0.05); ward (x^ = 3.05; p > 0.05); admission diagnosis: premature newborn (OR = 0.91; 95%CI 0.38 2.17), cardiovascular problems (OR = 1.0; 95%CI: 0.25 3.96), respiratory problems (OR = 1.83;

95% CI: 0.77 - 4.34), prior sepsis (OR = 2.37; 95%CI: 2.69 - 9.13); indotracheal insertion route (OR = 2.71 p > 0.05); length of ventilators > 4 days (x^= 5.5; p = 0,018. 75%) Gram (-), microorganism were isolated, P.

aeruginosa was on top.Conclusion: The incidence, proportion and mortality rates was high. There was significant association between VAP and length of MV over 4 days.

Keywords: ventilator associated pneumonia, incidence, proportion, mortality, association

NHAN MOT TRU'QNG HQP VIEM DA SUN TAI PHAT TAI BENH VIEN TAI M O I HONG TRUNG U'QNG

Quach Thi Cin Bdnh vidn Tai Mui Hong Trung wang

Viem da sun tai phat - RPC (Relapsing Polychondritis) li benh viem hoac thoii hda he thdng, tiin triin, giy ton thuxyng kin dio ciu triic, chirc nang toin vpn cua sun, ca quan cam giac bipt hda, tim mach, thin va he thdng than kinh. Die diim lam sing cua benh da dang. Tuy timg vi tri bj tdn thwang nen cd thi gap a tit ca chuyen khca khac nhau. Niu benh chi bleu hipn rdi rac a timg vj tri thi rit khd chan doin va nghT tdi. Nhan mdt trwdng hgp tai khoa cap ciru benh vien Tai Mui Hpng TW, tdi di cap tdi chin doan vi xCr tri cin bpnh nay.

Tu- khoa: viem da sun tai phat

1. OAT

VAN D E

Viem da sun t i i phit RPC (Relapsing Poly Chondritis) l i benh viem hoac thoii hda he thong, tiin triin, giy ton thuang kin d i o c i u true, chu-c nang toin ven cua sun, ea quan cam giic biet hda, tim mach, thin va he thing thin kinh. NhCrng hiiu biit v i nguyen nhin va bdnh sinh cua RPC dugc bio c i o mdt cich rdi rac d t i t ca cie chuydn khoa. D i e diem lim sang cua benh da dang. Tiiy tirng vj tri bj ton thuang nen cd the gap d t i t ca chuyen khoa khic nhau. Niu bdnh chi bieu hien rdi rac d tCrng vj tri thi r i t khd chin doin va nghT tdi. Trong chuyen khoa Tai Mui Hpng, benh nhin thudng tdi vdi biiu hien viem sun vinh tai, viem sun vung mui, viem thanh khi p h i quan. Nhan mdt trudng hgp tai khoa c i p eCru benh vien Tai Mui Hpng TW, tdi de cap tdi chin doin v i xu- tri cin benh niy.

II. MQTACABENH

1. Benh sir

Bdnh nhin Pham H i T, nu' 37 tuoi, vio vien vi khin tiing, khd thd, biin dang sun vinh tai.

Benh dien biin tCr thing 8/2001. Khdi dau, benh nhin xuit hien sung dau vinh tai, hai ben ty nhien, ed ehd s i n ngCra, da dugc chin doin vi diiu trj vidm sun vinh tai sau v i nhi thiy tieu hit sun vinh tai, da vinh tai ru xudng. Thing 2/2002, benh nhan dot ngdt ho, khd thd du- ddi, khdng sot;

da dugc md khi quan c i p cu-u tai bdnh vidn Tai - Mui - Hpng Trung uang v i soi thanh khi quan thay cd seo hep thanh khi quan, benh nhin dugc deo ong thd v i nhi. Nam 2003, BN ty phit hien song mui bj s i p xudng, khdng sdt, khdng sung ndng do dau. Sau dd, bdnh nhan thd qua eanuyl v i thudng xuit hien 1 - 2 dgt ho, khd thd c i p tinh trong nim.

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2. Kham hien tai l o a n than

- Benh nhan tinh. t i i p xue tot, khong sot The trang g i y .

- Da niem mac h6ng.

- Mach 80 lan/ phut. HA 110/70 mmHg.

Thanh quan to chu'c siii che l^p hoan toan thanh mon.

SOI l<hi quan: thanh khi quan xep nhe hinh oval.

mem mac hai n§, I<h6ng sui.

Kham Mat: Binh thifong.

Kham tim mach Binh thu-ang Kham chuyen khoa Tai Mui Hong:

Tai: vanh tai 2 ben da binh thudng, nCra tren ru xuong do tieu sun. dai tai, ong tai va mang tai 2 ben binh thudng,

Mui: S6ng mui sap xuong hinh yen ngu'a, vach ngan thing, tham do khong t h i y sun, sun canh mui binh thudng: khe va cu6n 2 ben binh thu'ong

F^

! g #

•^•-,

Hinh 1. Vanh tai cua benh nhan

Hinh 2. Sdng mui sap xudng hinh yen ngya

Vom nhin.

Hong- viem man tinh,

Co: Benh nhan dang deo canuyn s6 6, tha thong qua canuyn.

Hinh 3. Benh nhan dang deo canuyn sd 6

Hinh 4. Hinh anh soi thanh khi phe quan cua benh nhan

3. Xet nghiem

Cong thu'C mau: cac chi so trong giai han binh thuang

Oo thinh lu'C do: Binh thu'ang

Soi thanh quan, sinh thiet to chiic sui to chuc viem man tinh,

X-quang tim phoi thing- cac nhanh ph6 quan tang dam

CT CO, ngu-c hep toan bo thanh quan, ha thanh mon, khi quan nho hon binh thu--ong, hinh oval

Do chu'C nang ho h i p R 6 I loan thong khi tac nghen, mu'c do trung binh

III. BAN LUAN

v i benh nguyen va ca c h i benh sinh: Ban chat nguyen nhan va benh sinh cua benh nay hien v i n chu'a du'ac hieu ro Trong khi RPC thu'ong du'oc mo ta nhu- mot benh nguyen phat cua mo sun thi v i n x u i t hien cac bieu hien kem theo a m i t (viem cung mac, viem ket mac) hay giam sue nghe do ton thu-ang t h i n kinh Nam 1960, Reason da gai y cac bieu hien cua benh o cac mo khong phai la mo sun CO the do phan u'ng qua mifc cua he thing enzyme d6i vai mot vai c i u tao dang sun co d cac mo nay Sun la mot mo lien ket dwac c i u tao bai c h i t n i n , cac sai collagen va cac te bao NhOng thanh p h i n cua c h i t nen bao gom cac axit mucopolysaccharide, cung la thanh phin cua giac mac, cung mac, t h i thuy tmh, mang mai, day ching x o i n va vong, cac thanh cua me dao mang, noi va ngoai dich, Han nCra, xet a c i p do phan {(y hoa hoc thi nguyen nhan cac c i u true khong phai mo sun b! lien quan vai benh nay la do su' giing nhau v i thanh p h i n phan tu' eacbonhydrate

Vao nam 1966, Dolan da coi benh nay la mot hien tu-ong tu-' m i i n va tot nhit la phan loai theo cac nhom mach collagen Cac nghien cu'u danh d i u mau khang the m i i n dich bing fluorescent mac du chua thing nhit v i k i t qua nhung cung da gai ra cac khang the dac hieu cua benh Co mot s6 trieu chung x u i t hien d benh nay g i i n g nhu cac

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benh mach collagen khac. Kaye d i bao cao cd 3 benh nhin duang tinh vdi y i u to dang thap, 1 benh nhin duang tinh vdi lupus ban dd he thong, v i viem tuyin giip Hashimoto d mdt benh rihin khic. Nam 1970, Rabuzzi da biP cao mdt trudng hgp 25 tuoi viem ddng mach thii duang v i ddng mach canh trdn bdnh nhin tai biin mach nao. Mae dCi viem da sun xuit hien nhu mdt hdi chu-ng rieng bidt nhung nd cd t h i cd ehung nguyen nhan benh sinh vdi eic rdi loan cua cie md lien k i t khic, do viy din din xuit hien cie trieu chCrng eua benh khic. Biiu hidn lim sing cua RPC: Do thim nhiem v i o nhiiu ea quan khic nhau nen benh ed bieu hien toin thin rit phong phCi. RPC cin dugc phin biet vdi cie benh khic bdi sy xuat hidn kem theo cie thuang ton hoai tCr viem lan rdng kin dio lien quan tdi cie ciu true sun toin ea thi, ea quan giac quan v i hd thing tim mach. Tuy nhien, do sy thay doi v i khd doin trude cua eic trieu chCrng lim sing khiin cho chin doin trd len khd khan han.

Biiu hien d Tai - Mui - Hpng: Viem sun vinh tai:

Viem sun vinh tai xuit hien trong RPC la khdng nhiem khuan nhung eung ed t h i bj nhiim khuin thu- phit. Vide khdng xuit hien eic hach viem viing ggi y nghi ngd v i tinh trang viem khdng nhiim khuan.

Oiiu quan trpng cin phai ghi nhin l i bieu hien cua viem tai ngoii v i viem sun kdm theo tay dd nhe cd the bj giin doin trong vii tuin d mdt sd trudng hgp, thudng xuit hien d cie vj tri d i liin rdi.

Biin dang song mui : Viem sun kdm theo hoai tu- sun mui v i sy tiin triin kin dio eua biin dang song mui nhung eung cd t h i gap ton thuang 6 vidm d mdt so bdnh khic nhu nhiim khuin man tinh, u hat Wegener, viem hach lympho.

Hep dudng thd: Hep dudng thd ed t h i l i hiu qua eua ton thuang ben trong hoac cie t i c ddng giin, nen eua mdt q u i trinh tCr ben ngoii. Viem sun nip thanh thiet phai dugc xem xet khi ed nghi ngd tie nghen dudng hd hip tren. Trieu ehCrng ehinh eua viem sun nip thanh thiet thudng l i sy xuit hien dot ngdt dau hpng ning tren mdt ngudi trude dd khde manh. Thanh quan va eiy khi quan ed the bj viem man tinh, diy len v i xa hda thinh giy khin tiing, khd thd.

Trdn benh rihin nay ed diy du eic trieu ehu-ng eua vidm da sun t i i phit: Viem sun vinh tai, sun mui, viem sun thanh khi quaii.

Bieu hidn d ca quan khic: M i t (viem kit mac, vidm giic mac, viem cung mac, thugng eOng mac...), viem sun sudn, viem da khdp, viem ddng mach chu va phinh ddng mach chu, diic tiip nhan, chdng mat.

RPC ed the khd phan biet vdi u hat Wegener do eung ed nhirng trieu ehCi-ng phu xuit hidn kin dao cua vidm sun vinh tai, biin dang sdng mui, benh thanh khi p h i quan... Chan doin ehinh xie cin phai dya tren dinh gia md hpc v i tim ra tridu chCrng lim sing die hieu han nhu ten thuang dang hang tai phoi trong WG: xep khi phi quan lan tda v i phinh ddng mach chu trong RPC.

Can lim sing: Xet nghidm miu: Thudng khdng cd cie biin doi dac hieu; T i e dp miu ling tang.

Protein C phan Crng (CRP) ting; Giam qui trinh ting sinh bach cau hoac tiiu c i u ; Sy ting bach c i u i i toan thudng xuit hien: 10%o sd benh nhan RPC; Thiiu m i u thudng gap d mdt vii thdi diem eua q u i trinh benh iy-, thudng l i thieu man tinh;

CRP, bach c i u tang.

Dinh g i i ton thuang phoi: Cin dinh gii giai phau v i ehu-e ning dudng hd hip trdn v i dudi gom:

Chup XQ nguc cd the biiu hien mdt so hinh anh nhu md trudng phoi dp viem hay xep phoi, ting dim mach m i u phoi hay phu phoi.

Chup phim co nghieng ed t h i phit hidn hep khi quan, vdi hda sun thanh khi.

- Mae dCi chup XQ ea ban ed the hQ-u ieh doi vdi mdt sd trudng hgp, song d i biit chi tiit han thi cin phai ehup CT doi vdi benh nhin RPC.

Chup CT CO ngyc ed g i i trj han so vdi chup XQ thudng quy v i dinh g i i dugc cie ton thuang nhu diy thinh thanh khi phi quan, hep thinh mach, vdi hda sun, cd the thiy tim to, giin hay loi thinh ddng mach ehu. Oiiu niy ed t h i giai thich dugc tinh trang khin tiing, nuot khd hoic khd thd d benh nhin RPC. C i n chu y ky thuit khi chup CT.

Niu chup CT chl dugc thye hidn trong qui trinh hit v i o thi nhCrng thay doi v i dudng kinh eua eiy phe quan se khdng quan sat dugc. Cie phit hidn gan day cho thiy ring trdn benh nhin RPC ed thi phit hidn nhO-ng hinh anh b i t thudng eua dudng thd khi chup CT thi thd ra, trong khi chi mdt nCra s6 benh nhin dd cd bit thudng khi chyp CT thudng quy khi hit v i o . Do v i y , it n h i t c i e l i t eit eua

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dudng thd chinh ndn dugc chup d ea thi thd ra.

Tuy nhidn, chyp CT cung bj gidi han phin nio do khdng phin bidt dugc xa hda v i vidm.

- Chyp cdng hudng tir MRI vdi kha ning chup hinh anh trdn nhiiu mat phing v i uu the trong vide phin bidt phan md m i m ndn MRI die bidt hu-u ieh trong dinh g i i khi p h i quan v i phin biet xa hda vi vidm vdi phu.

- Ngoii ra cd the chup xa hinh xuang khao s i t mO-e dd lan tda eua ton thuang xuang syn, eic xet nghidm dinh g i i ton thuang tim mach lien quan (didn tim, sidu i m tim...).

Hda md miin djch:

Khing t h i ty miin khdng die hidu: Xet nghiem huyit thanh phit hien thiy khing the khing nhin ANA trong khoang 22 - 66% bdnh nhin RPC. Hinh anh hda md miin djch nhudm fluorescence cd nin ding nhit hay dang chim nhd nhung die trung cua khing nguyen gay benh thi ehua dugc biit rd.

Khing t h i khing DNA ty nhidn, Sm, U1 RNP v i Ro/La diu khdng die hieu doi vdi RPC. Cie bit thudng khic v i huyet thanh hpc cung ed t h i xuit hi$n nhu yiu to dang thip (trong 16% trudng hgp), test huyit thanh duang tinh gia vdi giang mai v i khing t h i khing phospholipit (duang tinh gia 1/8 cie trudng hgp).

Khing thi khing collagen typ II: TCr liu ngudi ta nhin djnh ra ring eic bdnh nhin RPC cd the cd miin djch djch t h i vi/hoic miin djch trung gian t i bio dip Crng vdi thinh phin chat niri ngoii t i bio cua md sun. Mie dCi y nghTa sinh bdnh hpc eua lip luin niy ehua thye sy dugc hieu biit hit, cie khing thi khing collagen typ II v i cie proteoglycan ty nhidn hoic biin tinh d i u dugc cho l i mdt hidn tu-gng phy khdi diu tir hidn tugng phi huy md v i khdng die hidu cho benh. Khing t h i khing collagen typ li dugc tim thay d dudi mdt nu-a sd b0nh nhin RPC, thudng xuit hidn d giai doan khdi diu. Sy hO-u ieh eua eic khing the niy doi vdi vide giim sit tiin triin cua bdnh v i d i p u-ng diiu trj cin thiit phai dugc phin tich nhiiu han.

Khing t h i khing bach c i u da nhin trung tinh d bio tuang: Mdt v i i biiu hidn d bdnh nhin RPC ggi y cho chCmg ta nghT tdi cd vide ting eic khing thi khing bgch c i u da nhin trung tinh d bio tifo-ng (ANCA).

Cie xdt nghidm khic: Xdt nghidm bo t h i toin

phin trong mau v i ndng dd C3, C4 trong RPC hiu hit diu binh thudng. Tinh trang ting nhit thdi ndng dd IgG, IgA hoic IgE ed t h i xuit hidn. Dien di protein huyit thanh ed the cho thay cie bit thudng khdng die hieu nhu giam albumin v i ting alpha - 1 v i gamma globulin.

Chin doin RPC: RPC dugc chin doin dya theo hai bd tieu chuan chin doin. Bd tieu chuin gdc theo McAdam v i cdng su nim 1976 cd it nhit 3 tieu chuin trong sd cdc dac diim dwdi ddy: Viem syn vinh tai 2 ben; Vidm da khdp khdng i n mdn, xet nghiem huyet thanh i m tinh; Viem syn mui;

Viem kit mac, vidm giac mac, viem cung mac hoic thugng cung mac, viem ming bd dio; Viem sun dudng thd (syn thanh va/hoae khi quan); Roi loan ehu-e ning tiin dinh hoic do tai - diic thin kinh u tai chdng mat.

Sau do cd nhCrng biin doi v i trieu ehCrng lim sing xuit hidn tai mdt thdi diim xic djnh nen din tdi nhirng thay doi trong tieu chuan chin doin d i phu hgp. V i tieu chuin niy da dugc hoin thien bdi Daminani v i Levine nim 1979. De dua rachin doin, benh nhin phai cd du mdt trong ba tidu chuin sau diy: Cd it nhit 3 trong so cie tidu chuin cua McAdam; Cd tCr mdt diu hidu lim sing nhu tren trd len eung vdi kit qua md hpc duang tinh phu hgp; Viem sun tCr 2 vj tri giai phau cich xa nhau trd Idn, d i p Crng vdi steroid vi/hoiedapsone.

Nhu viy, trdn bdnh nhin eua ehung tdi mic du khdng tim thiy mdt kit qua xdt nghidm hoic ton thuang die hidu d cac bd phin khic nhung doi chiiu vdi tieu chuan gdc theo McAdam cd 3 fidu chuin; Vidm sun vinh tai 2 bdn; Vidm, tieu syn vich ngin; Viem syn thanh khi quan.

Vide chin doin trdn benh nhin ehu yiu dya vio lim sing. Nhirng dgt cip viem syn thanh khi quan cua bdnh- nhin t i i phit nhieu lin diu dip u-ng tot vdi corticoid. Benh nhin vin ed t h i lim cdng vide nhe nhing mac du kha ning rut dng thd la rit khd khin. Va chung tdi dang tiip tyc theo ddi thim khim them v i lim thdm cie xet nghiem lim sing de phit hien nh&ng ton thuang khic.

Oiiu trj: Hiu hit benh nhin diu diiu tri ndi khoa nhung phie dd diiu trj ndi khoa ly tudng thi chua dugc tim thiy. Thuoc dieu trj diu tidn l i corticosteroid liiu cao de etru tinh mang bdnh nhin, sau dd ehuyin sang liiu duy tri. Corticosteroid

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ed tie dyng tot d giai doan vidm thanh khi quan cip nhung khdng giup dugc gi d giai doan mudn khi m i da tieu hit sun. Sun khi quan ed t h i bj xep ddt ngdt din d i n tu- vong do dd vide md khi quan tam thdi hoic vTnh vien la rit can thiit. Vide dat ndi khi quan l i rit khd khan die biet trong lue eo thit dudng thd lim dudng thd hep lai. Bdnh nhin niy ddi hdi mdt i p lye thdng khi duang. Vide tao hinh thanh khi quan trong cie trudng hgp nay eung cho kit qua khdng tdt lim. Phau thuit niy eung ehi lim dugc d nhii-ng ea sd y t i ed diy du trang thiit bj, cd phiu thuit vidn ed kinh nghiem v i bic sT giy me hoi su-c tdt. Trudng hgp nhe, benh nhin cd t h i dugc dieu trj vdi Diaminodiphenylsulphone (Dapsone). Dapsone ed tie dyng kim khuin. Ngoai ra edn ed aspirin v i eic thude khang viem nonsteroid khic. Thinh cdng dugc bao cao vdi cie loai thude nhu Azathiaprin, Cyclophosphamide, Mereaptopurine, Penicilamine, Cyclosporin.

IV. K^T LUAN

Viem da syn tii phit l i benh m i nguyen nhan edn ehua rd ring, da ed nhiiu gia thuyit duge dua ra cd lien quan tdi miin djch djch the va mien djch qua trung gian t i bio.

Khi ehua ed xet nghiem dang tin cay de chin doin benh thi vide chin doan ehu yiu dya vie cie tieu chuin chin doin cua McAdam dua tren eic trieu ehCrng lim sing. Vide tham kham thudng xuyen d i phit hien them cie ton thuang d cac bd phin khic nhu tim mach, mit l i rit cin thiet eung nhu eic xet nghiem die hieu d i ddng gdp them cho bd tieu chuan chin doin.

Benh nhin RPC ludn bj de dpa sy song bing eic dgt c i p viem thit thanh khi quan giy suy ho hip. Vide diiu trj corticoid trong cie dgt viem cap l i can thiet de eu-u tinh mang cho benh nhin.

TAI LIEU

THAM

KHAQ

1. Jaksch - Wartenhorst, R.: Polychondropathia (1923). Wien Ztsch inn. Med., 6: 93.

2. Pearson, C. M.; Kline, H. M., and Newcomer, V. D. (1960). Relapsing Polychondritis.

New Eng. Jour. Med., 263: 51 - 58.

3. Dolan, D. L.: Lemmon, G. D., and Tettelbaum, S. L. (1966). Relapsing Polychondritis.

Amer. Jour. Med., 41 : 285 - 299,

4. Kaye, R. L., and Sones, D. A.: Relapsing Polychondritis. (1964). Ann. Internal Med., 60:

653 - 664.

5. Rabuzzi, D. D.: Relapsing Polychondritis.

Arch. Otolaryngol. (1970). 91: 188 - 204,

6. Coste, F., et al. (1961). Polychondritis, Polyarthritis, and Gougerot Sjogren Syndrome.

Rev. Rheumat., 28: 498.

7. Purcelli, F M.; Nahum, A., and Moneli, C.

(1962). Relapsing Polychondritis with Tracheal collapse. Ann. Otol., Rhinol. and Laryngol., 71: 1120-

1129,

8. Jahn, S. K., and NIederwieser, A. (1970).

Composition of Connective Tissue in Biochemical Mechanisms in Hearing and Deafness. M.

Paparella, Editor. Charies C. Thomas, Springfield, III., 249-262,

Summary

CASE REPORT: RELAPSING POLYCHONDRITIS IN NATIONAL ENT HOSPITAL

Relapsing Polychondritis has been described as a recurrent painful inflammation of multiple cartilaginous structures followed by cartilage destruction and collapse. The present information concerning the history, clinical and laboratory findings, diagnois, prognosis and treatment is review. One unusual ease of this disease we have in National ENT hospital with exemplify the extreme of the symptomatology of this patient is presented. The purpose of this paper is to review the information and to repprt an unusual case of this disease.

Keyword: relapsing polychondritis