TOMTAT

Y Hpc TP. Hb Chi M i n h * T^p 20 * So 5 * 2016 Nghien cihi Y hoc

VAI TRO CtJA PROCALOTONIN TRONG T I £ N LU'ONG B$NH VIEM PHOI M A C PHAI C O N G D 6 N G TAI BENH VIEN TRl/NG V l / O N G

Tit Quoc Thanh*, Cao Thj Bich Ngdn', Vo Thf Van', Nguyhi Thi Bgch Tuyet*, Dodn Thi Minh Liin', Nguyin Thf Phuang Thdo"

TOMTAT

Md ddu vd M^c tieu: Vai tro cita Procalcitonin (PCT) trong tiin lugng mtic do ndng, biih chdng va tie vong cua viim phoi mdc phai cgng ddng (VPMPCB) Id diua ro rang. Muc tiiu nghien cieu la khao sat vai tro cim PCyr trong viic ddnh gid muc do mng vd Hen lugng bim ckimg, tie vong a binh nhdn VPMPCD nhdp viin dieu tri tai binh viin Trung Vutmg.

Ddi tugng vd Phuang phap: M6 ta hang logt ca co phan tich. Tdi cd cdc ca VPMPCD dugc ldm xit nghiim PCT ldc nhgp viin vd sau 48-72 gia. Cdc benh nhdn dugc phdn nhom mdc do ndng theo thang dimt PSI vd CURB-65, dugc dieu tri vd theo doi cdc bien chieng cho dm khi Idioi benh hoac tk vong.

Ket qua: Chdng tdi thu thgp dugc 131 binh nhan. Co moi tucmg quan giiea nong do PCT luc nhdp vien vd miec do ngng cua VPMPCD fheo thang dian PSI vd theo thang diem CURB-65 v&i he s6'tuang quan Spearman lan lugt Id Rs-^ 0,228 (p= 0,009) vd R^ 0,233 (p= 0,007). Ndng dd PCT ldc nhdp viin khong co khde biet giiea rihom co hiin diung vd nhdm khdng biih diung (p= 0,051), giiea nhom tie vong vd sdng con (p= 0,581). Ndng do PCT ldn 2 CO khac biit giiea nhom c6 biih ch^g vd nhom khdng biih thieng (p= 0,002), cdng nhu giUa nh&m tie vong vd nh&m song con (p< 0,001).

Kei luan: Nong do PCT liic nhdp vien co tuang quan v&i muc do nqng cim VPMPCD rihung dii a miec trung htnh vd khong co y nghia tien lugng bien chieng vd tie vong ciia VPMPCD. Nong do PCT tan 2 vd dong hoc PCT CO y nghia tiin higng hien chieng vd tie vong.

TiJC khoa: Viim phoi mac phdi cdng ddng, Ndng do Procalcitonin.

THE ROLE OF PROCALCITONIN IN PROGNOSIS OF COMMUNFTY ACQUIRED PNEUMONH IN TRUNG VUONG HOSPFTAL

Tu Quoc Thanh, Cao Thi Bich Ngan, Vo Thi Van, Nguyen Thi Bach Tuyet, Doan Thi Minh Lien, Nguyen I h i Phuong I h a o * Y Hoc TP. Ho Chi Minh * Vol. 20 - No 5 - 2016:1- 9 ABSTRACT

Background & Objectives: The role of procalcitonin (PCT) in the prognosis of severity, complications and mortality of community acquired pneumonia (CAP) is unclear. Objectives of the study were to investigate the role of PCT in assessing severity and prognosis of complications and mortality in patients hospitalized CAP at Trung Vuong Hospital.

Method: Descriptive case series study. All the cases of CAD zvere measured for PCT levels at admission and 48-72 hours later (2"^ PCT leveb). The patients were classified according to the severe scale of PSI and CURB-65, were treated andfolbwed up until recovery or death.

Results: 131 patients with CAP were enrolled in the study. There is a correlation between PCT levels at admission and severities ofCAF according PSI scale and CURB-65 scale with Spearman's correlation coefficient R= 0.228 (p= 0.009) and R= 0.233 (p= 0.007) respectively. There was no significant difference in PCT levels at admission between complicated and uncomplicated group (p= 0.051), between death and survival group (p=

* Khoa Dieu trj theo ygu cau B^nh vi^n Tnmg Vuong " Khoa Xet nghiem B^nh vien Tnmg Vuong Tdcgid lien lac: BS.CK2 Tir Quoc Thanh DT: 0903 968 892 Email: tuthanhmd@vahoo.com

1

Nghien ciiu Y hpc Y Hpc TP. Hb Chi Minh * Tap 20 * So 5 * 2016

0.581J. There was significant difference in 2'^ PCT levels between complicated and uncomplicated group fp=

0.002), as well as between the group of death and survival (p< 0.001).

Conclusion: The PCT leveb at admission have a correlation vnth the severity of CAP, but have no role in prognosis cf the complications and death cf CAD. 2"* PCT levels and PCT kinetics have a role in prognosis of complications and death of CAD.

Key words: Community acquired pneumonia (CAP), Procaldtonin (PCT) level.

D A T V A N D E

Viem phoi mac phai cong dong la mot benh ly nhilm trung c6 ty le mic va tir vong cao tren the gioi cung nhu 6 Viet Nam.

Trong thuc hanh lam sang, viec danh gia miic do nang, tien lircmg benh viem phoi la rat quan trong. Trong y van da ghi nhan nhieu thang diem de danh gia miic dp nang trong viem phoi rhu thang d i a n ciia Hoi Long nguc My ATS, ciia Hoi Long ngirc Anh BTS, thang diem PSI, CUI?B~65, A-DROP... Tuy nhien cac thang diem nay chua tien lugng day dii cho cac b&ih nhan viem phoi mac phai cpng dong.

Hien tai co nhieu chat danh dau dupe sii dung de tien lucmg trong benh viem phoi, trong do noi bat la Procaldtonin. O nguoi binh thuong, Procalcitonin co nong dp rat thap trong huyet thanh Nong dp Procjildtonin tang cao trong cac benh Iy nhiem trimg do nguyen nhan vi khuan, cac benh Iy nhiem trung toan than nang. Vi the, trong viem phoi, da co nhieu nghien ciiu khao sat vai tro cua Procaldtonin trong viec xac dinh tac nhan gay b?nh la do vi khuan hay virus, giiip chi dinh khang sinh, theo doi dien tien dieu tri, tien lupng miic dp nang cua benh, tien lupng b i s i chiing, tu vong va quyet dinh thoi gian dfeu tri khang sinh. Tuy nhien cac nghien oiu nay co ket qua chua ro rang va thong lihaifl-''^^^ Hien nay, 6 Viet Nam van chua co nhieu nghien ciiu ve van de nay. Vi the chiing toi ti&i hanh nghien oiu nay de khao sat vai tro cua Procaldtonin trong viec danh gia miic dp nang va tien lupng 6 benh nhan viem phoi mac phai cpng dong.

Muc tieu

Khao sat vai tro cua Procaldtonin trong viec

danh gia mtic dp n^mg va tien luong bien chiing, tu vong 6 benh nhan viem phS mac phai cpng dong nhap vien dieu tri tai Benh vien Trung Vuong.

DdlTL/GNG-PHLfONGPHAPNGHIENaJlJ Dbi tupng nghien cuu

Cac trudng hpp VPMPCD nhap vien t^i khoa Dieu tri theo yeu cau cita Benh vien Tmng Vuong tti thang 12/2014 d m thang 5/2016.

Ky thuat chpn mau

Chpn mau theo phuong phap chon mau ke tiep, Ian lugt cho dan h^t thoi gian nghien ciiu la 17 thang.

Thiet ke nghien cuu

Nghien ciiu tien oiu, mo ta hang loat ca co phan tich.

Phuong phap tien hanh

Cac benh nhan khi dupe chpn vao nghien a i u se dupe hoi benh va tham kham Iam san^

thuc hien cac xet nghiem mau, vi sinh, chan doan lunh anh, xet nghiem PCT luc nh^p vien va 24r48 gio sau. Nong do PCT dupe dinh lupng bang phuong phap mien didi hoa phat quang true tiep tu dpng (Automated direct chemiluminescent Immunoassay) tren may Advia Centaxn XP do hang Siemens- Diic che tao nam 2013. Cac benh nhan dupe theo doi cho den khi xuat vien hoac xay ra tir vong.

K E T Q U A

Dac diem dich te hpc, Iam sang, c?n Iam sang cua cac ca VPMPCD trong nghien cihi Chung toi thu thap dupe 131 benh nhan bao gom 61 nam (46,6%) va 70 nii (53,4%), tuoi tnmg binh ± dp lech diuan la 74,97 ±

Y H p c T P . H b C h i M i n h * T a p 20 * Sb 5 * 2016 N g h i e n curu Y hpc 14,93; nho nhat la 28 tuoi. Ion nhat la 102 tuoi.

Chiem da so la cac b?nh nhan >70 tuoi (69,4%). Co 124/131 benh nhan (94,7%) la co benh ly phoi hgrp, d u e m ty Ie cao nhat 106 ca (80,9%) la cac benh ly tim mgch, ke den la eae benh phoi man ehiem 40 ca (30,5%).

Trung vi nong dp PCT lue nhap vi&i la 0,23 ng/mL (0,12- 0,63); nho nhat la 0,01 ng/mL, Ion nhat la 36,29 ng/mL. Co 73 ca dupe lam PCT Ian 2 sau 48-72 gio. Trung vi nbng dp PCT ^ 2 la 0,28 ng/mL (0,16-0,81); nho nhat la 0,01 ng/mL, Ion nhat la 20,66 ng/mL.

Ket qua dieu tri co 117 ca (89,3%) song eon, CO 25 ca (19,1%) co bien chiing, trong so do co 16 ca (12,2%) phai tho may va 14 ca (10,7%) tii vong. Co 5 ca (3,8%) phai chuyen khoa Hoi siic tfch cue, 14 ca tli vong deu xay ra trong 30 ngay ke tir Iiic nhap vien, trong do co 3 ca tu vong vi b i a i ehiing suy ho hap va soc nhiem trung, 10 ca vi suy ho hap va 1 ca vi soc nhiem trung, khong CO ca tir vong vi nguyen nhan khae.

Chung toi dung thang diem PSI theo huong d i n Ctia Hpi Long nguc My de chia cac benh nhan luc nhap vien ra Iam 5 nhom I, H, HI, IV, V.

Ket qua cac benh nhan thupe nhom IV chiem nhieu nhat 56/131 ca (42,7%>), it nhat la nhom I chi CO 3 ca (23%)- Ty le co biett chiing tang dan fheo thang ddem. PSI, thap nhat la a nhom I khong CO ca nao co bien chiing, cao nhat la 6 rihom V CO 7/13 ca (53,8%) co bien chting. Ty le bi&i chiing giiia cac nhom PSI khac biet co y nghia (p< 0,001). Ty le tii vong cung tang dan theo thang diem PSI (tni nhom EI thap hon a nhom U), thap nhat la 6 nhom I khong co ca nao tli vong, cao nhat ia 6 nhom V co 6/13 ca (46,1%) tli vong. Ty Ie tii vong giiia eae nhom PSI khae biet CO y nghia (p= 0,003).

Chiing toi dung thang d i a n CURB-65 iheo huang dan ciia Hpi Long nguc Anh de chia cac benh nhan luc nhgip vien ra Iam 6 nhom: 0 diem, 1 diem, 2 diem, 3 di&n, 4 d i a n va 5 diem. Ket qua cac benh nhan thupe nh6m 1 diem la chion nhieu nha't 53/131 ca (40,5%), it nhat la nhom 4

diem 7/131 ca (5,3%) va khong co b&ih nhan nao thuoc nhom 5 diem. Ty le co Hen chiing tang dan Iheo ttiang diem CURB-65, thap nhat la 6 nhom 0 diem co 1/15 ca (6,7%), cao nhat la 6 nhom 4 diem co 4/7 ca (57,1%) co bi&i chiing. Ty le bien chiing giiia cac nhom CURB-65 khae biet CO y nghia (p= 0,049). Ty 1| tir vong ding tang dan theo thang diem CURB-65, thap nhat la a nhom 0 diem kh6ng c6 ca nao tir vong, cao nhat la a nhom 4 diem co 3/7 ca (42,9%) tir vong. Ty Ie tir vong giua cac nhom CURB-65 khac biet co y nghia (p= 0,038).

Xac d i n h mbi t u o n g q u a n cua n b n g dp PCT m a u luc n h a p vien va dp n a n g cua VPMPCD

Khi phan dp nang theo PSI, ket qua cho thay CO su khac biet co y nghia ve trung vj nong dp PCT mau Iiie nhap vien giua cac nhom dp nang theo PSI (p= 0,03). Phan tfch moi tuong quan giiia nbng dp PCT va miic dp nang a i a VPMPCD phan loai theo thang di&n PSI ta tl^y CO tuong quan, voi he so tuong quan Spearman R^ 0,228 (p= 0,009). So sanh nong dp PCT Iiic nhap vien 6 nhom VPMPCD co nguy co thap- trung binh (I, H, UT) va nhom nguy ea cao (IV, V) phan loai theo PSI cho thay co su khac bi^t co y nghia giiia 2 nhom nguy co thap- trung binh va nguy CO eao theo PSI (p= 0,03).

Khi phan dp n ^ g theo CURB-65, ket qua cho thay co su khac biet c6 y nghia ve nong dp PCT mau liic nhap vien giiia cac nhom dp nang theo CURB-65 (p= 0,005). Phan tich mbi tuong quan giiia nong dp PCT va miic dp nang ciia VPMPCD phan loai theo thang diem CURB-65 ta ciing thay eo tuong quan, vol he so Spearman Rs= 0,233 (p= 0,007). So sanh nbng dp PCT liic nhap vien a nhom VPMPCD CO nguy co thap-trung binh (0, 1, 2 diem) va nhom nguy co cao (3, 4 diem) phan loai theo CURB-65 cho thay khong c6 sir khac biet CO y nghia giua 2 nh6m nguy co thap- trung binh va nguy co cao theo CURB-65.

Dien tich duoi duong cong (AUC) giiip

Nghien cuu Y hpc Y Hpc TP. Hb Chl Minh * T^p 20 * Sb 5 * 2016 ti&n lupng nguy eo cao theo PSI ciia nong dp

PCT liic nhap vien la 61%, KTC 95% la 51,3%- 70,8%, p= 0,03 voi diem ck PCT= 0,135 ng/mL CO do nhay= 84,1%, dp chuyen= 40,3%, gia tri tien doan duong (PPV)= 61,1%, gia tri tien doan am (NPV)= 69,4%.

Vai tro ciia nbng dp PCT trong vi?c tien lirpng bi^n chucng ciia VPMPCD

Trung vi nong dp PCT liic nhap vien 6 nhom CO bi&i chiing la 0,42ng/mL (0,16-0,87) (trung vj- tli phan vi) va khong bi&i chiing la 0,215 ng/mL (0,09-0,58) khong co khac nhau eo y nghia (p= 0,051).

Trong nghien eihi co 73 ca dupe lam xet nghiem PCT Kn 2 sau 4&-72 gio. Day la moc thoi gian ma cac nha lam sang fhuong ap dung de khao sat lai cae xet nghiem, chup lai X quang phoi, nham danh gia dap iing dieu tn. Nong dp PCT Ian 2 6 nhom co bi&i ehiing va khong bien chiing khae nhau co y ngtua (0,76 ng/mL so vol 0,22 ngAnL, p= 0,002). AUC a i a nong dp PCT Ian 2 gitip phan phan biet eo bi&i chiing hay khong trong VPMPCD la 72,6%, KTC 95% la 59,7%- 85,6%, p= 0,002 voi di&n cit PCT Ian 2=

0,7 ng/mL co dp nhay= 54,5%, dp chuy&i=

84,3%, gja tri hen doan duong (PPV)= 60%, gja tri tien doan am (NPV)= 81,1%.

K& qua khao sat dpng hpc PCT cho thay ty le CO bi&i chiing 6 nhom dpng hpc PCT gjam (nbng dp PCT Ian 2 thap hon Iiic nhap vien) khac biet co y nghia voi nhom dpng hoc PCT tang hoac khong thay dbi (21,3% so voi 46,2%, p= 0,035).

Vai tro cua nbng dp PCT trong vi^c tien lupng hi vong ciia VPMPCD

Trung vi nong dp PCT Iiic nhap vien 6 nhom ttr vong la 0,185 ng/mL (0,16-0,8) va song con la 0,23 ng/mL (0,11-0,62) khong co khac nhau CO y nghia (p= 0,581).

Nong d6 PCT Ian 2 6 nhom tir vong vk sbng con khae nhau co y nghia (1,62 ng/mL so voi 0,23ng/mL, p< 0,001). AUC ciia nbng dp PCT Ian 2 giiip phan biet co ttr vong hay

khong trong VPMPCD la 89,2%, KTC 95% 1^

81,1%- 97,3%, p< 0,001 vai diem cat PCT lan 2= 0,7 ng/mL co dp nhay= 83,3 %, dp chuyen=

83,6%, gia tri tiSn doan duong (PPV)= 50%, gia tri tien doan am (NPV)= 96,2.

Ket qua khtio sat dpng hpc a i a PCT cho tiiay ty 1? tir vong a nhom dpng hpc PCT g i ^ khac bi?t eo y nghia voi nhom dpng hpc PCT tang hoac khong ttiay doi (2,1% so vol 42,3%, p< 0,001).

BANLUAN

Dac d i ^ dich te hpc, lam sang, can lam sang cua cac ca VPMPCD trong nghien ciiu Trong nghien ctiu cua chiing toi, b^nh nhan nam chi&n ty 1? it hon nii, khong nhu cac nghi&\ ciiu khae'5''''''^^">, tuy nhien it hon khong dang ke (61 nam so vol 70 nu). K& qua nay lai tuong dong v6i nghien a i u aia Kaplan®. Ve nhom tuoi mac benh thi ciing tuong tu cac nghien a i u khac, do la VPMPCD ttiuong gap 6 nhiing nguoi tren 50 tubi. Trong nghi&i aiu ciia dning t6i, co 124/131 b?nh nhan (94,7%) la o5 b^nh Iy phoi hpp. Nhiing benh nay tao dieu kien de mac vi&n phoi va Iam cho benh viem phbi n|ing hon, kho dieu tri hon. Ket qu^ nay phu hpp voi cac nghi&i ciiu khac.

Nong dp PCT tnmg binh liic nhap vien la 1,63 ng/mL, trung vi la 0,23 ng/mL. Ket qua nay thap hon trong nghi&i ciiu cua Dao Bach Que Anh® CO nbng dp trung binh PCT liic nhap vi?n la 1,73 ng/mL va a i a Vii Nguyin Nhan Ait^'l co trung vi PCT Iiic nhap vien la 2,02 ng/mL. Tuy nhi&i, ket qak a i a chiing toi l?i tuong duong voi HorieP' co trung vi PCT Iiic nh3.p vien la 0,2 ng/mL va cao hon cita Niu"* (2013) tr&i 113 ca VPMPCD CO trung binh PCI Iiic nhip vien la 0,35 ng/mL. Si^ khac biet nay co the do dp nhay a i a ky thuat xet nghiem d moi nai khac nhau, tac nhan gay b?nh (nong dp PCT cao hon neu tac nhan gay b?nh la vi khu&i diSi hinh so voi vi khuah khong diSi hinh hay virus), dp n^ng ciia benh, cac benh phoi hop.

Ty Ie bi&i chiing va tir vong trong nghi&i

Y H p c T P . H b C h i M i n h * T ? p 20 * Sb 5 * 2016 N g h i e n ctiu Y hpc o i u eiia chiing toi thap hon nghien o h i a i a Vti

Nguy&i Nhan AiO') lam 6 Benh vien Chp Ray va cvia Dao Bach Que Anh^ Iam 6 Benh vien Nguy&i Trai, nhung eao hon cac nghien a i u cua cae tac gia nuoc ngoai^'"'''^'. Viec so sanh nay thuong khong d u n h xae vl tiiy thupe vao nhieu y&i to: tuoi benh nhan, cac b^nh phoi hpp, thoi gian tir liic khoi phat benh d&i khi nhap vien, tac nhan gay benh, di&i kien cham soc 6 timg noi. Cac bi&i chiing trong nghien ciiu ciia chiing toi la suy ho hap, soc nhiem trimg/nhi&n trimg huyet, tbn thuong than cap ciing tuong tu nhu cac nghi&i ctiu khaci^'*'^^'").

Xac d i n h m b i t u o n g q u a n c^a n b n g db PCT m a u liic n h a p vi^n va d p n a n g cua V P M P C D

K& qua cua chiing toi dio thay trung vi nbng dp PCT mau Iiic nhap v i ^ eo su khae biet CO y nghia giiia cac nhom dp nang theo PSI (p=

0,03) va cac nhom dp nang theo CURB-65 (p=

0,(K)5). K&: qua nay ding phii hpp voi nghi&i a i u ciia Dao B^ch Que Anhl^', Vii Nguy&i Nhan Ai"'), Kimi'), Kruger<"), Menendez"^), ParkC^).

Phan tich moi tuong quan giira nong dp PCT liic nhap vi^n va miic dO n?ing ciia VPMPCD theo thang diem PSI ta thay co tuong quan, vol he so tuong quan Spearman Rs= 0,228 (p= 0,009). Ket qua nay ciing phu hpp voi nghien ciiu eua Dao Bach Que Anh'^) vdi he so Spearman Rs= 0,52 (p< 0,001), ciia Kim(») voi he so Spearman Rs= 0,306 (p= 0,01).

Tuong tu, khi phan tich moi tuong quan giiia nbng dp PCT Iiic nhap vien va miic dp nang a i a VPMPCD theo thang diem CURB-65 ta ciing thay co tuong quan, voi h$ so tuong quan Spearman Rs= 0,233 (p= 0,007). K& qua nay ciing phu hpp voi nghi&i o i n a i a Kim'^) voi he sb Spearman Rs= 0,309 (p= 0,01).

Chiing toi dua tr&i PSI chia cac benh nhan ra Iam 2 nhom: nhom nguy co thap-trung binh (PSI I, n, m) va nhom nguy co cao (PSI IV, V) de khao sat y nghia miic dp nang a i a nong dp PCT Iiic nhgp vi?n. K& qua cho thay co su khac biet

CO y nghia thong k8 ve nbng do PCT mau Itic nhap vi&i giiia 2 nhom nguy ea thap-trung binh va nguy co eao theo PSI (p= 0,03). Ket qua nay phit hpp voi nghi&i ciiu aia Dao Bach Que AnhH Masiai^^', Mennendezt'^'.

Chiing toi eiing dira tren CURB-65 de chia eae b?nh nhan ra Iam 2 nhom: nhom nguy co thap-trung binh (CURB-65 0, 1, 2 diem) va nhom nguy ca cao (3, 4 di&n). Ket qua cho thay kh6ng eo sir khac bi^t co y nghia thong ke ve nong dp PCT mau Iiic nhap vi^n giiia 2 nhom nguy co thap- trung binh va nguy co cao theo CURB-65. Ngupe Igii, trong nghien ciiu eua Menendez'") tren 480 b^nh nhan VPMPCD, nong dp PCT tang dang ke theo db nang ciia CURB-65. Trong nghign ciiu a i a Park"5} (2012) tren 126 b?nh nhan VPMPCD, trung vi PCT khac nhau co y nghia thong ke giiia eae phan nhom PSI (p< 0,01) va CURB-65 (p<0,01).

Nhu vay, trong nghi&i ciiu ciia ehiing t6i, nong dp PCT liic nhap vi?n co gia b i tien lupng miic dp nang ciia viem phoi phan logi theo PSI tot hon la phan loai theo CURB-65. Nong dp PCT tang cao hon 6 nhom co nguy co cao hon, tang theo su dap iing viem doi vcd nhiem trimg.

Su gia tang PCT thay doi phu thupe vao nhieu y&i to: vi tri nhiem trimg, miic dp lan rpng cita nhi&n trung (nhiem trimg khu tni hay toan than), miic dp nang aia b|nh. Nong dp PCT cao Ihuong xay ra o nhiing b^nh nhan eo dap iing viem toan than, co nhi&n trung huyet nang, soc nhi&n trimg va dac biet khi c6 roi loan chiic nang da co quan k&n theo.

Trong nghien ciiu, AUC giiip tien lupng nguy CO cao theo PSI eiia nong dp PCT liic nhap v i ^ la 61%. K& qua nay eho thay nbng dp PCT liic nhap vien chi co gia tri o n\iie dp trung binh trong viec ti^n lupng nguy ca cao ttieo PSI ciia VPMPCD.

Theo Schuetz"^ (2011) tr&i 925 benh nhan VPMPCD, AUC ciia PCT liic nhap vien trong vi?c tien lupng b?nh nhan nhap khoa Hoi siie

Nghien ciiu Y hpc Y Hpc TP. Hb Chi Minh » Tap 20 * Sb 5" 2016 tich cue la 69% (64%-75%.). Theo Vu Nguyin

Nhan Aif^') (2011), AUC a i a PCT liic nhap vien trong viec ti&i lupng viem phbi nang phan logi theo IDSA/ATS 2007 la 77,5%. Ket qua a i a chiing t6i la thap hon, eo le do each phan dp nang trong nghien ciiu chiing toi la theo PSI, khac voi phan dp ngng a i a tac gia Vii Nguyin Nhan Ai("'.

K& qua aia ehiing toi khac voi nghien eijru cua Raz<i« tr&i 31 benh nhan VPMPCD cho thay khong CO mbi li&i quan giira nong do PCT voi miic dp nang ciia b&ih. Tuong tu, trong nghien Ciiu Ciia Beovid2) tr&i 99 benh nhan VPMPCD ding khong thay co su khac biet nong dp PCT giiia eae nhom dd nang phan loai theo PSI.

Vai tro cua nbng dp PCT trong vi^c tien lupng bieh chiing cua VPMPCD Bdng 1. Trung vi ridng do PCT luc nhdp vien & 2 nhom CO biai chieng vd khdng bim chieng

Nghien CLFU Chung toi (n=131)

\/u Nguyen Nhan Ai (n=136;

eso Bgch Que Anh (n=57) Masia (n= 185) Schuetz (n=925)

C6 biln chi>ng 0,42 2,43 34 2,44

1,3

Khong biSn ChCmg

0,215 0,7 0,3 0,1 0,39

P 0,051 0,002

<0,001 0,03

<0,001

*Soliiu trinh bdy bang tmng vi, phep kiem Mann Whitney U.

Bang 1 cho thay PCT liic nhap vien trong nghi&i cihi ciia chiing toi kh&ig co vai tro trong ti&i lupng bi&i chiing aia VPMPCD va co su khac biet voi cac tac gia Dao Bgch Que AnH%

va Nguyin Nhan Ai'"), Masia''^) va Schuetzf'').

Sir khac biet gjiia ket qua ciia chiing toi voi cac tac gia khac co the la do co mau, miic dp nang aia cac benh nhan, cac benh phoi hpp, ty le bi&i chiing, tiioi gian tir liic co trieu chiing d&i khi dupe nhap vien, cac y&i to khac tac dpng d&i k& qua PCT, dp nhay ciia xet nghi&n PCT tai noi nghi&i oiu... Nghi&i ctiu aia Vii Nguyin Nhan Ai(=^ dupe tiiuc hien tai Benh vien Chp Riy, day la benh vien tuy&i cubi, nhgn nhi&i benh nang tir cac benh vien tuy&i truoc chuy&i d&i sau khi hp da dieu tri vdi ket qua khong on.

do do ty le benh nhan co bi&i chiing la rat cao 102/136 ca (75%.). Liic nay tinh ti:ang nhilm trung ciia berth nhan da diln ti&i ngng, nhieu benh nhan dupe dua vao khoa Hoi siic tich etrc ngay, dieu nay co the Iy giai viec bung vi PCT liic nhgp vi&i a nhom b^nh nhan co bi&i chiing la 2,43 ng/mL cao hon rat nhieu trong nghien ciiu eua ehiing toi (trung vi PCT Iiic nhgp vien 6 nhom bi&i chiing la 0,42 ng/mL). Cae benh nhan a i a chiing toi co the nhap vien som hon, thai diem nay tinh trgng nhiem trimg chua diin ti&i ngng n&i nbng dp PCT Iiic nhap vien diira tang nhieu. Ngoai ra do dac tiiii eiia khoa Dfeu trj theo y&i cau tai benh vien chung toi, cac benh nhan benh da nang 6 thai di&n nhap vien thi it dupe chuy&i vao khoa. Ttrong tu, cac benh nh&i trong nghi&i cihi a i a Dao Bach Que Anhi^

ding nang hon cac berth nh&i trong nghi&i aiu a i a chiing toi, voi ty le co bi&i ehimg la 43,9%, trung vi PCT Iiic nhap vien 6 nhom co bioi chiing l&i toi 34 ng/mL. Nghi&i oiu ciia MasiaC^) thi chi co 5 ca (2,7%) co bi&i chiing, con nghi&i o i u a i a Schuetz^^ thi co co mau (n= 925) Ian hon aia chiing toi (n= 131) rat nhieu. Su khac biet Ion ve co mau co the dan d&i ket qua so sanh khong chinh xac.

Ngoai ra, trong nghi&i ciiu a i a Dao Bach Que Anh(5>, AUC ciia nbng dp PCT liic nhap vien trong vi^c phan biet vi&n phoi co bi&\

ehiing va khong bi&i chiing la 83,7%, tiic la co gia trj kha tot trong viec tien lupng bi&i chiing ciia VPMPCD. Ngupc lai, trong nghi&i ciiu ciia Vu Nguyen Nhan Ai<»'>, AUC ciia nbng dp PCT liic nhgp vien trong viec tien lupng bi&i chiing cua VPMPCD chi la 67,5 %.

Trong nghi&i ciiu a i a Schuetz^^ thi gia tri nay ciing ehi la 66%. Di&i nay cho thay vai tio ciia PCT Iiic nhap vi&i trong viec ti§n lupng bi&i chiing ciia VPMPCD la khong ro rang va eiing chi o miic dp trung binh.

Trung vi nbng dp PCT lan 2 6 nhom co bien chiing khac bi^t co y nghia voi nhom khong co bi&i chimg (p= 0,002). Trong khi do riong dp PCT liic nhgp vien Igi khong khac biet giiia 2

Y Hpc TP. Hb Chi M i n h * T | p 20 * Sb 5 * 2016 N g h i e n cuu Y hpc

nhom. K& qua nay co the la do tiong nghien eiiu ciia chiing ^ i 6 thoi di&n nhap vi|n cac benh nhan chua co tinh trang nhi&n trimg ngng n&i PCT chua tang nhieu va diua eo su khae biet gitia 2 nhom. Sau 48-72 gio, d nhom bpnh nhan khong dap iing tot vai diieu tri, tinh trang nhiem trimg se di&i ti&i nang hon, riong dp PCT Iiic nay da hit dhi tang, va cac benh nhan nay thuang de co bi&i chiing. Dpng hpc PCT ding CO y nghia tuong tu.

Trong nghien ciin a i a chiing toi AUC a i a nbng dp PCT lan 2 giiip phan biet vi&n phbi co bi&i chiing hay khong la 72,6% (p= 0,002). Trong nghi&i o i u cita Schuetzt'^, nong dp PCT dupe Idiao sat them vao ngay thii 3, 5 va 7; AUC a i a nong dp PCT dinh tiong viec ti&i lupng bi&i chiing la 69% (khoang tin cgy 65%-74%), tuy co cao hon nbng dp PCT Iiic nhgp vien (66%) nhung gia b i ti&i lupng ding dii 6 miic dp trungbinh.

Vai tro cua nbng dp PCT trong vi^c tien lirpng h i v o n g cua VPMPCD

Bdng 2. Trung vi nong do PCT luc nhap vien ct 2 nh&m tie vong vd sm.g c&n

Nghien cim Ch0ngt6i(n=131) Ha Tan BLfC(n= 39) Vu Nguyin Nhan Ai (n= 136)

BSo Bgch Qu^ Anh (n= 57) tulasia (n= 185) Schuetz (n= 926) Boussei<ey (n= 100)

Charies (n= 180) Kiliger(n=1546) P a * (n= 126)

Ti> vong 0,186

4,96 2,3 6,16 0.5 0,83 6,4 43 0,88 1,96

sdng c6n 0,23 3,33 1,9 0,36 0,1 0,44 4,5 21,7 0,13 0,18

P 0,581

0.63 0,096

<0,001

<0,0001 0,02 0,03 0,3

<0,001

<0,01

*Solieu irinh hay hang trung vi, Phep hem Mann Whitney U.

Bang 2 cho thay nghi&i ciiu a i a chiing toi phii hpp voi cac tac gia Ha Tan Diic'^', Vu.

Nguy&i Nhan Ai'^^', Charles'^) nhung Igi khac voi cac tac gja Dao Bach Que Anhf^, BoussekeyP), Krugeri"), Masia.<^^>, Park<^^> va SehuetzP^. Su khac biet nay chiing to gia tri ti&i lupng tir vong ciia nong dp PCT liie nhap vien la kh6ng ro rang va thbng nhat. Nghi&i ciiu aia

KrugerPi) (2008) tien hanh tren 1546 benh nhan cho thay eo su khac biet co y nghia ve nong dp PCT Iiic nhgp vien 6 nhom tir vong va nhom sbng eon, va AUC cua PCT Iiic nhap vi&i trong viec ti&i doan tii vong la 80%, tiic gia tri ti&i doan tu vong la kha tbt. Tuong ttr, nghi&i o h i aia HorieP> (2012) tien 102 benh nhan thi AUC ciia PCT liic nhgp vi&i trong viec tien lupng tir vong la 82%., eao hon nong dp CRP (AUC 77%).

Nghien ciiu a i a Park^^ (2012) tr&i 126 benh nhan VPMPCD nhap khoa cap ciiu, AUC ciia PCT liic nhgp vien tiong ti&i lupng hi vong la 82,8%. Trong nghi&i ciiu aia Dao Bach Que AnhP) (2008) ti&\ 57 benh nhan ttii gia tij AUC nay la rat cao 95,9%.

Ngupc Igi, trong nghi&i ciiu aia SchuetzC^

(2011) ti&\ 925 benh nhan, ttii AUC a i a PCT Iiie nhap vien trong ti&i lupng tii vong chi la 60%.

Cac gia trj di&n cat aia PCT trong tien lupng tii vong eua viem phoi co dp nhgy, dp chuyen.

Likelihood Ratio (LR) duong va LR am chi a miic trung binh. Dieu nay chiing to no co gia tri ti&i doan ehi 6 miic dp trung binh. Nghi&i ciiu a i a Ugajincs) (2014) tr&i 213 benh nhan VPMPCD CO AUC ciia PCT liic nhap vien tiong tien lupng tii vong chi la 57%. Trong nghien eiiu a i a AndrijevicU (2014) tiren 101 b&ih nhan VPMPCD, gia tii AUC nay ciing chi la 66,7% va gia tri tien luong tir vong aia PCT tgi di&n eat 2,56 ng/mL co dp nhgy chl la 76% va dp chuyen la 61,8%. Trong nghi&i eiiu a i a Huangi^) (2008) tr&i 1651 benh nhan, nong do PCT tiong tien lupng tir vong 30 ngay co dp nhay 92% nhimg dp chuy&i chi la 35% va tae gja ciing nhari manh rang khong bao gio sir dung gia tri PCT don thuan trong viee dua ra nhiing quyet dinh lam sang, ding nhu thay the su danh gia a i a nguoi thay thuoc.

Trong nghi&i ciiu ciia chiing toi, trung vi nong dp PCT Ian 2 6 nhom tir vong khae biet eo y nghia thong ke voi nhom song (p< 0,001). Ty le tii vong 6 nhom dpng hpc PCT tang/khong thay doi (42,3%) cao hon ty le tir vong o nhom dpng hpc PCT giam (2,1%) (p< 0,001). Ket qua nay

Nghien ctru Y hpc Y Hpc TP. Hb Chi M i n h * T$p 20 * Sb 5 * 2016

phii hpp voi nghi&i eihi aia Schuetzt^^ (2011) ti&\ 925 benh nhan VPMPCD, trung vi nong dp PCT ngay 3, ngay 5 va ngay 7 6 nhom hi vong deu cao han nhom song con eo y nghia. Ket qua aia chiing toi ciing phit hpp voi nghi&i ciiu ciia Boussekey<3' (2006) ti&i 100 benh nhan VPMPCD nang co tiimg vi nbng dp PCT ngay 3 a nhom tii vong la 8,2 khac biet eo y nghia ttiong ke voi nhom s&ig eon la 1,6 (p< 0,001).

Dpng hpc PCT tang 6 nhom benh nhan tir vong va giam o nhom benh nhan song con (p= 0,01).

Nghi&i a i u ciia Vii Nguyen Nh&i Ai(") (2011) cung CO ket qua tuong ti^.

Tuy nhj&i nghi&i o i u cua Ha Tan Diic^') (2007) 6 benh vien Chp Riy ti^ 39 benh nh&i VPMPCD nang lai co k& qua khong tuang xiing, trung vi nbng dp PCT ngay 3 6 nhom tii vong la 2,225 khong khae biet eo y nghia thong ke voi nhom song con la 1,28 (p= 0,199). Dong hpc PCT 6 nhom tir vong va sbng con ding kh&ig khac biet co y nghia (p= 0,331). Trong nghi&i cthi ciia Charles^ (2009) tr&i 180 benh nhan nhi&n trimg huy& nang, tiong do co 51,7% benh nhan la vi&n phoi, trung vi riong dp PCT ngay 2 va dpng hpc PCT ngay 2 - ngay 1 khong CO khac bi& co y nghia giiia 2 nhom tii vong va sbng con (tirong ting p= 0,13 va p=

0,44); nhung trung vi nong dp PCT ngay 3 va dpng hpc PCT ngay 3- ngay 2 thi lai co khac biet CO y nghia giua 2 nhom tii vong va song con (tucmg ling p= 0,04 va p< 0,01).

Trong nghi&i o h i aia chiing toi AUC a i a nbng dp PCT Ian 2 giiip phan biet giiia tir vong va song eon tiong viem phoi la 89,2%>. Ket qua nay chiing to gja tri ti&i lupng tii vong trong VPMPCD ctia p e r do Ian 2 la kha tot. Tuy nhi&i, tiong nghi&i ciiu eua Schuetz'^^, nbng dp PCT dupe khao sat th&n vao ngay thii 3, 5 va 7 va AUC ciia nong dp PCT dinh trong viec ti&i lupng hi vong chi la 65% ( k h o ^ g tin cgy 57%- 72%), tijy eo cao hon nong dp PCT liic nhap vi|n (60%) nhtmg gia tri ti&i lupng ciia no cimg chi la 6 miic dp trung binh.

Nong dp PCT CO Hen quan d&i tinh tigng nhiem tnmg, PCT eao khi co nhilm tiimg nang nhung co nhieu ca tu vong trong cac nghien eiiu lai khong li&i quan d&i nhilm trimg nang. Trong nghien ciiu a i a chiing toi va a i a cae tac gia khac, co nhieu ea VPMPCD kem dpt clip a i a benh phoi tae nghen man tinh, va trong so nay co nhiing b&ih nhan tir vong nhieu kha nang la vi dot cap aia benh phbi tic nghen mgn tinh hon la vi tinh tigng nhiem trimg nang 6 phoi. Dieu nay gop phan giai thich cho cac truong hpp tir vong trong nhom cac benh nhan eo PCT lan 2 thap hogc dpng hpc PCT giam. Trong nghien a i u ciia chiing toi co 2 ca tii vong 6 nhom benh nhan CO PCT lan 2< 0,7 ng/mL va 1 ea hi vong 6 nhom benh nhan co dpng hpc PCT giam.

KETLUAN

Co moi tuong quan giiia riong dp PCT liic nhgp vien va miic dp ngng aia VPMPCD Iheo thang di&n PSI va theo thang di&n CURB-65 voi he sb tuang quan Spearman Kn lupt la Es=

0,228 (p= 0,009) va R ^ 0,233 (p= 0,007). AUC aia nong dp PCT liic nhap vien tiong tien lupng nguy CO eao trong VPMPCD la 61%; voi di&n cat la 0,135 ng/mL. K& qua nay cho Ihay nong dp PCT tiong ti&i lupng nguy co cao theo PSI aia VPMPCD chi co gia tii 6 miic dp tnmg binh.

Trung vi riong dp PCT Iiic nhgp vien khong CO khac biet co y nghia giiia rihom co biai chiing va nhom khong bi&i chiing (p= 0,051), ngupc lai trung vi nong dp PCT Ian 2 khac biet CO y nghia (p= 0,002). Tf Ie bi&i chiing 6 nhom dpng hpc PCT tang/khong thay doi eao hon 6 nhom dpng hpc PCT giam co y nghia (p= 0,035).

AUC nbng dp PCT Ian 2 tiong viec ti&i lirpng bi&i chiing ciia VPMPCD la 72,6%, voi di&n cat PC = 0,7 ng/mL. Nhu vay, gia tii ti&i lupng bi&i chiing aia PCT Jan 2 dii 6 miic trung binh.

Trung vi nbng dp PCT liic nhgp vien khong CO khae biet eo y nghia giiia nhom tir vong va rihom sbng con (p= 0,581), ngupc Igi trung v;

nbng dp PCT Ian 2 khac biet co y ngbia (p<

Y Hpc TP. Hb Chi M i n h * Tap 20 * Sb 5 * 2016 Nghien ciiu Y hpc

0,001). Ty Ie tir vong a nhom dpng hpc PCT tang/khong thay doi eao hon 6 nhom dpng hpc PCT giam co y nghia (p< 0,001). AUC nbng dp PCT lan 2 trong vipc ti&i lupng tir vong ciia VPMPCD la 89,2%, voi di&n eat PCT= 0,7 ng/mL. Nhu vay, gia tii ti&\ lupng tii vong a i a PCT lan 2 la tbt.

TAI LIEU THAM KHAO

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