— T/ikP CHl NGHIEN CLfU Y HQC Infectious Diseases. 6" ed Mandell G.L., Ben- encephalitis, arguments for a better vacci- nett J.E.. Dolin R (eds) Churchill Livingstone nation policy. Presse Med 28 (8), 395-397
7. Sherman F.E., Michaels R.H., and Kenny F.M. (1965). Acute Encephalopathy (Encephalitis) Complicating Rubella Report of Cases with Viroipgic Studies. Cprtispl- Prpduction Determinations, and Observations 1921-1926
4. Gulen F., Cagliyan E., Aydinok Y. et al. (2008) A patient with rubelia encephalitis and status epilepticus Minerva Pediatr 60(1), 141-144.
5. Lau K.K., Lai J.Y., Yan W.W., et al
(1998) Acute encephalitis complicating 3'Autopsy. JAMA. 192. 575-681 rubella. Hong Kong Med J. 4(3). 325-328 8. Steen E. and Torp K.H. (1956) En-
8. Merrer J., Perm- Dureau F., Appere C, cephalitis and thrombocytopenic purpura after etaL(1999). Severe forms pf rubella rubella Arch Dis Child. 31(160). 470-473
Summary
OUTCOME OF Rubella encephalitis AT NATIONAL HOSPITAL FOR TROPICAL DISEASES
The research was cpnducted tc study clinical presentaticn and putcome pf rubella encephalitis
at National Hospital fpr Trppicai Diseases The results show that 48 rubella encephalitis patientswere analyzed (22 males. 26 females), age 18,5 ± 6 6 years. 95,8% were not vacinated for ru- belia. The common symptoms were fever 97 9%. rash 95 8%. coma 96 8%. aggressive 68 8%.
seizure 60.4% CSF findings 97 9% pandy (+); leukocytosis mean 77.6 ± 60 1 ceji/mm^. lympho 63.9 ± 27 9%. protein average 0.73 ± 0.25 g/L. All patients sun/ived. average hospitalized and coma penpd were 7.7 ± 4 7 days and 2 8 ± 1 2 days respectively, no sequelae observed in con- ciuslcns. the common symptoms of rubella encephalitis were fever, rash. coma, aggressive and seizure. All rubella encephalitis patients survived rapidly without sequelae observed.
Key words: rubella, encephatilis
HIEU QUA CUA T H d AP Ll/C DU'aNG LIEN TUC QUA M O I T R O N G D I ^ U TRj SUY HO H A P DO VIEIVI P H 6 I
(y TRE DU'O'I 5 TU6l
Trdn Van T r u n g \ Pham Van Thdng^
'Bgnh vien Xanh Ron, ^Benh vign Nhi Trung uang Thd dp luc duong Hdn tuc qua mui (NCPAP) la mgt trong nhung bign phdp dieu tn suy hd hap (SHH) cd hieu qua cao, dd dp dung vd an todn. Nghien cuu nham danh gia hieu qua cua thd dp luc duang lien tuc qua mui (NCPAP) trong dieu tri SHH do viem phii d tre dudi 5 tuii tgi bgnh vign Xanh Pdn va xac (Xnh mdt so yiu td lien quan den kit qud diiu tn SHH bang NCPAP. Kit qua nghien cO-u cho thay ty le thdnh cong 73,6%, ty Ig that bgi 26.4%, thanh cdng tdp tmng cao vdo ngay thu 3 din ngay thu 5, that bgi chu yiu trong
T)BkP CHi NGHIEN Cl>U Y HQC •
3 ngdy diu tidn thd NCPAP. Cdc tndu chdng Idm sdng cOa SHH vd khi mdu cdi thidn sau 6 gia thd NCP/
vd duy tri tmng cdc thdi diim sau dd Cdc yiu ti lidn quan din kit qui diiu trj SHH bing NCPAP bao gii mCic dd SHH. Pad. PaCOi mdu trudc khi thd NCPAP.
Key words; Thd' dp lyc du'o-ng Ii6n tye qua mOI, NCPAP, suy hd h^p
I. DAT
V A NDt
Thd dp lyc duang lidn tye qua mOi (NCPAP) Id mOt trong nhOng bi$n phdp didu tn suy hd hap cd hidu qua cao, dd dp dgng vd an todn d trd em. Ngdy nay cdc bdc sy Idm sdng cd xu hud-ng chi djnh NCPAP cho cdc b$nh nhdn suy hd hdp s d m hon 6k gidm ty Id bdnh nhdn phdi ddt ndi khi quan vd thd mdy, qua dd giam nguy co vd tai bidn do thd mdy, ddc bidt Id nguy c c nhidm khudn bdnh vidn. O Vidt Nam, h$ thong NCPAP dd dup'c dua vdo s u dyng tir nh&ng ndm 1990 vd da cho thdy hieu qua tot trong didu trj suy hd hdp d tre em Cd nhieu tdc gia da nghidn ci>u ddnh gid hidu qua cua thd NCPAP d tre em nhung chu yeu tdp trung vao ddi tuo-ng tre s a sinh vd de non, co rdt it nghidn c u u ddnh gid hidu qua cua cua thd NCPAP trong dieu tn suy hd hap d dd tuoi Idn han vd trong cac bdnh iy rieng bidt cua trd em. Vi vdy chiing tdi nghidn ciru de tdi ndy vdi muc tieu:
1 Danh gid hidu qua cua thd NCPAP trong dieu tri suy hd hdp do vidm phdi d tre dud-i 5 tuoi tai bdnh vidn Xanh Pdn.
2, Xdc djnh mdt sd ydu to lidn quan ddn hidu qua cua thd NCPAP trong didu trj suy hd hdp.
II. D6\ TU'O'NG VA PHU'aNG PHAP
I . D d i tu'O'ng
110 bdnh nhdn dup-c chan dodn vidm phdi, cd SHH vd cd chi djnh t h d NCPAP, tudi ttr 1 thang den 5 tudi, dieu tr| tgi Khoa hdi sire cap ciru nhi bdnh vien Xanh Pdn.
- Tieu chuin chSn dodn SHH: Ldm sdng:
th6 nhanh (a 60 idn/phOt d trd 1 - 2 thdng, 50 Idn/phiit 6- trd tir 2 thdng ddn 1 tudi vd £ 4 Idn/phiit d trd tir 1 tudi ddn 5 tudi), rut Idm Idn ngyc, tfm tdi. Khi mdu Sa02 < 90% hod PaOz < 60mm Hg vd/hodc PaC02 > 50 mmHj vdi FiO-2= 2 1 % (tidu chudn cua Trdn Quy 2002 [4, 5].
- Chi dinh thd NCPAP- bdnh nhdn SHH Si thd oxy qua mask vdi luu luang tdi da 6 lit phiit trong thdi gian 1 gid md cdn mdt tront cdc ddu hidu sau thd- nhanh trdn 70 Ian/phut thd CO rut long nguc ndng, tim tdi, Sp02 <
90%, PaO; < 60 mmHg (Tidu chudn chi dint thd NCPAP cho bdnh nhdn vidm phoi - B^nh vi$n nhl dong 1, thdnh phd Hd Chi Minh [1]
- Tidu chuin lo^i trO-: cdc BN cd chong chi djnh cua thd- NCPAP trdn khi mdng phoi chira ddn luu, sdc giam the tich
2. Phu'ang phap
- Nghidn ciru tien ciru, can thidp didu tn, so sanh ddi chirng t r u 6 c sau
Phuang tidn nghidn cCru hd thdng NCPAP s u dyng van Benveniste dd tgo PEEP.
- Quy trinh t h d NCPAP:
+ T r u d c t h d NCPAP bdnh nhdn dircrc ddnh gid cdc ddu hidu n h u nhip thd, nhip lim, chuydn hda roi logn. tim tdi, S p O ; vd lam xet nghidm khi mdu.
+ Cdi ddt dp lyc ban dau Id 6 cmHzO va Fi02 khdi dau Id 60%, ndu bdnh nhdn SHH ndng thi cho FiOa ban ddu 80% hode 100%.
+ Theo ddi dien bien Idm sdng vd SpOz.
Neu BN ddp irng khdng tot thi tdng ddn FiO!
cir 10% sau mdi gid- vd tdng ddn dp lyc cil' 1 cmHaO sau m6i 30 phut ddn 1 gid. Ndu BN ddp irng tdt, tlnh trang ldm sdng cd cai thiSn
• TAP CHi NGHIEN Cl>U Y HOC
thi se giam ddn F1O2 cu- 10% sau mdi gid vd giam ddn dp lyc cir 1 cmHsO sau mdi 2 gid.
Muc tidu Id duy tri SpOz a mire > 92%.
+ Dirng t h d NCPAP khi bdnh nhdn thdnh cdng hode thdt bai vdi NCPAP
-Cde bidn nghien ciru:
+ Thdnh cdng: tidu chuan thdnh cdng vdi NCPAP: Idm sdng bdnh nhdn dn djnh ve Idm sdng (tinh, hdt khd t h d vd tim tdi, Sp02 >
92%) trong nhidu gid khi thd vdi FiOa £ 40%
va ap lyc < 4 cmH20, Cdc tri so khi mdu vd gia tri binh thudng.
+ That bai: tidu chuan thdt bgi vdi NCPAP Ngirng thd hode ed con ngirng thd, SpOz <
90% hode Pa02 < BOmmHg khi thd vdi dp lyc >
10 cmHaO va Fi02 > 60%, PaCOa > 60 mmHg.
+ Thay doi cdc dau hidu lam sdng (nhip thd, nhip tim, co riit Idng ngyc, tim tdi SPO2) va khi mau (PaOa, PaC02, pH) tai cdc thdi diem 6 gid (T6), 24 gid (T24) va luc ngirng NCPAP (Tn) so vai thdi diem tru-d-c khi thd NCPAP (To)
+ Tai bien va bien c h i r n g : tran khi mdng
phoi, trdn khi trung thdt, chudng byng, phii mdt, lodt mui,
+ MOt so ydu td anh hudng ddn kdt qua thd NCPAP- mire dd SHH, Pa02 mdu, PaC02 mdu, pH mdu vd tlnh trgng thieu mdu trudc khi thd NCPAP
- Phuang phdp xCr ly sd lidu: theo chuong trlnh thdng ke y hpe SPSS 10,0.
III. K^T QUA
110 bdnh nhdn dii tidu chuan vdo nghien eiru trong dd cd 75 tre trai, 35 tre gdi, tudi trung binh Id 6 thdng (thdp nhdt la 1,5 thdng, eao nhdt Id 36 thdng), cdn ndng trung binh Id 6 6kg (thdp nhat Id 3 kg vd cao nhdt Id 14kg).
-Kdt qua t h a NCPAP
+ Ty Id thanh cong, ty le that bgi cua thd NCPAP 81/110 bdnh nhdn thanh cdng (chidm 73,6%) va 29/110 bdnh nhdn thdt bai (chiem 26,4%)
+ Thdi gian thd NCPAP trung binh Id 4,6 ngdy, trong dd nhdm thdnh cdng Id 5,1 ngdy, nhdm that bai id 1,7 ngay
+ Thdi diem thdnh cdng, that bai Bang 1 . Thd'i d i l m thanh cong, thdt bai vd'i NCPAP
Ngay 1 Ngiy 2 Ngay 3 Ngay 4 Ngay 5 Ngay 6 Ngay > 7
T6ng
n 0 3 21 13 18 11 15 81
Thanh cong
%
0 3.7
25.9 16,0 22.2 13.6 18.6 100%n 15 11 3
29
T h i t bai%
51.7 37,9 10,4
100%
+ S y thay doi c i c d i u hi^u lam sang trudc vi sau tho NCPAP
Nhip tho va nhip tim ciJa benh nhan giam mSt each c6 y nghTa sau 6 gi& tho NCPAP (p <
0.06) vi duy tri tai cac tho'i diem sau do. Sp02 tang len c6 y nghTa (p < 0.05) sau 6 gio va duy tri tai cao thirl diem sau do (bang 2)
95.
T«P CHi NGHIEN ClJU Y HQC •
Bang 2. Sif thay a6l vk nhjp tttir, nhjp tim vi SpOi
Nhip th4 (i^n/phut) Nhip tim (lin/phut) Sp02 (%)
Bang 3.
Dau hi^u lam sang Co rut long nguc Tim tai
To 63.7 ±6.8 143.4 ±19.7
86.5 ±4.4 Svthay d6l v i d^i
To 85/110(77.3%) 68/110(61.8%)
Gia tri trung binh Ts
47.8 ±11.2 11B.9±17.3 95.7 ±3,1 J hidu co rOt l6ng
T^, 42.3 ±6.4 111.9±17.6
96,8 ±1.7 T„
46.8 ±12,6 116.7 ±17.8
93.6 ±6.3 ngLfc va tim tai S6 b^nh nhan T,
31/110(28.2%) T „ 8/110(7.4%) 45/110(40.9%) 27/110(24.5%)
T„
24/110(21.8%) 13/110(11.8%) Ty Id % bdnh nhdn tim tdi vd co riit Idng ngyc giam di cd y nghTa sau 6 gid- thd NCPAP + Su thay ddi khi mdu trudc vd sau thd NCPAP
Bang 4. SIP thay ddi vd khi mdu
Chi so l(hi mau PaOz (mmHg) PaC02 (mmHg) pH
To 66.4 ±12.9
41.7±8.1 7.37 ±0.05
Thd'i dilm Ts 94.7 ±27.1
39.5 ± 7.7 7.38 ± 0.05
T24
111.2±28.8 34.4 ± 5.0 7.39 ± 0.06
T„
97.3 ± 37.0 36.1 ±6.0 7.38 ± 0.06 + Ty 1$ tai bien. bi^n chCrng: c6 22/110 b$nh nhSn c6 tai biln do th6 NCPAP nhirng deu la tai bien nhe va c6 the khac phuc du'oc nhu' phi^ mat (8/110 hinh nhan). lo6t miii do c6 djnh bang dinh (6/110 benh nhSn) hay chuc^ng byng do khi vao da iky (8/110 b^nh nhan). KhOng c6 bSnti nhan nao bj tran khi mang ph6i hay tran khi trung thit.
- Mot s6 y l u td anh hyd'ng din kit qua diiu trj SHH bang NCPAP
Nhom SHH nhe va vua (kh6 th6 va khdng tim hoac chi tim khi ging sCrc) cd ty \i thanh cdng la 93.6%. cao hon 6 nhdm b$nh nhan SHH nang (khd thd va tim thu'dng xuydn) (thanh cdng 58.7%) (OR = 10.3, p < 0 01).
Nhdm benh nhan cd P a d tru'dc khi tha NCPAP > 60 mmHg cd ty Id thanh cdng la
77.3%. cao hon a nhdm b$nh nhan cd PaOi
mau tru'dc khi thd NCPAP < 60 mmHg (tliSnIi
cdng 66,7%) mot cdch cd j nghTa (OR = 1,78,
p <. 0,05). Ty 1$ thanh cdng d nhdm binh nhin
khdng cd tang CO2 mau trydc khi thd NCPAP
(Pa02 mau < 45 mmHg) cao hon d nh6m
banh nhan cd tang CO; mau (PaC02 > «
mmHg) wit each cd y nghTa (OR = 2.47, p '
0,05) Ty IS thdnh cdng cua nhdm b#nh nhS"
• TAP CHi NGHIEN Cl>U Y HQC
cd pH mdu binh t h u d n g (pH = 7,35 - 7,45) cung cao hon d nhdm bdnh nhdn ed tlnh trgng toan mau (pH < 7,35) (OR = 2,66, p < 0,05).
Ty Id thanh cdng d hai nhdm bdnh nhdn cd thieu mau vd khdng thidu mdu khdng ed s y khde biet (OR = 1,01. p > 0,05).
IV. BAN LUAN
Danh gia ket qua didu trj
•^ Ty Id thdnh cdng cua thd NCPAP trong nghien ciru nay la 73,6%, thap hon so vdi Nguydn Phudc Chudng [2]' nghidn ciru trdn ddi tuang SHH do vidm d u d n g hd hap d u d i d tre nhii nhi Id 84,3% Tuy nhidn tdc gid ndy chi dmh eho bdnh nhdn thd NCPAP s d m han chiing tdi Pa02 trud-c t h d NCPAP trung binh Id 89,14 mmHg trong khi cua chung tdi la 66,4 mmHg) So vdi mdt sd tdc gia nghien ciru trdn tre sa sinh n h u D d Hong San (56,3%) [51. Cam Thi Ngoc P h u a n g [3] (67.8%), Bassiouny MR [7] (61%) thi ty Id thdnh cdng cua chiing tdi cao hon
+ Da s6 benh nhdn thdnh cdng trong ngdy thir 3 ddn ngay thir 5 cua thd NCPAP (chidm 64.1%). Tat ea cdc benh nhdn that bai vdi NCPAP ddu xay ra d- 3 ngdy ddu tien, trong dd ngdy ddu tien ehidm ty Id cao nhdt (51,7%) Kdt qua trdn eho thdy vai trd quan trpng cua ngdy ddu vd ngay thir hai thd- NCPAP Neu chung ta dat d u o c muc tieu oxy hod mdu ngay trong cac gid ddu nay thi kha nang thdnh cdng se eao hon.
+ Cac dau hieu Idm sdng eua SHH ddu cai thldn rd rdng sau 6 gid t h d NCPAP (bang 2 vd 3). Nhip thd vd nhip tim deu giam cd y nghTa (p < 0,05), ty Id benh nhdn cd ddu hidu co rOt long nguc giam di rd ret, Sp02 tang mdt cdch CO •^ nghTa chirng td NCPAP giiip giam cdng hd hdp, cai thidn tinh trang SHH,
+ Thay ddi vd khi mau. Pa02 mau tdng mdt each cd y nghTa sau 6 g i d thd NCPAP vd duy
tri on dmh tgi cac thdi didm sau dd. Gid tn pH mdu vd PaC02 mdu khdng thay ddi mdt cdch cd ^ nghla qua cdc thdi didm ddnh gid chirng td NCPAP khdng gdy tdng CO2 mdu
+ Cdc tai bidn vd bidn chirng eua thd NCPAP nhu phCi mdt. lodi mOi, chudng byng ddu Id cdc bidn chirng nhg va ed the khdc phyc duQ-c Dieu dd chirng to thd NCPAP Id bidn phdp dieu tri an todn d tre em.
Mot s 6 ydu t d anh huid^ng ddn k i t qua thd- NCPAP
Ydu td dnh hudng rd rdt nhdt ddn thdnh cdng cua thd NCPAP la mire dp SHH eiia BN khi bdt ddu thd NCPAP (mire dd tim tdi, Pa02). Ty Id thdnh cdng se cao han rat nhidu neu NCPAP d u a c chf dinh sdm khI bdnh nhdn cdn suy hd hap d mire dd nhg, Tlnh trang tdng C02 mau vd toan hod mau cung anh hudng ddn kdt qua thd NCPAP
- Han chd cua dd tai cdi flat mire CPAP ban ddu Id 6em H2O. F1O2 Id 60 - 100% tuy muc dd SHH eua bdnh nhdn va didu chmh tuy theo ddp irng cua benh nhan. Tuy nhien, nghidn eiru chua dua ra dupe anh hudng cua mire PEEP khac nhau cung nhu mire F1O2 Idn kdt qua didu tn bdng NCPAP.
V. K^T LUAN
- Ty Id thdnh cdng cua thd NCPAP trong dieu tn SHH do vidm phdi d tre dudi 5 tuoi Id 73,6%, ty Id that bai Id 26,4%. Thdi diem thdnh cdng cao nhat Id ngdy thir 3 den ngdy thir 5 sau thd NCPAP Da sd benh nhdn thdt bai Id trong ngdy dau tien eua thd NCPAP
- NCPAP cd tdc dung eai thien rd rdt cdc tridu chu-ng Idm sdng eiia SHH nhu thd nhanh, eo rOt Idng ngyc, tfm tai vd Sp02 sau 6 gid va 24 gid. Dong thdi NCPAP cung cd tdc dung cai thidn PaOz mau sau 6 gid vd 24 gid NCPAP khdng Idm thay ddi pH va PaC02 mau.
- Bdnh nhdn d u o c chi dinh thd NCPAP khi
97
TAP CHi NGHIEN CLKU Y HQC ^ ^ ^ - ^ —
mire dd suy hd hdp cdn nh?, COa mdu ehua tdng, pH mdu trong gidi han binh thudng thi ket qua didu trj tdt Ndu chi djnh mudn thi kdt qua didu tn thdp han. Cho ndn mii'c dd suy hd hdp. CO2 mdu, pH mdu cd lidn quan ddn kdt qud didu m bdng NCPAP
TAI LI$U THAM K H A O 1. B^ch Vdn Cam (2006). Thd dp lyc duong hdn tuc qua mOi. Phdc dd didu trj nhi khoa, Nhd xudt ban Y hpe. 32 - 34,
2. Nguydn Phu-d-c Chyd'ng (2002). Khdo sdt hidu qud thd dp lyc dyong lidn tye qua mOi trong didu trj suy hd hdp cdp do nhidm khuln hd hdp dudi d trd em. Ludn vdn thgc sJ y hpe. Trudng Dgi hpc Y Duae thdnh phd Hd Chi Minh,
3. Cam Ngoc Phu-ang (2001). Thd dp lye duong hdn tuc qua mui dieu trj suy hd hap so smh Hdi thao Hoi sire cap eiru vd chdng ddc,
bdnh vidn Bgch Mai
4. Trdn Quy (2002). Suy hd hdp cdp tinh c trd em. Tdi lidu tdp hudn chuydn ngdnh Nh khoa, Hd NOi, 251 -269.
5. D 6 Hdng San (2002). Nghidn cO-u ttio dp lyc duong lidn tye qua mOi trong didu tr suy hd hdp cdp 6- trd so sinh dd non. LuSn vdn thgc sJ y hpc, Trud-ng Dgi hpc Y Hd NOi.
6. T? Vdn Trim (2000). Sa bd ddnh gid ve hidu qud eua thd dp lyc duong lidn tuc qua mOi trong didu tn suy hd hdp d' trd em Ttidi sy Y Dyp-c hgc. 239 - 241
7. Bassiouny MR (1994). Nasal CPAP in the treatment of respiratory distress syndrome An experience from a developing country. J Trop Pediatrics, 40 (6), 341 - 344,
8. Brochard L (1997). Noinvasive Ventilation in Acute Respiratory Failure. Handbook of Mechanical Ventilatory Support. 193-204-
Summary
NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE IN RESPIRATORY FAILURE DUE TO PNEUMONIA
IN CHILDREN UNDER 5 YEARS
Nasal Continuous Positive Ainway Pressure (NCPAP), one noninvasive treatment for respiratory failure, is highly effective, easy to apply and secure The study vt^as conducted to evaluate the effectiveness of nasal continuous airway positive pressure (NCPAP) in the treatment of respiratory failure due to pneumonia in children under 5 years old at the Saint Paul Hospital. 2, Evaluation of factors affecting treatment outcomes by NCPAP respiratory failure The resulte showed that the success rate 73.6%, failure rate 26,4%. most success ease focus on day 3 to day 5, the defeat focus on the first 3 days breathing NCPAP. The clinical symptoms of respiratory and blood gases improved after 6 hours of breathing NCPAP and maintained in the later time. Factors related to results of treathent for respiratory failure with NCPAP include: respiratory failure levels, Pa02, PaC02 before NCPAP