老年人吸入性肺炎

1、Diagnosis and therapy of aspiration pneumonia.Dtsch Med Wochenschr. 2006 Mar 24;131(12):624-8 Cabre M. Curr Opin Pulm Med. 2009 ;15:223-9Marik PE.N Engl J Med, 2001,344:665-671Marik PE.N Engl J Med, 2001,344:665-671Differences in the features of aspiration pneumonia according to site of acquisition:

2、 community or continuing care facility. J Am Geriatr Soc. 2006 Feb;54(2):296-302. 易導(dǎo)致吸入易導(dǎo)致吸入性肺炎性肺炎的基礎(chǔ)疾病的基礎(chǔ)疾病腦梗腦梗正常對(duì)照組正常對(duì)照組腦干梗塞腦干梗塞其他部位腦梗其他部位腦梗 消化道返流物、口咽消化道返流物、口咽部分泌物及部分泌物及積聚在氣積聚在氣管套管氣囊上方的膿管套管氣囊上方的膿性液體，性液體，含有大量致含有大量致病菌，通過(guò)誤吸隨時(shí)病菌，通過(guò)誤吸隨時(shí)可以進(jìn)入下呼吸道可以進(jìn)入下呼吸道6 6、機(jī)械通氣、機(jī)械通氣口咽部分口咽部分泌物直接泌物直接侵入肺部侵入肺部氣管與氣氣管與氣囊之間的囊之

3、間的間隙間隙氣管氣管套管套管6 6、機(jī)械通氣、機(jī)械通氣Cichero and Murdoch (2006), Leonard and Kendall (2008), Mandell et al.(2007) and Reichmuth and Meyer (2003).后后4條引自條引自 Marik PE.N Engl J Med, 2001,344:665-671Garon BR.J Neurosci Nurs. 2009 ;41:178-85Ramsey D.Dysphagia. 2005 Summer;20(3):218-25Fujiki R, et al.J Infect Chemot

4、her. 2007;13(3):157-65Cichero and Murdoch (2006), Leonard and Kendall (2008), Mandell et al.(2007) and Reichmuth and Meyer (2003).Cichero and Murdoch (2006), Leonard and Kendall (2008), Mandell et al.(2007) and Reichmuth and Meyer (2003).病史：病史：吞咽障礙、有吸入危險(xiǎn)因素吞咽障礙、有吸入危險(xiǎn)因素(癡呆癡呆)、疾病也可以、疾病也可以隱匿發(fā)生。隱匿發(fā)生。臨床表現(xiàn)

5、：臨床表現(xiàn)：發(fā)熱、肺部水泡音、肺部爆裂音或濕羅音、發(fā)熱、肺部水泡音、肺部爆裂音或濕羅音、喘鳴、呼吸音減弱、肺順應(yīng)性下降。喘鳴、呼吸音減弱、肺順應(yīng)性下降。胸部胸部X片：片：滲出性改變，站立或半臥位吸入容易發(fā)生滲出性改變，站立或半臥位吸入容易發(fā)生在肺的下葉，而平臥位吸入容易發(fā)生在肺的上葉。在肺的下葉，而平臥位吸入容易發(fā)生在肺的上葉。肺部分泌物培養(yǎng)陽(yáng)性率較其他肺炎要高。肺部分泌物培養(yǎng)陽(yáng)性率較其他肺炎要高。脈搏血氧飽和度脈搏血氧飽和度92%。實(shí)驗(yàn)室檢查：血象高。實(shí)驗(yàn)室檢查：血象高。Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical

6、 Use of Drugs,2005Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005Ali A. El-Solh et al. Am J Respir Crit Care Med Vol 167. pp 16501654, 2003病原菌比例病原菌比例(%)Niederman MS. Severe Pneumonia 2005Ni

7、ederman MS. Severe Pneumonia 2005Chest 2005;128:38541、盡量減少導(dǎo)致誤吸的危險(xiǎn)因素、盡量減少導(dǎo)致誤吸的危險(xiǎn)因素吞咽困難者進(jìn)行鼻飼：吞咽困難者進(jìn)行鼻飼：對(duì)反復(fù)嗆咳和誤吸者改鼻對(duì)反復(fù)嗆咳和誤吸者改鼻空腸管或胃造瘺；空腸管或胃造瘺；體位的保持：體位的保持：對(duì)吞咽異常和反流患者應(yīng)保持床頭對(duì)吞咽異常和反流患者應(yīng)保持床頭抬高抬高3045度。度。2、經(jīng)常性的嚴(yán)格的口腔護(hù)理。、經(jīng)常性的嚴(yán)格的口腔護(hù)理。3、預(yù)防接種：、預(yù)防接種：注射肺炎球菌多糖疫苗和滅活流感注射肺炎球菌多糖疫苗和滅活流感疫苗，可使疫苗，可使65歲及以上人群罹患侵入性肺炎球菌感歲及以上人群罹患侵

8、入性肺炎球菌感染疾病機(jī)會(huì)下降染疾病機(jī)會(huì)下降44%75%。Diagnosis and therapy of aspiration pneumonia.Dtsch Med Wochenschr. 2006 Mar 24;131(12):624-8 吸氧或機(jī)械通氣；吸氧或機(jī)械通氣；重癥肺炎時(shí)應(yīng)用糖皮質(zhì)激素；重癥肺炎時(shí)應(yīng)用糖皮質(zhì)激素；水電解質(zhì)和酸堿平衡的維持；水電解質(zhì)和酸堿平衡的維持；保證營(yíng)養(yǎng)。保證營(yíng)養(yǎng)。使用帶套囊上吸引裝使用帶套囊上吸引裝置的氣管插管和套管置的氣管插管和套管Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Us

9、e of Drugs,2005IDSA. CID，2003；37：1405-1433Expert Opin. Pharmacother，2006；7：499-507 Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005 Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clini

10、cal Use of Drugs,2005Ann Pharmacother. 2007 Apr;41(4):549-55. Ann Pharmacother. 2007 Apr;41(4):549-55. Ann Pharmacother. 2007 Apr;41(4):549-55. 1、Classen DC, Pestotnik SL, Evans RS, et al: Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. J

11、AMA 1997; 277: 301-3064.2、Evans RS, Classen DC, Pestotnik SL, et al: Improving empiric antibiotic selection us ing computer decision support. Arch Intern Med 1994; 154:878-88493 優(yōu)化抗感染治療策略優(yōu)化抗感染治療策略42ATS Am J Respir Crit Care Med, 2005,171:388-416.Song JH, et al . Am J Infect Control 2008;36:S83-92亞洲共

12、識(shí)與亞洲共識(shí)與IDSA/ATS治療早發(fā)治療早發(fā)HAP推薦意見(jiàn)比較推薦意見(jiàn)比較亞洲共識(shí)與亞洲共識(shí)與IDSA/ATS治療晚發(fā)治療晚發(fā)HAP推薦意見(jiàn)比較推薦意見(jiàn)比較ATS Am J Respir Crit Care Med, 2005,171:388-416.Song JH, et al . Am J Infect Control 2008;36:S83-92Mary Anne Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005汪復(fù)等，實(shí)用抗感染治療學(xué)，汪復(fù)等，實(shí)用抗感染治療學(xué)，2004，p475Mary Ann

13、e Koda-Kimble,et al.Applied Therapeutics:The Clinical Use of Drugs,2005汪復(fù)等，實(shí)用抗感染治療學(xué)，汪復(fù)等，實(shí)用抗感染治療學(xué)，2004，p457Dtsch Med Wochenschr. 2006 Mar 24;131(12):624-8ATS/IDSA Guidelines. Am J Respir Crit Care Med. 2005;171:388-416.抗生素療程抗生素療程 -2005 ATS/IDSA 指南指南如有非發(fā)酵菌感染如有非發(fā)酵菌感染(銅綠假單孢菌銅綠假單孢菌)需要更需要更長(zhǎng)的療程。長(zhǎng)的療程。Song JH, et al . Am J Infect Control 2008;36:S83-92Marin H Kollef. Appropriate Empiric Antimicrobial Therapy of Nosocomial Pneumonia: The Role of the Carbapenems. Respiratory Care, 2004, 49(12): 1530-1541老年人老年人吞咽和咳嗽障礙吞咽和咳嗽障礙易引發(fā)誤吸造成吸入性肺炎。易引發(fā)誤吸造成吸入性肺炎。吸入性肺炎以混合性感染多見(jiàn)，吸入性肺炎以混合性感染多見(jiàn)，其中其中G-桿菌和厭氧菌占較桿菌和厭氧菌占較高比列，耐