重症医学资质培训呼吸机相关性肺炎.pptx

大标题（绿色,32,磅大黑体字）,一级（黑色,28,磅宋体加粗，英文,Times New Roman,）,第二级（绿色,24,磅宋体加粗，英文,Times New Roman,）,第三级（绿色,20,磅宋体加粗，英文,Times New Roman,）,#,重症医学专科资质培训,标准教材,2009,呼吸机相关性肺炎,HAP/VAP:,概要,流行病学,诊断策略,抗生素治疗,HAP/VAP:,问题,1,呼吸机相关性肺炎指应用机械通气多长时间以后发生的肺炎,?,24,小时,48,小时,72,小时,96,小时,48-72,小时,HAP/VAP/HCAP:,定义,医院获得性肺炎,(,HAP),住院,48,小时后发生且住院时不处于潜伏期的肺炎,呼吸机相关性肺炎,(,VAP),气管插管,48,小时以后发生的肺炎,因重度,HAP,需要气管插管者应按照,VAP,处理,医疗相关肺炎,(HCAP),发生感染前,90,天内在急性病医院住院,2,天,在养护院或长期医疗机构住院,近期接受静脉抗生素治疗、化疗或发生感染前,30,天内接受伤口治疗,就诊于医院门诊或透析门诊,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,流行病学,发病率,美国医院获得性感染的第二位,5-15,例,/1,000,住院病例,罹患率和病死率升高,预后,住院日延长,7-9,天,医疗费用增加,$40,000,HAP/VAP:,流行病学,Kumpf G,et al.J Clin Epidemiol 1998;54:495-502,Lizioli A,et al.J Hosp Infect 2003;54:141-148,Richards MJ,et al.Crit Care Med 1999;27:887-892,HAP/VAP:,流行病学,机械通气,5,10,累积患病率,(%),3%/d,1%/d,2%/d,Cook DJ,Walter SD,Cook RJ,Griffith LE,Guyatt GH,Leasa D,Jaeschke RZ,Brun-Buisson C.Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.Ann Intern Med 1998;129:440,d,迟发性,HAP,50%,早发性,HAP,50%,HAP/VAP:,流行病学,机械通气,5,10,累积患病率,(%),d,敏感菌引起,预后好,致病菌常是多药耐药菌,(MDR),病死率高,HAP/VAP:,病死率,总病死率,30-70%:,大多数,HAP,患者死于基础病,归因病死率,33-50%,VAP,的归因病死率升高与菌血症、耐药菌,(,如铜绿假单胞菌、不动杆菌属,),感染、不恰当的抗生素治疗等因素相关。,HAP/VAP:,危险因素,气管插管和机械通气,平卧位,缺乏感染控制措施,缺乏,ICU,感染监测,经鼻气管插管,紧急插管或再次插管,基础肺病,肠道营养,气管插管套囊压力低,HAP/VAP:,危险因素,H2,受体拮抗剂进行应激性溃疡预防,“,自由,”,输血,去白细胞输血,血糖控制不佳,ARDS,深度镇静或肌松,HAP/VAP:,病因学,F,agon,Kollef,Papazian,Rello,Timsit,Torres,革兰阴性杆菌,55 85%,铜绿假单胞菌,19,29,27,50,16,28,不动杆菌属,10,4,5,0,12,24,嗜麦芽,窄食单胞菌,0,7,3,0,0,0,肠杆菌属,1,6,8,0,0,4,流感嗜血杆菌,6,1,8,10,13,0,其他革兰阴性杆菌,24,10,28,4,10,32,革兰阳性球菌,2030%,金黄色葡萄球菌,20,30,21,9,26,20,肺炎链球菌,4,1,0,7,4,4,HAP/VAP:,病因学,支气管远端标本培养分离出口咽部定植菌（草绿色链球菌，凝固酶阴性葡萄球菌，奈瑟氏菌属，棒状杆菌属）,难以解释,在免疫抑制甚至免疫正常患者可能引起感染,Cabello H,Torres A,Celiss R,El-Ebiary M,de la Bellacasa JP,Xaubet A,Gonzalez J,Augusti C,Soler N.Bacterial colonization of distal airways in healthy subjects and cronic lung diseases:a bronchoscopic study.,Eur Respir J,1997;10:11371144,HAP/VAP:,病因学,金黄色葡萄球菌,糖尿病，头颅创伤，住,ICU,厌氧菌：在,VAP,中的重要性尚不明确,非插管患者误吸,VAP,罕见,肺炎军团菌：发生率缺乏数据，但重要性受关注,免疫抑制患者如器官移植，,HIV，,糖尿病，基础肺病，终末期肾病,HAP/VAP:,病因学,真菌（包括念珠菌和曲霉菌）,器官移植，免疫抑制，中性粒细胞缺乏,免疫正常患者罕见,病毒,免疫正常者罕见,流感病毒，副流感病毒，腺病毒，麻疹病毒，呼吸道合胞病毒占病毒的,70%,HAP/VAP:MDR,危险因素,既往,90,天应用抗生素,住院,5,天,所在社区或医院病房中抗生素耐药率高,HCAP,危险因素,发生感染前,90,天内在急性病医院住院,2,天,在养护院或长期医疗机构住院,家庭输液治疗（包括抗生素）,30,天内接受慢性透析,家庭伤口护理,家人有多重耐药菌感染,/,定植,免疫抑制疾病和（或）治疗,HAP/VAP:,分类,0,1,2,3,4,5,6,7,8,Early-onset HAP,Late-onset HAP,Time from,hospitalization,(days),0,1,2,3,4,5,6,7,8,Early-onset VAP,Late-onset VAP,Time from,Intubation,(days),ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,病因学,早发性,HAP/VAP,迟发性,HAP/VAP,细菌学,肺炎链球菌,铜绿假单胞菌,流感嗜血杆菌,不动杆菌,MSSA,MRSA,敏感,GNB,耐药肠杆菌科,大肠杆菌,肠杆菌属,肺炎克氏菌,ESBL+ve,菌,变形杆菌属,克雷伯菌属,肠杆菌属,嗜肺军团菌,粘质沙雷氏菌,洋葱伯克霍尔德菌,曲霉菌属,预后,病情较轻，对预后影响小,归因病死率高,病死率低,罹患率高,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,问题,2,以下哪个不是呼吸机相关性肺炎确切的发病机制,误吸,直接吸入,血行性播散,胃肠道细菌移位,以上答案均不对,HAP/VAP:,发病机制,改变胃排空及胃,液,pH,值的药物,有生物膜的装置,(,气管插管,鼻胃管,),既往应用抗生素,宿主因素,(,免疫抑制,烧伤,),消化道细菌定植,细菌误吸,细菌吸入,医院获得性肺炎,水,药物溶液及呼,吸治疗装置污染,感染控制措施不够,(,洗手,隔离衣,手套,),医务人员不足,经胸种植,原发性菌血症,胃肠道细菌移位,HAP/VAP:,影像学诊断,对于可疑肺炎患者，如果根据其他临床表现不能确诊，影像学判断也不能提高诊断的正确性,若胸片显示明显浸润影，则鉴别心源性肺水肿、非心源性肺水肿、肺挫伤和肺不张将非常困难,各种影像学表现的敏感性和特异性差异很大，诊断准确性均不超过,70%,支气管气像诊断肺炎的准确性最高,(64%),HAP/VAP:,影像学诊断,CXR vs.CT,手术后肺实变：敏感性,0.33 1.00,，特异性,0.79,不同医生判读的一致性,放射科医生：,kappa 0.27,ICU,医生：,12 39%,Wunderink RG,Woldenberg LS,Zeiss J,et al.The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia.Chest 1992;101:458-63.,Fagon J,Chastre J,Hance A.Evaluation of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients.Chest 1993;103:547-53.,Beydon L,Saada M,Liu N,et al.Can portable chest x-ray examination accurately diagnose lung consolidation after major abdominal surgery?:a comparison with computed tomography scan.Chest 1992;102:1698-703.,HAP/VAP:,临床,诊断,胸片新出现浸润影或原有浸润性加重,以下临床表现中两条：,T 38C,白细胞增多或白细胞缺乏,脓性气道分泌物,敏感性,69%，,特异性,75%,HAP/VAP:,细菌学诊断,下呼吸道标本的半定量培养,特异性低：培养结果阳性可能仅提示定植,敏感性高：培养结果阴性有助于除外感染,除非刚刚应用或更换抗生素,常导致过度应用抗生素,革兰染色结果结合培养结果有助于指导抗生素治疗,HAP/VAP:,细菌学诊断,PSB,ETA,BAL,诊断阈值,10,3,cfu/mL,10,5,10,6,cfu/mL,10,4,10,5,cfu/mL,敏感性,66,76,73,特异性,90,75,82,特异,敏感,准确,采样部位越远 特异性越高 敏感性越低 诊断阈值越低,HAP/VAP:,细菌学诊断,试验设计,:,多中心随机临床试验,入选标准,:,免疫功能正常的成年患者,住,ICU,超过,4,天后怀疑呼吸机相关性肺炎,排除标准,:,假单胞菌属或,MRSA,定植或感染,分组,:,诊断,:BALF,定量培养,vs.ETA,的非定量培养,治疗,:,美罗培南,+,环丙沙星,vs.,美罗培南,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,HAP/VAP:,细菌学诊断,ETA(n=374),BAL(n=365),合计,(n=739),明确,VAP,0,1,(0.3),1,(0.1),高度可疑,VAP,0,180,(49.3),180,(24.4),可能,VAP,310,(82.9),134,(36.7),444,(60.1),无,VAP,64,(17.1),50,(13.7),114,(15.4),高度可疑,VAP=,临床诊断,+BALF 10,4,cfu/ml;,可能,VAP=,临床诊断,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,HAP/VAP:,细菌学诊断,ETA,BAL,P,值,28,天病死率,18.4%,18.9%,0.94,6,天时针对性治疗,74.6%,74.2%,0.90,无抗生素存活天数,10.6 7.9,10.4 7.5,0.86,最高,MODS,评分,8.6 4.0,8.3 3.6,0.26,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,HAP/VAP:,细菌学诊断,呼吸道分泌物分离出念珠菌,，很少提示深部念珠菌感染,，不应进行抗真菌治疗,(A-III),Pappas PG,Kauffman CA,Andes D,et al.Clinical practice guidelines for the management of candidiasis:2009 update by the Infectious Diseases Society of America.2009;48:503-535,HAP/VAP:,综合诊断,CPIS,评分,0,1,2,气管吸取物,无,无脓性分泌物,脓性分泌物,CXR,浸润影,无浸润影,弥漫性浸润影,局灶性浸润影,肺部浸润影进展,无进展,有进展,体温,C,36.5,且,38.4,38.5,且,38.9,39,或,36,WCC,x 10,9,/L,4.0,且,11.0,11.0,11.0+,杆状核,0.5,PaO,2,/FiO,2,mmHg,240,或,ARDS,240,且无,ARDS,的证据,微生物学,阴性或少量,中等量或大量,+,革兰染色发现同样微生物,Pugin J,Auckenthaler R,Mili N,Janssens JP,Lew PD,Suter PM.Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic blind bronchoalveolar lavage fluid.Am Rev Respir Dis 1991;143:1121-1129,肺部感染评分,HAP/VAP:,综合诊断,CPIS,评分,0,1,2,气管吸取物,无,无脓性分泌物,脓性分泌物,CXR,浸润影,无浸润影,弥漫性浸润影,局灶性浸润影,肺部浸润影进展,无进展,有进展,体温,C,36.5,且,38.4,38.5,且,38.9,39,或,36,WCC,x 10,9,/L,4.0,且,11.0,11.0,11.0+,杆状核,0.5,PaO,2,/FiO,2,mmHg,240,或,ARDS,240,且无,ARDS,的证据,微生物学,阴性或少量,中等量或大量,+,革兰染色发现同样微生物,Pugin J,Auckenthaler R,Mili N,Janssens JP,Lew PD,Suter PM.Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic blind bronchoalveolar lavage fluid.Am Rev Respir Dis 1991;143:1121-1129,CPIS,超过,6,分即诊断,HAP,HAP/VAP:,鉴别诊断,肿瘤,结缔组织疾病,血管炎综合征,肺泡出血,药物诱发肺泡炎,肺不张,血栓栓塞性疾病,胃内容物误吸,未治愈社区获得性肺炎,充血性心力衰竭,HAP/VAP:,治疗,Luna CM,Vujacich P,Niederman MS,et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest 1997;111:676-685,不充分的抗生素治疗,2000,名连续收治的,MICU/SICU,患者,655(25.8%),罹患感染,169(8.5%),抗生素治疗不充分,Kollef MH,Sherman G,Ward S,et al.Inadequate antimicrobial treatment of infections.A risk factor for hospital mortality among critically ill patients.Chest 1999;115:462-474,因此，临床高度怀疑,VAP,时，立即开始正确的经验性抗生素治疗至关重要,HAP/VAP:,经验性抗生素,无,MDR,致病菌危险因素、任何严重程度、早发性,HAP/VAP,的初始抗生素,可能致病菌,推荐抗生素,肺炎链球菌,头孢曲松,流感嗜血杆菌,或,MSSA,左旋氧氟沙星，莫西沙星或环丙沙星,敏感的肠道革兰阴性杆菌,或,大肠杆菌,氨苄青霉素,/,舒巴坦,肺炎克雷伯菌,或,肠杆菌属,厄他培南,变形杆菌属,粘质沙雷氏菌,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,经验性抗生素,有,MDR,致病菌危险因素、任何严重程度、迟发性,HAP/VAP,的初始抗生素,可能致病菌,推荐抗生素,上表中致病菌及,抗假单胞菌头孢菌素（头孢吡肟，头孢他啶）,MDR,致病菌,或,铜绿假单胞菌,抗假单胞菌碳青霉烯（亚胺培南或美罗培南）,肺炎克雷伯菌,(ESBL+),或,不动杆菌属,-,内酰胺,/-,内酰胺酶抑制剂（哌拉西林,/,他唑巴坦）,加,抗假单胞菌喹诺酮（环丙沙星或左旋氧氟沙星）,或,氨基糖甙（阿米卡星，庆大霉素或妥布霉素）,加,MRSA,利奈唑烷或万古霉素,嗜肺军团菌,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,抗生素,剂量,抗生素,剂量,抗假单胞菌头孢菌素,头孢吡肟,1 2 g,q8 12 h,头孢他啶,2 g q8h,抗假单胞菌碳青霉烯,亚胺培南,500 mg q6h,1 g q8h,或美罗培南,1 g q8h,-,内酰胺,/-,内酰胺酶抑制剂,哌拉西林,/,他唑巴坦,4.5 q6h,氨基糖甙,阿米卡星,20 mg/kg/d,，庆大霉素,7 mg/kg/d,妥布霉素,7 mg/kg/d,抗假单胞菌喹诺酮,左旋氧氟沙星,750 mg qd,环丙沙星,400 mg q8h,万古霉素,15 mg/kg q12h,利奈唑烷,600 mg q12h,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,治疗,怀疑,HAP/VAP,迟发性,HAP/VAP,或,MDR,危险因素,否,是,使用窄谱抗生素治疗,使用广谱抗生素治疗,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,治疗,怀疑,HAP/VAP/HCAP,采取下呼吸道,(LRT),进行培养,(,定量或半定量,),和显微镜检,除非肺炎的临床概率低且,LRT,镜检阴性，否则应根据当地细菌流行病资料应用经验性抗生素,第,2/3,天：培养结果并评价临床疗效,(,体温,WCC,CXR,氧合,脓痰,循环改变及器官功能,),ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,治疗,ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,48-72,小时临床改善,寻找其他致病菌,并发症,其他诊断或其他感染灶,调整抗生素,寻找其他致病菌,并发症,其他诊断或其他感染灶,考虑停用抗生素,如可能抗生素降阶梯,治疗,7-8,天后再次评估,培养阴性,培养阳性,培养阴性,培养阳性,否,是,培养阴性,培养阳性,培养阴性,培养阴性,培养阳性,培养阳性,培养阴性,培养阴性,培养阳性,HAP/VAP:,局部抗生素,局部注射氨基糖甙,局部用药提高细菌学清除率，但不改变临床预后,雾化吸入氨基糖甙或多粘菌素,B,治疗,MDR,致病菌,副作用,耐药率,?,诱发支气管痉挛,Hamer DH.Treatment of nosocomial pneumonia and tracheobronchitis caused by multidrug-resistant Pseudomonas aeruginosa with aerosolized colistin.Am J Respir Crit Care Med 2000;162:328-330.,Brown RB,Kruse JA,Counts GW,Russell JA,Christou NV,Sands ML,Endotracheal Tobramycin Study Group.Double-blind study of endotracheal tobramycin in the treatment of gram-negative bacterial pneumonia.Antimicrob Agents Chemother 1990;34:269-272,Klick JM,du Moulin GC,Hedley-Whyte J,Teres D,Bushnell LS,Feingold DS.Prevention of gram-negative bacillary pneumonia using polymyxin aerosol as prophylaxis.II.Effect on the incidence of pneumonia in seriously ill patients.J Clin Invest 1975;55:514-519,HAP/VAP:,联合用药,抗生素的协同效应,体外试验证实有效,中性粒细胞缺乏或血行性感染患者,预防耐药发生,增加抗菌谱,-,内酰胺,+,氨基糖甙,-,内酰胺,+,喹诺酮,?,HAP/VAP:,联合用药,美罗培南,+,环丙沙星,(n=369)vs.,美罗培南,(n=371),RR 1.05,95%CI 0.78 1.42,MDR,革兰阴性杆菌感染,(n=56),28,天细菌学清除：,64.1%vs.29.4%,机械通气时间：,10.7(3.3)vs.15.0(9.3),ICU,住院日：,14.2(8.1)vs.21.2(14.1),ICU,病死率：,23.1%vs.29.4%,住院病死率：,33.3%vs.41.2%,Heyland D,Dodek P,Muscedere J,et al.Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia.Crit Care Med 2008;36(3):737-744,HAP/VAP:,联合用药,Paul M,Benuri-Silbiger I,Soares-Weiser K,et al.-lactam monotherapy versus-lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients:systematic review and meta-analysis of randomised trials.BMJ 2004;328:668,总病死率,RR 0.90,95%CI 0.77 1.06,临床失败,率,RR 0.87,95%CI 0.78 0.97,细菌学失败,率,RR 0.86,95%CI 0.72 1.02,HAP/VAP:,联合用药,Paul M,Benuri-Silbiger I,Soares-Weiser K,et al.-lactam monotherapy versus-lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients:systematic review and meta-analysis of randomised trials.BMJ 2004;328:668,针对,VAP,经验性治疗时，应根据当地细菌耐药情况，选择适当的抗生素进行单药治疗,HAP/VAP:,问题,3,呼吸机相关性肺炎的抗生素疗程应为,8,天,15,天,肺部感染评分,CPIS,评分,6,血清降钙素原,PCT 6,CPIS 6,可疑,HAP/VAP,3,天后重新评估,CPIS,CPIS 6:,按照肺炎治疗,CPIS 6:,停用环丙沙星,Singh N,Rogers P,Atwood CW,et al.Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit.Am J Respir Crit Care Med 2000;162(2):505-511,HAP/VAP:,抗生素疗程,PCT,指导抗生素治疗,社区获得性下呼吸道感染,不良预后相似,(15.4%vs.18,9%)，,抗生素疗程缩短,(5.7 d vs.8.7 d),AECOPD,减少抗生素使用,(40%vs.72%),，,减少,6,个月内抗生素使用,(RR 0.76;95%CI 0.64 0.92),社区获得性肺炎,减少抗生素使用,(RR 0.52,95%CI 0.48 0.58),Schuetz P,Christ-Crain M,Thomann R,et al.Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections:The ProHOSP randomized controlled trial.JAMA 2009;302(10):1059-1066,Stolz D,Christ-Crain M,Bingisser R,et al.Antibiotic treatment of exacerbations of COPD.Chest 2007;131:9-19,Christ-Crain M,Stolz D,Bingisser R,et al.Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia:a randomized trial.Am J Respir Crit Care Med 2006;174:84-93,HAP/VAP:,抗生素疗程,PCT 0.25 g/ml,推荐应用抗生素,PCT 0.5 g/ml,强烈推荐应用抗生素,Schuetz P,Christ-Crain M,Thomann R,et al.Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections:The ProHOSP randomized controlled trial.JAMA 2009;302(10):1059-1066,HAP/VAP:,疗效评估,应采用临床指标评估初始经验性抗生素疗效,(II),。应当联合临床指标和微生物学数据调整经验性抗生素治疗,(III),病情改善通常需要,48 72,小时，此前不应改变治疗，除非病情迅速恶化,(III),。疗程第,3,天常可根据临床指标评估治疗,有无反应,(II),对于治疗有反应的患者，可以根据培养结果进行抗生素的降阶梯，使用窄谱抗生素进行针对性治疗,(II),对治疗无反应患者应重新评估，包括类似肺炎的非感染因素，其他或,MDR,致病菌，肺外感染灶，以及肺炎并发症。应针对上述原因进行诊断检查,(III),ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416,HAP/VAP:,问题,4,呼吸机相关性肺炎最有效的预防措施为,床头抬高,30,应用无创通气,持续或间断声门下吸引,预防性抗生素,胸部物理治疗,HAP/VAP:,预防,床头抬高至少,30,经口气管插管,经口留置胃管,监测胃残余量并防止腹胀,减少抗生素的使用,尽早开始适当的营养支持,严格控制血糖,使用无创通气避免插管,缩短插管时间,保持套囊压力,20 mmHg,间断吸引声门下分泌物,口腔护理减少耐药菌定植,避免深度镇静或肌松,每日唤醒减少镇静药剂量,HAP/VAP:,总结,危重病患者,HAP/VAP,罹患率和病死率较高,HAP/VAP,的诊断需要综合考虑临床表现、影像学特点及微生物学检查结果,HAP/VAP,的经验性抗生素治疗至关重要,及时根据临床疗效和培养结果进行降阶梯治疗,缩短抗生素疗程有助于减少细菌耐药,THE END,