雾化吸入N-乙酰半胱氨酸对气管导管内生物被膜致呼吸机相关肺炎的影响  

Effect of N-acetylcysteine inhalation on ventilator-associated pneumonia caused by biofilm in endotracheal tubes

作　　者：曲东[1] 任晓旭[1] 郭琳瑛[1] 梁金鑫[1] 徐文健[2] 韩晔华[3] 祝益民[4] 

机构地区：[1]首都儿科研究所附属儿童医院重症医学科,北京100020 [2]首都儿科研究所附属儿童医院检验科,北京100020 [3]中国医学科学院基础医学研究所中心实验室电镜室 [4]湖南省人民医院儿童医学中心

出　　处：《中华儿科杂志》2016年第4期278-282,共5页Chinese Journal of Pediatrics

基　　金：“十二五”国家科技支撑计划（2012BA104B00）

摘　　要：目的研究机械通气患儿气管导管内生物被膜形态、病原学特点及雾化吸入N-乙酰半胱氨酸（NAC）对气管导管生物被膜内病原学及呼吸机相关肺炎（VAP）的影响。 方法选取2010年9月至2012年8月在首都儿科研究所附属儿童医院重症监护病房行气管插管并机械通气≥48 h的患儿117例，按计算机生成随机数字法，按预计收集120例患儿生成随机数字，按单双数分为研究组57例和对照组60例，研究组机械通气12 h内按不同年龄段经气管导管雾化吸入不同剂量NAC，每8小时给药1次，直至停止机械通气。对照组不予NAC雾化干预。通过前瞻性研究，比较两组扫描电镜下生物被膜结构、生物被膜培养阳性率、VAP发生率、下气道分泌物与生物被膜内病原学特点及耐药性。 结果（1）电镜下，机械通气早期气管导管内壁即形成生物被膜，随着机械通气时间延长，生物被膜结构日趋复杂，相同机械通气下，研究组生物被膜厚度小于对照组；（2）研究组生物被膜培养阳性率及VAP发生率均低于对照组[65%（37/57）比80%（48/60），P〈0.05；11%（6/57）比32%（19/60），P〈0.01]；（3）生物被膜内寄殖大量病原菌，以革兰阴性杆菌为主，且随着机械通气时间延长，下气道分泌物与生物被膜培养病原菌趋于一致。 结论随着机械通气时间延长，气管导管内生物被膜结构日趋复杂，VAP发生率逐渐增高；雾化吸入NAC可以抑制生物被膜形成，减少VAP发生。Objective To observe the formation of the biofilm in endotracheal tubes, the characteristics of etiology, drug resistance and effect on the biofilm and ventilator-associated pneumonia （VAP） of inhaled N-aeetyleysteine （NAC）. Method We selected 117 tracheally intubated and undergoing mechanical ventilation for ≥48 h in our hospital ICU from September 2010 to August 2012. All the cases were randomly divided into control group （60 cases） and study group （57 cases）. The patients in the study group were treated with different doses of aerosolized NAC according to different ages, starting the frst administration within 12 hours of mechanical ventilation, once every 8 hours, until stopping mechanical ventilation. Comparison was pertbrmed on the two groups in biofilm structure under the scanning electron microscopy, biofilm euhure positive rate, VAP incidence, the etiology and drug resistance of the lower airway secretions and bioIihns. Result （ I ） Electron microscopy showed that biofihn had formed in the endotracheal tube inner wall in early period of mechanical ventilation. With prolonged mechanical ventilation, biofihn structure improved. At the same time of mechanical ventilation, the thickness of biofilm in the study group decreased as compared with the control group. （2） Biofilm culture positive rate and incidence of ventilator-associated pneumonia decreased in the study group compared with in the control group （65% （37/57） vs. 80% （48/60）, P 〈0. 05; 11% （6/57）vs. 32% （19/60）, P 〈 0. 01）. （3） A large number of pathogenic bacteria cohmized in the biofilm and gram-negative bacilli dominated. With prolonged mechanicalventilation,thecuhured pathogens converged from the lower airway secretions and biofilm. Conclusion With prolonged mechanical ventilation, biofilm structure was improved. Inhalation of NAC can inhibit biofilm formation and reduce the incidence of VAP.

关 键 词：生物被膜 呼吸机相关肺炎 气管导管 N-乙酰半胱氨酸 病原菌 

分 类 号：R725.6[医药卫生—儿科]