Nco tseg: Zaj lus no yog muab ntaub ntawv qhia xwb, tsis hloov chaw kuaj mob lossis txoj kev kho mob uas kws kho mob teev tseg. Mob ntsws hnyav yuav loj zuj zus sai; tus neeg mob ua pa nyuaj, lub cev xiav, tsis meej pem, ntshav siab poob lossis SpO₂ qis yuav tsum tau txais kev kho mob ceev tam sim ntawd.
Kev kuaj mob thiab kho mob ntsws hnyav yuav tsum ua ntau yam tib lub sijhawm: txheeb xyuas seb mob hnyav npaum li cas, nrhiav yam ua rau mob uas kho tau, pib tshuaj tua kab mob raws sijhawm thiab tiv thaiv kev ua haujlwm ntawm lub ntsws. Kws kho mob kuj yuav tsum cais mob ntsws kis hauv zej zog (CAP), mob ntsws hauv tsev kho mob (HAP), mob ntsws cuam tshuam nrog tshuab pab ua pa (VAP) thiab mob ntsws los ntawm kev nqus tau, vim kev pheej hmoo ntawm kab mob tiv taus tshuaj thiab txoj kev kho tsis zoo ib yam.
1. Txheeb xyuas mob ntsws hnyav thiab tshuaj xyuas thawj zaug
Mob ntsws hnyav tsis yog txiav txim los ntawm duab X-ray nkaus xwb. Yuav tsum tshuaj xyuas tag nrho lub cev, kev ua pa, kev ncig ntshav, kev nco qab thiab cov cim qhia tias cov khoom nruab nrog cev ua haujlwm tsis txaus. Cov cim ceeb toom muaj xws li ua pa ceev, siv zog ua pa ntau, ntshav muaj oxygen tsawg, ntshav siab poob, tso zis tsawg, tsis meej pem, metabolic acidosis lossis xav tau tshuab pab ua pa.
Kev tshuaj xyuas ABCDE
- A – Txoj hlab pa: kuaj seb puas muaj peev xwm tiv thaiv txoj hlab pa, kev pheej hmoo txhaws pa thiab seb puas muaj hnoos qeev ntau.
- B – Kev ua pa: ntsuas SpO₂, kuaj ntshav ntawm txoj hlab ntsha thaum tsim nyog, tshuaj xyuas qhov teb rau oxygen thiab cov cim qhia tias cov leeg ua pa nkees.
- C – Kev ncig ntshav: ntsuas ntshav siab, kev ntws ntshav rau ntu kawg ntawm lub cev, thiab lactate thaum xav tias muaj kev poob siab; tso txoj hlab ntsha thiab kho sepsis raws li txheej txheem ntawm lub chaw kho mob.
- D – Paj hlwb: tshuaj xyuas kev nco qab, kev ntxhov siab lossis tsis meej pem vim oxygen tsawg, kab mob lossis tshuaj.
- E – Tag nrho lub cev: nrhiav lwm qhov chaw muaj kab mob, pob khaus, lub cev qhuav dej thiab cov kab mob uas twb muaj lawm uas ua rau kev pheej hmoo tuag siab ntxiv.
Cov qhab nia xws li CURB-65 lossis PSI yuav pab txiav txim siab txog kev txais pw hauv tsev kho mob rau CAP, tab sis tsis hloov kev tshuaj xyuas hauv tsev kho mob. Thaum muaj kev ua pa tsis txaus, poob siab lossis ntau lub cev nruab nrog cev ua haujlwm tsis txaus, yuav tsum txiav txim siab kho tus neeg mob hauv chav saib xyuas mob hnyav.
2. Kev kuaj thiab cais CAP, HAP, VAP
CAP: mob ntsws kis hauv zej zog
CAP tshwm sim sab nraum tsev kho mob lossis tshwm sim ntxov tom qab nkag tsev kho mob. Feem ntau kuaj mob raws li cov tsos mob ntawm kev kis kab mob hauv txoj hlab ua pa qis, cov cim qhia thoob lub cev thiab qhov ntxoov tshiab hauv duab hauv siab. X-ray tej zaum tseem tsis pom meej thaum ntxov; CT hauv siab siv thaum xav tau kom paub meej qhov kuaj mob lossis teeb meem ntxiv xwb, tsis yog kev kuaj niaj hnub rau txhua tus neeg mob.
Thaum CAP hnyav, yuav tsum sau ntshav thiab qauv khoom ntawm txoj hlab ua pa mus kuaj kab mob ua ntej muab tshuaj tua kab mob yog tias tsis ua rau kev kho qeeb. Kev kuaj PCR rau kab mob hauv txoj hlab ua pa yuav pab tau raws caij nyoog thiab xwm txheej kis kab mob. Tsis tsim nyog siv procalcitonin ib leeg los txiav txim tsis pib tshuaj tua kab mob thaum cov tsos mob hauv tsev kho mob qhia tias tej zaum yog CAP los ntawm kab mob.
HAP thiab VAP
Mob ntsws hauv tsev kho mob (HAP) feem ntau txhais tias yog mob ntsws tshwm sim tom qab nkag tsev kho mob tsawg kawg 48 teev, uas tsis muaj lossis tseem tsis tau pib tshwm thaum nkag tsev kho mob. Mob ntsws cuam tshuam nrog tshuab pab ua pa (VAP) tshwm sim tom qab tso raj rau hauv txoj hlab pa ntev dua 48 teev. Kev kuaj mob yog saib qhov ntxoov hauv ntsws tshiab lossis hnyav zuj zus nrog cov cim qhia kev kis kab mob xws li kub taub hau, qe ntshav dawb nce, hnoos qeev muaj kua paug lossis oxygen qis; tsis muaj ib qho qauv kuaj ib leeg uas zoo tag nrho.
Yuav tsum sau qauv ntawm txoj hlab ua pa mus cog kab mob ua ntej koob tshuaj tua kab mob thawj zaug yog tias ua tau. Tus qauv yuav yog hnoos qeev, nqus los ntawm raj hlab pas lossis khoom kuaj tau los ntawm kev siv lub koob yees duab kuaj sab hauv, nyob ntawm tus neeg mob thiab txheej txheem hauv cheeb tsam. Yuav tsum txhais qhov kuaj tau nrog rau qhov zoo ntawm tus qauv, kev hloov pauv ntawm tus kab mob thiab tus qauv kev tiv taus tshuaj hauv tsev kho mob.
3. Cov hauv paus ntsiab lus kho mob ntsws hnyav
Pib tshuaj tua kab mob ntxov, tab sis yuav tsum muaj tswv yim meej
Thaum muaj sepsis ua rau poob siab lossis muaj peev xwm kis kab mob siab heev, yuav tsum muab tshuaj tua kab mob txhaj rau hauv hlab ntsha ntxov tom qab sau cov qauv tsim nyog, tsis txhob ncua tos qhov kuaj cog kab mob. Kev xaiv thawj zaug nyob ntawm hom mob ntsws, qib mob hnyav, cov tshuaj tua kab mob uas twb siv lawm, sijhawm pw hauv tsev kho mob, keeb kwm kab mob tiv taus tshuaj, kev ua haujlwm ntawm raum thiab daim ntawv qhia kev tiv taus tshuaj hauv cheeb tsam.
- CAP hnyav feem ntau yuav tsum muab tshuaj sib xyaw uas npog pneumococcus thiab cov kab mob tsis txawv; qee qhov xwm txheej yuav tsum ntxiv tshuaj tua Staphylococcus aureus tiv taus methicillin lossis Gram-negative bacilli raws li cov xwm txheej pheej hmoo.
- HAP/VAP muaj kev pheej hmoo kab mob Gram-negative tiv taus tshuaj, suav nrog Pseudomonas aeruginosa. Txoj kev kho sim thawj zaug yuav tsum dựa vào daim ntawv qhia kev tiv taus tshuaj hauv tsev kho mob thiab kev pheej hmoo ntawm tus kheej; tsis tsim nyog siv tib daim qauv rau txhua qhov chaw yam tsis xav txog qhov txawv.
- Tsis txhob siv tshuaj tua kab mob virus, tshuaj tua pwm lossis tshuaj tua kab mob dav heev yog tsis muaj laj thawj tsim nyog los ntawm kev kuaj mob, microbiology lossis xwm txheej kis kab mob.
Tom qab 48–72 teev, yuav tsum tshuaj xyuas qhov teb rau kev kho thiab cov txiaj ntsig kev cog kab mob kom txo hom tshuaj tua kab mob thaum ua tau. Kho qhov ntau ntawm cov tshuaj raws li kev ua haujlwm ntawm raum, qhov hnyav thiab kev lim ntshav; saib xyuas kev phiv thiab tshuaj lom. Lub sijhawm kho nyob ntawm yam ua rau mob, qhov teb rau kev kho thiab teeb meem ntxiv. Rau HAP/VAP uas teb zoo, ntau txoj kev kho niaj hnub feem ntau nyiam lub sijhawm luv dua li kev xav qub, tab sis tus kws kho mob kho tus neeg mob yog tus txiav txim zaum kawg.
Kev txhawb kev ua pa thiab kev ncig ntshav
Xaiv kev kho oxygen, oxygen ntws siab, tshuab pab ua pa tsis nkag lossis nkag rau hauv cev raws li qib kev ua pa tsis txaus, kev nco qab thiab peev xwm tiv thaiv txoj hlab pa. Thaum muaj acute respiratory distress syndrome, txoj kev tshuab pab ua pa tiv thaiv ntsws, txwv siab thiab ntim pa kom haum yog lub hauv paus. Tus neeg mob uas oxygen qis hnyav yuav xav tau pw tig xub ntiag thaum muaj cai ua tau thiab yuav tsum tau saib xyuas hauv ICU.
Yog muaj kev poob siab, kev muab kua rov qab rau lub cev yuav tsum kho raws tus neeg mob, thiab zam kev muab kua ntau dhau rau tus neeg mob plawv tsis txaus, raum tsis txaus lossis ntsws raug mob hnyav. Thaum ntshav siab tseem qis tom qab tshuaj xyuas qhov xav tau kua, feem ntau yuav xav txog tshuaj txhawb ntshav siab; lub hom phiaj thiab hom tshuaj yog txiav txim los ntawm pab pawg kho mob hnyav.
4. Mob ntsws los ntawm kev nqus tau, kev tiv thaiv thiab cov ntsiab lus yuav tsum nco
Cais kev nqus tau kua thiab mob ntsws los ntawm kev nqus tau
Kev nqus tau kua hauv plab yuav ua rau mob ntsws los ntawm tshuaj lom, feem ntau pib sai tom qab txhaws pa thiab tsis yog txhua zaus yuav tsum siv tshuaj tua kab mob. Tab sis, mob ntsws los ntawm kev nqus tau yog kev kis kab mob tom qab nqus tau kua hauv qhov ncauj–qa lossis kua hauv plab; feem ntau xav txog thaum muaj kub taub hau, hnoos, hnoos qeev muaj kua paug thiab qhov ntxoov hauv ntsws loj zuj zus lossis tsis zoo dua.
Tsis tsim nyog cia li ntxiv tshuaj tua kab mob anaerobic rau txhua kis mob ntsws los ntawm kev nqus tau. Kev nthuav kev npog kab mob anaerobic feem ntau tsuas xav txog thaum muaj abscess hauv ntsws, kua paug hauv daim nyias nyias qhwv ntsws lossis kab mob hniav thiab qhov ncauj hnyav, raws li kws kho mob tshuaj xyuas.
Tiv thaiv teeb meem thiab rov tshuaj xyuas
- Tshuaj xyuas kev nqos thiab lub cev zaum thaum noj mov rau tus neeg muaj kev nco qab tsis zoo, mob stroke lossis kab mob paj hlwb.
- Tu qhov ncauj thiab hniav, txwv tsis pub siv tshuaj ua kom tsaug zog uas tsis tsim nyog thiab tsa taub hau txaj thaum tsim nyog.
- Rau tus neeg siv tshuab pab ua pa, ua raws pob kev tiv thaiv VAP: txo sijhawm siv tshuab pab ua pa, ntxuav tes, saib xyuas txoj hlab pa thiab tshuaj xyuas txhua hnub seb puas muaj peev xwm txo lossis tshem tshuab.
- Nrhiav teeb meem xws li kua nyob hauv daim nyias nyias qhwv ntsws, abscess, ntshav kis kab mob, raum raug mob sai thiab kev noj zaub mov tsis txaus.
Lub ntsiab lus tseem ceeb ntawm kev kho mob ntsws hnyav tsis yog hloov tshuaj tua kab mob xwb. Kws kho mob yuav tsum rov tshuaj xyuas qhov kuaj mob, tswj qhov chaw muaj kab mob, kho kev tshuab pa–ntws ntshav kom zoo tshaj, kho qhov nyiaj kua thiab nrhiav cov kab mob tsis yog los ntawm kev kis kab mob xws li kua nyob hauv ntsws, ntshav txhaws mus rau ntsws lossis mob ntsws uas twb muaj lawm hnyav zuj zus. Tus neeg mob thiab tsev neeg yuav tsum muab daim npe tshuaj, keeb kwm fab tshuaj, cov tshuaj tua kab mob siv tsis ntev los no, sijhawm nkag tsev kho mob thiab kev pheej hmoo txhaws pa, kom pab xaiv txoj kev kho uas nyab xeeb dua.
Cov ntaub ntawv siv
- Hospital-Acquired and Ventilator-Associated Pneumonia
- Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock
- Pneumonia in children
