骆文志肺炎评分系统介绍课件.ppt

肺炎评分系统的应用,暨南大学附属第一医院呼吸科骆文志,主要内容,目前肺炎诊治现状各种评分系统介绍文献回顾和meta分析总结,1.由于社会人口老龄化、罹患慢性病人群增加、免疫损害宿主增加、病原体变迁和抗生素耐药率上升,CAP成为威胁人群健康的重要疾病之一,病死率高,治疗费用昂贵,值得深入研究。2.在美国每年约有CAP患者300万一560万例,住院患者超过100万例次,平均病死率8.8-15.8,直接医疗费用84亿一97亿美元,而重症监护病房(ICU)的重症CAP患者死亡率高达50%。,目前现状,3.在中国,CAP死亡原因中排在第五位,带来极大的经济负担。在中国,患者和医生可能对肺炎的严重程度过分高估,导致不必要的或过长的住院治疗,带来极大的医疗资源和经济的浪费。4.研究发现不同国家和地区，肺炎的住院率、住院时间、诊治措施及死亡率存在很大的差异,医生在决定患者是否住院治疗及采用何种治疗措施时存在很大的主观性。普遍存在高估病人的严重程度而导致不必要的住院治疗及过度医疗现象,浪费医疗资源。,目前现状,5.PSI、CURB-65评分在西方国家已经通过大样本的回顾性分析,被认为是有效的,能够准确地对CAP患者进行危险分层,帮助临床医生做出临床决策。6.准确地对CAP患者进行严重度评分,可以规范医生行为,减少医疗行为的随意性,按最佳方式开展诊治工作,提高医院的医疗水平,识别和清除过度的医疗行为,减少资源浪费,降低医疗费用,提高医疗工作效率,降低平均住院日及死亡率。,目前现状,HOW?WHEN?WHERE?WHAT?,主要内容,目前肺炎诊治现状各种评分系统介绍文献回顾和meta分析总结,肺炎评分发展史,1987年BTS（英国）1997年PORT评分（美国）CURB评分（英国）2003年CURB-65评分（英国）2009年SMATR-COP评分（澳大利亚）,CURB评分：Confusion、Uremia、Respiratoryrate、舒张压60mmHg,BTS标准：Uremia尿素氮7mmol/l、Respiratoryrate30次/分、舒张压60mmHg,PORT评分：Fine分层（略）,CURB-65评分：Confusion、Uremia7mmol/l、R30次/分、收缩压20breaths/minorPaCO212000/Lor10%immatureforms,脓毒症休克,非特异性损伤引起的临床反应,满足2条标准,SIRS=systemicinflammatoryresponsesyndrome,SIRS及可疑或明确的感染,Chest1992;101:1644.,全身性感染伴器官衰竭,顽固性低血压,SIRS,Sepsis,SevereSepsis,SepticShock,存在以下任何一项指标：R30次/分,Pa02/FIO2250,双肺/多叶肺炎,SBP90mmHg，DBP60mmHg,需要机械通气,在48h内肺部浸润50%,脓毒症休克或需要血管活性药物支持4h,急性肾衰竭。（敏感性极高,特异性很低）,符合一个以上主要指标主要指标:需要机械通气;脓毒症休克;在48h内肺部浸润扩大50%;急性肾功能衰竭。或者两个以上次要指标：R30次/分;Pa02/FIO2250;双肺或多肺叶肺炎;SBP90mmHg；DBP60mmHg。,具备1项主要指标：气管插管需机械通气,脓毒症休克需要血管活性药物。或者至少3项次要指标：T36,R30次/分,低血压需要积极的液体复苏,多肺叶浸润,意识障碍和/或定向障碍,U7mml/L,WBC4000个/mm3,PLT100,000/mm3,Pa02/FIO2250。,中国社区获得性肺炎诊断和治疗指南,主要内容,目前肺炎诊治现状各种评分系统介绍文献回顾和meta分析总结,文章1.RiskPredictionModelsforMortalityinCommunity-AcquiredPneumonia:ASystematicReview,（1）数据来源：1.MEDLINEresults:768potentialabstracts2.EMBASEresults:879potentialabstracts3.Cochranelibraryresults:300potentialabstract（2）剔除：75articleswereexcludedbecausetheywerenot:1)derivationstudies;2)initialvalidationstudies（3）纳入：18articleswereincludedinreviewwhichevaluated20pneumoniascores,Searchresultsandstudyselection.,共纳入19篇文章,Frequencyofvariablesusedinprognosticorseverityscoresincommunity-acquiredpneumonia.,年龄-性别-免疫抑制-肾病-脉搏-血压-呼吸-体温-休克-神智-尿素氮-白细胞-氧合指数-HCT-钠-ph-胸水-多肺叶炎症-机械通气,结果1：BalancedaccuracyandareaunderROCofpneumoniaseverityscoresversusnumberofvariables.,结果2：Sensitivityandspecificityofpneumoniaseverityscoresbyanumberofvariables.,结论,1.不考虑各种肺炎评分系统的复杂性和纳入因子的多少，在平衡精确性和AUC方面，各评分系统表现相似。2.虽然有众多肺炎危险预测模型，但只有一些模型经得起正确的评价；并没有明确证据表明其他新采用的评分系统优于临床采用已久的CURB-65和PSI系统。3.仍需要高质量的随机对照研究以更准确地评价其临床价值。,文章2：Predictionofseverecommunity-acquiredpneumonia:asystematicreviewandmeta-analysis,1.采用系统回顾和Meta分析对各种CAP严重性评分系统进行分析，评估预测入住ICU和强化治疗的价值。2.数据来源：searchedMedline,Embase,andtheCochraneControlledTrialsregistryforclinicaltrials。,Componentsofthemainseverityscores,机械通气-休克-年龄-性别-共病-神智-心率-血压-呼吸-体温-氧合指数-ph-多肺叶渗出-HCT-钠-高血糖-Urea-ALB-中性粒-血小板,2019/12/15,29,可编辑,OperativecharacteristicsoftheprincipalscorestopredictICUadmissionattheirusualcut-off(95%CI),SROCcurveandareaunderthecurve(AUC)ofPneumoniaSeverityIndex(PSI)andCURB-65topredictICUadmission,Individualstudiesarerepresentedbyanumberindicatingthecut-offused.Theirplaceonthediagramrepresentsthesensitivityandspecificityoftheindividualstudy.Diamondsrepresentmeta-analyticteststatisticsforeachcut-off.,PooleddiscriminativeperformanceoftheprincipalscoresforsevereCAPcomparedwithPneumoniaSeverityIndex(PSI)andCURB-65ROCcurve.,Conclusions,1.NewseverityscoresforpredictingtheneedforICUorintensivetreatmentinpatientswithCAP,suchasATS/IDSA2007minorcriteria,SCAPscore,andSMART-COP,havebetterdiscriminativeperformancescomparedwithPSIandCURB-65.2.Highnegativepredictivevalueisthemostconsistentfindingamongthedifferentpredictionrules.3.TheserulesshouldbeconsideredanaidtoclinicaljudgmenttoguideICUadmissioninCAPpatients.,不同肺炎严重度评分系统在社区获得性肺炎病人管理中的应用,浙江大学2009年,文章:3：CRP,PCT,CPISANDPNEUMONIASEVERITYSCORESINNURSINGHOMEACQUIREDPNEUMONIA,1.目的：评价CRP,PCT,CPIS（临床肺部感染评分）和各种肺炎严重性评分（CURB-65,PSI,NHAPindex,SMART-COP,SOAR)在预测（诊断）护理院居住者获得性肺炎的能力。2.方法：采用观察性研究，因急性呼吸系统疾病住院的护理院居住者被纳入。A组：护理院获得性肺炎B组：其他肺部疾病。收集CPIS（临床肺部感染评分）和肺炎评分系统的临床、影像学、实验室数据，并检测CRP和PCT浓度。,RESPIRATORYCAREPaperinPress.PublishedonOctober08,2013asDOI:10.4187/respcare.02741,结果1：,结果2：,Atcut-offvalueof0.475ng/ml,PCThadsensitivity83%andspecificity72%.Atcut-offvalueof8.05mg/dl,CRPhadsensitivity81%andspecificity79%.Theinpatientmortalitywas17.2%ingroupA.,结果3：,PCTandCURB-65weresignificantlygreateramongnon-survivors(p0.001andp=0.034respectively).PCTlevelswere4.675.4ng/mlinnon-survivorsand0.860.9ng/mlinsurvivors(p0.001).Areaunderthecurve(AUC)forPCTinpredictinginpatientmortalitywas0.84(95%CI0.70-0.98,p=0.001).APCTlevelonadmissionabove1.1ng/mlwasanindependentpredictorofinpatientmortality.（Asurvivalanalysis,usingKaplan-Meiercurvesandthelog-ranktest）,AUC:inpredictinginpatientmortality,Conclusion:,TheCPIS,PCTandCRParereliableforthediagnosisofNHAP.PCTandCURB-65wereaccurateinpredictinginpatientmortalityinNHAP.,文章4：PredictiveValuesofSemi-QuantitativeProcalcitoninTestandCommonBiomarkersfortheClinicalOutcomesofCommunity-AcquiredPneumonia,1.回顾性分析，纳入2010年8月-2012年10月因CAP住院，且检测了半定量PCT的患者，共213例。2.收集人口背景学特征、实验室生物标记物、微生物学检验结果，并计算PSI,CURB-65,和A-DROP评分值。3.观察终点：住院28天死亡率、入住ICU率。,结果,1.213例患者被纳入，20例死亡，32例入住ICU。2.Mortalitydidnotdiffersignificantlyamongsubjectswithdifferentsemi-quantitativeserumPCTlevels;however,subjectswithserumPCTlevels10.0ng/mLweremorelikelytorequireintensivecarethanthosewithlowerlevels(p0.001)。3.PCT水平有一定的预示致病菌作用，特别是肺炎链球菌。,Distributionofsubjectswithdifferentsemi-quantitativeserumprocalcitoninlevels.(A)Relationwithmortality.Significantdifferenceswerenotobservedbetweenany2concentrationgroups.(B)Relationwiththerequirementforintensivecare.Subjectswithserumprocalcitoninlevels10.0ng/mLweresignificantlymorelikelytorequireintensivecarethanthosewithlevels10.0ng/mL(p0.001).,Analysisofthereceiver-operatingcharacteristicscurves.(A)Forpredictingmortality.Theareaunderthecurvevalueswere0.86forthePSIclass,0.81fortheB/Aratio,0.80fortheCURB-65,and0.57forthesemi-quantitativePCTtest.(B)Forpredictingtherequirementforintensivecare.Theareaunderthecurvevalueswere0.87forthePSIclass,0.86fortheCURB-65,0.85fortheB/Aratio,and0.72forthesemiquantitativePCTtest.PSI:pneumoniaseverityindex;B/Aratio:bloodureanitrogentoserumalbuminratio;PCT:procalcitonin.,Conclusion,1.Thesemi-quantitativeserumPCTlevelonadmissionwaslesspredictiveofmortalityfromCAPascomparedtotheB/Aratio.2.ThesubjectswithserumPCTlevels10.0ng/mLweremorelikelytorequireintensivecarethanthosewithlowerlevels.,文章5：UsefulnessofCURB-65andpneumoniaseverityindexforinfluenzaAH1N1vpneumonia.,CONCLUSIONS:UseofCURB-65andPSIintheemergencydepartmentmayunderestimatetheriskofpatientswithInfluenzaAH1N1vpneumonia.Basedinourresults,theabilityofthesescalestopredictICUadmissionsforInfluenzaAH1N1vpneumoniaisquestioned.,MonaldiArchChestDis.2012Sep-Dec;77(3-4):118-21.,文章6：SeverityofInfluenzaA2009(H1N1)PneumoniaIsUnderestimatedbyRoutinePredictionRules.,VeryrecentlytheInfluenzaA(H1N1)pandemicin2009,providedtheopportunitytocheckthelowestpredictivevalueandusefulnessofthedifferentscoresinpatientswithviralpneumonia.,BjarnasonA,ThorleifsdottirG,LveA,GudnasonJF,AsgeirssonH,HallgrimssonKL,etal.ResultsfromaProspective.PopulationBasedStudyPLOSONEPublicLibraryofScience.2012;7:e46816EP,文章7：医生因素不可忽视！,1.AsurveyconductedinAustraliafoundthatonly12%ofrespiratoryphysiciansand35%ofemergencyphysiciansreportedusingthePSIalwaysorfrequentlyeventhoughitisrecommendedbytheA