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93

VIM PHI CNG NG (VPC)

BS. Nguyn vn K

Mc tiu hc tp

1. Lit k c cc tc nhn gy bnh, c im dch t, sinh bnh hc ca

VPC

2. M t c cc biu hin lm sng v hi chng thng gp ca VPC

3. Nu c phng php chn on xc nh v nguyn nhn ca VPC

4. Trnh by c cc bin php iu tr v phng bnh VPC

I. I CNG

Vim phi l bnh nhim trng nhu m phi, do nhiu loi vi khun, mycoplasma,

chlamydiae, rickettsiae, virus, vi nm v k sinh trng gy nn. Mi loi c dch t

hc, sinh bnh hc, biu hin v din tin lm sng khc nhau. y l nhim trng

nng so vi nhim trng ph qun, chn on lm sng i khi kh v xc nh tc

nhn gy bnh phi tinh vi.

Vim phi cng ng (CommunityAcquired Pneumonia/CAP hoc Pneumonies

Communautaires) l nhng bnh vim phi mc phi cng ng, ngc li vi

vim phi bnh vin mc bnh vin.

Khi vim phi xy ra cc vin chm sc lu di (nh t thin, ) th nhiu bc s

xem nh l VPC; tri li, nhiu ngi khc xem nh vim phi bnh vin.

II. DCH T HC

Vim phi xy ra nhiu nht vo nhng thng ma lnh, thng gp nht la

tui nh v gi, v nam mc bnh nhiu hn n.

Cc yu t nguy c mc VPC gm nghin ru, hen, suy gim min dch, v tui

trn 70. Mt tr, ng kinh, suy tim huyt, bnh mch mu no, ht thuc, nghin

ru, v bnh phi tc nghn mn tnh (COPD) l nhng yu t nguy c vim phi

do ph cu, trong ht thuc l nguy c mnh nht mc bnh ph cu xm ln.

Yu t nguy c mc bnh do legionella l nam gii, ang ht thuc, tiu ng,

bnh mu c tnh, ung th, bnh thn giai on cui, v nhim HIV.

Ngi nghin ru nng (v d, ung >100g ethanol /ngy trong sut 2 nm trc)

mc vim phi do vi khun gramm cao hn, triu chng lm sng xu hn, v

cn iu tr khng sinh tim mch lu hn ngi khng ung. Bnh nhn vim

phi do ph cu nghin ru kinh nin st ko di hn, chm khi hn, v d b

trn m mng phi (empyema) hn ngi khng ung. Hn na, ung ru qu

l mt yu t nguy c pht trin hi chng nguy kch h hp cp (ARDS).

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III. TC NHN GY BNH

Trn 100 mm bnh gy VPC ghi nhn gm vi khun, vi nm, virus, v k

sinh trng. May mn thay, hu ht cc trng hp vim phi do mt t mm bnh

thng thng, gm S. pneumoniae, H. influenzae, S. aureus, M. pneumoniae, C.

pneumoniae, Moraxella catarrhalis, Legionella spp., trc khun gram m hiu kh,

Influenza viruses, Adenovirus, v Respiratory syncytial virus (RSV).

1. Tc nhn gy vim phi cng ng:

Trong k nguyn trc khng sinh, vim phi hu nh ng ngha vi nhim S.

pneumoniae. Ph cu cn chim 3060% ca tt c VPC c th xc nh

nguyn nhn. c bit n c th gy VPC nng cn nhp vin v gy vim

phi ngi gi trn 60 tui.

Nguyn nhn vi khun thng th hai l H. influenzae, chim khong 10%, c

bit bnh nhn COPD d mc. Moraxella catarrhalis thng t hn H. influenzae

nhiu. Cng nh H. influenzae, bnh nhn bnh tim phi d b vim phi do M.

catarrhalis. Staphylococci v trc khun gram-m thng t hn nhiu, nhng gy

bnh nng hn. Trong cng ng, vim phi do staphylococci thng xy ra sau

cm, vim phi do trc khun gramm thng nht xy ra bnh nhn mi nhp

vin v iu tr khng sinh, ngi ht thuc v c bnh phi mn tnh, v

bnh nhn suy gim min dch. Tip xc vi nc phun nhim l yu t nguy c

nhim Pseudomonas aeruginosa, v nghin ru c kh nng mc vim phi do

Klebseilla. Vim phi do Meningococcus him thy. Nhiu loi vi khun khc

gm L. pneumophila c th gy VPC. Vi bnh nhn c th mc bnh do ht hn

hp nhiu vi khun thng tr trong ming.

Khong mt na trng hp VPC khng th xc nh c tc nhn gy bnh.

Cc tc nhn khng phi do vi khun (cn gi l khng in hnh) cn l nguyn

nhn ca nhiu trng hp, nht l bnh nhn tr. C. pneumoniae cng nhn bit

nh l nguyn nhn VPC ngi ln mc COPD. Cc virus h hp gm

Respiratory syncytial virus (RSV), Adenovirus, v Influenza hoc Parainfluenza,

cng c th gy VPC tt c mi la tui.

2. Tc nhn gy vim phi bnh nhn suy gim min dch:

Bnh nhn suy gim min dch, c bit AIDS, d nhim mt chui rng mm

bnh phi. Thm vo nhiu mm bnh gy VPC v VPBV, h cn nhy cm vi

nhiu mm bnh c hi khng chc gy vim phi ngi c min dch bnh

thng.

Nguyn nhn thng gp:

- Pneumocystis (PCP): cn chim hn ca.

- S. pneumoniae: 100300 ln hn bnh nhn khng nhim HIV.

- H. influenzae v S. aureus: cng l nhng tc nhn gy bnh thng gp.

- Mycobacteria: tuberculosis v non-tuberculous.

- Cryotococcus neoformans v CMV.

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Tc nhn gy vim phi khng in hnh thp. Khong 1/3 ca khng bit c

nguyn nhn.

Bng 1. Tc nhn gy VPC theo th t tn sut gn ng

BNH NHN NGOI TR BNH NHN NM VIN VIM PHI NNG/SSB

Streptococcus pneumoniae S. pneumoniae S. pneumoniae

Mycoplasma pneumoniae H. influenzae Legionella spp.

Chlamydia pneumoniae M. pneumoniae H. influenzae

Haemophilus influenzae C. pneumoniae M. pneumoniae

Virus h hp Nhim trng hn tp Trc khun gramm ng

rut

Linh tinh, gm Legionella spp.,

P. carinii, v vi nm

Trc khun gramm ng

rut

Pseudomonas aeruginosa

Vi khun k kh (vim phi

ht)

Mycoplasma pneumoniae

Virus h hp Virus h hp

Legionella spp. Linh tinh, gm C.

pneumoniae,

M. tuberculosis, S. aureus,

P. carinii, v vi nm

Linh tinh, gm M.

tuberculosis, S. aureus,

Moraxella catarrhalis,

P. carinii, v vi nm

Adapted from American Thoracic Society: Guidelines for management of adults with community-

acquired pneumonia: Diagnosis, assessment of severity, initial antimicrobial therapy, and

prevention. Am J Respir Crit Care Med 2001;163:17301754.

IV. SINH BNH HC

1. Cc c ch bo v k ch

Bnh thng, phi khng cha vi trng. ngi khe mnh, mt chui c ch bo

v phc tp duy tr tnh cht v trng i u vi s xm lng vi sinh nng n

ng h hp trn, ht phi hng ngn vi khun hng ngy, v ht cht tit ca

ng h hp trn gn nh din ra trong sut gic ng hng m. Khim khuyt

cc c ch bo v k ch l nguyn nhn ca hu ht cc trng hp vim phi.

Suy gim min dch l yu t thun li xy ra nhim trng, c th thy trong cc

trng hp:

Ct lch hoc lch mt chc nng,

Gim bch cu ht, bch cu ht khng c, hoc chc nng v hiu,

Nhim HIV,

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Gammaglobulinmu ton thn hoc khu tr gim hoc khng c (thiu IgA

xut tit),

Tr sanh thiu thng v tui gi, nghin ru, tiu ng, suy dinh dng,

thng l nguyn nhn xy ra bnh phi do bin i cc hng ro min dch.

2. Ly truyn mm bnh vo phi

2.1. ng khng kh

Quan trng nht, vi s xm nhp vo cy khph qun ca cc mm bnh ngoi

sinh (Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma

pneumoniae, Legionella pneumophila, ) hoc ni sinh (vi khun hoi sinh

ming, ng t h hptiu ha v vng ph cn).

Mm bnh t ng h hptiu ha trn. Yu t thun li gm: ri lon nut, lit,

hn m, bnh tai mi hng hoc ming, nht l u bu. Cng c th do tai nn

(ngt nc).

Ht phi nhng git kh dung l nguyn nhn ly truyn virus h hp, nh cm, ly

lan nhiu v thng xy ra khi c dch. Tng t, Mycoplasma spp. ly truyn t

ngi sang ngi gy vim phi khng in hnh nguyn pht, Chlamydiae ly

truyn t loi chim (Chlamydia psittaci) hoc ngi (C. pneumoniae).

Mycobacterium tuberculosis ly lan t ngi sang ngi bi cc git phun. Mm

bnh gy nhim vi nm ton thn c l ht phi t cc ngun ca thin nhin.

Trong cc vi khun gy vim phi, Legionella pneumophila l loi c l ly lan do

ht cc cht phun xut pht t nc ngt nhim. Pneumococci lan trn t ngi

sang ngi bi cc git kh dung, nhng vim phi do ph cu ly khng nhiu v

gy ra trong nhiu ca ht mm bnh mi hu, c ch nhim trng quan trng th

hai. Ht phi mm bnh mi hu xy ra hu nh tt c mi ngi sut khi ng

v c l chu trch nhim trong hu ht cc vim phi do vi khun, gm

Staphylococci, trc khun gramm: chc chn l nguyn nhn ca vim phi hoi

t, do ht cc vi khun thng tr hn hp ming.

2.2. ng mu

Ly lan theo ng mu, t thng nht, l nguyn nhn ca cc ca vim phi do

t cu (Staphylococci) l t bnh nhn b vim ni tm mc van ba l hoc vim

tc tnh mch nhim trng. C ch ny cng chu trch nhim cho nhiu vim phi

do trc khun gramm bnh nhn nhim trng huyt, phi ng vai tr ci lc

vi khun.

3. Thay i dn lu kh-ph qun

L kt qu ca s ph hy cu trc thng b hoc ca mt chng ngi vt dn

n thi tr mm bnh v hiu:

Vim ph qun mn, gin ph qun, bnh x nang (mucoviscidose), nghin

thuc l, ht bi hoc c cht.

Hp ng th do u bu hoc nguyn nhn khc.

Bnh ph qun cp do virus, v d cm.

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4. p ng m

Mc d p ng vim l cn bn kim sot nhim trng, n c th gy tn hi

m, h hng tc dng ca nhung mao, v ngn cn thc bo.

p ng vim vi Streptococcus pneumoniae hoc Haemophilus influenzae

thng to nn ng c thy, nhng hoi t m him khi c. Ngc li,

Staphylococci v nhiu trc khun gramm thng gy hoi t, c th dn n

to l hng v ngay c pxe thc s, c im l quanh ph qun, nhng ng

c thy c th xy ra. Virus thng gy vim m k hn l tit dch trong khong

khng. Nhim trng thng hai bn v gy tn thng ph nang lan ta v ph

m k. p ng m tng t c th gy bi Mycoplasma, Chlamydia, v

Legionella spp., bi nhim trng huyt gramm (sc phi), v bi cc nguyn

nhn khc ca hi chng nguy kch h hp cp. Mycobacteria v vi nm to p

ng ht chm mt cch in hnh.

i vi nh bnh hc, vim phi l mt nhim trng ph nang, ng h hp xa,

v m k phi, biu hin bi trng lng phi tng, thay th tnh xp bnh thng

ca phi bng s ng c, v ph nang y bch cu, hng cu v fibrin.

V. LM SNG

Vim phi c th biu hin t nh n ti cp v gy t vong, vi bnh trm trng

xy ra ngay c nhng ngi mnh khe trc y. Bnh c th khi pht t

ngt v nguy kch hoc t t. St km n lnh hoc lnh run, ho khan hoc khc

m nh m hay c mu g st, au nhi ngc, v kh th l cc biu hin in

hnh ca vim phi. i khi nhc u, bun nn, i, tiu chy, au c, au khp,

hoc mt mi. L ln c th l biu hin quan trng ngi gi.

Triu chng thc th gm th nhanh, g c, rung thanh tng, rale n, v ting c

mng phi. Du hiu nng hu ch duy nht l nhp th > 30 ln /pht ngi

khng c bnh phi trc.

Vi nguyn nhn v mm bnh kt hp vi t l t vong cao. T vong cao nht

(>50%) l vim phi gy ra bi P. aeruginosa, k n l Klebsiella spp., E. coli, S.

aureus.

Hu ht nhng bnh nhn nhp vin v vim phi l ngi gi v c nhiu bnh i

km (tiu ng, suy tim huyt, hen ph qun, hoc bnh tim thiu mu, ).

Nhiu bin chng xy ra sut thi gian nm vin, thng nht l suy h hp, suy

tim huyt, sc, ri lon nhp tim, nhi mu c tim, xut huyt tiu ha, v suy

thn. T l t vong bnh vin khong 8%, nguyn nhn cht tc th thng nht

l suy h hp, suy tim v nhim trng, mt na do vim phi, mt na do cc bnh

i km.

Cc hi chng vim phi cng ng thng gp:

1. VPC cp

Bnh nhn thng tui gia 50 v cui 60, hu ht c mt hoc nhiu bnh mn

tnh trc, gm COPD, bnh tim mch, thn kinh, tiu ng, hoc nghin ru.

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Suy gim min dch lin quan n bnh c tnh, gim bch cu ht, dng corticoid

hay thuc c ch ty lu di, hoc nhim HIV c th chim n 57% bnh nhn.

Khong 81% biu hin ging nh m t c in: bnh khi pht t ngt vi lnh

run theo bi st, au ngc, v ho khc m nht m.

Triu chng thay i ty tui, c iu tr khng sinh trc, v nng ca bnh.

Mt s triu chng khng phi h hp gm mt mi, bing n, m hi v bun

nn. Triu chng h hp v khng phi h hp t thy nhm tui gi hn. Th

nhanh (>2430 /pht) thng thy nhm tui gi hn. Nghe phi c rale (khong

78%), du ng c (khong 29%).

Bch cu thng 15.00035.000/mm3, gim BC c th gp v l du tin lng

xu. CRP tng 50100mg/L thy sm. m c v m, c th mu g st, nhum

Gram thy nhiu Neutrophile v vi khun, thng c mt mm bnh tri nht.

Phim phi thy nhng vng tn thng nhu m, thng vi tin trnh lp y ph

nang. Ngay c vi nhng xt nghim y , ch 2070% c chn on vi sinh.

S. pneumoniae cn l nguyn nhn chnh. Mt s gy ra do H. influenzae. S t do

S. aureus gy vim phi ngi gi v nhng ngi mc bnh cm. Phn cn li

do vi khun Gram m hiu kh (ngoi tr H. influenzae) v cc vi khun k kh v

hiu kh hn hp. Mt na trc khun Gram m l Pseudomonas aeruginosa, nghi

ng bnh nhn cng mc bnh phi v mi nhp vin.

Ngoi ra, cn gp vim phi do Legionella spp., c biu hin lm sng khc vim

phi do cc vi khun khc. St cao > 40oC, nam gii, iu tr lactam, tn

thng nhiu thy bt thng, Xquang din tin nhanh, cn chm sc c bit, bt

thng d dy rut v thn kinh, men gan v creatinine tng kt hp vi vim phi

Legionella. Moraxella catarrhalis cng gp, l mm bnh quan trng ngi gi

c COPD, v cc th suy gim min dch khc.

2. VPC ngi gi

Biu hin lm sng khng r nh ngi tr, vi khi pht t t hn, st v

nhng triu chng c in ca vim phi. St t xy ra, cng nh n lnh v rt

run. Trong mt na ngi gi, c th khng c ho v kh th. t thy th nhanh

(nhp th > 2430 ln/pht). Thng nghe c rale, mc du nhng hi chng

ng c t tm thy.

Cc triu chng khng phi h hp c th l biu hin chnh. Biu hin u tin c

th gm gim tng trng, yu, thay i nh tm trng, bing n v au bng.

ngi gi thng b nhim trng huyt, nhim trng di cn v t vong cao hn.

3. VPC. nh

Thng iu tr ngoi tr, do cc tc nhn gy bnh thng gp: S. pneumoniae,

H. influenzae, S. aureus, M. pneumoniae, v cc loi virus (thng gp Influenzae

A v B, Parainfluenzae, Adenovirus v RSV).

4. VPC. nng

Khong 10% VPC cn sn sc c bit/thng kh c hc.

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- S. pneumoniae v L. pneumophila thng gp nht.

- Klebsiella spp. ngh n khi c bnh quan trng trc nh COPD, tiu

ng, nghin ru.

- M. pneumoniae,

Th nhanh (> 30 ln /pht), huyt p tm trng < 60mmHg v BUN > 7mmol /L

thng dn n t vong. Cc tnh cht khc lm tng t l t vong gm c bnh

nng trc, bnh c tnh, trn 60 tui, khng au ngc mng phi, thay i tm tr,

suy h hp cp cn h tr thng kh, tn thng phi hai bn, nhim trng huyt,

N < 3.500/mm3, protein huyt thanh < 45g/L, creatinin huyt >15mg/L, c sc,

iu tr khng sinh lc u khng , X quang chng t bnh ang lan rng, v

vim phi do S. aureus hoc trc khun Gram m.

5. VPC. chm khi

c nh ngha khi gim < 50% bt thng X quang 2 tun v cha sch ht

khi n 4 tun. Cc yu t k ch nh > 50 tui, ung ru, c bnh nng trc

(COPD, tiu ng, suy tim huyt, hen ph qun, c tnh) kt hp vi vim phi

chm khi. Mc khi cng ty thuc tc nhn gy bnh, vi S. pneumoniae thng

cn n 6 tun, Legionella 26 thng, Mycoplasma vi tun.

Khi vim phi chm khi, cn xem c th: tc nhn gy bnh khng thuc, chn

on mm bnh sai, hoc chn on vim phi khng ng. Cn chn on phn

bit vim phi vi bnh c tnh, vim mch mu, xut huyt phi, v vim phi

tng bch cu i toan.

6. Hi chng vim phi khng in hnh

Nguyn nhn quan trng nht l: M. pneumoniae, Chlamydophila (Chlamydia)

pneumoniae, v L. pneumophila. Tc nhn gy bnh khc gm: Chlamydophila

(Chlamydia) psittaci, Francisella tularensis, M. tuberculosis, Coxiella burnetii, v

mt loi virus h hp (Adenovirus, ). bnh nhn AIDS, Pneumocystis v cc

Mycobacteria non-tuberculous cng l nhng tc nhn gy bnh.

Phn bit VPC do vi khun in hnh v cc tc nhn khng in hnh khng r

rng.

Trong th c in, nhim Mycoplasma biu hin nhng triu chng c nng v

tin trin t ng h hp trn xung di. Thng bt u au hng. Khi c vim

mng nh bng nc (5%), ngh n nhim Mycoplasma. Triu chng chnh l st,

kh chu, s mi, nhc u v ho. t thy au ngc, kh th v suy h hp. C th

nghe ran n hoc m. Khc m bin thin, trng hp c th c nh m.

Tn thng phi trn X quang thng lan rng hn khm thc th: thm nhim

mt hoc hai bn mt hay hai phn phi, thng thy di, phn b theo ph

qun hoc quanh ph qun. Him thy tn thng thy trn v trn dch. Hu ht

din tin lnh tnh. Triu chng c nng bin mt trong tun 1 v 2, mc d ho v

cc thay i X quang c th ko di vi tun. Thnh thong, nhim M. pneumoniae

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100

cn sn sc c bit. Mt s ln c biu hin ngoi phi gm tn thng da, h

thn kinh trung ng, mu v thn.

- Chlamydophila pneumoniae gy vim phi khng in hnh, cng l mt ng

sinh bnh quan trng, thng kt hp vi S. pneumoniae. Bnh thng l t, mc

d ghi nhn c xy ra dch. a s khng triu chng hoc nh. Bt u au hng

v khan ting, nhng din tin chm hn trong vim phi Mycoplasma v virus.

Ho c th bt u sau vi ngy n hng tun, ngh n mt bnh c hai thi k.

Khan ting v au xoang thng hn trong bnh nhn nhim Mycoplasma hoc

virus. Bch cu mu him khi cao. Bnh thng nh, mc d c th chm khi

hn. Ho v kh chu c th ko di hng tun n hng thng. Biu hin ngoi phi

gm vim tai, vim xoang, vim mng ngoi, mng trong v c tim.

- Chlamydia trachomatis gy bnh vi ho khc, au c v st, kt hp vi thm

nhim lan ta.

Tc nhn virus ngi ln thng nht l Influenzae A v B, Adenovirus type 3,

4 v 7, Parainfluenzae, v RSV. c im bnh s kh kh v khm nghe ran rt.

- Legionella c th gy VPC khng hoc in hnh, trong L. pneumophila

chim 80%. Mc d kh chu, au c, nhc u, ho khan ging hi chng siu vi,

thng triu chng h hp v st tng i cao c gi tr. Kt hp vi cc triu

chng ngoi phi gm: thay i tm tr, phn lng hoc tiu chy, nhc u, tim

chm. Biu hin X quang kh phn bit, c im l thm nhim m k, hoc nt

c th tin trin nhanh d iu tr , trn dch c th ghi nhn n bnh nhn.

7. Vim ph qun-phi (VPQ-P)

a s do virus, ngoi tr ngi c bnh ph qun mn.

7.1. Do virus: RSV c th gy dch trong tp th tr nh, vi nguy c nng tr s

sinh v nh nhi. Tng t nh Myxovirus parainfluenzae I, II, III. Phn nh do

mc si hoc thy u nng.

7.2. Do vi khun: thng l bi nhim.

- S. pneumoniae cn l mm bnh thng nht.

- H. influenzae tr em, gy tn thng lan ta, kt hp vi vim mng no, vim

tai, hoc vim np thanh qun.

- S. aureus ngi ln, tin trin nhanh n to pxe v trn m mng phi. tr

nh nhi, bnh cnh thng m h, vi triu chng bng, tng trng thay i sm

v nng vi nguy c suy h hp. Din tin ch bi xut hin hnh nh bng hi,

thnh mng, gy ngt th v nguy c v vo mng phi.

- Pseudomonas aeruginosa xy ra ngi VPQ mn, iu tr nhiu khng sinh,

bnh nhn suy gim min dch c tin cn nhp vin.

- Bordetella pertussis gy bnh ho g.

7.3. Do vi nm: xy ra nht l ngi suy gim min dch.

8. Vim phi m k

8.1. Do virus

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101

Thng xy ra dch theo ma (cm v RSV trong ma lnh).

Adenovirus thng nht ngi tr, thng kt hp vi vim kt mc hai bn,

hch c to, pht ban dng si, ngay c tiu chy.

CMV thng gy bnh ngi suy gim min dch.

8.2. Do vi khun

- M. pneumoniae: bnh bt u t t vi st < 39oC, ho khan, tng cn bui ti.

Triu chng ngoi phi gm: au c, vim ngoi b quanh cc l t nhin. X

quang ngc thy cc hnh hn hp vi sang thng m k tri nht trn hnh ph

nang (nhiu nht y phi). Bng dng cm tri y phi.

- Chlamydia psitttaci: c tip xc vi vt, b cu, vt, g li. Bnh phi khng in

hnh vi mch khng tng, kh th v cc triu chng ngoi phi (au c quanh

dy tht lng, hch trung tht, lch to v hoi t t bo gan). C. pneumoniae gy

nhim ng h hp trn v di, ly t ngi sang ngi.

- Coxxiella burnetii: ly qua ngi theo ng khng kh t cc cha mm bnh

loi gm nhm, cu, d, b, th n tht trong nh. Bnh bt u t ngt, st cao

nguyn 3940oC, au c lan ta, gan lch thng to.

8.3. Do k sinh trng

Pneumocystis carinii, Toxoplasma gondii, thng xy ra ngi suy gim

min dch. Bnh thng bt u t t, tn thng lan ta.

VI. CHN ON

1. Chn on xc nh

Da trn bnh s, cc biu hin lm sng v xt nghim.

1.1 Vim phi gm mt nhm triu chng (st, lnh run, ho, au ngc

mng phi, khc m, tng hoc gim nhit, nhp th nhanh, g c, rale

ph qun, rale n, ting c mng phi), kt hp vi t nht mt bng m

trn X quang ngc.

Vim phi do vi khun v khng do vi khun biu hin lm sng khc nhau.

Vim phi khng do vi khun thng xy ra nht tr ln v ngi ln cn

tr. Bnh nhn vim phi do virus, Mycoplasma, hoc Chlamydiae thng

than phin ho khan nng, nhng khc m tht s bt thng. Bnh nhn

vim phi vi khun khc m nhiu, cng nh khi pht bnh t ngt, st

cao, lnh run, v pht trin trn dch ng k. Khm thc th, thng thy

du hiu ng c phi hoc t nht l nhng rale khu tr. Tng phn vi

bnh nhn vim phi khng do vi khun, ch thy t rale nh, v thng,

du thc th t lan rng hn cc bt thng trn X quang.

Chn on vim phi da trn lm sng c nhy 4769% v chuyn

bit 5875%.

1.2 X quang ngc, khng nhy n 100%. Xquang ngc thy ng c

mt phn, hoc mt thy phi, pxe phi, hoc trn dch mng phi ng

Gio trnh Bnh nhim

102

k, c th l vim phi do vi khun hn. Trong khi thm nhim lm m,

khng u, m k tht s ngh n nguyn nhn khng phi vi khun.

Bng 2. Yu t k ch kt hp vi mm bnh vim phi chuyn bit

TNH TRNG BNH NHN VI SINH VT LIN I

Nghin thuc l tch cc/COPD Streptococcus pneumoniae, Haemophilus influenzae,

Legionella pneumophila

Sng nh an dng S. pneumoniae, trc khun gramm, H. influenzae,

Staphylococcus aureus, Chlamydia pneumoniae, vi khun

k kh, lao

Nghin ru

S. pneumoniae (k c dng khng thuc), trc khun gram

m, vi khun k kh, lao

Ht nng/ b rng xu km Vi khun k kh

Du lch n Ty nam Hoa k Coccidioides immitis

Tip xc vi di Histoplasma capsulatum

Tip xc vi loi chim Cryptococcus neoformans, C. psittaci, H. capsulatum

Tip xc vi th Francisella tularensis

Tip xc vi cc ng vt trang tri Coxiella burnetii (Q fever)

Bnh cm Influenza, S. aureus, S. pneumoniae, H. influenzae

Gin ph qun, X ha nang

Pseudomonas aeruginosa, P. cepacia, S. aureus,

Aspergillus spp., Mycobacterium avium complex

Dng thuc tim mch S. aureus, vi khun k kh, lao, P. carinii

Tc ni ph qun Vi khun k kh

iu tr khng sinh mi y S. pneumoniae khng thuc, P. aeruginosa

Adapted from American Thoracic Society: Guidelines for management of adults with

community-acquired pneumonia: Diagnosis, assessment of severity, initial antimicrobial therapy,

and prevention. Am J Respir Crit Care Med 2001:163:17301754.

1.3 CT rt hu ch vi nhim trng hn hp. CT thnh thong tm thy

nhng m m phi trn nhng bnh nhn c triu chng nghi vim phi, nhng

hnh X quang khng chng t vim phi. Nu lm sng nghi nhiu n vim phi,

m phim ngc u tin khng thy m m, cn chp X quang lp li trong 2448

gi hoc chp CT. Cn phn bit vi xp phi.

VIM PHI THY LAO PHI

Gio trnh Bnh nhim

103

Thnh thong, mt chn on nguyn nhn ngh n trn hnh X quang ngc. V

d, sang thng c hang thy trn c l do lao phi, v c bu kh ngh n

vim phi do Staphylococcus aureus. Mc nc hi do pxe phi, thng do

nhiu vi khun. ngi suy gim min dch, du li lim ngh n vim phi do

Aspergillus.

VIM PHI DO

S. AUREUS

PXE PHI (T) VIM PHI DO ASPERGILLUS

2. Chn on nguyn nhn

Mm bnh gy vim phi c th nhn bit t cy mu, m, dch mng phi, m

phi, hoc cht tit trong ph qun ly t pht hay ra ph qun. Cc phng php

khc xc nh nguyn nhn vim phi gm pht hin p ng IgM hoc hiu

gi khng th vi khng nguyn ca mt vi sinh c bit tng gp 4 ln v tm thy

khng nguyn trong nc tiu, huyt thanh, hay dch mng phi. Trong vi trng

hp, khuch i DNA hoc RNA ca mt mm bnh h hp t mt trong cc bnh

phm trn hoc t cht pht hu hng c th dng cho mc ch ny.

2.1. Cy mu

Cng thc mu trong vim phi do vi khun, c th c tng bch cu a nhn

trung tnh.

bnh nhn iu tr ngoi tr, cn ly mu cy khi c mt trong du hiu sau:

thn nhit >38.5C, hoc

Gio trnh Bnh nhim

104

Kt qu cy phi lun tng quan vi nhum. Vi mm bnh phn lp trong m

nn lun xem l gy bnh gm: M. tuberculosis, Legionella spp., B. dermatitidis,

H. capsulatum, v C. immitis.

Cn kho st xm ln bnh nhn suy gim min dch, bnh nguy kch, tht bi

vi iu tr thng thng. Bin php gm ht qua kh qun, soi ph qun (i khi

cn sinh thit), pht ph qun, BAL, hoc ly mu phi xuyn qua da, sinh thit

phi m.

Bng 3. Phn loi chn on nguyn nhn vim phi

Xc nh

(Definition)

Mm bnh tm thy t mu, dch mng phi, hoc m phi.

Legionella spp. hoc M. tuberculosis phn lp t m.

Th nghim khng nguyn Legionella trong nc tiu dng tnh.

C nhiu kh nng

(Probable)

Phn lp bt c vi sinh no sau y t mu m m, vi hnh dng

tng t trn nhum Gram s ln hoc va: Staphylococcus aureus,

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella

catarrhalis, Pseudomonas aeruginosa.

Hiu gi khng th vi mm bnh h hp tng 4 ln hoc hn gia

mu huyt thanh thi k hi phc v cp tnh.

Th nghim khng nguyn S. pneumoniae trong nc tiu ngi

trng thnh dng tnh.

C th

(Possible)

Nhum Gram mt mu m c th chp nhn chng t Song cu

trng gram dng (S. pneumoniae), T cu gram dng (S. aureus),

hoc Trc cu trng gram m (H. influenzae) chim u th.

Phn lp mt mm bnh t mu m m trong khi nhum Gram tng

ng khng thy.

Hiu gi n c hoc khng thay i cao vi Legionella pneumophila

(=1:1024) hoc Mycoplasma pneumoniae (=1:64).

2.3. Tm khng nguyn ca mm bnh phi trong nc tiu

Khng nguyn L. pneumophila serogroup 1 c th tm thy trong nc tiu bnh

nhn mc bnh do vi khun ny bi th nghim ELISA.

ELISA cn tm khng nguyn S. pneumoniae trong nc tiu bnh nhn vim

phi ph cu nhim trng huyt. tr em, mang mm bnh S. pneumoniae trong

hu hng c th cho kt qu dng tnh.

2.4. Huyt thanh hc

Tm thy khng th IgM hoc chng minh hiu gi khng th vi mt tc nhn c

bit, tng 4 ln mu huyt thanh thi k hi phc so vi thi k cp tnh thng

chng t tc nhn ny l nguyn nhn gy vim phi. Cc tc nhn gy bnh sau

y thng chn on bng xt nghim huyt thanh: M. pneumoniae, C.

pneumoniae, Chlamydia psittaci, Legionella spp., C. burnetii, Adenovirus, Para

v Influenza virus A.

Gio trnh Bnh nhim

105

Cc xt nghim huyt thanh gm: gn b th, min dch hunh quang gin tip, v

ELISA. Th nghim tm khng th IgM v IgG tch bit c th thc hin vi 2 th

nghim sau. Kh khn l c huyt thanh hc ca p ng khng th n dng i

vi mt tc nhn.

2.5. PCR

Nhiu phn ng cho php tm DNA ca Legionella spp., M. pneumoniae, C.

pneumoniae. Th nghim ny t tin v khng lm thng qui.

Nhn dng tc nhn gy bnh vim phi nn phn loi l tc nhn xc nh, c

nhiu kh nng, hoc c th, ty thuc ngun vi sinh hoc th nghim dng

khm ph. Phn loi chn on nh vy hu ch khng nhng trong nghin cu so

snh v nguyn nhn vim phi, m cn trong cch tip cn bnh nhn vim

phi.(Bng 3)

3. Chn on phn bit

3.1 Bnh khng phi do nhim trng:

Vim ph qun dng hen.

Vim phi qu mn.

COPD, k c kh ph thng v dn ph qun (bronchiectasis).

Xp phi, nhi mu phi, ph phi v bu phi.

Phn ng qu mn v c t do thuc hoc ha cht dng phun, ung chch.

Vim phi do tia bc x, bnh sarcoidosis, vim mch mu, vim phi do

urhuyt xut huyt phi, vim phi tng bch cu i toan.

3.2 Bnh nhim trng:

Vim ph qun cp (c th phi hp/do cng tc nhn gy bnh).

VII. IU TR

V nguyn nhn vim phi thng khng bit, iu tr khng sinh ban u thng

theo kinh nghim v cn c trn bnh s, biu hin lm sng, kiu bt thng trn

X quang phi, cc kt qu soi m hoc cc dch th khc, v mu nhy cm hin

nay ca mm bnh nghi ng i vi khng sinh.

Chn khng sinh phc tp do tn xut khng thuc ca ph cu, cn kim sot c

mm bnh khng v in hnh v d kin ngh iu tr phi hp.

Penicillin cn c vai tr quan trng trong iu tr VPC. Vi ph cu khng nhy,

dng liu cao hn hoc khong cch gia cc liu ngn hn c th iu tr hiu

qu nhng mm bnh khng thuc tng i. Cc loi Penicillin ung nh

Amoxicillin v Amoxicillinclavulanic acid c th to c tc dng ny ngay

c i vi vi mm bnh khng Penicillin.Trong cc Cephalosporin ung,

Cefuroxime c li nht, nhng ch i vi dng ph cu nhy va vi Penicillin.

Penicillin liu cao v Cephalosporin th h th III nh Ceftriaxone v Cefotaxime

khng ch ngay c nhng dng khng thuc. Cc loi khc nh Ceftazidime v

Ceftizoxime t mnh hn.

Gio trnh Bnh nhim

106

Mt s Quinolone ng h hp (Levofloxacin, Moxifloxacin, Gemifloxacin,

Gatifloxacin) c tc dng chng a s cc tc nhn in hnh v khng in hnh

gy nhim trng h hp di. Nhng dng ph cu khng vi cc Quinolone

ng h hp cng tng trnh, s tht bi trong iu tr nhim ph cu bng

Quinolone do khng thuc rt bt thng.

C tc dng hip ng gia lactam v Macrolide, nht l Azithromycin. Phi

hp iu tr vi cc khng sinh ny lm gim t l t vong v thi gian nm bnh

vin ca nhng ngi bnh gi mc VPC v vim phi c chng minh do ph

cu, gm c trng hp nhim trng huyt.

Telithromycin l mt thnh phn th nht ca loi Ketolide nghin cu lm sng

c tc dng tt chng nhng dng ph cu, H. influenzae, v Moraxella spp. nhy

v khng vi Penicillin.. N cng tc dng chng dng ph cu khng Macrolide.

Ch cn c vo tui, thng khng nh hng n chn thuc. Ni m nguy c

ph cu khng thuc thp, chn lactam (Amoxicillinclavulanic acid,

Cefuroxime axetil), Macrolide/Azalide (Erythromycin, Azithromycin, hoc

Clarithromycin), hay Fluoroquinolone ng h hp ung.

bnh nhn m nguy c tng do tui hoc bnh c sn, hay nguy c nhim ph

cu khng thuc, Fluoroquinolone ng h hp l khng sinh c l hiu qu nht.

Chng c tc dng chng tt c dng ph cu, k c dng khng Penicillin, v cn

tc dng chng mm bnh khng in hnh.

Khi mm bnh c phn lp, chn theo khng sinh , ph cng hp cng tt.

Bnh nhn cn nhp vin, nn iu tr bng thuc chch khng ch nhng mm

bnh c th. Nn chn Fluoroquinolone ng h hp, hoc Ceftriaxone phi hp

vi Azithromycin.

Trong thi gian c dch cm, nghi ng vim phi do t cu khng Methicillin, c

th dng Vancomycin, Linezolid, hoc Quinupristin/Dalfopristin.

Nghi vim phi do ht, dng khng sinh chng vi khun k kh ming, gm

Ampicillinsulbactam hoc Clindamycin.

Nu nghi trc khun gram m, c th nhim Pseudomonas aeruginosa, iu tr

bng lactam chng pseudomonas (nh Cefepime, Piperacillintazobactam,

imipenem, hoc meropenem). Nu loi tr Pseudomonas, dng Cefotaxime,

Ceftriaxone. Phi hp lactam vi Aminoglycoside hoc Quinolone iu tr

vim phi gram m cn bn ci. Bnh nhn d ng vi Penicillin, c th dng

Aztreonam vi Fluoroquinolone ng h hp, thm Aminoglycoside hay khng.

Sau y l hng dn chn khng sinh iu tr VPC theo kinh nghim ca Hi

Lng ngc, Hi Bnh truyn nhim Hoa K. (bng 4)

Gio trnh Bnh nhim

107

Bng 4. Hng dn chn khng sinh theo kinh nghim iu tr bnh nhn b

VPC

TNH TRNG BNH NHN LA CHN IU TR THCH HP

Khng iu tr khng sinh mi y C iu tr khng sinh mi y Khng iu tr khng sinh mi y C iu tr khng sinh mi y Nhim trng nghi do ht phi Cm c bi nhim vi khun

Ngoi tr

Khe mnh trc y Macrolide1 hoc Doxycycline Fluoroquinolone h hp3 n c, hoc Macrolide mi + Amoxicillin (hay Amoxicillinclavulanate) liu cao C sn bnh COPD, tiu ng, suy tim/thn, c tnh Macrolide mi2 hoc Fluoroquinolone h hp Fluoroquinolone h hp n c, hoc Macrolide mi + lactam Amoxicillinclavulanate hoc Clindamycin lactam, hoc Fluoroquinolone h hp

Khng iu tr khng sinh mi y C iu tr khng sinh mi y Khng do nhim Pseudomonas Do nhim Pseudomonas

Ni tr

Khoa Ni Fluoroquinolone h hp n c, hoc Macrolide mi + lactam

Macrolide mi + lactam, hoc Fluoroquinolone h hp n c (chn ty khng sinh dng mi y) Khoa Sn sc c bit lactam + Macrolide mi, hoc + Fluoroquinolone h hp (D ng lactam: Fluoroquinolone h hp Clindamycin) Thuc chng pseudomonas4 + Ciprofloxacin, hoc Thuc chng pseudomonas + Aminoglycoside + Fluoroquinolone h hp hoc Macrolide (D ng lactam: Aztreonam + Levofloxacin, hoc Aztreonam + Motifloxacin hoc Gatifloxacin Aminoside)

ang iu tr nh iu dng

nhp vin

Nh iu dng

Fluoroquinolone h hp n c, hoc

Amoxicillinclavulanate + Macrolide mi

iu tr nh Khoa Ni v Khoa Sn sc c bit 1 = Erythromycin, Azithromycin, hoc Clarithromycin. 2 = Azithromycin, hoc Clarithromycin. 3 = Motifloxacin, Gatifloxacin, Levofloxacin, hoc Gemifloxacin. 4 = Piperacillin, Piperacillintazobactam, imipenem, meropenem, hoc Cefepime.

Data from Mandell LA, Bartlett JG, Dowell SF, et al. Update of practice guidelines for the management of community-acquired pneuminia in immunocompetent adults. Clin Infect Dis. 2003:37:1405-1433.

V mt lch s, tin trnh iu tr vim phi l 1014 ngy, ty thuc bnh nhn c

cn phi nhp vin khng, c lc ca tc nhn gy bnh, s hin din ca nhng

Gio trnh Bnh nhim

108

bnh i km, v mc p ng. Azalide, Ketolide, v Quinolone dng liu cao

v/hoc iu tr thi gian ngn 57 ngy vi thnh cng ban u. Hin nay, iu tr

1014 ngy cho bnh nhn nhp vin dng nh thch hp nht.

VIII. PHNG BNH

Tt c nhng ngi nghin thuc l b vim phi nn khuyn b thuc.

Chch nga cm v ph cu.

Khi b ht phi (aspiration) dch hoc kh, cn c bin php phng nga vim

phi.

TI LIU THAM KHO

1. Gerald R. Donowitz, Gerald L. Mandell. Acute pneumonia. In Mandell,

Douglas and Bennetts Principle and Practice of Infectious Diseases, 6th edition,

2005, Chapter 61 (Pages 819839).

2. APPIT. Pneumonies communautaires. Dans Maladies Infectieuses et Tropicales,

E. Pilly, 17 dition, 2M2, 2000, Chapitre 20 (Pages 154164).

3. Thomas J. Marrie, G. Douglas Campbell, David H. Walker, Donald E. Low.

Pneumonia. In Harrisons Principle of Internal Medicine, 16th edition, 2005,

Chapter 239 (Pages 15821595).

4. Andrew H. Limper. Overview of pneumonia. In Cecil Textbook of Medicine,

22nd edition, 2004, Chapter 92 (Pages 462 465).

5. Harvey B. Simon. Pulmonary infections. In The Clinician's Guide to Diagnosis,

Treatment, and Prevention, 2004. Chapter 6 (Pages 5156).

6. INFECTIOUS DISEASES AND ANTIMICROBIALS NOTES. Pneumoniae

(Page 216). Copyright PDA Medical Solutions, All Rights Reserved. Last

Revised on July 2002. Type: PDB File. Modified: 8/12/2005.

CU HI TRC NGHIM

1. Mt tr, ng kinh, suy tim huyt, bnh mch mu no, ht thuc, nghin

ru, v bnh phi tc nghn mn tnh (COPD) l nhng yu t nguy c vim

phi do ph cu, trong ht thuc l nguy c mnh nht mc bnh ph cu

xm ln.

A. ng

B. Sai

2. Hai tc nhn gy vim phi thng gp nht l:

A. S. aureus v H. influenzae

B. Staphylococci v trc khun gramm

C. S. pneumoniae v H. influenzae

D. C. pneumoniae v P. carinii

Gio trnh Bnh nhim

109

3. Chn cu sai khi ni v sinh bnh hc ca vim phi:

A. Khim khuyt cc c ch bo v k ch l nguyn nhn ca hu ht vim

phi

B. Ly lan thng nht l theo ng mu n phi

C. Thay i dn lu khph qun dn n thi tr mm bnh v hiu nh

vim ph qun mn, gin ph qun

D. p ng vim c th gy tn hi m, h hng tc dng ca nhung mao, v

ngn cn thc bo

4. Biu hin lm sng in hnh ca vim phi:

A. Bnh c th khi pht t ngt v nguy kch hoc t t.

B. St km n lnh, ho khan hoc khc m, au nhi ngc, v kh th

C. Triu chng thc th gm th nhanh, g c, rung thanh tng, rale n

D. C a, b, v c

5. VPC ngi gi:

A. Khi pht t ngt hn, vi st v nhng triu chng c in ca vim phi

B. Cc triu chng khng phi h hp c th l biu hin chnh, gm gim

tng trng, yu, thay i nh tm trng, bing n v au bng

C. Thng thy th nhanh (nhp th > 2430 ln/pht)

D. Thng khng nghe c rale, mc du nhng hi chng ng c thng

tm thy

6. Chn on vim phi:

A. Chn on vim phi da trn lm sng, cn xc nh bi hnh chp X

quang ngc

B. Xquang ngc thy ng c mt phn, hoc mt thy phi, pxe phi,

hoc trn dch mng phi ng k, c th l vim phi do vi khun hn

C. Mm bnh gy vim phi c th nhn bit t cy mu, m, dch mng

phi, m phi, hoc cht tit trong ph qun

D. Xt nghim m l chnh chn on nguyn nhn. Ra ph qunph

nang (BAL) hiu qu tm tc nhn gy bnh hn

E. Tt c cc cu trn

P N: 1. A 2. C 3. B 4. D 5. B

6. E