the management of parapneumonic effusions and empyema · logic characteristics of the effusion, the...

Editorial

The management of parapneumonic effusions andempyema

Key Words:Effusion, parapneumonic, pneumonia, empyema

It is estimated that four million patients develop bacterial pneumoniain the United States annually and approximately 20% of these require hos-pitalization1. The incidence of parapneumonic effusion in patients hospi-talized with pneumonia is about 40%2. Patients who have pneumonia andpleural effusion have greater morbidity and higher mortality rates than dopatients with pneumonia alone3. In one study, the relative risk of mortalityin patients with community-acquired pneumonia was 7.0 times higher forpatients with bilateral pleural effusions and 3.4 times higher for patientswith a unilateral pleural effusion of moderate or greater size comparedwith other patients with community-acquired pneumonia alone3. Improp-er management of the parapneumonic pleural effusion is at least partiallyresponsible for some of the increased morbidity and mortality.

One reason for the increased morbidity and mortality seen in pneumo-nia patients with effusions is that the presence of a pleural effusion is asso-ciated with a more advanced pneumonia. In one study the prevalence ofpleural effusion was 40% in bacteremic patients and 21% in nonbacterem-ic patients4. The presence of a pleural effusion greater than 1.0 cm in thick-ness on a decubitus chest radiograph has served as a definite criterion foradmission to the hospital in some studies5.

DEFINITIONS

A parapneumonic pleural effusion is a pleural effusion associated withbacterial pneumonia, lung abscess or bronchiectasis6. An empyema is pusin the pleural space. By definition pus is thick, purulent-appearing pleuralfluid. A complicated parapneumonic effusion is a parapneumonic effu-sion for which tube thoracostomy is necessary for its resolution. A loculat-ed parapneumonic effusion is a parapneumonic effusion which is not free-flowing. A multi-loculated parapneumonic effusion is a loculated parap-neumonic effusion with more than one loculus.

Richard W. Light, M.D.

Professor of Medicine, Vanderbilt University, DirectorPulmonary Disease Program, Saint Thomas Hospital,Nashville, TN

128 ÐÍÅÕÌÙÍ Ôåý÷ïò 2ï, Ôüìïò 15ïò, MÜéïò - Áýãïõóôïò 2002

tion, sheets of fibrin form that partition the fluid intoloculi and cover the visceral pleura which prevents theunderlying lung from re-expanding.

CLASSIFICATION OF PARAPNEUMONIC EFFUSIONAND EMPYEMA

The American College of Chest Physicians has re-cently developed a new classification of parapneumoniceffusions and empyema which is based upon the radio-logic characteristics of the effusion, the pleural fluid bac-teriology and the pleural fluid chemistry (Table 1)8. It ismodeled somewhat after the TNM system for staging can-cer. The key aspects to note about this classification arethe characteristics that indicate that the patient has amoderate to high risk of a poor outcome without drain-age. Radiological characteristics associated with a poorprognosis are an effusion that occupies more than 50%of the hemithorax, is loculated, or is associated with athickened parietal pleura. However, I personally wouldnot use the thickened parietal pleura as a sign of a poorprognosis. In a recent study of 50 patients with parap-neumonic effusions, 46 of 50 (92%) had pleural thicken-ing. The thickness of the pleura, however, was not relat-ed to the requirement for surgery9. Bacteriological crite-

NATURAL HISTORY OF PARAPNEUMONIC EFFUSION

The evolution of a simple parapneumonic effusionto an empyema represents a continuous progression froma small amount of free-flowing, non-infected pleural flu-id to a large amount of frank pus which is multi-loculat-ed and is associated with a thick visceral pleura that pre-vents the underlying lung from expanding if the fluid isremoved. When a patient develops pneumonia, the rateof pleural fluid formation is increased. Mainly, the in-crease is due to lung interstitial fluid, secondary to thepneumonia, traversing the visceral pleura to enter thepleural space. Increased permeability of the capillariesin the pleurae probably also contributes to the increasedrate of fluid formation. When the amount of pleural flu-id entering the pleural space exceeds the capacity of thepleural lymphatics to reabsorb the fluid, pleural fluidbegins to accumulate. When the fluid initially begins toaccumulate, the effusion is not loculated. The pleuralfluid has a normal glucose and pH and the lactic aciddehydrogenase (LDH) level and the WBC count are low7.In some patients the process progresses with bacteriainvading the pleural fluid. After the pleural fluid becomesinfected, the pleural fluid glucose and pH become pro-gressively lower, the LDH becomes progressively higherand the fluid becomes increasingly more viscid. In addi-

Table 1. Categorizing Risk for Poor Outcome in Patients With PPE

Pleural Space Anatomy Pleural Fluid Pleural Fluid Category Risk of DrainageBacteriology Chemistry Poor Outcome

A0 Minimal, free-flowing AND Bx culture and AND Cx pH unknown 1 Very low Noeffusion (<10 mm Gram stainon lateral decubitus) results unknown

A1 Small to moderate AND Bo negative culture AND Co pH > 7.20 2 Low Nofree-flowing effusion and Gram stain(<10 mm and< ½ hemithorax)

A2 Large, free-flowing OR B1 positive culture OR C1 pH < 7.20 3 Moderate YESeffusion and Gram stain(³ ½ hemithorax),loculated effusion,or effusion withthickened parietalpleura

B2 pus 4 High YES

129PNEUMON Number 2, Vol. 15, Ìay - Áugust 2002

ria associated with a poor prognosis are a positive cul-ture, a positive Gram stain, or the presence of pus. Thepleural fluid chemistry criterion associated with a poorprognosis is a pleural fluid pH less than 7.20. If the pleu-ral fluid pH is used, it is important to measure the pHwith a blood gas machine; pH meters and dip sticks donot provide sufficiently accurate pH measurements10.Alternative pleural fluid chemistry criteria are a pleuralfluid glucose less than 60 ml/dl8 or a pleural fluid LDHmore than three times the upper limit of normal for se-rum2.

TREATMENT OF PARAPNEUMONIC EFFUSION ANDEMPYEMA

Antibiotics: Antibiotic therapy is indicated for pa-tients with parapneumonic effusions or empyema. Theinitial antibiotic selection should be based on whetherthe pneumonia is community- or hospital-acquired andthe severity of illness. Pleural fluid antibiotic levels arecomparable to those in serum7, except for aminoglyco-sides which appear to penetrate poorly into purulentpleural fluid. The recommended treatment for a patientwith community-acquired pneumonia that is not severeis a â-lactam-â-lactamase inhibitor with or without amacrolide11. Alternatively, the newer generation fluoro-quinolones such as levofloxacin can be used. The rec-ommended treatment for severe community-acquiredpneumonia is a macrolide or a new generation fluoro-quinolone plus cefotaxime, ceftriaxone, or a â-lactam-â-lactamase inhibitor11. Pneumonia acquired in institutionssuch as nursing homes or hospitals is frequently causedby enteric gram-negative bacilli, P. aeruginosa, or S. au-reus with or without oral anaerobes. If S. Aureus infec-tion is suspected, either nafcillin or vancomycin shouldbe administered. If gram-negative infection is suspect-ed, the patient should be treated with a third generationcephalosporin or a â-lactam-â-lactamase inhibitor plusan aminoglycoside.

Initial Therapeutic Thoracentesis. When a patient withpneumonia is first evaluated, the possibility of a parapn-eumonic effusion should be considered. If both diaphra-gms cannot be seen throughout their entirety on boththe posteroanterior and lateral chest radiographs, thenbilateral decubitus chest radiographs, chest ultrasound

or a chest CT scan should be obtained. If the thicknessof the pleural fluid is less than 10 mm, the effusion isnon-significant and no thoracentesis is indicated2. If itappears from the standard radiographs that the patienthas a loculated pleural effusion, this possibility shouldbe evaluated with ultrasound.

If the thickness of the pleural fluid is more than 10mm or if the pleural fluid is loculated, one needs to ex-amine the pleural fluid to determine the category of theeffusion. Since a thoracentesis is required for this exam-ination, it is reasonable to perform a therapeutic ratherthan a diagnostic thoracentesis. If the fluid is removedcompletely with the therapeutic thoracentesis and doesnot reaccumulate, no additional therapy needs to be di-rected toward the effusion. At the time of the initial ther-apeutic thoracentesis, the pleural fluid should be Gram-stained and cultured and analyzed for the cell count anddifferential, LDH, glucose and pH levels. Indicators of apoor prognosis from the pleural fluid include a positiveGram-stain or culture, a glucose less than 60 mg/dl, anLDH more than three times the upper limit of normal,or a pH less than 7.20 (Table 2).

If the therapeutic thoracentesis removes all the pleu-ral fluid and the fluid recurs, the next step is guided bythe initial pleural fluid findings. If none of the poor prog-nostic indicators were present, no invasive proceduresare indicated if the patient is doing well clinically. If anyof the poor prognostic indicators were present at the in-itial thoracentesis, a second therapeutic thoracentesisshould be performed and the pleural fluid should be re-analyzed. If the pleural fluid accumulates a third time, asmall 8 - 13 French chest tube should be inserted intothe pleural space unless none of the poor prognostic fac-tors (Table 2) were present at the time of the second tho-racentesis.

Table 2. Indicators of a poor prognosis with a complicated para-pneumonic effusion

Fluid is pusPositive Gram-stain or culturePleural fluid pH < 7.20Pleural fluid glucose < 60 mg/dlPleural fluid LDH > 3X upper limit of normal for serumLoculated pleural fluid


Loculated Pleural Fluid: If the pleural fluid cannot beremoved completely with a therapeutic thoracentesis orwith a small chest tube, it is probably loculated. The loc-ulation indicates a high level of inflammation in thepleural space. The majority of loculated pleural effusionsrequire drainage. If the pleural fluid is loculated and ifany of the poor prognostic factors listed in Table 1 arepresent, efforts should be made to break down the locu-lations in order to obtain complete drainage of the pleu-ral space.

Loculations may be broken down chemically by theintrapleural injection of fibrinolytics or physically withthoracoscopy. There have been multiple uncontrolledstudies which have reported high success rates with theintrapleural administration of either streptokinase12-15 orurokinase12,15,16. The usual dose of urokinase is 100,000IU while that for streptokinase is 250,000 IU. Each agentis diluted with normal saline to a total volume of 50 - 100ml and given daily. Urokinase is no longer available inthe United States.

There have been three randomized controlled stud-ies comparing the therapeutic efficacy of intrapleural fi-brinolytics with saline. In the first study Davies and asso-ciates17 compared streptokinase with saline in a rand-omized double blind study. In this study the streptoki-nase group tended to do better, although the numberswere small and the differences did not reach statisticalsignificance. Bouros and associates compared urokinasewith saline in a randomized double blind study of 31 pa-tients and reported that the patients receiving urokinasedid significantly better in regards to the need for addi-tional treatment18. Recently, Tuncozgur and associatesrandomized 49 patients to urokinase or normal salineand reported that the patients who received urokinasehad significantly shorter duration of fever, lower percent-age of decortication and shorter duration of hospitaliza-tion19. At the present time there is an ongoing multi-cent-er study in the United Kingdom comparing streptoki-nase with saline. Since this study will have 400 patientsupon its completion, it will probably be the definitivestudy on the efficacy of fibrinolytics for the treatment ofloculated parapneumonic effusions.

The alternative approach to the patient with loculat-ed pleural effusions is thoracoscopy with the breakdownof adhesions. In recent years there have been several

uncontrolled studies purporting to show the utility of thisapproach20-24. One advantage of this procedure is thatthe chest tube can be positioned in the most dependentpart of the empyema cavity. Before thoracoscopy is per-formed, a CT scan should be obtained. This examina-tion will provide information about the size and extentof the empyema cavity that will guide the planned pro-cedure. A thickened visceral pleural peel without septa-tions suggests that the empyema may be chronic andprobably will not be amenable to thoracoscopic debride-ment alone25.

When faced with a patient with a loculated parap-neumonic effusion, should fibrinolytics be administeredintrapleurally or should thoracoscopy be performed? Inone study, 20 patients with loculated parapneumonic ef-fusions were randomized to receive chest tubes with strep-tokinase or thoracoscopy26. The patients in the thora-coscopy group had a significantly higher primary treat-ment success, and a shorter duration of chest tube drain-age and hospitalization. The patients in the fibrinolyticgroup who failed were subsequently treated successfullywith thoracoscopy. Based on this study, it is recommend-ed that patients with loculated parapneumonic effusionsand poor prognostic indicators in the pleural fluid betreated initially with thoracoscopy if the expertise for thisprocedure is available locally. At thoracoscopy the fibrinmembranes are broken down and the chest tube is placedoptimally. If the lung does not expand, then attempts toperform a decortication via thoracoscopy are indicated.If the lung does not expand during thoracoscopy, then athoracotomy with decortication is indicated. If the ex-pertise for thoracoscopy is not available locally, then atrial of fibrinolytics is warranted. If there is not substan-tial improvement with the fibrinolytics within a few days,one should proceed to more invasive procedures.

Thoracotomy with Decortication: This is the most inv-asive procedure for the treatment of parapneumoniceffusions and empyema. With decortication all the fi-brous tissue is removed from the visceral pleura and allpus is evacuated from the pleural space. The primaryindication for decortication is a trapped lung; loculationsare better treated with thoracoscopy.

In summary, for the treatment of parapneumonic ef-fusions and empyema one uses progressively invasivetreatments if the previous treatment is not successful


within a matter of days. Initially, a therapeutic thoracen-tesis is done to provide fluid for analysis and to removeall the fluid. For recurring pleural effusion, repeat ther-apeutic thoracentesis or tube thoracostomy is indicatedif poor prognostic indicators (Table 2) were present atthe time of the original thoracentesis. If the fluid cannotbe removed due to loculations, one proceeds to intrap-leural fibrinolytics or thoracoscopy. If one selects intra-pleural fibrinolytics, thoracoscopy should be performedif the fibrinolytics are not successful within a few days. Ifthe lung does not expand at thoracoscopy, one shouldproceed to decortication. The primary mistake in themanagement of patients with complicated parapneumon-ic effusions and empyema is that one progresses fromone therapy to another too slowly. A definitive proce-dure should be done within 10-14 days after the patientis initially seen. A recent article from Canada demon-strates how much delay still occurs in certain regions. Inthis study of 34 patients from Regina General Hospitalin Regina, Saskatchewan, the mean time from admissionto thoracic surgery referral was 47 days and the meannumber of CT scans was more than 1027.

REFERENCES

1. Neiderman MS, Bass JB, Campbell GD, Fein AM,Grossman RF, Mandell LA, et al. Guidelines for the in-itial management of adults with community-acquiredpneumonia: diagnosis, assessment of severity, and ini-tial antimicrobial therapy. Am Rev Respir Dis 1993, 148:1418-26.

2. Light RW, Girard WM, Jenkinson SG, George RB. Par-apneumonic effusions. Am J Med 1980, 69: 507-11.

3. Hasley PB, Albaum MN, Li Y-H, Fuhrman CR, BrittonCA, Marrie TJ et al. Do pulmonary radiographic find-ings at presentation predict mortality in patients withcommunity-acquired pneumonia? Arch Intern Med1996, 156: 2206-12.

4. Musher DM, Alexandraki I, Graviss EA, Yanbeiy N, EidA, Inderias LA, Phan HM, Solomon E. Bacteremic andnonbacteremic pneumococcal pneumonia. A prospectivestudy. Medicine (Baltimore) 2000, 79: 210-21.

5. Dean NC, Suchyta MR, Bateman KA, Aronsky D, Had-lock CJ. Implementation of admission decision supportfor community-acquired pneumonia. Chest 2000, 117:1368-77.

6. Light RW, MacGregor MI, Ball WC Jr, Luchsinger PC.

Diagnostic significance of pleural fluid pH and Pco2.Chest 1973, 64: 591-6.

7. Light RW. Pleural Diseases. Fourth Edition. LippincottWilliams and Wilkins, Philadelphia, 2001.

8. Colice GL, Curtis A, Deslauriers J, Heffner J, Light R,Littenberg B, Sahn S, Weinstein RA, Yusen RD. Medi-cal and surgical treatment of parapneumonic effusions:an evidence-based guideline. Chest 2000, 118: 1158-71.

9. Kearney SE, Davies CW, Davies RJ, Gleeson FV. Com-puted tomography and ultrasound in parapneumoniceffusions and empyema. Clin Radiol 2000, 55: 542-7.

10. Cheng D-S, Rodriguez RM, Rogers J, Wagster M,Starnes DL, Light RW. Comparison of pleural fluid pHvalues obtained using blood gas machine, pH meter, andpH indicator strip. Chest 1998, 114: 1368-72.

11. Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Com-munity-acquired pneumonia in adults: Guidelines formanagement. Clin Infect Dis 1998, 26: 811-38.

12. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Pan-agou P, Siafakas NM. Intrapleural streptokinase versusurokinase in the treatment of complicated parapneumon-ic effusions: a prospective, double-blind study. Am JRespir Crit Care Med 1997, 155: 291-5.

13. Jerjes-Sanchez C, Ramirez-Rivera A, Elizalde JJ, Del-gado R, Cicero R, Ibarra-Perez C, Arroliga AC, PaduaA, Portales A, Villarreal A, et al. Intrapleural fibrinoly-sis with streptokinase as an adjunctive treatment in he-mothorax and empyema: a multicenter trial. Chest 1996,109: 1514-9.

14. Laisaar T, Puttsepp E, Laisaar V. Early administrationof intrapleural streptokinase in the treatment of multi-loculated pleural effusions and pleural empyemas. Tho-rac Cardiovasc Surg 1996, 44: 252-6

15. Temes RT, Follis F, Kessler RM, Pett SB Jr, WernlyJA. Intrapleural fibrinolytics in management of empye-ma thoracis. Chest 1996, 110: 102-6.

16. Moulton JS, Benkert RE, Weisiger KH, Chambers JA.Treatment of complicated pleural fluid collections withimage-guided drainage and intracavitary urokinase.Chest 1995, 180: 1252-9.

17. Davies RJO, Traill ZC, Gleeson FV. Randomised con-trolled trial of intrapleural streptokinase in communityacquired pleural infection. Thorax 1997, 52: 416-21.

18. Bouros D, Schiza S, Tzanakis N, Chalkiadakis G, Drosi-tis J, Siafakas N. Intrapleural urokinase versus normalsaline in the treatment of complicated parapneumoniceffusions and empyema. A randomized, double-blindstudy. Am J Respir Crit Care Med 1999, 159: 37-42.


19. Tuncozgur B, Ustunsoy H, Sivrikoz MC, Dikensoy O,Topal M, Sanli M, Elbeyli L. Intrapleural urokinase inthe management of parapneumonic empyema: a ran-domised controlled trial. Int J Clin Pract 2001, 55: 658-60.

20. Hornick P, Townsend ER, Clark D, Fountain SW. Vid-eothoracoscopy in the treatment of early empyema: Aninitial experience. Ann Royal Coll Surg Eng 1996, 78:45-8.

21. Mackinlay TAA, Lyons GA, Chimondeguy DJ, PiefreasMAB, Angaramo G, Emery J. VATS debridement ver-sus thoracotomy in the treatment of loculated postpneu-monia empyema. Ann Thorac Surg 1996, 61: 1626-30.

22. Sendt W, Forster E, Hau T. Early thoracoscopic debri-dement and drainage as definite treatment for pleuralempyema. Europ J Surg 1995, 161: 73-6.

23. Striffeler H, Ris HB, Wursten HU, Hof VI, Stirnemann

P, Althaus U. Video-assisted thoracoscopic treatmentof pleural empyema. A new therapeutic approach. Eu-rop J Cardio-Thorac Surg 1994, 8: 585-8.

24. Waller DA, Rengarajan A. Thoracoscopic decortication:A role for video-assisted surgery in chronic postpneu-monic pleural empyema. Ann Thorac Surg 200, 71: 1813-6.

25. Silen ML, Naunheim KS. Thoracoscopic approach to themanagement of empyema thoracis. Indications and re-sults. Chest Surg Clin N Am 1996, 6: 491-9.

26. Wait MA, Sharma S, Hohn J, Dal Nogare A. A rand-omized trial of empyema therapy. Chest 1997, 111: 1548-51.

27. Chu MW, Dewar LR, Burgess JJ, Busse EG. Empyemathoracis: Lack of awareness results in a prolonged clini-cal course. Can J Surg 2001, 44: 284-8.

Editorial

Pneumonology or Pneumology?An Etymologic Approach

1Ioanna Ramoutsakis, PhD2Ioannis Ramoutsakis, MD3Demosthenes Bouros, MD, FCCP

1Philologist at the Pankretion Lyceum, 2Private prac-tice, 3Bouros is Associate Professor, Department ofPneumonology, Medical School of the University ofCrete, Heraklion, Crete, Greece

"Wise the accurate"Ancient Greek motto

Not surprisingly, most medical terms are of ancient Greek origin. How-ever, their etymology frequently is not widely known and neither is the firstusage of the main words that are used in medical practice, which originat-ed in ancient Greece. Consequently, these words are misused. The ancientGreek sophist Antisthenis1 claimed that "the examination of names is thebeginning of science", emphasizing that words as names (onomata in Greek)of things were directly connected with the objects they indicated and thatthey can lead us to their real origin and, consequently, to the beginnings ofscience.

The variety of and confusion over the name of the specialty called pneu-monology, names which range from pneumology, lungology, respirology,thoracic medicine, and pulmology to the correct term, pneumonology,prompted us to study the etymology of the words pneumonology and pneu-mology and to examine which term is more appropriate and etymological-ly correct in relation to other relevant terms.

PNEUMON OR PLEUMON

The word pneumon or pleumon (lung) in Greek comes from the an-cient Greek verb pneo, which means to blow or to breathe. This verb hasits origin in the Indo-European2 root *pleumon- (*plumon-), which is alsorelevant to the Indo-European root *pleu-, which means to swim2. (Theasterisk is placed in front of the Indo-European root to denote the formthat once was in popular usage but then disappeared). Therefore, pleu-mon or pneumon is the word for something that floats on water, on liquid.

The term pleumon (lung) is seen in Homer3 and in later writers, and italso agrees with the Latin form pulmo. Liddell and Scott4 claimed that theoriginal form was pleumon, originating from the root plef (ie, to sail orfloat), that it is used because of the light constitution of the lungs, and thatlater the term pneumon was introduced because of its hypothetical ety-

Reprinted with

permission

from CHEST, vol 121, N

o 5,

May 2002

Correspondence:Demosthenes Bouros, MD, FCCP, Depart-ment ofPneumonology, University of Crete, Heraklion,Crete, Greece, GR-71409;e-mail: [email protected]


mology in the root pny (to blow). Aristotle5 presents it inhis work Peri Anapnoe's ("About Breath"), giving yetanother version of its etymological origin, by claimingthat "it seems to have taken its name pneumon due to itsshape as it plays the role of the reception (hypodohi inGreek) of pneumata (winds)", while Plato6 states thatpneumon is the cashier of pneumata (winds) of the hu-man body. In addition, Euripides7 emphasizes that pneu-ma or pnoe comes from pneumones (the lungs). So-phocles 8 estimates that pneumones (lungs) are the mostvivid parts of the human body.

The word pneumonologia is not found anywhere inthe ancient Greek literature as a composite form. In theancient Greek texts4,9,10, we often find the words pneu-mon or pleumon (both meaning the lung) pneumonis,or pneumonitis,or pneumonia (all meaning inflamma-tion of the lungs)4,11, and other words relevant to them,but not the word pneumonologia. Consequently, the lastword is a modern Greek term. It is a composite wordconsisting of the ancient Greek words pneumon + log-os, meaning speech or logic, and is derived from the an-cient Greek verb lego, meaning to speak about.

Pneumonologia in Greek means the following: (1)the talk on pneumonology matters; (2) the scientific fieldof pneumonology or the occupation of the specialty ofpneumonology; (3) the study of pneumonology as a spe-cialty; and (4) the total of what the first component (pneu-mon-) of the word pneumonologia means12. This wordof Greek origin, pneumonologia, must be translated intopneumonology in English.

PNEUMA

However, many modern scientists simplify the wordpneumonology as pneumology without understandingand knowing why this shortened version is not correct.In the case of the wrongly used term pneumology, onecan emphasize that the first component, the word pneu-ma, comes from the Indo-European word *pnefo, whichis the origin of the ancient Greek verb pneo2. Pneumameans pnoe` (blow), the blow of the wind, breath, andsoul-heart in ancient Greek and, finally, the air. Conse-quently, from the word pneuma the term pneumothoraxcan be derived, but not the term pneumonology. What ismore, in modern medical dictionaries13 we often find both

the word pneuma (air, breathing) and its combined formswithout any discrimination from the word pneumon andits derivatives. Thus, under the catchword pneuma, thefollowing meanings can be listed: (1) air; (2) the lungs;(3) breathing and respiration; and (4) pneumonia. Someof these meanings are incorrect; the road to accuracyseems to be long. We finally find catchwords such aspneumatocele, pneumomediastinum, pneumatorrhachis,pneumatosis, or pneumaturia, all words deriving frompneuma that are connected with air.

In omitting the suffix -no, which ultimately is the dif-ference between pneumonology and pneumology, as inpneumocentesis, pneumology,or pneumoconio-sis12, andinstead using the words pneumonocentesis, pneumonol-ogy, or pneumonoconiosis, it is not clear that the first setof words is connected with the air, while the second, cor-rect set, which is connected with the suffix -no, and isrelated to the lungs.

As a synonym for the term pneumology, one can usethe term pneumatology, which derives from the genitiveof the word pneuma-tos + logos, and also the term aer-ology, because aer means air in Greek and is a synonymfor pneuma. However, pneumatology is the study of themediator of ghosts in the communication between Godand humans12, while aerology or aerologia is to speakabout the air12, completely different meanings from theterm lung (pneumon in Greek). Pneuma means mainlyair in Greek and not the lung.

RELATED TERMS OF VARIOUS ORIGINS

Instead of the term pneumonology, some users ac-cept as official terms like pulmonology, and as being ac-ceptable synonyms like the following13: pulmonary med-icine and pulmonary specialist (eg, pediatrician); andthoracic surgeon. Some users characterize as borderlineother hypothetical synonyms such as chest medicine,whereas at the same time they suggest that terms likepneumology, lung medicine, or thoracic medicine shouldbe discouraged (emphasizing the phrase "for almost anyapplication") and that terms such as bronchology,respirology, and lungology should be banned13-15. Theseterms are in use today but are not correct, and they couldnot play the role of synonym to the word pneumonology.

Lung medicine, for example, is a phrase that omits


other relevant subjects that belong to the field of pneu-monology, whereas the term thoracic medicine is not usedin modern Greek since it is not correct for general use.It refers not only to the lungs but also to the heart andthe other organs of the thorax.

In particular, the term pulmonology might be accept-able as a synonym if one did not have to combine a Latinword meaning lung (pulmo) and a Greek word meaningspeech or talk (logos), neither of which have in them theGreek suffix -no (pulmonology), which might send us inanother direction.

To the argument that "pneumonology, a good candi-date, might be confused with pneumoniology, a study ofpneumonias,"14 one can counter that when a user knewthe origin of the terms, he could hardly make a mistake.To another argument that says that "pneumology is anacceptably shortened form of pneumonology, avoids theabove confusion, is used on the European continent, andis listed in modern medical dictionaries,"14 one can claimthat pneumology14 is not an acceptable shortened formof pneumonology, because the first term comes frompneuma, while the latter derives from pneumon. Further-more, the term that is widely used today, otorhinolaryn-gology, is etymologically correct although it is long.

Thus, the confusion would not come from the simi-larity of the terms, but from the ignorance of the realmeanings and origins of the terms, which modern medi-cal dictionaries should provide. Some terms seem to de-pict the reality; others represent the simplification. Butwhat about the accuracy?

As far as the use of other terms such as lung medi-cine, bronchology,or respirology, which are presentedoccasionally as synonyms to pneumonology, one can sim-ply argue that they are not able to cover every facet ofthis specialty that only the term pneumonology can fullyexpress. In the Spanish medical language, one can alsofind the term neumology or neumologia. However, theword composed of the Greek words neuma and logosleads us to another meaning that is completely differentfrom the user's intention, because the word neuma actu-ally means a kind of head movement that expresses agree-ment or emphasis of something. The ancient Greek wordneuma comes from the verb neuo and has nothing to dowith the lungs. Such usage in published articles has beenresponsible for the wrong use of the main term for the

last 25 years.In conclusion, the main medical term of Greek ori-

gin, pneumonologia, and its derivatives have to be trans-lated into pneumonology and not pneumology in Eng-lish, because we speak about the lungs and whatever be-longs to this specialty that concerns the lungs, and we donot speak about the air, even though the lungs are filledwith air. This example demonstrates the roots of pneu-monology in the ancient Greek world and shows also therichness of the Greek language. The clarification of itsmeaning provides the opportunity to see not only the lin-guistic origin of such words, but also the chance to usethem consciously and properly.

REFERENCES

1. Antisthenis Fragmenta. In: Dumont DS, Smith RM, eds.Thesaurus linguae Graecae [book on CD-ROM, version10d-32]. Los Angeles, CA: Musaios, 1992-1995.

2. Hoffman JB. Etymologisches worterbuch des Grie-chischen. M?nchen, Germany: Verlag Von R. Olden-bourg, 1950.

3. Homer. The iliad. Murray AT, trans. Cambridge, MA:Harvard University Press, 1976- 1978; rhapsody D (verse528), and rhapsody Y (verse 486).

4. Liddell HG, Scott RA. Greek-English lexicon. 9th ed.London, UK: Clarendon Press, 1996.

5. Aristotle. Peri anapnoe's (about breath). In: Dumont DS,Smith RM, eds. Thesaurus linguae Greacae [book onCD-ROM, version 10d-32]. Los Angeles, CA: Musaios,1992-1995; chapter 10, section 6.

6. Plato. Timeos. In: Bury RG, trans. Plato's works (volII). Cambridge, MA: Harvard University Press, 1975;70c.

7. Euripides. Orestis (vol II). Way AS, trans. Cambridge,MA: Harvard University Press, 1978; verse 277.

8. Sophocles. Trachiniae (vol II). Storr F, trans. Cambridge,MA: Harvard University Press, 1978; verse 778.

9. Hippocrates. The sacred disease. In: Jones WHS, trans.Hippocrates works (vol II). Cambridge, MA: HarvardUniversity Press, 1967; chapter 9, section 5.

10. Hippocrates. Aphorisms. In: Jones WHS, trans. Hippoc-rates works (vol II). Cambridge, MA: Harvard Univer-sity Press, 1967; Aphorism No. LXXXVII.

11. Galen. Explanation of the Hippocratic terms. In: Du-mont DS, Smith RM, eds. Thesaurus linguae Greacae[book on CD-ROM, version 10d-32]. Los Angeles, CA:Musaios, 1992- 1995; 546.


12. Babiniotis G. Lexicon of the new Greek language. Ath-ens, Greece: Lexicology Center, 1998.

13. McDonough JT Jr, ed. Stedman's medical dictionary.Baltimore, MD: Williams & Wilkins, 1987.

14. Waring W. A lung is a lung is a lung. Am Rev Respir Dis1976; 113:1- 2.

15. Gaensler AE, Goff MA. The passing of the phthisiolo-gist. Am Rev Respir Dis 1977; 113:569-572.

Ì. ÃêÜãêá

Bñá÷åßá Áíáóêüðçóç

¢óèìá êáé åãêõìïóýíç

ÐÅÑÉËÇØÇ. Ôï Üóèìá óõ÷íÜ åðéðëÝêåé ôçí åãêõìïóýíç, ïé äåêñßóåéò Üóèìáôïò ðñïêáëïýí õðïîõãïíáéìßá ðïõ áðåéëåß ôï Ýì-âñõï. Åßíáé áðáñáßôçôï ëïéðüí íá èåñáðåýåôáé ôï Üóèìá óùóôÜêáé ìå öÜñìáêá ðïõ äåí ðñïêáëïýí óõããåíåßò áíùìáëßåò. Óôçíáíáóêüðçóç áíáöÝñïíôáé ïé áëëçëåðéäñÜóåéò Üóèìáôïò êáé åãêõ-ìïóýíçò êáé ïé ïäçãßåò ãéá ôç óõíäõáóìÝíç áíôéìåôþðéóç. Ðíåý-ìùí 2002, 15(2)137-142.

Ôï Üóèìá åßíáé Ýíá áðü ôá ðéï êïéíÜ íïóÞìáôá ðïõ åðéðëÝêïõí ôçíåãêõìïóýíç. Ðñüóöáôåò ìåëÝôåò äåß÷íïõí ðùò ðåñßðïõ 0,5 Ýùò 4% ôùíêõÞóåùí åðéðëÝêïíôáé áðü Üóèìá1-3. ÅðéðëÝïí, ïé ìåëÝôåò äåß÷íïõí üôéôï ìçôñéêü Üóèìá óõó÷åôßæåôáé óõ÷íÜ ìå óïâáñÜ äõóìåíÞ óõìâÜíôá ôçòêýçóçò üðùò ï èÜíáôïò ôïõ åìâñýïõ, ç ðñüùñç äéáêïðÞ ôçò êýçóçò, õðåñ-ôáóéêÝò äéáôáñá÷Ýò Þ äéáâÞôçò ôçò êýçóçò üðùò êáé áéìïññáãßá ðñéí êáéìåôÜ ôïí ôïêåôü1-4. Ãé' áõôïýò ôïõò ëüãïõò, ïé êõïöïñïýóåò ãõíáßêåò ìåìç åëåã÷üìåíï Üóèìá áðïôåëïýí ìéá ïìÜäá õøçëïý êéíäýíïõ ðïõ ÷ñåéÜ-æåôáé ðñïóåêôéêÞ ðáñáêïëïýèçóç êáé êáôÜëëçëç èåñáðåßá.

ÖÕÓÉÏËÏÃÉÊÅÓ ÁËËÁÃÅÓ ÊÁÔÁ ÔÇÍ ÅÃÊÕÌÏÓÕÍÇ

Ïé ðåñéóóüôåñåò áëëáãÝò óôç öõóéïëïãßá ôïõ áíáðíåõóôéêïý óõóôÞ-ìáôïò ïöåßëïíôáé óôçí áõîçìÝíç ðáñáãùãÞ ïñìïíþí5. Ôá åðßðåäá ôçòðñïãåóôåñüíçò, ôçò ïéóôñáäéüëçò êáé ôçò êïñôéæüëçò áõîÜíïõí êáôÜ ôçíêýçóç. Ç ðñïãåóôåñüíç áõîÜíåé ôïí êáôÜ ëåðôü üãêï áåñéóìïý êáé ìåéþ-íåé ôçí áíôßóôáóç ôùí áåñáãùãþí êáé ôùí áããåßùí. Ïé áëëáãÝò óôç ëåé-ôïõñãßá ôùí ðíåõìüíùí ðåñéëáìâÜíïõí ôç ìåßùóç ôçò FRC êáé ôïõ RVêáé ìéá áýîçóç óôçí IC åíþ ç VC äåí åðçñåÜæåôáé6-8. Ëüãù ôïõ áõîçìÝíïõêáôÜ ëåðôüí áåñéóìïý (êáôÜ 20-40%), ôá áÝñéá áßìáôïò áëëÜæïõí óçìá-íôéêÜ, ç PO2 ãßíåôáé 100-105 mmHg êáé ç PCO2 åßíáé 32-34 mmHg, åíþ ôïpH äéáôçñåßôáé ëüãù áõîçìÝíçò íåöñéêÞò áðÝêñéóçò äéôôáíèñáêéêþí.

ÖõóéïëïãéêÜ óôçí åãêõìïóýíç äåí ðáñáôçñïýíôáé óçìáíôéêÝò áëëá-ãÝò óôïõò äõíáìéêïýò üãêïõò. ÏðïéåóäÞðïôå ëïéðüí áëëáãÝò óôç FEV1,óôï ëüãï FEV1/FVC Þ óôç ìÝãéóôç ñïÞ åßíáé ðáèïëïãéêÝò êáé èá ðñÝðåé

Åðßê. Êáèçã. Ðíåõìïíïëïãßáò, ÐíåõìïíïëïãéêÞ Êëé-íéêÞ Ðáíåðéóôçìßïõ Áèçíþí, ÍÍÈÁ "Ç ÓÙÔÇÑÉÁ"

ËÝîåéò êëåéäéÜ:¢óèìá, åãêõìïóýíç, öÜñìáêá, âñïã÷ïäéáóôáë-ôéêÜ, êïñôéêïåéäÞ

Aëëçëïãñáößá:Ì. ÃêÜãêá, Åðßê. Êáèçã. Ðíåõìïíïëïãßáò, Ðíåõ-ìïíïëïãéêÞ ÊëéíéêÞ Ðáíåðéóôçìßïõ Áèçíþí,ÍÍÈÁ, Ìåóïãåßùí 152, 115 27 ÁèÞíá,ôçë.: 010 7778827

138 ÐÍÅÕÌÙÍ Ôåý÷ïò 2ï, Ôüìïò 15ïò, ÌÜéïò - Áýãïõóôïò 2002

íá åðéóôÞóïõí ôçí ðñïóï÷Þ ôïõ ãéáôñïý. Äýóðíïéá Þìéá áõîçìÝíç óõíáßóèçóç ôçò áíáðíïÞò ßóùò åßíáé ðá-ñïýóá êáôÜ ôçí åãêõìïóýíç, éäéáßôåñá óôï ôåëåõôáßïôñßìçíï. Áõôü áðïäßäåôáé åßôå óôï áõîçìÝíï Ýñãï ôçòáíáðíïÞò Þ óôéò åíôïíüôåñåò áíáðíåõóôéêÝò êéíÞóåéò.ÅðéðëÝïí, óõ÷íÜ õðÜñ÷åé ñéíéêÞ áðüöñáîç êáôÜ ôçíêýçóç êáé ïöåßëåôáé óå õðåñáéìßá êáé ïßäçìá, áõôÞ äåôïíßæåé ôçí áõîçìÝíç áßóèçóç ôçò áíáðíïÞò. Åßíáé óç-ìáíôéêü íá äéáöïñïðïéÞóïõìå áõôÞ ôçí ïìáëÞ äýóðíïéáôçò åãêõìïóýíçò áðü ôçí ðáèïëïãéêÞ äýóðíïéá.

ÅÐÉÄÑAÓÅÉÓ ÔÇÓ ÅÃÊÕÌÏÓYÍÇÓ ÓÔÏ ÁÓÈÌÁ

Ôï Üóèìá ìðïñåß íá âåëôéùèåß, íá óôáèåñïðïéçèåßÞ íá ÷åéñïôåñÝøåé êáôÜ ôçí åãêõìïóýíç êáé ìåñéêÝò áíá-óêïðÞóåéò äåß÷íïõí ôá áêüëïõèá óôïé÷åßá8-14: ÓôïÜóèìá Ýíá ôñßôï ôùí ãõíáéêþí åðçñåÜæïíôáé áñíçôéêÜ,ôï Ýíá ôñßôï âåëôéþíåôáé êáé ôï Ýíá ôñßôï ðáñáìÝíåé óôá-èåñü. Ïé ãõíáßêåò ìå óïâáñü Üóèìá åßíáé ðéï ðéèáíüíá åðéäåéíùèïýí åíþ ïé ãõíáßêåò ìå Þðéï Üóèìá óõíÞ-èùò âåëôéþíïíôáé. Ïé áëëáãÝò óôï Üóèìá êáôÜ ôç äéÜñ-êåéá ôçò åãêõìïóýíçò åßíáé óõíÞèùò üìïéåò óå åðüìå-íåò êõÞóåéò. Ïé ðáñïîýíóåéò Üóèìáôïò åßíáé ðéï óõ÷íÝòóôï ôñßôï ôñßìçíï êáé ëßãåò áóèåíåßò ãßíïíôáé óõìðôù-ìáôéêÝò êáôÜ ôïí ôïêåôü. ÖõóéïëïãéêÜ, ïé áëëáãÝò ðïõóçìåéþíïíôáé óôïí Ýëåã÷ï ôïõ Üóèìáôïò êáôÜ ôçí êýç-óç åðáíÝñ÷ïíôáé óôá ðñï ôçò åãêõìïóýíçò åðßðåäá 3ìÞíåò ìåôÜ ôïí ôïêåôü. Ìéá ðñüóöáôç ìåëÝôç áíáöÝñåéüôé ïé Ýãêõåò ãõíáßêåò ðïõ åðéóêÝðôïíôáé ôï ôìÞìá Åðåé-ãüíôùí Ðåñéóôáôéêþí ìå óïâáñü Üóèìá äåí äéáöÝñïõíáðü ôéò ãõíáßêåò ðïõ äåí åãêõìïíïýí óå óïâáñüôçôá Þóå äéÜñêåéá ôçò êñßóçò. ¼ìùò, ïé Ýãêõåò ãõíáßêåò áíôé-ìåôùðßæïíôáé ëéãüôåñï åðéèåôéêÜ ìå êïñôéêïóôåñïåéäÞêáé Ý÷ïõí ôñéðëÜóéá ðéèáíüôçôá íá åîáêïëïõèïýí íáâñßóêïíôáé óå ðáñüîõíóç ìåôÜ áðü 2 åâäïìÜäåò15.

ÅÐÉÄÑÁÓÅÉÓ ÔÏÕ ÁÓÈÌÁÔÏÓ ÓÔÇ ÌÇÔÅÑÁ ÊÁÉ ÔÏÅÌÂÑÕÏ

á) ÅðéäñÜóåéò óôç ìçôÝñá

Ïé ìçôñéêÝò åðéðëïêÝò ðïõ ó÷åôßæïíôáé ìå ôï ìç åëåã-÷üìåíï Üóèìá ðåñéëáìâÜíïõí ðñïåêëáìøßá, ðñüäñï-ìï ðëáêïýíôá, õðÝñôáóç ôçò êýçóçò, õðåñåìåóßá ôçòåãêýïõ, êïëðéêÞ áéìïññáãßá, ôïîéíáéìßá, ðñïêëçôü êáéåðéðëåãìÝíï ôïêåôü, êáéóáñéêÞ ôïìÞ êáé ðáñáôåôáìÝ-

íç íïóïêïìåéáêÞ ðáñáìïíÞ ôçò ìçôÝñáò1-5. Ìéá ðñü-óöáôç ìåëÝôç Ýäåéîå üôé ãõíáßêåò ìå Üóèìá Ý÷ïõí áõ-îçìÝíï êßíäõíï ãéá êáèåìéÜ áðü áõôÝò ôéò åðéðëïêÝò óåó÷Ýóç ìå ôéò ãõíáßêåò ðïõ äåí Ý÷ïõí Üóèìá (OR 1,6-2,2)4. ÁõôÜ ôá óôïé÷åßá ôïíßæïõí ôçí áíÜãêç ãéá Ýíôïíçèåñáðåßá ôïõ Üóèìáôïò êáôÜ ôçí êýçóç.

â) ÅðéäñÜóåéò ôïõ Üóèìáôïò óôï Ýìâñõï

Ôï áßìá ôïõ åìâñýïõ ïîõãïíþíåôáé óôïí áíèñþðé-íï ðëáêïýíôá. Ôï ïîõãïíùìÝíï áßìá óôçí ïìöáëéêÞöëÝâá åîéóïññïðåß ìå ôï ìçôñéêü öëåâéêü áßìá. Ãé� áõôüóôï ïîõãïíùìÝíï åìâñõéêü áßìá ç PO2 åßíáé ðïëý ÷á-ìçëÞ êáé áíÝñ÷åôáé óå 29-37 mmÇg. Ôï Ýìâñõï áíÝ÷å-ôáé áõôÞ ôç ÷áìçëÞ PO2 åðåéäÞ ÷ñçóéìïðïéåß áíôéóôáè-ìéóôéêïýò ìç÷áíéóìïýò ðïõ ðåñéëáìâÜíïõí õøçëÞ óõ-ãêÝíôñùóç åìâñõéêÞò áéìïóöáéñßíçò, ìéá áëëáãÞ èÝóçòóôçí êáìðýëç êïñåóìïý áéìïóöáéñßíçò ðïõ õðïóôçñß-æåé ôçí áðïäÝóìåõóç ïîõãüíïõ óôï Ýìâñõï, õøçëü åì-âñõéêü êáñäéáêü ðáëìü êáé ìéá ðñïíïìéáêÞ äéáíïìÞôçò åìâñõéêÞò êáñäéáêÞò ðáñï÷Þò óå æùôéêÜ üñãáíá,üðùò ï åãêÝöáëïò êáé ç êáñäéÜ. Êñßóéìç áíáðíåõóôéêÞáóèÝíåéá ôçò ìçôÝñáò üðùò ìéá óïâáñÞ ðáñüîõíóç ôïõÜóèìáôïò, ìðïñåß íá ïäçãÞóåé óå ìéá ðôþóç ôçò ìçôñé-êÞò áñôçñéáêÞò PO2 êáé ìéá Ýíôïíç ìåßùóç óôçí PO2 ôïõåìâñýïõ êáé ôçí ïîõãüíùóç ôùí éóôþí. ÅðéðëÝïí, áíôé-óôáèìéóôéêïß ìçôñéêïß ìç÷áíéóìïß èá ôåßíïõí íá óõíôç-ñïýí ôçí ïîõãüíùóç êáé ôç ñïÞ ôïõ áßìáôïò óôá æùôéêÜüñãáíá ôçò ìçôÝñáò, óå âÜñïò ôçò ñïÞò ôïõ áßìáôïò óôçìÞôñá êáé ôçò ïîõãüíùóçò ôïõ åìâñýïõ. Ãé� áõôü, êßí-äõíïò ãéá ôï Ýìâñõï õðÜñ÷åé áêüìç êáé åðß áðïõóßáòìçôñéêÞò õðïîßáò Þ õðüôáóçò. Ïé åðéðëïêÝò ôïõ åìâñýïõóôçí åãêõìïóýíç åðß ãõíáéêþí ìå ìç åëåã÷üìåíï ÜóèìáðåñéëáìâÜíïõí áõîçìÝíï êßíäõíï ðåñéãåííçôéêÞò èíç-óéìüôçôáò, åíäïìÞôñéá êáèõóôÝñçóç ôçò áíÜðôõîçò, ÷á-ìçëü âÜñïò ãÝííçóçò, ðñüùñç ãÝííçóç êáé õðïîßá ôïõíåïãíïý16-19.

ÅËÅÃ×ÏÓ ÁÓÈÌÁÔÏÓ ÓÔÇÍ ÅÃÊÕÌÏÓÕÍÇ

Ïé óôü÷ïé ôçò èåñáðåßáò ôïõ Üóèìáôïò óôçí åãêõ-ìïóýíç Ý÷ïõí ùò óôü÷ï ôçí êáëÞ êáôÜóôáóç õãåßáò êáéôçò ìçôÝñáò êáé ôïõ åìâñýïõ. Éäéáßôåñá ïé óôü÷ïé åßíáé:� ¸ëåã÷ïò ôùí çìåñÞóéùí êáé íõ÷ôåñéíþí óõìðôùìÜ-

ôùí� ÄéáôÞñçóç ôçò öõóéïëïãéêÞò Þ ôçò êáëýôåñçò ðíåõ-

139PNEUMON Number 2, Vol. 15, Ìay - August 2002

óìÝíá óå ìåëÝôåò êõïöïñßáò óå æþá êáé áíèñþðïõò (Ðß-íáêáò 1). Ôá öÜñìáêá óôçí êáôçãïñßá × áíôåíäåßêíõ-íôáé ãéá ÷ñÞóç êáôÜ ôçí åãêõìïóýíç. ÊáíÝíá öÜñìáêïãéá ôï Üóèìá ðïõ êõêëïöïñåß äåí Ý÷åé ôáîéíïìçèåß óôçíïìÜäá Á üðïõ ïé ìåëÝôåò óå æþá êáé áíèñþðïõò äåíäåß÷íïõí êáíÝíá êßíäõíï ãéá ôï Ýìâñõï. Ôá ðéï ðïëëÜöÜñìáêá åßíáé ôáîéíïìçìÝíá óôéò ïìÜäåò Â êáé C üðïõôá ïöÝëç áðü ôçí áãùãÞ èåùñåßôáé üôé õðåñâáßíïõí ôïíêßíäõíï. Óå áóèìáôéêÞ Ýãêõï ï óïâáñüôåñïò êßíäõíïòóôçí åãêõìïóýíç ïöåßëåôáé óå ìç åëåã÷üìåíï Üóèìá.Áõôü ðñÝðåé íá ôïíéóèåß óôçí áóèåíÞ. ¼ìùò, ç ðéèáíü-ôçôá êéíäýíïõ áðü ôç öáñìáêåõôéêÞ áãùãÞ ðñÝðåé åðß-óçò íá åîçãçèåß êáé ç óõíáßíåóç ôçò áóèåíïýò ðñÝðåéíá æçôçèåß êáé íá êáôáãñáöåß. Óôçí åðéëïãÞ óõãêåêñé-ìÝíçò öáñìáêåõôéêÞò áãùãÞò ãéá ÷ñÞóç êáôÜ ôçí êýç-óç, ðñïôéìïýíôáé ôá åéóðíåüìåíá êáé ôá ðáëéüôåñá öÜñ-ìáêá ìå ìáêñÜ éóôïñßá ÷ñÞóçò êáé ìå ìåãÜëï áñéèìüäçìïóéåõìÝíùí óôïé÷åßùí áóöáëåßáò. Åéóðíåüìåíïé â2

äéåãÝñôåò, åéóðíåüìåíá óôåñïåéäÞ, ÷ñùìïãëõêßíç, èåï-öõëëßíç êáé óôåñïåéäÞ áðü ôï óôüìá åßíáé öÜñìáêá ðïõìðïñïýí íá ÷ïñçãçèïýí êáôÜ ôçí åãêõìïóýíç. Ç Êá-íáäéêÞ ¸êèåóç ôùí èÝóåùí ïìïöùíßáò ãéá ôï Üóèìáôïõ 19992 êáèþò êáé ç áíôßóôïé÷ç ôïõ Áìåñéêáíéêïý Éí-óôéôïýôïõ Õãåßáò (NIH) ôïõ 19933 ôïíßæåé ôç óðïõäáéü-ôçôá ôçò ÷ñÞóçò ôùí åéóðíåïìÝíùí öáñìÜêùí óå ó÷Ýóçìå ôá áðü ôïõ óôüìáôïò êáé ôùí ðáëáéüôåñùí óå ó÷Ýóçìå ôá íåüôåñá ãéá ÷ñÞóç óôçí åãêõìïóýíç. Áíáêïõöé-óôéêÜ êáé ðñïöõëáêôéêÜ öÜñìáêá ðïõ ìðïñïýí íá ÷ñç-óéìïðïéçèïýí ðåñéëáìâÜíïõí ôá áêüëïõèá:

ìïíéêÞò ëåéôïõñãßáò� ÖõóéïëïãéêÜ åðßðåäá äñáóôçñéüôçôáò� Ðñüëçøç óïâáñþí ðáñïîýíóåùí� ÅëÜ÷éóôåò äõíáôÝò ðáñåíÝñãåéåò áðü ôá öÜñìáêá� ÃÝííçóç åíüò õãéïýò íåïãíïý.

Ç óôñáôçãéêÞ ãéá ôïí Ýëåã÷ï èá åßíáé åðéôõ÷Þò åÜíâáóßæåôáé óå:� ÁêñéâÞ åêôßìçóç ôçò óïâáñüôçôáò� Óõ÷íÞ ðáñáêïëïýèçóç� Åêðáßäåõóç ôïõ áóèåíÞ� ÁðïöõãÞ ôùí åêëõôéêþí ðáñáãüíôùí ôïõ Üóèìáôïò� ÖáñìáêåõôéêÞ èåñáðåßá.

Åßíáé óçìáíôéêü íá ðáñÝ÷åôáé ðáñÜëëçëá ç öñïíôß-äá ôïõ Üóèìáôïò ìå ìáéåõôéêÞ öñïíôßäá, éäéáßôåñá óåðåñéðôþóåéò ìÝôñéïõ-óïâáñïý Üóèìáôïò Þ åãêõìïóýíçòìå åðéðëïêÝò. Åßíáé åðßóçò ðïëý óçìáíôéêü íá áðïöåý-ãïíôáé ïé åêëõôéêïß ðáñÜãïíôåò üðïõ åßíáé äõíáôü. ÇáíáöïñÜ ôïõ ÁìåñéêÜíéêïõ Éíóôéôïýôïõ Õãåßáò (NIH)ôïõ 1993 ãéá ôï Üóèìá êáé ôçí åãêõìïóýíç2 ôïíßæåé ôçóïâáñüôçôá ôçò åðéèåôéêÞò èåñáðåßáò ôïõ Üóèìáôïòóôçí åãêõìïóýíç, ðïõ ðñÝðåé íá åßíáé üìïéá ìå ôç èå-ñáðåßá ôùí ìç åãêýùí. Ðáñ� üëá áõôÜ, üôáí åðéëÝãïõ-ìå ïðïéïäÞðïôå öÜñìáêï óôçí åãêõìïóýíç, ôá èåñá-ðåõôéêÜ ïöÝëç ðñÝðåé íá óôáèìéóèïýí Ýíáíôé ôùí ðéèá-íþí êéíäýíùí ãéá ôç ìçôÝñá êáé ôï Ýìâñõï. Ï Ïñãáíé-óìüò Ôñïößìùí êáé ÖáñìÜêùí (FDA) óôéò ÇÐÁ äçìï-óßåõóå ïäçãßåò ãéá ôç ÷ïñÞãçóç öáñìÜêùí êáôÜ ôçíåãêõìïóýíç. Ôá öÜñìáêá ôáîéíïìÞèçêáí óå ïìÜäåò A,B, C, D êáé × óýìöùíá ìå äåäïìÝíá áóöÜëåéáò âáóé-

Ðßíáêáò 1. FDA: Âáèìïíüìçóç ôùí öáñìÜêùí ãéá ÷ñÞóç óôçí åãêõìïóýíç

Êáôçãïñßá Ïñéóìüò

A Åëåã÷üìåíåò ìåëÝôåò äåß÷íïõí üôé äåí õðÜñ÷åé êßíäõíïò � ÌåëÝôåò óå æþá äåí äåß÷íïõí ôåñáôïãÝíåóç êáé óå åðáñ-êåßò, êáëÜ åëåã÷üìåíåò ìåëÝôåò óå Ýãêõåò ãõíáßêåò äåí Ý÷åé áðïäåé÷èåß êßíäõíïò ãéá ôï Ýìâñõï.

B Äåí õðÜñ÷åé Ýíäåéîç ãéá êßíäõíï óå áíèñþðïõò � Åßôå ôá óôïé÷åßá áðü ìåëÝôåò óå æþá åßíáé áñíçôéêÜ áëëÜ äåíÝ÷ïõí ãßíåé åðáñêåßò ìåëÝôåò óå áíèñþðïõò åßôå ôá óôïé÷åßá áðü ìåëÝôåò óå æþá äåß÷íïõí êßíäõíï áëëÜ ôá óôïé-÷åßá áðü ìåëÝôåò óå áíèñþðïõò äåí äåß÷íïõí.

C Ï êßíäõíïò äåí ìðïñåß íá áðïêëåéóèåß � Ïé ìåëÝôåò óå áíèñþðïõò åßíáé åëëéðåßò êáé ïé ìåëÝôåò óå æþá åßíáé åßôåèåôéêÝò ãéá êßíäõíï óôï Ýìâñõï Þ åðßóçò åßíáé åëëéðåßò. ¼ìùò, äõíçôéêÜ ïöÝëç ßóùò áéôéïëïãïýí ôï äõíçôéêüêßíäõíï.

D ÈåôéêÞ Ýíäåéîç ãéá êßíäõíï � ÅñåõíçôéêÜ äåäïìÝíá êáé óôïé÷åßá ðïõ óõëëÝãïíôáé ìåôÜ ôçí êõêëïöïñßá ôïõ öáñ-ìÜêïõ äåß÷íïõí êßíäõíï ãéá ôï Ýìâñõï. Ðáñ� üëá áõôÜ, ðéèáíÜ ïöÝëç ßóùò õðåñâáßíïõí ôïí êßíäõíï.

X Áíôåíäåßêíõôáé êáôÜ ôçí êýçóç � ÌåëÝôåò óå æþá Þ áíèñþðïõò Þ åñåõíçôéêÝò Þ ìåôÜ ôçí êõêëïöïñßá ôïõ öáñìÜ-êïõ áíáöïñÝò Ý÷ïõí äåßîåé êßíäõíï ãéá ôï Ýìâñõï, ðïõ óßãïõñá õðåñâáßíïõí ïðïéïäÞðïôå ðéèáíü üöåëïò ãéá ôçíáóèåíÞ.


â-áäñåíåñãéêïß áãùíéóôÝò

Ïé åêëåêôéêïß â2 áãùíéóôÝò öáßíåôáé íá åßíáé áóöá-ëåßò ãéá ÷ñÞóç óôçí åãêõìïóýíç êáé åéóðíåüìåíåò ìïñ-öÝò ÷ñçóéìïðïéïýíôáé åõñÝùò. ÌåãÜëåò ìåëÝôåò äåíÝ÷ïõí äåßîåé êÜðïéï êßíäõíï ðïõ íá ó÷åôßæåôáé ìå ôç÷ñÞóç ôïõò2,20. Ç ôåñâïõôáëßíç êáôáôÜóóåôáé óôçí êá-ôçãïñßá Â åíþ üëïé ïé Üëëïé â2 áãùíéóôÝò êáôáôÜóóï-íôáé óôçí êáôçãïñßá C. Ç ÷ñÞóç åðéíåöñßíçò äåí óõíé-óôÜôáé ãéáôß ìðïñåß íá äçìéïõñãÞóåé áããåéïóýóðáóç óôçìÞôñá êáé íá ìåéþóåé ôçí êõêëïöïñßá ôïõ áßìáôïò óôçìÞôñá êáé óôïí ðëáêïýíôá. Ç áðü ôïõ óôüìáôïò ÷ïñÞ-ãçóç â2 áãùíéóôþí ìðïñåß íá ðñïêáëÝóåé ôá÷õêáñäßá,õðïãëõêáéìßá êáé ôñüìï åíþ óôï 3ï ôñßìçíï ôçò åãêõ-ìïóýíçò ç per os ÷ñÞóç, ìðïñåß íá äñÜóåé ìõï÷áëáñù-ôéêÜ óôç ìÞôñá êáé íá áíáêüøåé ôéò ùäßíåò, êáé ùò åêôïýôïõ, ç ÷ñÞóç â2 áãùíéóôþí per os áíôåíäåßêíõôáé.

ÓôåñïåéäÞ

Ôá åéðíåüìåíá óôåñïåéäÞ èåùñïýíôáé áóöáëÞ ãéá÷ñÞóç óôçí åãêõìïóýíç. ¼ëá ôá åéóðíåüìåíá óôåñïåé-äÞ ôáîéíïìïýíôáé óôçí êáôçãïñßá C óýìöùíá ìå ôïFDA, åêôüò ôçò âïõäåóïíßäçò, ç ïðïßá ôáîéíïìåßôáé óôçíêáôçãïñßá Â. Ç ìðåêëïìåèáæüíç åßíáé ôï ðáëáéüôåñïöÜñìáêï êáé óõíéóôÜôáé áðü ôçí áíáöïñÜ ôïõ Áìåñé-êÜíéêïõ Éíóôéôïýôïõ Õãåßáò (NIH) ôïõ 19932 ãéá ÷ñÞóçêáôÜ ôçí êýçóç. Ðñüóöáôá äåäïìÝíá áðü ìéá ìåãÜëçìåëÝôç ðïõ áíáêïéíþèçêáí ôï 1999 äåí äåß÷íïõí áõîç-ìÝíï êßíäõíï óõããåíþí áíùìáëéþí óå 2014 íÞðéá áðüãõíáßêåò ðïõ ëÜìâáíáí âïõäåóïíßäç óôéò áñ÷Ýò ôçò êýç-óçò21. Ôá óôåñïåéäÞ áðü ôï óôüìá ÷ñçóéìïðïéïýíôáé ãéáôç èåñáðåßá åíüò ìåãÜëïõ áñéèìïý öëåãìïíùäþí êá-ôáóôÜóåùí êáé ãé' áõôü Ý÷ïõí ÷ñçóéìïðïéçèåß åêôåíþòêáôÜ ôçí êýçóç. ÐéèáíÜ áíåðéèýìçôá óõìâÜìáôá óôïÝìâñõï ðïõ ó÷åôßæïíôáé ìå ôç ÷ñÞóç ôùí óôåñïåéäþí áðüôï óôüìá ðåñéëáìâÜíïõí óõããåíåßò áíùìáëßåò êáé éäéáß-ôåñá ëõêüóôïìá, ÷áìçëü âÜñïò ãÝííçóçò êáé åðéíåöñé-äéáêÞ áíåðÜñêåéá ôïõ íåïãíïý. ¼ìùò, êáìéÜ áðüäåéîçãéá óõããåíåßò áíùìáëßåò äåí Ý÷åé áðïäåé÷èåß óå áíèñþ-ðïõò êáé ìéá ðñüóöáôç ìåãÜëç ìåëÝôç ìå 824 êõïöï-ñïýóåò ãõíáßêåò ìå Üóèìá êáé 678 åãêýïõò ÷ùñßò ÜóèìáÝäåéîå üôé ôá óôåñïåéäÞ áðü ôï óôüìá ó÷åôßæïíôáé ìüíïìå áõîçìÝíç åðßðôùóç ðñïåêëáìøßáò óôçí åãêõìïóý-íç22. Ðáñ� üëá áõôÜ, ïé ìåëÝôåò åðßóçò äåß÷íïõí üôé ôïóïâáñü Üóèìá êáé ïé ðáñïîýíóåéò Üóèìáôïò äåí åëÝã-÷ïíôáé êáëÜ ÷ùñßò óôåñïåéäÞ áðü ôï óôüìá15 êáé ôï ìç

åëåã÷üìåíï Üóèìá áðïôåëåß êßíäõíï êáé ãéá ôç ìçôÝñáêáé ãéá ôï Ýìâñõï. Ç ÷ñÞóç ôùí óôåñïåéäþí áðü ôï óôü-ìá êáôÜ ôçí êýçóç äåí ðñÝðåé íá áíáóôÝëëåôáé.

×ñùìüíåò

Ôï ÷ñùìïãëõêéêü íÜôñéï èåùñåßôáé áóöáëÝò ãéá÷ñÞóç óôçí åãêõìïóýíç, åßíáé ôáîéíïìçìÝíï óôçí êáôç-ãïñßá Â êáé óõíéóôÜôáé áðü ôçí áíáöïñÜ ôïõ ÁìåñéêÜ-íéêïõ Éíóôéôïýôïõ Õãåßáò (ÍÉÇ)2. ËéãïóôÝò ðëçñïöï-ñßåò åßíáé äéáèÝóéìåò ãéá ôç ÷ñÞóç ôçò íåíôïêñïìßëçò.

Ìåèõëîáíèßíåò

Ç ÷ñÞóç ôçò èåïöõëëßíçò êáé ôçò áìéíïöõëëßíçò èåù-ñåßôáé áóöáëÞò êáôÜ ôçí êýçóç (ÍÉÇ)2. ¼ìùò, äåí åß-íáé ç èåñáðåßá åêëïãÞò. ÅÜí ÷ïñçãçèåß, ôá åðßðåäá ôïõöáñìÜêïõ óôï ðëÜóìá ðñÝðåé íá åßíáé ÷áìçëÜ êáôÜ ôçíåãêõìïóýíç, ìåôáîý 8 êáé 12 ìg/ml. ¼ìïéá ìå ôïõò â2

áãùíéóôÝò, ç èåïöõëëßíç ìðïñåß íá áíáêüøåé ôéò ùäß-íåò ðéèáíþò ìÝóù áõîáíüìåíçò êõêëéêÞò ÁÌÑ êáé ìðï-ñåß íá ðñïêáëÝóåé ôá÷õêáñäßá êáé åõåñåèéóôüôçôá óôïÝìâñõï.

Áíôé÷ïëéíåñãéêÜ

Ðáñ� üëï ðïõ ôá áíôé÷ïëéíåñãéêÜ äåí áðïôåëïýí ôïâñïã÷ïäéáóôáëôéêü åêëïãÞò óôï Üóèìá, ôï éðñáôñüðéïèåùñåßôáé áóöáëÝò ãéá ÷ñÞóç óôçí åãêõìïóýíç3.

ÁíôéëåõêïôñéåíéêÜ

Ôá äåäïìÝíá óå æþá äåí äåß÷íïõí ôåñáôïãÝíåóç ìåzafirlukast êáé montelukast êáé ôáîéíïìïýíôáé óôçí êá-ôçãïñßá Â óýìöùíá ìå ôï FDA. Ðáñ� üëá áõôÜ, åðåéäÞåßíáé öÜñìáêá áðü ôï óôüìá êáé Ý÷ïõí ðáñïõóéáóèåßóôçí áãïñÜ ðñüóöáôá, äåí ìðïñïýí íá óõóôçèïýí ãéá÷ñÞóç óôçí åãêõìïóýíç3.

Áí ÷ñåéáóèïýí áíôéúóôáìéíéêÜ ãéá èåñáðåßá óõìðôù-ìÜôùí áðü ôïõò áíþôåñïõò áåñáãùãïýò, ôüôå åßíáé ðñï-ôéìüôåñï íá ÷ïñçãçèïýí ôá ðáëáéüôåñá áíôéúóôáìéíéêÜóå ó÷Ýóç ìå ôá íåüôåñá ìå ìç êáôáðñáûíôéêÝò éäéüôç-ôåò2, ðáñ� üëï ðïõ êáíÝíáò êßíäõíïò äåí Ý÷åé áðïäåé-÷èåß ìå ôá äåýôåñá3.

ÁðïóõìöïñçôéêÜ ôïõ ñéíéêïý âëåííïãüíïõ åêôüòáðü ôçí øåõäïåöåäñßíç åßíáé êáëýôåñá íá áðïöåýãï-íôáé êáôÜ ôçí êýçóç3.

ÁíôéâéïôéêÜ ìðïñïýí íá ÷ñçóéìïðïéçèïýí ãéá ôçèåñáðåßá ôùí ðáñïîýíóåùí ðïõ ïöåßëïíôáé óå ëïéìþ-

141PNEUMON Number 2, Vol. 15, Ìay - August 2002

ñéüôåñá áíôéáóèìáôéêÜ öÜñìáêá êáé ç âáèìïíüìçóÞôïõò óýìöùíá ìå ôï FDA ãéá ÷ñÞóç óôçí åãêõìïóýíç.

îåéò êáé óôïõò êáôáëüãïõò ôïõ FDA ãéá ôçí áóöÜëåéáôùí öáñìÜêùí êáôÜ ôçí êýçóç óõìðåñéëáìâÜíïíôáé êáéôá áíôéâéïôéêÜ. Óôïí Ðßíáêá 2 ðåñéëáìâÜíïíôáé ôá êõ-

Ðßíáêáò 2. ÁíôéáóèìáôéêÜ öÜñìáêá óôçí åãêõìïóýíç. FDA: âáèìïíüìçóç ôùí åéäéêþí öáñìÜêùí ãéá ôï Üóèìá ãéá ÷ñÞóç óôçíåãêõìïóýíç

Êáôçãïñßá öáñìÜêïõ ÖáñìáêåõôéêÞ ïõóßá Êáôçãïñßá FDA

â áäñåíåñãéêïß áãùíéóôÝò Áäñåíáëßíç CÌåôáðñïôåñåíüëç C

Ìðéôïëôåñüëç CÐéñâïõôåñüëç CÓáëâïõôáìüëç CÔåñâïõôáëßíç BÓáëìåôåñüëç CÖïñìïôåñüëç C

Måèõëîáíèßíåò Èåïöõëëßíç CAìéíïöõëëßíç C

Aíôé÷ïëéíåñãéêÜ Éðñáôñüðéï BÊïñôéêïóôåñïåéäÞ Âïõäåóïíßäç Â

Ìðåêëïìåèáæüíç CÖëïõíéóïëßäç CÖëïõôéêáæüíç CÔñéáìóéíïëüíç C

Ðñåäíéæüíç BÐñåäíéæïëüíç C

×ñùìüíåò ×ñùìïãëõêïíéêü íÜôñéï BÍåíôïêñïìßëç B

ÁíôéëåõêïôñéåíéêÜ Montelukast BZafirlukast B

Zileuton CAíôéúóôáìéíéêÜ Áóôåìéæüëç C

Ëïñáôáäßíç BÓåôéñéæßíç B

Öåîïöåíáäßíç C×ëùñöåíéñáìßíç B

ÁðïóõìöïñçôéêÜ Øåõäïåöåäñßíç C

SUMMARY

Ásthma in pregnancy

Gaga M.

Asthma often complicates pregnancy while asthma exacerbations may cause hypoxemia of the motherand fetus and threaten the outcome of pregnancy. It is imperative to properly treat asthma with medi-cations that have been proven to be safe for the fetus. This review discusses the impact of asthma onpregnancy as well as the current guidelines on the treatment of asthma during pregnancy. Pneumon2002, 15(2):137-142.

Key words: Asthma, pregnancy, therapy, bronchodilators, corticosteroids.


ÂÉÂËÉÏÃÑÁÖÉÁ

1. Wen SW, Demissie K, Liu S. Adverse outcomes in preg-nancies of asthmatic women: result from a Canadianpopulation. Ann Epidemiol 2001, 11: 7-12.

2. Report of the Working Group on Asthma and Pregnan-cy, Executive Summary: Management of Asthma dur-ing Pregnancy, National Asthma Education Program,National Heart Lung and Blood Institute, NHI Publica-tion No 93-3279A March 1993.

3. Boulet LP, Becker A, Berube D, Beveridge R, Ernst P,on behalf of the Canadian Asthma Consensus Group.Canadian asthma consensus report, 1999. CMAJ 1999,161(11 Suppl): S8-S14.

4. Demissie K, Breckenridge MB, Rhoads GG. Infant andmaternal outcomes in the pregnancies of asthmatic wom-en. Am J Respir Crit Care Med 1998, 158: 1091-95.

5. Mortola JF. Hormonal changes during normal pregnan-cy and their consequences. In: Asthma and Immunolog-ic Diseases in Pregnancy and Early Infancy 1998 (edsM. Schatz, R.S. Zeiger & H.N. Claman), pp. 3-25. Mar-cel Dekker, New York.

6. Bonica JJ. Maternal respiratory changes during pregnan-cy and partuition. In: Marx GF (ed) Partuition and Peri-natology. Philadelphia: F.A. Davis, 1973: 2-19.

7. Cousins L, Catanzarite VA. Fetal oxygenation, acid-basebalance, and assessment of well-being in the pregnancycomplicated by asthma or anaphylaxis. In: Asthma andImmunologic Diseases in Pregnancy and Early Infancy1998 (eds M. Schatz, R.S. Zeiger & H.N. Claman), pp.27-56. Marcel Dekker, New York.

8. Wise RA. Pulmonary function during pregnancy. In:Asthma and Immunologic Diseases in Pregnancy andEarly Infancy 1998 (eds M. Schatz, R.S. Zeiger & H.N.Claman), pp. 57-72, Marcel Dekker, New York.

9. Schatz M, Harden K, Forsythe A, et al. The course ofasthma during pregnancy, postpartum and with succes-sive pregnancies: a prospective analysis. J Allergy ClinImmunol 1998, 81: 509-517.

10. Gluck JC, Gluck PA. The effects of pregnancy on asth-

ma: a prospective study. Ann Allergy 1976, 37: 164-168.11. Juniper EF, Newhouse MT. Effect of pregnancy on asth-

ma: a systematic review and metaanalysis. In: Asthmaand Immunological Diseases in Pregnancy and EarlyInfancy 1998 (eds M Schatz, RS Zeiger & HC Claman),pp. 401-427. Marcel Dekker, New York.

12. Schatz M. Asthma during pregnancy: interrelationshipsand management. Ann Allergy 1992, 68: 123-133.

13. Weinberger ST, Weiss ST, Cohen WR, et al. Pregnancyand the lung. Am Rev Respir Dis 1980, 121: 559-581.

14. Witlin AG. Asthma in pregnancy. Semin Perinatol 1997,21: 284-97.

15. Cydulka RK, Emerman CL, Schreiber D, Molander KH,Woodruff R, Camargo CA Jr. Acute asthma among preg-nant women presenting to the emergency department.Am J Respir Crit Care Med 1999, 160: 887-892.

16. Perlow JM, Montgomery D, Morgan MA, et al. Severityof asthma and perinatal outcome. Am J Obstet Gynecol1992, 167: 963.

17. Schatz M, Zeiger RS, Hoffman CP, et al. Intrauterinegrowth is related to gestational pulmonary function inpregnant asthmatic women. Chest 1990, 98: 389.

18. Schatz M, Zeiger RS, Hoffman CP, et al. Perinatal out-comes in the pregnancies of asthmatic women: A pro-spective controlled analysis. Am J Respir Crit Care Med1995, 151: 1170.

19. Stenius-Aarniala R, Piirila P, Teramo K. Asthma andpregnancy: a prospective study of 198 pregnancies. Tho-rax 1988, 43: 12-18.

20. Schatz M, Zeiger RS, Harden KM, et al. The safety ofinhaled beta-agonist bronchodilator during pregnancy.J Allergy Clin Immunol 1988, 82: 686.

21. Köllen B, Rydhstroem H, and Aberg A. Congenitalmalformations after the use of inhaled budesonide inearly pregnancy. Obstet Gynecol 1999, 93: 392-395.

22. Schatz M, Zeiger RS, Harden K, Hoffman CC, Chiling-ar L, Petitti D. The safety of asthma and allergy medica-tions during pregnancy. J Allergy Clin Immunol 1997,100: 301-306.

ÅíäïãåíÝò Üóèìá

Âñá÷åßá Áíáóêüðçóç

ËÝîåéò-ÊëåéäéÜ: ¢óèìá, áôïðßá, êõôôáñïêßíåò

Ê. ÆåúìðÝêïãëïõ,Á. Ðáðáìé÷áëüðïõëïò,Í. ÃåùñãÜôïõ

ÐÅÑÉËÇØÇ. Ðñüóöáôåò ìåëÝôåò Ý÷ïõí äåßîåé üôé ìåôáîý åíäï-ãåíïýò êáé åîùãåíïýò Üóèìáôïò, ðáñÜ ôç äéáöïñåôéêÞ êëéíéêÞÝêöñáóç, õößóôáíôáé êïéíïß áíïóïðáèïëïãéêïß ìç÷áíéóìïß. Ìç-÷áíéóìïß, ðïõ óõíäÝïíôáé ìå ôçí ðáñáãùãÞ IgE, ìðïñåß íá óõí-äÝïíôáé ìå ôçí ðáèïãÝíåéá ôïõ Üóèìáôïò, áíåîÜñôçôá áðü ôçíáôïðßá, üðùò öáßíåôáé áðü ôá áõîçìÝíá åðßðåäá IgE ïñïý êáéêõôôÜñùí ìå õðïäï÷åßò õøçëÞò óõããÝíåéáò ãéá FcåRI, IL-4, IL-13, Éå êáé Cå. ÐåñáéôÝñù Ýñåõíåò óôï åíäïãåíÝò Üóèìá ðéèáíþòíá ïäçãÞóïõí óôçí ôáõôïðïßçóç íÝùí áëëåñãéïãüíùí, ôç ëåðôï-ìåñÝóôåñç ðåñéãñáöÞ ôçò ôïðéêÞò ðáñáãùãÞò IgE áðü ôï âñïã-÷éêü âëåííïãüíï êáé ôçí êáôáíüçóç ðéèáíÞò äõóëåéôïõñãßáò ôùíìáêñïöÜãùí. ÔÝëïò, ðñÝðåé íá äéåõêñéíéóèåß ï ñüëïò ôçò ëïßìù-îçò êáé ôùí áõôïÜíïóùí ìç÷áíéóìþí. Ðíåýìùí 2002, 15(2)143-146.

Óôéò áñ÷Ýò ôïõ áéþíá ï Rackeman ðñþôïò åéóÞãáãå ôïí üñï "åíäïãå-íÝò Üóèìá" ãéá íá ðåñéãñÜøåé ìéá ìïñöÞ ôçò íüóïõ ðïõ äå ó÷åôßæåôáé ìåáëëåñãßá1.

Ïé ìç-áëëåñãéêïß Þ åíäïãåíåßò áóèìáôéêïß ÷áñáêôçñßæïíôáé áðü áñ-íçôéêü áôïìéêü êáé ïéêïãåíåéáêü éóôïñéêü ãéá áëëåñãßá, áñíçôéêÝò äåñ-ìáôéêÝò äïêéìáóßåò óôá äéÜöïñá áëëåñãéïãüíá êáé öõóéïëïãéêÜ åðßðåäáïëéêÞò êáé åéäéêÞò áíïóïóöáéñßíçò Å (IgE) óôïí ïñü ôïõ áßìáôïò. ÅßíáéóõíÞèùò ìåãáëýôåñïé óå çëéêßá áðü ôïõò áëëåñãéêïýò áóèìáôéêïýò, çíüóïò ðñùôïåìöáíßæåôáé óôçí 3ç ìå 4ç äåêáåôßá ôçò æùÞò êáé Ý÷åé óõíÞ-èùò óïâáñüôåñç ðïñåßá. Ç ðñïóâïëÞ ôïõ ãõíáéêåßïõ öýëïõ, ç ðáñïõóßáñéíéêþí ðïëõðüäùí êáé åõáéóèçóßáò óôçí áóðéñßíç åßíáé óõ÷íüôåñåò óåáõôÞ ôç ìïñöÞ ôçò íüóïõ.

Áí êáé äåí õðÜñ÷ïõí ôåêìçñéùìÝíá åðéäçìéïëïãéêÜ äåäïìÝíá, ðéóôåýå-ôáé üôé ðåñßðïõ 10% ôùí áóèìáôéêþí áóèåíþí åßíáé ìç áëëåñãéêïß. Óå ìéáðñüóöáôç ìåëÝôç ðïõ ðñáãìáôïðïéÞèçêå óôçí Åëâåôßá (SAPALDIA) êáéóõììåôåß÷áí 9000 áóèìáôéêïß, ôï 1/3 Þôáí åíäïãåíåßò áóèìáôéêïß.

¼óïí áöïñÜ óôçí áéôéïëïãßá ôïõ ìç-áëëåñãéêïý Üóèìáôïò ðïëëÝò

10ç ÐíåõìïíïëïãéêÞ ÊëéíéêÞ ÍÍÈÁ "Ç ÓÙÔÇÑÉÁ"

Aëëçëïãñáößá:Ê. ÆåúìðÝêïãëïõ, 10ç ÐíåõìïíïëïãéêÞ ÊëéíéêÞÍÍÈÁ "Ç ÓÙÔÇÑÉÁ", Ìåóïãåßùí 152, 115 27 ÁèÞ-íá


èåùñßåò Ý÷ïõí ðñïôáèåß, áëëÜ ç áêñéâÞò áéôßá ôçò íü-óïõ äåí åßíáé áêüìç ãíùóôÞ. Ìéá èåùñßá õðïóôçñßæåéðùò ôï åíäïãåíÝò Üóèìá áðïôåëåß áõôïÜíïóï íüóçìáðïõ ðõñïäïôåßôáé áðü öëåãìïíþäç ìç÷áíéóìü, áöïýðñùôïåìöáíßæåôáé óõíÞèùò ìåôÜ áðü ëïßìùîç ôïõ áíá-ðíåõóôéêïý. ¢ëëïé ìåëåôçôÝò ðñïôåßíïõí ðùò áõôüò ïôýðïò Üóèìáôïò ó÷åôßæåôáé ìå áëëåñãßá êáé ðùò ïé åí-äïãåíåßò áóèìáôéêïß åßíáé áëëåñãéêïß óå êÜðïéï áëëåñ-ãéïãüíï ðïõ äåí Ý÷åé áêüìç ôáõôïðïéçèåß. Ìç åìöá-íåßò áëëåñãßåò óå ðñïóèåôéêÜ ôñïößìùí, ç ñýðáíóç, çóùìáôéêÞ Üóêçóç, ç ãáóôñïïéóïöáãéêÞ ðáëéíäñüìçóç,êáèþò êáé áíùìáëßåò ôïõ ðáñáóõìðáèçôéêïý óõóôÞìá-ôïò åßíáé ðéèáíÜ áßôéá ôçò íüóïõ.

¼óïí áöïñÜ óôçí áíïóïðáèïãÝíåéá ôçò íüóïõ, ðñü-óöáôåò ìåëÝôåò Ýäåéîáí ðïëëÝò ïìïéüôçôåò ìåôáîý áë-ëåñãéêïý êáé ìç-áëëåñãéêïý Üóèìáôïò. ÁõôÝò ïé ìåëÝ-ôåò ÷ñçóéìïðïéþíôáò ôéò ôå÷íéêÝò ôïõ in situ õâñéäéóìïýêáé áíïóïúóôï÷çìåßá âñÞêáí üôé ï âñïã÷éêüò âëåííï-ãüíïò êáé óôéò äýï ìïñöÝò ôçò íüóïõ ÷áñáêôçñßæåôáéáðü: i) ÁõîçìÝíç äéÞèçóç áðü åíåñãïðïéçìÝíá çùóéíüöé-

ëá (EG2+ êýôôáñá) êáé âïçèçôéêÜ Ô ëåìöïêýôôá-ñá ôýðïõ 2 (Th-2)2,3.

ii) ÁõîçìÝíç ðáñáãùãÞ éíôåñëåõêéíþí IL-2, IL-4, IL-5êáé IL-134,5.

iii) ÁõîçìÝíç ðáñáãùãÞ mRNA ãéá ôçí åëåýèåñç êáéóõíäåäåìÝíç ìïñöÞ ôçò á-õðïïìÜäáò ôïõ õðïäï÷Ýáôçò IL-56.

iv)ÁõîçìÝíç ðáñáãùãÞ ôùí ÷çìåéïêéíþí RANTES,MCP-3, MCP-4, åïôáîßíçò êáé åïôáîßíçò 27,8.

v) ÁõîçìÝíç äéÞèçóç áðü ìáóôïêýôôáñá ôá ïðïßá öÝ-ñïõí óôçí åðéöÜíåéÜ ôïõò, ôïõò õðïäï÷åßò õøçëÞòóõããÝíåéáò ôçò áíïóïóöáéñßíçò Å (FcåRI)9.

vi)ÁõîçìÝíï áñéèìü êõôôÜñùí ðïõ åêöñÜæïõí mRNAãéá ôçí ðñüäñïìç ìïñöÞ ôçò IgE (Éå), êáèþò êáé ãéáôç âáñéÜ Üëõóï å ôçò IgE (Cå)8.Ðñïò ôï ðáñüí ç ó÷Ýóç IgE, áëëåñãßáò êáé Üóèìá-

ôïò äåí Ý÷åé ðëÞñùò äéåõêñéíéóèåß. Áí êáé óôç ìåãÜëçôïõ ðëåéïøçößá ôï Üóèìá ó÷åôßæåôáé ìå ôç óõììåôï÷Þôçò IgE, ôá áõîçìÝíá åðßðåäá äåí áöïñïýí ìüíï óôïðåñéöåñéêü áßìá. ¸íäåéîç ãéá ôïðéêÞ ðáñáãùãÞ IgEÝ÷åé äåé÷èåß óå CD20+ Â ëåìöïêýôôáñá óôï ñéíéêü âëåí-íïãüíï ñéíéôéäéêþí áóèåíþí, êáèþò êáé áõîçìÝíç ðá-ñáãùãÞ êõôôÜñùí ðïõ åêöñÜæïõí ôçí ðñüäñïìç êáé ôå-ëéêÞ ìïñöÞ ôïõ õðïäï÷Ýá ôçò IgE10.

ÁõôÞ ç áðñüóìåíç óõììåôï÷Þ ôçò IgE áðü ôï âñïã-÷éêü âëåííïãüíï åíäïãåíþí áóèìáôéêþí, Ý÷åé ïäçãÞ-óåé ôïõò ìåëåôçôÝò íá ðñïôåßíïõí ôçí ýðáñîç ôïðéêÞòðáñáãùãÞò IgE áðü ôï âñïã÷éêü âëåííïãüíï, Ýóôù êáéåðß áðïõóßáò áõîçìÝíùí åðéðÝäùí óôï ðåñéöåñéêü áßìá,ç ïðïßá ßóùò íá óôñÝöåôáé åíáíôßïí ìç ôáõôïðïéçìÝ-íïõ áíôéãüíïõ-áëëåñãéïãüíïõ. ÕðÜñ÷ïõí ìÜëéóôá 2 ìå-ëÝôåò ðïõ Ýäåéîáí üôé áðïìÜêñõíóç ôùí åíäïãåíþíáóèìáôéêþí áðü Ýêèåóç óå áëëåñãéïãüíá âåëôéþíåé ôçíüóï ôïõò12. ÔÝëïò, ç ðáñïõóßá áõôïáíôéóùìÜôùí Ýíá-íôé ôïõ õðïäï÷Ýá ôçò ÉgE åßíáé ðéèáíÞ êáé óôçí ðåñß-ðôùóç ôïõ ìç-áëëåñãéêïý Üóèìáôïò, üðùò Ý÷åé äåé÷èåßêáé ãéá ôç ÷ñüíéá éäéïðáèÞ êíßäùóç, åðß áðïõóßáò áë-ëåñãéêþí, ìïëõóìáôéêþí êáé öõóéêþí áéôßùí13. ÔÝëïò,áîßæåé íá óçìåéùèåß ðùò óôï áßìá åíäïãåíþí áóèìáôé-êþí Ý÷ïõí áíé÷íåõôåß áõôïáíôéóþìáôá ðïõ êáôåõèýíï-íôáé åíáíôßïí áíôéãüíïõ ôçò åðéöÜíåéáò ôùí áéìïðåôá-ëßùí êáé åíäïèçëéáêþí êõôôÜñùí, áëëÜ ï ñüëïò ôïõòäåí Ý÷åé áêüìç ìåëåôçèåß ðëÞñùò14.

Ðáñ� üëåò ôéò ïìïéüôçôåò ðïõ ðáñáôçñÞèçêáí ìåôá-îý ôùí äýï ôýðùí Üóèìáôïò õðÜñ÷ïõí ùóôüóï êáé äéá-öïñÝò. ÁõôÝò ïé äéáöïñÝò áöïñïýí êõñßùò óôá ìáêñï-öÜãá, áöïý õøçëüò áñéèìüò ìáêñïöÜãùí êáèþò êáéìáêñïöÜãùí ðïõ öÝñïõí ôçí á-õðïïìÜäá ôïõ õðïäï-÷Ýá ôçò êõôôáñïêßíçò GM-CSF âñÝèçêå íá äéçèåß ôïâñïã÷éêü âëåííïãüíï åíäïãåíþí áóèìáôéêþí15. Óôáðôýåëá åíäïãåíþí áóèìáôéêþí, ìðïñåß íá âñåèåß ìåéù-ìÝíç ðáñáãùãÞ ôùí êõôôáñïêéíþí IL-10 êáé IL-12 ðïõåêêñßíïíôáé êáè' õðåñï÷Þ áðü ôá ìáêñïöÜãá. Áõôü ôïåýñçìá èá ìðïñïýóå íá åîçãÞóåé ôç óïâáñüôåñç ðï-ñåßá ôïõ ìç-áëëåñãéêïý Üóèìáôïò, áöïý ïé ðáñáðÜíùéíôåñëåõêßíåò Ý÷ïõí åõåñãåôéêü ñüëï óôï Üóèìá16. ÔÝ-ëïò, óôá ðôýåëá åíäïãåíþí áóèìáôéêþí17, âñÝèçêå áõ-îçìÝíç ðáñáãùãÞ ôïõ ÷çìåéïôáêôéêïý ðáñÜãïíôá ôùíçùóéíïößëùí åïôáîßíç.

Ôá åõñÞìáôá áõôÜ ìðïñåß íá äçëþíïõí üôé óôï åí-äïãåíÝò Üóèìá: i) Ç áíôéãïíïðáñïõóßáóç áðü ôá ìáêñïöÜãá ãßíåôáé

ìå äéáöïñåôéêü ìç÷áíéóìü. ii) Ôá ìáêñïöÜãá åíåñãïðïéïýíôáé äéáöïñåôéêÜ ùò

áðïôÝëåóìá öëåãìïíþäïõò Þ áõôïÜíïóïõ ìç÷áíé-óìïý.

iii) Äéáöïñåôéêüò ìç÷áíéóìüò äéÝðåé ôçí ðáñáãùãÞ åï-ôáîßíçò.

iv)Oé ðáñáôçñïýìåíåò äéáöïñÝò åßíáé ðëáóìáôéêÝò êáé

145PNEUMON Number 2, Vol. 15, May - August 2002

áðëÜ áíôáíáêëïýí äéáöïñÝò ðïõ ïöåßëïíôáé óôçíçëéêßá Þ ôç äéÜñêåéá ôçò íüóïõ.ÐåñáéôÝñù Ýñåõíá üóïí áöïñÜ óôç ëåéôïõñãéêüôç-

ôá ôùí ìáêñïöÜãùí, ôçí ôáõôïðïßçóç ðéèáíþí áëëåñ-ãéïãüíùí, êáèþò êáé ôï åíäå÷üìåíï ôçò ðáñïõóßáò áõ-ôïÜíïóïõ ìç÷áíéóìïý èá Ýññé÷íå ðåñéóóüôåñï öùò

óôïõò áíïóïëïãéêïýò ìç÷áíéóìïýò ðïõ äéÝðïõí ôï åí-äïãåíÝò Üóèìá, åíþ ÷ñåéÜæåôáé ðåñéóóüôåñïò ÷ñüíïòÝùò üôïõ áíáêáëõöèïýí ìç÷áíéóìïß ðïõ íá äåß÷íïõíêáôÜ ðüóïí ïé äýï áõôïß ôýðïé Üóèìáôïò åêðñïóùðïýíôçí ßäéá íïóïëïãéêÞ ïíôüôçôá.

SUMMARY

Intrinsic asthma

K. Zeibecoglou, A. Papamichalopoulos, N. Georgatou

Recent findings suggest that extrinsic and intrinsic asthma, despite showing distinct clinical features,share many common immunopathological mechanisms. Inappropriate IgE-mediated mechanismsmight occur in asthma, irrespective of its atopic status, as suggested by elevated serum IgE concentra-tions and bronchial mucosal expression of cells positive for FcåÑÉ, IL-4, IL-13, Iå and Cå. Futuredirections of research regarding intrinsic asthma include possible identification of novel allergens,detailed description of local bronchial mucosal IgE production and understanding of a possible mac-rophage dysfunction. In addition, a role for infectious or autoimmune processes has yet to be firmlyidentified. Pneumon 2002, 15(2):143-146.

Key words: Asthma, atopy, cytokines.

Med 1996, 154: 1497-1504.5. Humbert M, Durham SR, Kimmitt P. Elevated expres-

sion of mRNA encoding IL-13 in the bronchial mucosaof atopic and non-atopic subjects with asthma. J AllergyClin Immunol 1997, 99: 657-665.

6. Yasruel Z, Humbert M, Kotsimbos TC, PloysongsangY, Minshall E, Durham SR, Pfister R, Menz G, Tavern-ier J, Kay AB, Hamid Q. Membrane-bound and solublealpha IL-5 receptor mRNA in the bronchial mucosa ofatopic and nonatopic asthmatics. Am J Respir Crit CareMed 1997, 155: 1413-1418.

7. Humbert M, Ying S, Corrigan C, Menz G, Barkans J,Pfister R, Meng Q, Van Damme J, Opdenakker G, Dur-ham SR, Kay AB. Bronchial mucosal expression of thegenes encoding chemokines RANTES and MCP-3 insymptomatic atopic and nonatopic asthmatics: relation-ship to the eosinophil-active cytokines interleukin (IL)-5, granulocyte macrophage-colony-stimulating factor,and IL-3. Am J Respir Cell Mol Biol 1997, 16: 1-8.

8. Ying S, Meng Q, Zeibecoglou K, Macfarlane AI, Rob-inson DS, Humbert M, Kay AB. Eosinophil chemotac-tic chemokines (eotaxin, eotaxin-2, RANTES, MCP-3,MCP-4), and C-C chemokine receptor 3 expression in


1. Rackeman F. A working classification of asthma. Am JMed 1947, 3: 601-606.

2. Bentley AM, Menz G, Storz C, Robinson DS, BradleyB, Jeffery PK, Durham SR, Kay AB. Identification of Tlymphocytes, macrophages, and activated eosinophils inthe bronchial mucosa in intrinsic asthma. Relationshipto symptoms and bronchial responsiveness. Am RevRespir Dis 1992, 146: 500-506.

3. Ying S, Humbert M, Barkans J, Corrigan CJ, Pfister R,Menz G, Larche M, Robinson DS, Durham SR, Kay AB.Expression of IL-4 and IL-5 mRNA and protein productby CD4+ and CD8+ T cells, eosinophils, and mast cellsin bronchial biopsies obtained from atopic and nonat-opic (intrinsic) asthmatics. J Immunol 1997, 158: 3539-3544.

4. Humbert M, Durham SR, Ying S, Kimmitt P, BarkansJ, Assoufi B, Poster R, Menz G, Robinson DS, Kay AB,Corrigan CJ. IL-4 and IL-5 mRNA and protein in bron-chial biopsies from patients with atopic and nonatopicasthma: evidence against "intrinsic" asthma being a dis-tinct immunopathologic entity. Am J Respir Crit Care


bronchial biopsies from atopic and non-atopic (intrin-sic) asthmatics. J Immunology, 1999, 163(11): 6321-9.

9. Ying S, Robinson DS, Meng Q, Rottman J, Kennedy R,Ringler DJ, Mackay CR, Daugherty BL, Springer MS,Durham SR, Williams TJ, Kay AB. Enhanced expres-sion of eotaxin and CCR3 mRNA and protein in atopicasthma. Association with airway hyperresponsiveness andpredominant colocalization of eotaxin mRNA t bron-chial epithelial and endothelial cells. Eur J Immunol1997, 27: 3507-3516.

10. Humbert M, Grant JA, Taborda Barata L, Durham SR,Pfister R, Menz G, Barkans J, Ying S, Kay AB. High-affinity IgE receptor (FcepsilonRI)-bearing cells in bron-chial biopsies from atopic and nonatopic asthma. Am JRespir Crit Care Med 1996, 153: 1931-1937.

11. Durham SR, Gould HJ, Thienes CP, Jacobson MR,Masuyama K, Rak S, Lowhagen O, Schotman E, Cam-eron L, Hamid QA. Expression of epsilon germ-line genetranscripts and mRNA for the epsilon heavy chain ofIgE in nasal B cells and the effects of topical corticoster-oid. Eur J Immunol 1997, 27: 2899-2906.

12. Mehlhop PD, van de Rjin M, Goldberg AB, Brewer JP,Kurup VP, Martin TR, Oettgen HC. Allergen-inducedbronchial hyperreactivity and eosinophilic inflammationoccur in the absence of IgE in a mouse model of asthma(see comments). Proc Natl Acad Sci USA, 1997, 94:1344-1349.

13. Dorward AJ, Colloff MJ, MacKay NS, McSharry C,Thomson NC. Effect of house dust mite avoidance meas-ures on adult atopic asthma. Thorax 1988, 43: 98-102.

14. Hide M, Francis DM, Grattan CE, Hakimi J, KochamJP, Greaves MW. Autoantibodies against the high-af-finity IgE receptor as a cause of histamine release inchronic urticaria (see comments). N Engl J Med 1993,1599-1604.

15. Lassalle P, Delneste Y, Gosset P, Gras Masse H, Wal-laert B, Tonnel AB. T and B cell immune response to a55-kDa endothelial cell-derived antigen in severe asth-ma. Eur J Immunol 1993, 23: 796-803.

16. Kotsimbos AT, Humbert M, Minshall E, Durham S,Pfister R, Menz G, Tavernier J, Kay AB, Hamid Q.Upregulation of alpha GM-CSF-receptor in nonatopicasthma but not in atopic asthma. J Allergy Clin Immu-nol 1997, 99: 666-672.

17. Zeibecoglou K, Ying S, Meng Q, Poulter L, RobinsonDS, Kay AB. The expression of IL-10 and IL-12 in in-duced sputum of atopic, non-atopic asthmatics, atopicand normal control subjects. J All Clin Immunol, 2000,106: 697-704.

18. Zeibecoglou K, Ying S, Meng Q, Robinson DS, Kay AB.Eotaxin expression in induced sputum of atopic, non-atopic asthmatics, atopic and normal control subjects.Allergy 2000, 55: 1042-48.

Ðñüôõðï óýìðôõîçò ôïõ ðíåýìïíá óå áóèåíåßòìå óýíäñïìï ïîåßáò áíáðíåõóôéêÞò äõó÷Ýñåéáòôùí åíçëßêùí (ARDS) � Åðßäñáóç ôçò PEEPÅ. ÊïíäýëçÃ. ÐñéíéáíÜêçòÇ. ÁèáíáóÜêçòÄ. Ãåùñãüðïõëïò

ÐÅÑÉËÇØÇ. Ôï ðñüôõðï óýìðôõîçò ôïõ ðíåýìïíá ìåëåôÞèçêåóå 10 äéáóùëçíùìÝíïõò áóèåíåßò ìå óýíäñïìï ïîåßáò áíáðíåõ-óôéêÞò äõó÷Ýñåéáò (ARDS). Óå ôÝóóåñá äéáöïñåôéêÜ åðßðåäáÑÅÅÑ (0, 5, 10, 15 cm H2O) ç ðßåóç óôçí ôñá÷åßá (Ptr), ç ðßåóçôùí áåñáãùãþí (Paw), ç ñïÞ (V�) êáé ï üãêïò (V) êáôáãñÜöïíôáíóõíå÷þò. Ï åêðíåõóôéêüò üãêïò (ðáèçôéêÞ åêðíïÞ) ÷ùñßóôçêåóå 5 ßóá óõíå÷üìåíá ôìÞìáôá êáé ç óôáèåñÜ ÷ñüíïõ (ôe) êáé çóôáôéêÞ åêðíåõóôéêÞ åíäïôéêüôçôá (Crs) êÜèå ôìÞìáôïò, õðïëï-ãßóôçêáí ìå ãñáììéêÞ áíÜëõóç ðáëéíäñüìçóçò, áðü ôç ó÷Ýóç V/V� êáé V/Ptr áíôßóôïé÷á. Óå êáèÝíá áðü ôá åðéìÝñïõò ôìÞìáôáüãêïõ, ïé ïëéêÝò åêðíåõóôéêÝò áíôéóôÜóåéò Rtot (ôï Üèñïéóìá ôùíáíôéóôÜóåùí ôïõ áíáðíåõóôéêïý óõóôÞìáôïò [Rrs], ôùí áíôéóôÜ-óåùí ôïõ ôñá÷åéïóùëÞíá [Rtube] êáé ôùí áíôéóôÜóåùí ôïõ êõ-êëþìáôïò ôïõ áíáðíåõóôÞñá [Rvent],) õðïëïãßóôçêáí áðü ôïëüãï ôe/Crs. Ìå ðáñïõóßá ðåñéïñéóìïý åêðíåõóôéêÞò ñïÞò ïé RrsèåùñÞèçêáí ßóåò ìå Rtot, åíþ ÷ùñßò ðåñéïñéóìü åêðíåõóôéêÞòñïÞò ïé Rrs õðïëïãßóèçêáí áðü ôç äéáöïñÜ ôùí Rtube êáé Rventáðü ôéò Rtot. Ç óôáèåñÜ ÷ñüíïõ ôïõ áíáðíåõóôéêïý óõóôÞìáôïò(ôers) õðïëïãßóôçêå áðü ôï ãéíüìåíï Rrs x Crs. Ìå 0 PÅÅÑ (ZEEP)ç ôers ôïõ áíáðíåõóôéêïý óõóôÞìáôïò, áõîÞèçêå óçìáíôéêÜ áðüôçí áñ÷Þ ðñïò ôï ôÝëïò ôçò åêðíïÞò (Äôers 55,5±31%), ëüãù ôçòóçìáíôéêÞò áýîçóçò ôùí Rrs (ÄRrs 63,9±45%). Ìå ôçí åöáñìï-ãÞ ÑÅÅÑ, ïé Rrs äéáôçñÞèçêáí ó÷åôéêÜ óôáèåñÝò óå üëç ôç äéÜñ-êåéá ôçò åêðíïÞò, áõîÞèçêå ï ñõèìüò óýìðôõîçò ôïõ áíáðíåõ-óôéêïý óõóôÞìáôïò êáé áìâëýíèçêå óçìáíôéêÜ ç äéáöïñÜ óôç ôers

ìåôáîý ôçò áñ÷Þò êáé ôïõ ôÝëïõò ôçò åêðíïÞò. ÓõìðåñáóìáôéêÜ,óå áóèåíåßò ìå ARDS ôï áíáðíåõóôéêü óýóôçìá óõìðôýóóåôáéáíïìïéïãåíþò ëüãù ôçò óçìáíôéêÞò áýîçóçò ôùí áíôéóôÜóåùí ôïõáíáðíåõóôéêïý óõóôÞìáôïò óå ÷áìçëïýò üãêïõò ðíåýìïíá. ÇåöáñìïãÞ ÑÅÅÑ áõîÜíåé óçìáíôéêÜ ôçí ïìïéïãÝíåéá êáé ôï ñõè-ìü óýìðôõîçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò. Ðíåýìùí 2002,15(2)147-157.

ÊëéíéêÞ ÅíôáôéêÞò èåñáðåßáò, Ðáíåðéóôçìéáêü Íï-óïêïìåßï Çñáêëåßïõ, ÐáíåðéóôÞìéï ÊñÞôçò

ÊëéíéêÞ ÌåëÝôçBñáâåõìÝíç Åñãáóßá

ÐáíåëëÞíéï ÓõíÝäñéï ÍïóçìÜôùíÈþñáêïò - Èåóóáëïíßêç 2001

ËÝîåéò êëåéäéÜ: ARDS, PEEP, óýìðôõîç ðíåýìï-íá, åêðíåõóôéêÞ ñïÞ

Aëëçëïãñáößá:Ä. Ãåùñãüðïõëïò, Áí. ÊáèçãçôÞò, Ä/íôÞò Êëéíé-êÞò ÅíôáôéêÞò Èåñáðåßáò, Ðáíåðéóôçìéáêü Íïóï-êïìåßï Çñáêëåßïõ, ÐáíåðéóôÞìéï ÊñÞôçò, ÇñÜ-êëåéï ÊñÞôçò, Fax: (0810) 392636,e-mail: [email protected]


ÅÉÓÁÃÙÃÇ

Ôï óýíäñïìï ôçò ïîåßáò áíáðíåõóôéêÞò äõó÷Ýñåéáò(ARDS) åßíáé ç Ýêöñáóç ôçò åêóåóçìáóìÝíçò öëåãìï-íþäïõò áíôßäñáóçò ôïõ ðíåõìïíéêïý ðáñåã÷ýìáôïò, óåäéÜöïñåò õðïêåßìåíïõò íüóïõò1-4. Ôï óýíäñïìï ÷áñá-êôçñßæåôáé áðü ìéá óçìáíôéêÞ áíïìïéïãÝíåéá óôéò âëÜ-âåò ôïõ ðíåõìïíéêïý ðáñåã÷ýìáôïò, ìå ðåñéï÷Ýò ïéïðïßåò äéáôçñïýí ôç äïìÞ ôïõò êáé Üëëåò ðïõ ðÜó÷ïõíóå ìåãÜëï âáèìü5. Ëüãù áõôÞò ôçò áíïìïéïãÝíåéáò ôïõðáñåã÷ýìáôïò åßíáé ðïëý ðéèáíü ôï ðñüôõðï óýìðôõ-îçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò êáôÜ ôçí ðáèçôéêÞåêðíïÞ íá åßíáé åðßóçò áíïìïéïãåíÝò, ùò áðïôÝëåóìáäéáöïñåôéêþí ÷ñïíéêþí óôáèåñþí (ôe). Ï ôñüðïò óý-ìðôõîçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò óå áóèåíåßò ìåARDS ìÝ÷ñé ôþñá äåí Ý÷åé ìåëåôçèåß åðáñêþò. Ïé Gut-tman êáé óõí.6 ðáñáôÞñçóáí üôé óå áóèåíåßò ìå ARDSõðü ìç÷áíéêü áåñéóìü ìå ÑÅÅÑ, åðéìÝñïõò ôìÞìáôá ôïõåêðíåüìåíïõ üãêïõ åß÷áí ó÷åäüí üìïéá ÷ñïíéêÞ óôá-èåñÜ, üðùò õðïëïãßóèçêå áðü ôç ó÷Ýóç ìåôáîý ôïõüãêïõ êáé ôçò ñïÞò (V/V�) êáôÜ ôç äéÜñêåéá ôçò ðáèçôé-êÞò åêðíïÞò. Ôá åõñÞìáôá áõôÜ óõíçãïñïýóáí õðÝñ ôïõüôé ôï áíáðíåõóôéêü óýóôçìá ôùí áóèåíþí ìå ARDSóõìðôýóóåôáé ïìïéïãåíþò. Ïé Guttmann êáé óõí.6 áðÝ-äùóáí áõôÞ ôç óõìðåñéöïñÜ êáôÜ ìåãÜëï ìÝñïò óôéòáíôéóôÜóåéò ôïõ åíäïôñá÷åéáêïý óùëÞíá. Áöáéñþíôáòôéò áíôéóôÜóåéò ôïõ åíäïôñá÷åéáêïý óùëÞíá êáé ôïõ êõ-êëþìáôïò ôïõ áíáðíåõóôÞñá, õðïëüãéóáí ôç ÷ñïíéêÞóôáèåñÜ ôïõ áíáðíåõóôéêïý óõóôÞìáôïò êáé Ýäåéîáí üôéáõôÞ áõîÜíåôáé ðñïïäåõôéêÜ áðü ôçí áñ÷Þ ðñïò ôï ôÝ-ëïò ôçò åêðíïÞò. Óôç ìåëÝôç áõôÞ üìùò, ï õðïëïãéóìüòôçò ÷ñïíéêÞò óôáèåñÜò ôïõ áíáðíåõóôéêïý óõóôÞìáôïòÝãéíå èåùñþíôáò üôé ç åíäïôéêüôçôá ôïõ áíáðíåõóôéêïýóõóôÞìáôïò åßíáé óôáèåñÞ êáé äåí äéáöÝñåé ìåôáîý åé-óðíïÞò êáé åêðíïÞò. Åßíáé ãíùóôü üìùò, üôé áöåíüò çó÷Ýóç ðßåóçò -üãêïõ äåí åßíáé ãñáììéêÞ5 êáé áöåôÝñïõüôé õðÜñ÷åé ôï öáéíïìÝíïõ ôçò õóôÝñçóçò7. ÅðéðëÝïíÝ÷åé âñåèåß üôé áóèåíåßò ìå ARDS õðü ìç÷áíéêü áåñé-óìü åßíáé ðéèáíü íá åìöáíßóïõí ðåñéïñéóìü óôç ñïÞêáôÜ ôçí åêðíïÞ8. Ó� áõôïýò ôïõò áóèåíåßò ïé áíôéóôÜ-óåéò ôïõ åíäïôñá÷åéáêïý óùëÞíá êáé ôïõ êõêëþìáôïòôïõ áíáðíåõóôÞñá äåí åðçñåÜæïõí ôçí åêðíåõóôéêÞ ñïÞêáé ôï ñõèìü óýìðôõîçò ôïõ ðíåýìïíá9,10. Óêïðüò ôçòðáñïýóáò åñãáóßáò Þôáí íá ìåëåôçèåß ôï ðñüôõðï óý-ìðôõîçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò óå áóèåíåßò ìå

ARDS êáé ç åðßäñáóç ôçò åöáñìïãÞò ÑÅÅÑ óå áõôü. Ç÷ñïíéêÞ óôáèåñÜ ôïõ áíáðíåõóôéêïý óõóôÞìáôïò ôres

(÷ùñßò ôéò áíôéóôÜóåéò ôïõ ôñá÷åéïóùëÞíá êáé ôïõ êõ-êëþìáôïò ôïõ áíáðíåõóôÞñá) ìåôñÞèçêå óå äéáöïñåôé-êÜ åðßðåäá ÑÅÅÑ êáôÜ ôç äéÜñêåéá ôçò ðáèçôéêÞò åê-ðíïÞò, áðü ôéò êáìðýëåò ñïÞò-üãêïõ êáé ôç óôáôéêÞ åê-ðíåõóôéêÞ êáìðýëç ðßåóçò�üãêïõ, ëáìâÜíïíôáò õðüøçôçí ðáñïõóßá Þ ìç ôïõ ðåñéïñéóìïý ôçò åêðíåõóôéêÞòñïÞò (ÐÅÑ).

ÌÅÈÏÄÏÓ

ÌåëåôÞèçêáí 10 áóèåíåßò ìå ARDS õðü ìç÷áíéêüáåñéóìü. Ç äéÜãíùóç ôïõ ARDS Ýãéíå ìå âÜóç ôá êñé-ôÞñéá êïéíÞò áðïäï÷Þò ôçò ÁìåñéêáíéêÞò êáé Åõñùðáú-êÞò Åôáéñßáò. Ùò êñéôÞñéá áðïêëåéóìïý ïñßóôçêáí ôïéóôïñéêü áðïöñáêôéêÞò íüóïõ, ç ýðáñîç óùëÞíá ðá-ñï÷Ýôåõóçò óôçí õðåæùêïôéêÞ êïéëüôçôá ìå äéáöõãÞáÝñá êáé ç áéìïäõíáìéêÞ áóôÜèåéá. Ãéá ôç óõììåôï÷Þôïõ áóèåíïýò óôç ìåëÝôç æçôÞèçêå ç Ýããñáöç óõíáßíå-óç ôïõ ßäéïõ Þ ôùí óõããåíþí êáé ç áðïäï÷Þ ôçò Åðéôñï-ðÞò Äåïíôïëïãßáò ôïõ íïóïêïìåßïõ.

¼ëïé ïé áóèåíåßò Þôáí äéáóùëçíùìÝíïé êáé áåñßæï-íôáí ìç÷áíéêÜ (Siemens, Servo Ventilator 300, Solna,Sweden) óå åëåã÷üìåíï ìïíôÝëï áåñéóìïý óôáèåñïýüãêïõ ìå óôáèåñÞ ñïÞ. Ïé óõíèÞêåò áåñéóìïý åß÷áíðñïêáèïñéóèåß áðü ôï èåñÜðïíôá éáôñü (Ðßíáêáò 1).Ïé áóèåíåßò Þôáí õðü êáôáóôïëÞ êáé ìõï÷Üëáóç ìå ðñï-ðïöüëç-öåíôáíýëç êáé cis-atracurium áíôßóôïé÷á. Óåüëç ôç äéÜñêåéá ôçò ìåëÝôçò ãéíüôáí óõíå÷Þò êáôáãñá-öÞ ôçò ñïÞò (V�) ìÝóù èåñìáéíüìåíïõ ðíåõìïôá÷ïãñÜ-öïõ (Hans-Rudolf 3700, Kansas, U.S.A.) êáé ìïñöïìå-ôáôñïðÝá ðßåóçò ðïõ åß÷áí ôïðïèåôçèåß ìåôáîý ôïõ ôñá-÷åéïóùëÞíá êáé ôïõ ôìÞìáôïò Õ ôïõ áíáðíåõóôéêïýêõêëþìáôïò. Ìéá çëåêôñïíéêÞ âáëâßäá áðüöñáîçò,ôïðïèåôçìÝíç ìåôáîý ôïõ ðíåõìïôá÷ïãñÜöïõ êáé ôïõôìÞìáôïò Õ ôïõ áíáðíåõóôÞñá, åðÝôñåðå ôçí ôá÷åßááðüöñáîç ôùí áåñáãùãþí êáôÜ ôç äéÜñêåéá ôçò åê-ðíïÞò. Ï üãêïò (V) õðïëïãéæüôáí áõôüìáôá óå êÜèå÷ñïíéêÞ óôéãìÞ áðü ôçí ïëïêëÞñùóç ôçò êõìáôïìïñöÞòôçò V�. Ç ðßåóç ôùí áåñáãùãþí (Paw) êáôáãñáöüôáíóõíå÷þò ìÝóù ìïñöïìåôáôñïðÝá ðßåóçò (Micro-Switch140PC, Honeywell Ltd., Ontario, Canada) áðü ïðÞ åõ-ñéóêüìåíç ìåôáîý ôïõ ðíåõìïôá÷ïãñÜöïõ êáé ôïõ åí-äïôñá÷åéáêïý óùëÞíá. Ç ðßåóç óôçí ôñá÷åßá (Ptr) ìå-


Ðßíáêáò 1. ×áñáêôçñéóôéêÜ áóèåíþí êáé âáóéêÝò ñõèìßóåéò áíáðíåõóôÞñá

ÁóèåíÞò Çëéêßá Öýëï PEEP VT Fr ÇìÝñåò ALI ÁéôßáNo. (Ýôç) (cm H2O) (L) (áíáðí./min) ìç÷. áåñ. score ARDS

1 62 Á 7 0.46 19 7 2 Åéóñüöçóç2 50 Á 6 0.52 20 9 2.3 Ðíåõìïíßá3 52 Á 8 0.50 21 4 2.3 Åéóñüöçóç4 35 È 5 0.31 30 3 2 ÓÞøç5 73 È 8 0.42 24 5 2 ÓÞøç6 38 È 5 0.40 20 5 2 Ðíåõìïíßá7 65 Á 9 0.50 15 2 3 Åéóñüöçóç8 63 È 8 0.48 15 5 2.3 Åéóñüöçóç9 68 È 8 0.49 21 6 2.3 Ðíåõìïíßá

10 40 È 8 0.45 18 4 2.6 ÓÞøç

Á: ¢ññåí, È: ÈÞëõ, PEEP: ÈåôéêÞ ôåëïåêðíåõóôéêÞ ðßåóç, VT: áíáðíåüìåíïò üãêïò, Fr: óõ÷íüôçôá áíáðíïþí áíáðíåõóôÞ-ñá, ARDS: óýíäñïìï ïîåßáò áíáðíåõóôéêÞò äõó÷Ýñåéáò åíçëßêùí

ãßíïíôáí ïé ðáñáêÜôù ÷åéñéóìïß:1) Ï áóèåíÞò áöçíüôáí íá åêðíåýóåé óôçí ðáèçôéêÞ

FRC (ðïõ Þôáí äéáöïñåôéêÞ óå êÜèå åðßðåäï ÑÅÅÑ).Óå êÜèå åðßðåäï ÑÅÅÑ êáôáãñÜöçêáí 5-7 åêðíïÝò.Áðü ôç ìåëÝôç üëùí ôùí ðñïóðáèåéþí Ýãéíå ç êáôá-ãñáöÞ ìéáò óõíïëéêÞò êáìðýëçò ñïÞò�üãêïõ (V�/V).

2) ÌåôÜ ôçí ôåëïåéóðíåõóôéêÞ ðáýóç, ìÝóù ôçò çëå-êôñïíéêÞò âáëâßäáò áðüöñáîçò, ãéíüôáí áðüöñáîçôùí áåñáãùãþí óå ôõ÷áßåò ÷ñïíéêÝò óôéãìÝò êáôÜôçí åêðíïÞ äéÜñêåéáò 3 äåõôåñïëÝðôùí êáé ç óôáôé-êÞ Ptr êáôáãñÜöïíôáí. Óå êÜèå åðßðåäï ÑÅÅÑ ðñáã-ìáôïðïéÞèçêáí ôïõëÜ÷éóôïí 20 ôÝôïéåò áðïöñÜîåéò,ìéá óå êÜèå åêðíåõóôéêÞ ðñïóðÜèåéá. Áðü ôç óõ-ó÷Ýôéóç ôùí ìåôñïýìåíùí ôéìþí ôçò Ptr ìåôÜ áðüêÜèå áðüöñáîç ìå ôïí áíôßóôïé÷ï üãêï ðÜíù áðüôçí FRC óå ÑÅÅÑ 0 cm H2O (FRCZEEP) Ýãéíå ç êá-ôáãñáöÞ ôçò óôáôéêÞò åêðíåõóôéêÞò êáìðýëçò ðßå-óçò-üãêïõ (P-V) óå êÜèå åðßðåäï ÑÅÅÑ.

3) Ìå ÑÅÅÑ 0 cm H2O (ÆÅÅÑ) ï áóèåíÞò áöçíüôáííá åêðíåýóåé ðáèçôéêÜ óôïí áôìïóöáéñéêü áÝñááðïóõíäÝïíôÜò ôïí áðü ôï êýêëùìá ôïõ áíáðíåõ-óôÞñá óôï ôÝëïò ôçò ôåëïåéóðíåõóôéêÞò áðüöñáîçò.¼ôáí åöáñìïæüôáí ÑÅÅÑ, áõôÞ ìåéùíüôáí êáôÜ 2cm H2O óôï ôÝëïò ôçò ôåëïåéóðíåõóôéêÞò ðáýóçò êáéï áóèåíÞò áöçíüôáí íá åêðíåýóåé ðáèçôéêÜ óôï íÝïåðßðåäï ÑÅÅÑ. Ãéá êÜèå åðßðåäï ÑÅÅÑ ãßíïíôáí 5-7 ôÝôïéåò ðñïóðÜèåéåò. Áðü ôï ìÝóï üñï ôùí ðñï-óðáèåéþí áõôþí Ýãéíå ç êáôáãñáöÞ ìéáò íÝáò óõíï-ëéêÞò êáìðýëçò V�/V ÷ùñßò ôï åêðíåõóôéêü êýêëù-

ôñÞèçêå ìå êáèåôÞñá ï ïðïßïò ôïðïèåôÞèçêå 2-3 åêá-ôïóôÜ ìåôÜ ôï ôåëéêü Üêñï ôïõ ôñá÷åéïóùëÞíá.

ÐÑÙÔÏÊÏËËÏ

Áñ÷éêÜ ç óõãêÝíôñùóç ôïõ åéóðíåüìåíïõ Ï2 (FiO2)ñõèìßóôçêå íá åßíáé 1,0 êáé ðáñÝìåéíå Ýôóé óå üëç ôçäéÜñêåéá ôçò ìåëÝôçò. ÊÜèå áóèåíÞò ìåëåôÞèçêå, ìåôõ÷áßá óåéñÜ, óå 4 åðßðåäá ÑÅÅÑ (0, 5, 10, 15 cm H2O).Óå êÜèå åðßðåäï ÑÅÅÑ ïé ðáñÜìåôñïé ôïõ áíáðíåõóôÞ-ñá (áíáðíåüìåíïò üãêïò [VT] êáé áíáðíåõóôéêÞ óõ÷íü-ôçôá [f]) Þôáí ðáñüìïéåò ìå áõôÝò ðïõ åß÷å êáèïñßóåé ïèåñÜðùí éáôñüò. ¼ôáí ïé áóèåíåßò (óå êÜèå åðßðåäïÑÅÅÑ) ðáñÝìåíáí óôáèåñïß ãéá ôïõëÜ÷éóôïí 15 min, ïéðáñÜìåôñïé áåñéóìïý Üëëáæáí óå: VT 0,5-0,6 L ìå óôá-èåñÞ ñïÞ, f 10 /ëåðôü êáé ó÷Ýóç åéóðíåõóôéêïý ðñïòïëéêü áíáðíåõóôéêü ÷ñüíï (ÔÉ/ÔÔÏÔ) 0,3. ÐñïêåéìÝíïõíá åëåã÷èåß åÜí ìå áõôÝò ôéò óõíèÞêåò áåñéóìïý ôï áíá-ðíåõóôéêü óýóôçìá óôï ôÝëïò ôçò åêðíïÞò Þôáí óå èÝóçéóïññïðßáò (FRC), ãßíïíôáí áðïêëåéóìüò ôïõ åêðíåõ-óôéêïý óêÝëïõò ôïõ áíáðíåõóôéêïý êõêëþìáôïò åíåñ-ãïðïéþíôáò ôï åéäéêü êïõìðß ôïõ áíáðíåõóôÞñá. ÅÜíìåôÜ ôçí ôåëï-åêðíåõóôéêÞ ðáýóç åìöáíéæüôáí áýîçóçóôçí Paw -åíäïãåíÞò ÑÅÅÑ (PEEPi)- ï VT ìåéùíüôáíáíÜëïãá ìÝ÷ñéò åîÜëåéøçò ôïõ öáéíïìÝíïõ. Ìå ôéò óõí-èÞêåò áõôÝò ï áóèåíÞò áåñéæüôáí ãéá 10 áíáðíïÝò. Óôçí11ç áíáðíïÞ, ç ïðïßá ïíïìÜóèçêå áíáðíïÞ ìåëÝôçò,ãéíüôáí áðüöñáîç ôùí áåñáãùãþí óôï ôÝëïò ôçò åé-óðíïÞò äéÜñêåéáò 3 äåõôåñüëåðôùí, êáé óôç óõíÝ÷åéá


ìá êáé óå êÜèå ìåéùìÝíï åðßðåäï ÑÅÅÑ. Ç óýãêñé-óç ôçò êáìðýëçò áõôÞò ìå ôçí áíôßóôïé÷ç ðïõ åß÷åêáôáãñáöåß óå ÆÅÅÑ êáé óå åðßðåäá ÑÅÅÑ 5, 10êáé 15 cm H2O åðÝôñåøå ôïí Ýëåã÷ï ðáñïõóßáò Þ ìçðåñéïñéóìïý ôçò åêðíåõóôéêÞò ñïÞò (ÐÅÑ), üðùòáíáöÝñåôáé áíáëõôéêüôåñá óôç óõíÝ÷åéá.

4) ¼ôáí åöáñìïæüôáí ÑÅÅÑ óôï ôÝëïò ôçò ôåëïåé-óðíåõóôéêÞò ðáýóçò áõôü áöáéñïýíôáí êáé ï áóèå-íÞò áöçíüôáí íá åêðíåýóåé ðáèçôéêÜ óå ÆÅÅÑ. Áðüôç äéáöïñÜ ôïõ ôåëïåêðíåõóôéêïý üãêïõ ìåôáîýÑÅÅÑ êáé ÆÅÅÑ, õðïëïãßóôçêå ç ìåôáâïëÞ ôïõ ôå-ëïåêðíåõóôéêïý üãêïõ ðïõ ðñïêÜëåóå ç åöáñìïãÞÑÅÅÑ.

ÁÍÁËÕÓÇ ÄÅÄÏÌÅÍÙÍ

ÂÞìá 1: Ðñïóäéïñéóìüò ôïõ ðåñéïñéóìïý åêðíåõóôéêÞòñïÞò (ÐÅÑ)

Ìå ÆÅÅÑ Ýãéíå óýãêñéóç ôçò êáìðýëçò V�/V ìå áõôÞðïõ êáôáãñÜöçêå üôáí ï áóèåíÞò áöçíüôáí íá åêðíåý-óåé óôïí áôìïóöáéñéêü áÝñá. Ìå ÑÅÅÑ ï ðñïóäéïñé-óìüò ôïõ ÐÅÑ ãéíüôáí ìå ôç óýãêñéóç ôçò êáìðýëçò V�/V óôï óõãêåêñéìÝíï åðßðåäï ìå ôçí áíôßóôïé÷ç ðïõ êá-ôáãñÜöïíôáí ìåôÜ ôç ìåßùóç ôïõ ÑÅÅÑ êáôÜ 2 cm H2O.Ç óýãêñéóç ôùí äýï êáìðõëþí ãéíüôáí èåùñþíôáò üôéï ôåëïåéóðíåõóôéêüò üãêïò Þôáí üìïéïò8,10,11. ÅÜí ç åê-ðíåõóôéêÞ ñïÞ Þôáí ìåãáëýôåñç ìåôÜ ôç ìåßùóç ôçò ïäç-ãïý ðßåóçò (ìåßùóç ôçò ÑÅÅÑ êáôÜ 2cm H2O Þ áðïìÜ-êñõíóçò ôïõ áíáðíåõóôéêïý êõêëþìáôïò) èåùñïýíôáíüôé ï áóèåíÞò äåí åß÷å ÐÅÑ. ÁíôéèÝôùò ç ýðáñîç ÐÅÑôåêìçñéùíüôáí åÜí ìåôÜ ôç ìåßùóç ôçò ïäçãïý ðßåóçò çåêðíåõóôéêÞ ñïÞ äåí ìåôáâáëëüôáí.

ÂÞìá 2. Ðñïóäéïñéóìüò ôïõ ìïíôÝëïõ åêðíïÞò

Óå êÜèå åðßðåäï ÑÅÅÑ êáôáãñÜöçêå ç êáìðýëç V�/V. Ï åêðíåüìåíïò üãêïò áðü ôç ìÝãéóôç åêðíåõóôéêÞñïÞ Ýùò ôï ôÝëïò ôçò åêðíïÞò ÷ùñßóôçêå óå 5 ßóá äéáäï-÷éêÜ ôìÞìáôá. ÊáèÝíá áðü ôá ôìÞìáôá áõôÜ ìåëåôÞèç-êå îå÷ùñéóôÜ èåùñþíôáò üôé Ý÷åé óôáèåñÞ åíäïôéêüôç-ôá êáé åêðíåõóôéêÞ áíôßóôáóç. ×ñçóéìïðïéþíôáò ôçìÝèïäï ôçò ðáëßíäñïìçò áíÜëõóçò, óå êáèÝíá áðü ôáðÝíôå ôìÞìáôá áõôÜ õðïëïãßóôçêå ç êëßóç ôçò êáìðý-ëçò V/V�. ÊáôÜ ôç äéÜñêåéá ðáèçôéêÞò åêðíïÞò ï ëüãïòáõôüò áíôéðñïóùðåýåé ôç óôáèåñÜ ÷ñüíïõ (time const-ant, ô) ðïõ åßíáé ßóç ìå ôï ãéíüìåíï Rtot x Crs, (üðïõ

Rtot ïé óõíïëéêÝò åêðíåõóôéêÝò áíôéóôÜóåéò ôïõ áíá-ðíåõóôéêïý óõóôÞìáôïò êáé Crs ç óôáôéêÞ åêðíåõóôéêÞåíäïôéêüôçôá)6,12,13. Ïé Rtot åßíáé ôï Üèñïéóìá ôçò áíôß-óôáóçò ôïõ ôñá÷åéïóùëÞíá (Rtube), ôùí áíôéóôÜóåùíôïõ åêðíåõóôéêïý êõêëþìáôïò ôïõ áíáðíåõóôÞñá(Rvent) êáé ôùí áíôéóôÜóåùí ôïõ áíáðíåõóôéêïý óõóôÞ-ìáôïò (Rrs). Oé Rtot ãéá êáèÝíá áðü ôá áíôßóôïé÷á ôìÞ-ìáôá üãêïõ õðïëïãßóôçêáí áðü ôï ëüãï ôe/Crs, üðïõCrs ç åêðíåõóôéêÞ åíäïôéêüôçôá ðïõ õðïëïãßóôçêå ìåáíÜëõóç ãñáììéêÞò ðáëéíäñüìçóçò áðü ôçí êëßóç ôçòåêðíåõóôéêÞò êáìðýëçò P-V ãéá ôï áíôßóôïé÷ï ôìÞìáüãêïõ. Óçìåéþíåôáé üôé, ãéá íá åßíáé äõíáôÞ ç áíÜëõóçôçò êáìðýëçò P-V ðïõ åß÷å êáôáãñáöåß óå êÜèå åðßðå-äï ÑÅÅÑ ìå âÜóç ôéò ìåôñïýìåíåò ôéìÝò ðßåóçò êáé üãêïõåöáñìüóèçêå ç óéãìïåéäÞò åîßóùóç ðïõ Ý÷åé ðñïôáèåßáðü ôïõò Venega êáé óõí.14-16, Ýôóé þóôå íá Ý÷ïõìå áñ-êåôÜ óçìåßá ãéá ôç ãñáììéêÞ ðáëéíäñüìçóç (Åéêüíá 1).

Óôá ôìÞìáôá üãêïõ óôá ïðïßá äåí õðÞñ÷å ÐÅÑ ôïõ-ëÜ÷éóôïí êáôÜ 95% ôïõ ôìÞìáôïò ç óôáèåñÜ ÷ñüíïõ ôïõáíáðíåõóôéêïý óõóôÞìáôïò (ôers) õðïëïãßóôçêå áðü ôçó÷Ýóç ôers = Crs x Rrs. Ïé Rrs õðïëïãßóèçêáí áðü ôéòRtot ìåôÜ ôçí áöáßñåóç Rtube êáé Rvent.

ÅÜí ãéá êÜðïéï ôìÞìá üãêïõ õðÞñ÷å ç Ýíäåéîç ÐÅÑ,ïé Rrs õðïëïãßóôçêáí ùò åîÞò:Á. Ãéá ôìÞìáôá üãêïõ óôá ïðïßá õðÞñ÷å ÐÅÑ ôïõëÜ÷é-

óôïí óôü 95% ôïõ ôìÞìáôïò ïé Rrs èåùñÞèçêå üôé åß-íáé ßóåò ìå Rtot.

Â. Åðß åíäåßîåùò ðáñïõóßáò ÐÅÑ óå Ýíá ðïóïóôü ôïõôìÞìáôïò üãêïõ ïé Rrs õðïëïãßóôçêáí áðü ôçí åîß-óùóç: R rs = RrsÐÑ x ÐÑ + RrsÌÐÑ x ÌÐÑ,

üðïõ RrsÐÑ êáé RrsÌÐÑ ïé åêðíåõóôéêÝò áíôéóôÜóåéò óôïôìÞìá ôïõ üãêïõ ðïõ õðÞñ÷å ðåñéïñéóìüò ñïÞò êáé óåáõôü ðïõ äåí õðÞñ÷å, áíôßóôïé÷á. ÐÑ êáé ÌÐÑ åßíáé ôïðïóïóôü ôïõ ôìÞìáôïò (%) óôï ïðïßï õðÞñ÷å Þ ü÷é ÐÅÑ,áíôßóôïé÷á.

Ç áíÜëõóç ôùí äåäïìÝíùí Ýãéíå ìå ôçí ðïëõðáñá-ãïíôéêÞ áíÜëõóç ôçò ìåôáâëçôüôçôáò (ANOVA). Ç ôéìÞp< 0,05 èåùñÞèçêå óôáôéóôéêÜ óçìáíôéêÞ.

ÁÐÏÔÅËÅÓÌÁÔÁ

Ìå ÆÅÅÑ ç ìÝóç ôéìÞ ôïõ åêðíåüìåíïõ üãêïõ óôçáíáðíïÞ ìåëÝôçò Þôáí 0,56± 0,061. Ìå ôçí åöáñìïãÞôùí ôñéþí åðéðÝäùí ÑÅÅÑ ç ìÝóç ôéìÞ ôïõ åêðíåüìå-íïõ üãêïõ óôçí áíáðíïÞ ìåëÝôçò Þôáí 0,54± 0,07,


Åéêüíá 1. ¢íù: ÓôáôéêÞ åêðíåõóôéêÞ êáìðýëç ðßåóçò-üãêïõ ôïõ áíáðíåõóôéêïý óõóôÞìáôïò óå Ýíáí áíôéðñïóùðåõôéêü áóèåíÞ.Êëåéóôïß êýêëïé: Êáìðýëç äåäïìÝíùí. Áíïé÷ôÜ ôñßãùíá: Óçìåßá ðïõ åëÞöèçóáí ìåôÜ áðü ôçí åöáñìïãÞ ôçò óéãìïåéäïýò åîßóù-óçò. ÊÜôù: ÅêðíåõóôéêÞ åíäïôéêüôçôá (Crs) õðïëïãéóìÝíç ìå ãñáììéêÞ ðáëéíäñüìçóç ôùí äåäïìÝíùí ðïõ åëÞöèçóáí áðü ôçóéãìïåéäÞ åîßóùóç ãéá êáèÝíá áðü ôá ôìÞìáôá üãêïõ (100 ml ôï êÜèå Ýíá, 1 ìÝ÷ñé 5). Ôá âÝëç äåß÷íïõí ôçí ðïñåßá ôçò åêðíïÞò.ÁíáôñÝîôå óôï êåßìåíï ãéá ðåñéóóüôåñåò ëåðôïìÝñåéåò.

H2O/l/sec óôï ðÝìðôï ôìÞìá. Ïé áíôßóôïé÷åò ôéìÝò ôùíRvent óôï ðñþôï ôìÞìá Þôáí 5,7±0,5, 4,5±0,7, 4,6±0,7êáé 4,5±0,7 êáé åëáôôþèçêáí óå 3,3±1,1, 3,6±1,1,3,3±1,0 êáé 3,4±1,1 óôï ðÝìðôï.

Ìå ÆÅÅÑ ç ôe ìåéþèçêå óçìáíôéêÜ áðü ôçí áñ÷Þ(1ï ôìÞìá üãêïõ) ðñïò ôï ôÝëïò (5ï ôìÞìá üãêïõ) ôçòåêðíïÞò (Ðßíáêáò 2). Ç äéáöïñÜ áõôÞ óôç ôe áðü ôçíáñ÷Þ ðñïò ôï ôÝëïò ôçò åêðíïÞò ìåéþèçêå ðñïïäåõôéêÜìå ôçí áýîçóç ôçò ÑÅÅÑ, Ýôóé þóôå ìå ÑÅÅÑ 10 êáé 15cm H2O, ç ôe Þôáí ó÷åäüí óôáèåñÞ óå üëç ôç äéÜñêåéáôçò åêðíïÞò. Ìå ÆÅÅÑ ç Crs Þôáí ó÷åôéêÜ ÷áìçëÞ óôïðñþôï êáé ðÝìðôï ôìÞìá ôïõ üãêïõ. Ç ìÝãéóôç ôéìÞ CrsðáñáôçñÞèçêå óôï ìÝóï ôçò åêðíïÞò (3ï ôìÞìá üãêïõ).Ìå ÑÅÅÑ 15 cm H2O ç Crs áõîÞèçêå ðñïïäåõôéêÜ áðüôçí áñ÷Þ ðñïò ôï ôÝëïò ôçò åêðíïÞò. ÁíåîÜñôçôá áðüôï åðßðåäï ÑÅÅÑ ïé Rtot Þôáí óçìáíôéêÜ ìåãáëýôåñåò

0,53±0,07 êáé 0,52±0,07 L ãéá ôéìÝò ÑÅÅÑ 5, 10, 15 cmH2O, áíôßóôïé÷á. Ç ìÝóç ôéìÞ ôùí õðü åîÝôáóç ôìçìÜ-ôùí Þôáí 0,10±0,01, 0,10±0,01, 0,10±0,02 êáé 0,09±0,01ml ãéá ÑÅÅÑ 0, 5, 10, 15 cm H2O, áíôßóôïé÷á.

Ìå ÆÅÅÑ 9 áóèåíåßò åìöÜíéóáí ÐÅÑ. Óå 8 áóèå-íåßò õðÞñ÷å Ýíäåéîç ÐÅÑ óå üëï ôï ôåëåõôáßï ôìÞìáüãêïõ, åíþ óå 6 áóèåíåßò ÐÅÑ õðÞñ÷å êáé óôï ôÝôáñôïôìÞìá üãêïõ óå ðïóïóôü 25-44% ôïõ óõíïëéêïý üãêïõôïõ ôìÞìáôïò. Ç åöáñìïãÞ ÑÅÅÑ åîáöÜíéóå ôïí ÐEÑóå üëïõò ôïõò áóèåíåßò.

Ãéá äåäïìÝíï ôìÞìá ôïõ åêðíåüìåíïõ üãêïõ ïé Rt-ube êáé ïé Rvent äéÝöåñáí ðåñßðïõ êáôÜ 1 êáé 0,5 cmH2O/l/sec, áíôßóôïé÷á. Óôï ðñþôï ôìÞìá ç ìÝóç ôéìÞ ôçòRtube Þôáí 4,6±0,8, 4,8±0,8, 4,8±0,9 êáé 5,0±0,8 cmH2O/l/sec, áíôßóôïé÷á ìå 0, 5, 10 êáé 15 cm H2O êáé åëáô-ôþèçêáí óå 0,8±0,2, 0,9±0,2, 0,9±0,3 êáé 0,9±0,2 cm


Ðßíáêáò 2. ÓôáèåñÜ ÷ñüíïõ (ôe), åêðíåõóôéêÞ åíäïôéêüôçôá (Crs) êáé ïëéêÝò åêðíåõóôéêÝò áíôéóôÜóåéò (Rtot) ôùí äéáäï÷éêþíôìçìÜôùí üãêïõ (1-5) ìå äéÜöïñá åðßðåäá PEEP

PEEP (cmH2O) 0 5 10 15ÔìÞìá üãêïõ

ôe (sec)1 0,91±0,3* 0,81±0,2* 0,70±0,2+ 0,65±0,2+

2 0,88±0,3* 0,81±0,2* 0,76±0,2 0,70±0,2+

3 0,85±0,3* 0,83±0,3* 0,81±0,3 0,70±0,2+

4 0,78±0,2 0,73±0,2 0,74±0,3 0,70±0,3+

5 0,70±0,2 0,68±0,2 0,71±0,3 0,64±0,2Crs (l/cm H2O)

1 0,047±0,02 0,048±0,01 0,040±0,01*+ 0,036±0,01*+

2 0,054±0,02* 0,057±0,02* 0,052±0,02 0,045±0,01*

3 0,058±0,02* 0,061±0,02* 0,057±0,02 0,051±0,024 0,055±0,01* 0,060±0,02* 0,059±0,02 0,055±0,025 0,045±0,01 0,053±0,01 0,057±0,02+ 0,054±0,02+

Rtot (cm H2O/l/sec)1 20,15±3,3* 17,43±3,3* 17,10±3,6* 19,06±3,33*

2 16,61±3,6 14,33±2,0 14,84±2,2 15,67±1,93 14,79±2,6 13,63±1,4 14,05±2,7 13,89±1,64 14,30±2,0 12,34±2,0+ 12,40±1,4+ 12,64±2,1+

5 15,99±2,9 12,75±1,7+ 12,30±1,8+ 11,97±2,8+

*ÓôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ áðü ôçí ôéìÞ ôïõ ðÝìðôïõ ôìÞìáôïò üãêïõ+ ÓôáôéóôéêÜ óçìáíôéêÞ äéáöïñÜ áðü ôçí ôéìÞ ôïõ áíôßóôïé÷ïõ ôìÞìáôïò üãêïõ ìå ZEEP.

óôçí áñ÷Þ ôçò åêðíïÞò. Ìå ÆÅÅÑ ïé Rtot óôï 5ï ôìÞìáüãêïõ Þôáí óçìáíôéêÜ ìåãáëýôåñåò áðü ôéò áíôßóôïé÷åòìåôÜ áðü åöáñìïãÞ äéáöüñùí åðéðÝäùí ÑÅÅÑ.

Ìå ÆÅÅÑ ç ôers êáé ïé Rrs áõîÞèçêáí óçìáíôéêÜ óôïôÝëïò ôçò åêðíïÞò (Ðßíáêáò 3). ÓõãêñéôéêÜ ìå ôï 1ï ôìÞ-ìá üãêïõ, ç ôers óôï 5ï ôìÞìá Þôáí õøçëüôåñç êáôÜ 55.5± 31,3%, åíþ ç áíôßóôïé÷ç áýîçóç ãéá ôéò Rrs Þôáí 63,9± 45%. Ìå ÑÅÅÑ ïé Rrs äéáôçñÞèçêáí ó÷åôéêÜ óôáèå-ñÝò êáôÜ ôç äéÜñêåéá ôçò åêðíïÞò, ìå áðïôÝëåóìá ç äéá-öïñÜ ôçò ôrs ìåôáîý ôçò áñ÷Þò êáé ôïõ ôÝëïõò ôçò åê-ðíïÞò íá ìåéùèåß óçìáíôéêÜ.

Ç ìÝóç ôe êáé ôers (ìÝóç ôéìÞ ôùí ðÝíôå ôìçìÜôùíãéá êÜèå åðßðåäï ÑÅÅÑ) áðåéêïíßæåôáé óôçí åéêüíá 2.¼ðùò öáßíåôáé ç ìÝóç ôe êáé ôers ìåéþèçêáí óçìáíôéêÜìå ôçí áýîçóç ôçò ÑÅÅÑ áðü 0 óôá 15 cm H2O.

Óå óýãêñéóç ìå ôïí ôåëïåêðíåõóôéêü üãêï ðíåýìï-íá (ÔÏÐ) ìå ZEEP, ï ÔÏÐ áõîÞèçêå ðñïïäåõôéêÜ ìåôçí áýîçóç ôçò åöáñìïæüìåíçò ÑÅÅÑ. Ç áýîçóç áõôÞÞôáí êáôÜ ìÝóï üñï 0,27±0,1, 0,61±0,2, 1,00±0,33 L ìåÑÅÅÑ 5, 10, 15 cm H2O áíôßóôïé÷á.

Ç êáôáãñáöÞ ôçò óõíïëéêÞò êáìðýëç P-V ãéá üëïõò

ôïõò áóèåíåßò óå êÜèå åðßðåäï ÑÅÅÑ Ýäåéîå ìßá óçìá-íôéêÞ ìåôáôüðéóç ðñïò ôá ðÜíù õðïäçëþíïíôáò åðé-ðëÝïí åðéóôñÜôåõóç êõøåëßäùí (Åéêüíá 3).

ÓÕÆÇÔÇÓÇ

Ôá êõñéüôåñá áðïôåëÝóìáôá ðïõ åîÜãïíôáé áðüáõôÞ ôç ìåëÝôç åßíáé: 1) Ìå ÆÅÅÑ ôï áíáðíåõóôéêü óý-óôçìá óôïõò áóèåíåßò ìå ARDS óõìðôýóóåôáé äéá ìÝ-óïõ ôïõ åíäïôñá÷åéáêïý óùëÞíá êáé ôïõ åêðíåõóôéêïýêõêëþìáôïò ôïõ áíáðíåõóôÞñá ðñïò ôçí áôìüóöáéñááíïìïéïãåíþò, ìå ñõèìü ðïõ áõîÜíåôáé ðñïïäåõôéêÜðñïò ôï ôÝëïò ôçò åêðíïÞò. 2) Ç áíïìïéïãÝíåéá óôï ñõè-ìü óýìðôõîçò åëáôôþíåôáé üóï áõîÜíåôáé ç ÑÅÅÑ.3) Ìå ÆÅÅÑ, ôï áíáðíåõóôéêü óýóôçìá óõìðôýóóåôáéðñïò ôïí åíäïôñá÷åéáêü óùëÞíá åðßóçò áíïìïéïãåíþò,áëëÜ ï ñõèìüò óýìðôõîçò ðñïïäåõôéêÜ åëáôôþíåôáéðñïò ôï ôÝëïò ôçò åêðíïÞò. Áõôüò ï áñãüôåñïò ñõèìüòïöåßëåôáé óå óçìáíôéêÞ áýîçóç óôéò åêðíåõóôéêÝò áíôé-óôÜóåéò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò ðïõ ðáñáôçñïý-íôáé óå ÷áìçëïýò üãêïõò ðíåýìïíá. 4) Ìå ÑÅÅÑ, ïé åê-


Ðßíáêáò 3. ÓôáèåñÜ ÷ñüíïõ (ôers) êáé áíôéóôÜóåéò (Rrs) ôïõ áíáðíåõóôéêïý óõóôÞìáôïò ôùí äéáäï÷éêþí ôìçìÜôùí üãêïõ (1-5) ìåäéÜöïñá åðßðåäá PEEP.

PEEP (cmH2O) 0 5 10 15ÔìÞìá üãêïõ

ôe (sec)1 0,44±0,1* 0,37±0,1 0,34±0,2* 0,33±0,12 0,40±0,1* 0,36±0,1 0,38±0,1 0,35±0,13 0,41±0,2* 0,41±0,2 0,44±0,2 0,37±0,14 0,53±0,2* 0,39±0,1 0,44±0,2 0,42±0,25 0,68±0,2 0,44±0,1+ 0,48±0,2+ 0,41±0,2+

Rrs (cm H2O/l/sec)1 9,88±2,6* 8,10±2,8 8,11±3,0 9,81±3,32 7,67±2,9* 6,22±1,8 7,51±2,0 7,92±1,73 7,20±2,2* 6,65±1,6 7,83±2,6 7,45±1,84 9,78±2,0* 6,66±1,9+ 7,38±1,3+ 7,58±2,0+

5 15,41±2,9 8,31±1,6+ 8,16±1,8+ 7,73±2,4+

ÁíáôñÝîôå óôïí ðßíáêá 2 ãéá ôç óôáôéóôéêÞ äéáöïñÜ.

Åéêüíá 2. ÌÝóç óôáèåñÜ ÷ñüíïõ êáé óôáèåñÞ áðüêëéóç üëùí ôùí ôìçìÜôùí áíÜëïãá ìå ôï åðßðåäï ôçò ÑÅÅÑ. Áíïé÷ôÜ ôåôñÜãù-íá: ÌÝóç óôáèåñÜ ÷ñüíïõ ôe (ãéá ôá ðÝíôå ôìÞìáôá üãêïõ). ÊëåéóôÜ ôåôñÜãùíá: ÌÝóç ôers (ãéá ôá ðÝíôå ôìÞìáôá üãêïõ).

ðíåõóôéêÝò áíôéóôÜóåéò ôïõ áíáðíåõóôéêïý óõóôÞìáôïòðáñÝìåéíáí ó÷åôéêÜ óôáèåñÝò êáè� üëç ôç äéÜñêåéá ôçòåêðíïÞò, ïäçãþíôáò Ýôóé óå óçìáíôéêÞ åëÜôôùóç ôçòáíïìïéïãÝíåéáò ôïõ ñõèìïý óýìðôõîçò. 5) Ï óõíïëéêüòñõèìüò óýìðôõîçò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò åßôåðñïò ôçí áôìüóöáéñá åßôå ðñïò óôïí åíäïôñá÷åéáêüóùëÞíá áõîÜíåôáé üóï áõîÜíåôáé ôï åðßðåäï åöáñìï-æüìåíçò ÑÅÅÑ. 6) Ìå êáé ÷ùñßò PEEP ç åêðíåõóôéêÞåíäïôéêüôçôá ôïõ áíáðíåõóôéêïý óõóôÞìáôïò äåí åßíáéóôáèåñÞ.

Ìå ÆÅÅÑ, 9 áðü ôïõò 10 áóèåíåßò åìöÜíéóáí ÐÅÑ.

Ôá áðïôåëÝóìáôá áõôÜ óõìöùíïýí ìå ôá åõñÞìáôá ìéáòðñüóöáôçò ìåëÝôçò ôùí Koutsoukou êáé óõí.8. Óôçí ðá-ñïýóá ìåëÝôç áðïäåßîáìå åðéðëÝïí, üôé óå üëåò ôéò ðå-ñéðôþóåéò ï ÐÅÑ, åîáöáíßóèçêå ìå ôçí åöáñìïãÞÑÅÅÑ, Ýóôù êáé ôçò ôÜîçò ôùí 5 cm H2O, åýñçìá ðïõõðïäçëþíåé üôé ÐÅÑ åìöáíßæåôáé óå ÷áìçëïýò üãêïõòðíåýìïíá. Åðß ðáñïõóßáò ÐÅÑ ç ìÝôñçóç ôùí åêðíåõ-óôéêþí áíôéóôÜóåùí ìå âÜóç ôç äéáöïñÜ ðßåóçò ìåôáîýóôüìáôïò êáé êõøåëßäùí åßíáé áíáîéüðéóôç9. Ï õðïëï-ãéóìüò ôùí åêðíåõóôéêþí áíôéóôÜóåùí óôïõò áóèåíåßòìå ARDS, ðåñéðëÝêåôáé áêüìç ðåñéóóüôåñï, åðåéäÞ ç


Åéêüíá 3. ÌÝóç åêðíåõóôéêÞ êáìðýëç ðßåóçò-üãêïõ óå äéáöïñåôéêÜ åðßðåäá ÑÅÅÑ, õðïëïãéæüìåíç ìåôÜ áðü ëÞøç ìÝóùí ôéìþíðßåóçò êáé üãêïõ óôçí áñ÷Þ, ìÝóï êáé ôÝëïò ôïõ êÜèå ôìÞìáôïò üãêïõ. Ï üãêïò áíáöÝñåôáé óôçí ðáèçôéêÞ FRC (FRCZEEP). Ãéáäéåõêüëõíóç ôçò ðáñïõóßáóçò ïé óôáèåñÝò áðïêëßóåéò Ý÷ïõí ðáñáëçöèåß. Êëåéóôïß êýêëïé: ÑÅÅÑ 0 (ÆÅÅÑ). Áíïé÷ôïß êýêëïé:ÑÅÅÑ 5 cm H2O. ÊëåéóôÜ ôñßãùíá: 10 cm H2O PEEP. Áíïé÷ôÜ ôñßãùíá: 15 cm H2O PEEP.

ó÷Ýóç ðßåóçò�üãêïõ êáôÜ ôçí åêðíïÞ äåí åßíáé ãñáììé-êÞ, ìç åðéôñÝðïíôáò ôïí õðïëïãéóìü ôçò êõøåëéäéêÞòðßåóçò ÷ñçóéìïðïéþíôáò óôáèåñÞ ôéìÞ åëáóôéêüôçôáò.Ìå âÜóç ôá ðáñáðÜíù óõìðåñáßíåôáé üôé êáôÜ ôïí õðï-ëïãéóìü ôùí åêðíåõóôéêþí áíôéóôÜóåùí óå áóèåíåßò ìåARDS èá ðñÝðåé íá ëáìâÜíåôáé õðüøç ôüóï ï ÐÅÑ,üóï êáé ç áðïõóßá ãñáììéêüôçôáò óôç ó÷Ýóç P�V. Óýì-öùíá ìå ôéò ãíþóåéò ìáò ç ðáñïýóá ìåëÝôç åßíáé ç ðñþ-ôç ðïõ Ýëáâå õðüøç áõôïýò ôïõò äýï ðáñÜãïíôåò.

Óôçí ðáñïýóá ìåëÝôç ÷ñçóéìïðïéÞóáìå óõíå÷üìå-íá ôìÞìáôá üãêïõ ìåãÝèïõò ðåñßðïõ 100 ml (110-60 ml).Óå áõôÜ ôá ó÷åôéêÜ ìéêñÜ ôìÞìáôá üãêïõ, ç ó÷Ýóç V/V�Þôáí ìå ìåãÜëç áêñßâåéá ãñáììéêÞ ìå ôéìÞ ôïõ r ðïõðëçóßáæå ôç ìïíÜäá (>0,98). Ãé' áõôü êáé èåùñÞóáìåüôé ç ìåôáâïëÞ ôïõ üãêïõ óå áõôü ôï ìéêñü ôìÞìá èáìðïñïýóå åðáñêþò íá ðåñéãñáöåß ìå ìéá ôéìÞ óôáèå-ñÜò ÷ñüíïõ.

Ç åêðíåõóôéêÞ óôáôéêÞ åíäïôéêüôçôá Þôáí äéáöïñå-ôéêÞ óå êáèÝíá áðü ôá óõíå÷üìåíá ôìÞìáôá üãêïõ. Çìç ãñáììéêÞ óõìðåñéöïñÜ ôçò ó÷Ýóçò P-V êáôÜ ôçí åé-óðíïÞ Ý÷åé ðåñéãñáöåß óå ðåéñáìáôüæùá ìåôÜ áðü êá-ôáóôñïöÞ ôïõ åðéöáíåéïäñáóôéêïý ðáñÜãïíôá17. Åðé-ðëÝïí, óå áóèåíåßò ìå ïîåßá âëÜâç ðíåýìïíá18 êáé óåáðïìïíùìÝíïõò ðíåýìïíåò êïõíåëéþí ìåôÜ áðü áöáß-ñåóç ôïõ åðéöáíåéïäñáóôéêïý ðáñÜãïíôá19, ç åíäïôéêü-ôçôá ôïõ áíáðíåõóôéêïý óõóôÞìáôïò âñÝèçêå üôé åßíáéåîáñôþìåíç áðü ôïí üãêï. Áðü üóï ãíùñßæïõìå, ç ðá-ñïýóá ìåëÝôç åßíáé ç ðñþôç ðïõ áðïäåéêíýåé üôé ç ó÷Ý-óç Ñ-V åßíáé ìç ãñáììéêÞ êáé êáôÜ ôç äéÜñêåéá ôçò åê-

ðíïÞò. Ï ðáñáôçñïýìåíïò ôýðïò ìåôáâïëþí óôç CrsêáôÜ ôçí åêðíïÞ åßíáé äýóêïëï íá åêôéìçèåß ìå áêñß-âåéá. Ç áýîçóç ôçò Crs óôçí åêðíïÞ èá ìðïñïýóå íáïöåßëåôáé åßôå óôç ìåßùóç ôçò õðåñäéÜôáóçò åßôå óôïêëåßóéìï êõøåëßäùí ðïõ åß÷áí äéáíïé÷ôåß íùñßôåñá óôïôÝëïò ôçò åéóðíïÞò7. Ôï ôåëåõôáßï åíäå÷üìåíï öáßíåôáéðïëý ðéèáíü ìå ÆÅÅÑ Þ ÷áìçëü åðßðåäï ÑÅÅÑ, éäßùòåÜí ëçöèåß õðüøç üôé ç ðßåóç óýãêëåéóçò ôùí êõøåëß-äùí åßíáé óõíÞèùò ÷áìçëüôåñç áðü ôçí áíôßóôïé÷ç ðßå-óç äéÜíïéîÞò ôïõò20. Áõôü óçìáßíåé, üôé êáôÜ ôç äéÜñ-êåéá ôçò åêðíïÞò, óõãêñéôéêÜ ìå ôçí åéóðíïÞ, ðåñéóóü-ôåñåò êõøåëßäåò èá åßíáé áíïéêôÝò ãéá ôçí ßäéá ôéìÞ óôá-ôéêÞò ðßåóçò. Áõôü ôï öáéíüìåíï ðéèáíÜ åíéó÷ýåôáé êáôÜôçí Ýíáñîç ôçò åêðíïÞò üðïõ ïé ðéÝóåéò åßíáé ó÷åôéêÜõøçëÝò êáé ç åíäïôéêüôçôá ÷áìçëÞ7. ¼óï ç åêðíïÞ ðñï-÷ùñÜ ðåñéóóüôåñåò êõøåëßäåò êëåßíïõí, áõîÜíïíôáòÝôóé ôçí Crs. Óôï ôÝëïò ôçò åêðíïÞò ôï ôìÞìá ôïõ ðíåý-ìïíá ðïõ ðáñáìÝíåé áíïé÷ôü åßíáé ó÷åôéêÜ ìéêñü, ïäç-ãþíôáò Ýôóé óå åëÜôôùóç ôçò Crs. Ç Üðïøç áõôÞ åíé-ó÷ýåôáé áðü ôï ãåãïíüò üôé ç Crs áõîÜíåôáé óçìáíôéêÜóôï ôÝëïò ôçò åêðíïÞò ìå ôçí áýîçóç ôçò ÑÅÅÑ. ÐñÜã-ìáôé, óå õøçëÜ åðßðåäá ÑÅÅÑ, ç Crs ðñïïäåõôéêÜ áõ-îáíüôáí áðü ôçí áñ÷Þ ðñïò ôï ôÝëïò ôçò åêðíïÞò. Áíêáé ç áýîçóç ôçò Crs èá ìðïñïýóå íá áðïäïèåß óå ìåßù-óç ôçò õðåñäéÜôáóçò, èåùñïýìå ùò ôïí åðéêñáôÝóôåñïìç÷áíéóìü, ôï êëåßóéìï êõøåëßäùí ðïõ åß÷áí åðéóôñá-ôåõôåß, áöïý ãéá ìéá äåäïìÝíç êõøåëéäéêÞ ðßåóç ï üãêïòôïõ ðíåýìïíá Þôáí óçìáíôéêÜ ìåãáëýôåñïò ìå ÑÅÅÑ 15cm H2O áðü üôé ìå ÑÅÅÑ 10 cm H2O. ÅðéðëÝïí, ãéá


Ýíáí óõãêåêñéìÝíï ðíåõìïíéêü üãêï ç Crs Þôáí óçìá-íôéêÜ õøçëüôåñç ìå ÑÅÅÑ 15 cm H2O áðü üôé ìå ÑÅÅÑ10 cm H2O, åíþ ç êõøåëéäéêÞ ðßåóç êáé êáôÜ óõíÝðåéáç äéáðíåõìïíéêÞ ðßåóç Þôáí ÷áìçëüôåñåò. Áðü ôçí ÜëëçðëåõñÜ, åÜí ç åëÜôôùóç ôçò õðåñäéÜôáóçò áðïôåëïýóåôïí êýñéï ìç÷áíéóìü ãéá ôçí ðáñáôçñïýìåíç áýîçóç ôçòCrs êáôÜ ôçí åêðíïÞ, èá ðåñéìÝíáìå ðáñüìïéåò Crs êáéêõøåëéäéêÝò ðéÝóåéò ãéá Ýíáí äåäïìÝíï êõøåëéäéêü üãêïìåôáîý ôùí äýï õøçëüôåñùí åðéðÝäùí ÑÅÅÑ.

Óå ÆÅÅÑ, ôï áíáðíåõóôéêü óýóôçìá öáßíåôáé íáóõìðôýóóåôáé ðñïò ôïí áôìïóöáéñéêü áÝñá ìå áíïìïéï-ãåíÞ ôñüðï êáé ìå ñõèìü ðïõ ðñïïäåõôéêÜ áõîÜíåôáéðñïò ôï ôÝëïò ôçò åêðíïÞò. Áõôüò ï ôñüðïò óýìðôõîçòïöåéëüôáí áðïêëåéóôéêÜ óôçí ðáñïõóßá ôïõ åíäïôñá-÷åéáêïý óùëÞíá êáé ôïõ åêðíåõóôéêïý êõêëþìáôïò ôïõáíáðíåõóôÞñá, ôá ïðïßá åðçñÝáæáí ôçí áñ÷éêÞ öÜóçôçò åêðíïÞò üðïõ ïé ñïÝò Þôáí ó÷åôéêÜ õøçëÝò. Ï ñõè-ìüò ìå ôïí ïðïßï ôï áíáðíåõóôéêü óýóôçìá óõìðôýóóå-ôáé ðñïò ôïí åíäïôñá÷åéáêü óùëÞíá Þôáí äéáöïñåôéêüòêáé åìöÜíéæå ðñïïäåõôéêÞ åëÜôôùóç ðñïò ôï ôÝëïò ôçòåêðíïÞò. Ç åðéâñÜäõíóç ôïõ ñõèìïý óýìðôõîçò óå ÷á-ìçëïýò ðíåõìïíéêïýò üãêïõò, öáßíåôáé üôé ïöåßëåôáéóôçí áõîçìÝíç áíôßóôáóç óôç ñïÞ áÝñá, åðåéäÞ ç åê-ðíåõóôéêÞ åíäïôéêüôçôá Þôáí ÷áìçëüôåñç óôï ôÝëïò ôçòåêðíïÞò. ÐñÜãìáôé, ç åêðíåõóôéêÞ áíôßóôáóç ôïõ áíá-ðíåõóôéêïý óõóôÞìáôïò áõîÞèçêå óçìáíôéêÜ óôïõò ÷á-ìçëïýò üãêïõò ðíåýìïíá, ãåãïíüò ðïõ ðéèáíþò áíôá-íáêëÜ êëåßóéìï Þ óôÝíùóç ìéêñþí áåñáãùãþí.

Ï ñõèìüò óýìðôõîçò ðáñïõóßáóå óçìáíôéêÝò ìåôá-âïëÝò áíÜëïãá ìå ôï åðßðåäï ôçò åöáñìïæüìåíçò ÑÅÅÑ.Ç áíïìïéïãÝíåéá óýìðôõîçò ôïõ áíáðíåõóôéêïý óõóôÞ-ìáôïò óôçí áôìüóöáéñá åìöÜíéóå ðñïïäåõôéêÞ åîïìÜ-ëõíóç ìå ôçí áýîçóç ôïõ ÑÅÅÑ. ÁõôÜ ôá åõñÞìáôá åß-íáé óýìöùíá ìå åêåßíá ôùí Guttmann êáé óõíåñãáôþí6,ïé ïðïßïé ðåñéÝãñáøáí Ýíá óôáèåñü ðñüôõðï óýìðôõ-îçò óå áóèåíåßò ìå ARDS óå ìç÷áíéêü áåñéóìü, ìå åðß-ðåäï åöáñìïæüìåíçò ÑÅÅÑ 12 cm H2Ï. Ç ðáñïýóáìåëÝôç äåß÷íåé åðéðëÝïí üôé ç ïìïéïãÝíåéá óôç óýìðôõ-îç ôïõ ðíåýìïíá ïöåéëüôáí óå ìéá ðñïïäåõôéêÞ áýîç-óç ôçò Crs êáé áíôßóôïé÷ç åëÜôôùóç ôùí ïëéêþí áíôé-óôÜóåùí ôùí áåñáãùãþí êáôÜ ôï ôÝëïò ôçò åêðíïÞò. Óå

óýãêñéóç ìå ÆÅÅÑ, ç åöáñìïãÞ ÑÅÅÑ âåëôßùóå óå óç-ìáíôéêü âáèìü ôçí áíïìïéïãÝíåéá óôç óýìðôõîç. Áõôüïöåéëüôáí óôç óçìáíôéêÞ åðßäñáóç ôçò ÑÅÅÑ óôéò Rrs,ïé ïðïßåò ðáñÝìåíáí óôáèåñÝò êáôÜ ôç äéÜñêåéá ôçòåêðíïÞò êáé óå åðßðåäá óçìáíôéêÜ ÷áìçëüôåñá óå ó÷Ý-óç ìå áõôÜ ðïõ ðáñáôçñÞèçêáí ìå ÆÅÅÑ. Åßíáé ðéèá-íü, üôé ç åöáñìïãÞ ÑÅÅÑ ïäÞãçóå óå åëÜôôùóç ôùíåêðíåõóôéêþí áíôéóôÜóåùí ðáñåìðïäßæïíôáò ôç óý-ãêëåéóç Þ ôç óôÝíùóç ôùí ìéêñþí áåñáãùãþí21,22. Óåó÷Ýóç ìå ôï ÆÅÅÑ, ï ñõèìüò óýìðôõîçò åßôå óôçí áôìü-óöáéñá åßôå óôïí åíäïôñá÷åéáêü óùëÞíá, Þôáí ãñçãï-ñüôåñïò ìå ôçí åöáñìïãÞ ÑÅÅÑ. Ç äéáöïñÜ áõôÞ ÞôáíïõóéáóôéêÞ óå õøçëÜ åðßðåäá ÑÅÅÑ. ÐñÜãìáôé, ç ìÝóçôe üëùí ôùí ôìçìÜôùí ôùí ðíåõìïíéêþí üãêùí åëáôôþ-èçêå êáôÜ 18% üôáí ç ÑÅÅÑ áõîÞèçêå áðü 0 óå 15 cmH2O, åíþ ç áíôßóôïé÷ç ôéìÞ áýîçóç ãéá ôç ìÝóç ôers Þôáí23%.

Ç åëÜôôùóç ôùí åêðíåõóôéêþí áíôéóôÜóåùí ðïõðáñáôçñÞèçêå ìå ÑÅÅÑ Ýñ÷åôáé óå áíôßèåóç ìå ôá áðï-ôåëÝóìáôá ôçò ìåëÝôçò ôùí Pesenti êáé óõí.23, ïé ïðïßïéÝäåéîáí üôé óå áóèåíåßò ìå ARDS ç åöáñìïãÞ ÑÅÅÑïäÞãçóå óå áýîçóç ôùí åêðíåõóôéêþí áíôéóôÜóåùí. ÓôçìåëÝôç áõôÞ üìùò, ïé óõããñáöåßò õðïëüãéóáí ôéò åêðíåõ-óôéêÝò áíôéóôÜóåéò èåùñþíôáò üôé ç åíäïôéêüôçôá ÞôáíóôáèåñÞ óå üëç ôç äéÜñêåéá ôçò åêðíïÞò, åíþ åðéðëÝïíäåí åëÞöèç õðüøç ç ðéèáíüôçôá ðáñïõóßáò ÐÅÑ. Çðáñïýóá ìåëÝôç áðïäåéêíýåé êáèáñÜ üôé ç åêðíåõóôé-êÞ åíäïôéêüôçôá ôïõ áíáðíåõóôéêïý óõóôÞìáôïò êáè�üëç ôç äéÜñêåéá ôçò åêðíïÞò äåí åßíáé óôáèåñÞ êáé åðé-ðëÝïí üôé ç ðëåéïíüôçôá ôùí áóèåíþí ìå ARDS, åìöá-íßæïõí ÐÅÑ óå ìéêñïýò üãêïõò ðíåýìïíá.

ÓõìðåñáóìáôéêÜ, ç ðáñïýóá ìåëÝôç äåß÷íåé üôé ïñõèìüò óýìðôõîçò ôïõ ðíåýìïíá óå áóèåíåßò ìå ARDSåßíáé áíïìïéïãåíÞò êõñßùò åîáéôßáò ôçò óçìáíôéêÞò áý-îçóçò ôçò áíôßóôáóçò ôùí áåñáãùãþí óå ÷áìçëïýò ðíåõ-ìïíéêïýò üãêïõò. Ìå ôçí åöáñìïãÞ ÑÅÅÑ ïé åêðíåõ-óôéêÝò áíôéóôÜóåéò ôïõ áíáðíåõóôéêïý óõóôÞìáôïò ðá-ñáìÝíïõí ó÷åôéêÜ óôáèåñÝò êáè� üëç ôç äéÜñêåéá ôçòåêðíïÞò, ìå áðïôÝëåóìá ï ðíåýìïíáò íá óõìðôýóóåôáéïìïéïãåíþò êáé ìå ôá÷ýôåñï ñõèìü.


SUMMARY

Lung collapse pattern in adult patients with acute respiratory distress syndrome (ARDS) -The effect of PEEP

E. Kondili, G. Prinianakis, I. Athanasakis, D. Georgopoulos

The lung collapse pattern was studied in 10 intubated adult patients with acute respiratory distresssyndrome (ARDS). Tracheal pressure (Ptr), airway pressure (Paw), airflow (V�) and volume (V) atfour different PEEP levels (0, 5, 10, 15 cm H2O) were continually recorded. Expiratory volume (pas-sive expiration) was divided in four equal contiguous segments; time constant (ôe) and static respira-tory compliance (Crs) of each segment were separately calculated using linear regression analysis of V/V� and V/Ptr ratios, respectively. The ôe/Crs ratio was used for the calculation of total expiratory resist-ance (Rtot, the sum of the respiratory system resistance [Rrs], plus the endotracheal tube airflowresistance [Rtube], plus the ventilator circuit resistance [Rvent]). In the presence of expiratory flowlimitation, Rrs was assumed equal to RTOT. If no expiratory flow limitation was documented, Rrs wascalculated as Rtot minus the sum of Rtube plus Rvent. The time constant of the respiratory system(ôers) is represented by the product of Rrs and Crs. At zero PEEP (ZEEP), ôers was shown to increasesignificantly from the beginning toward the end of expiration (Äôers 55.5±31%) due to the markedincrease in Rrs (ÄRrs 63.9±45%). When PEEP was applied, Rrs was maintained relatively constantthroughout expiration, the collapse rate of the respiratory system increased and the difference in ôers

from the beginning toward the end of expiration reduced. Conclusively, the lungs of ARDS patientsdemonstrate a nonhomogeneous collapse rate during expiration as a result of a marked increase inrespiratory system resistance observed in low lung volumes. The use of PEEP leads to a homogeneousand higher lung collapse rate. Pneumon 2002, 15(2)147-157.

Key words: ARDS, PEEP, lung collapse, expiratory flow


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Dependence of FEV1 on preceding inspiration during

methacholine challenge testing in asthmatic patients

ABSTRACT. Background: In normal subjects, and patients withobstructive and restrictive lung defects, flows during an FVC ma-noeuver are higher after a fast inspiration without an end-inspir-atory pause as compared to a slow inspiration with an end-inspir-atory pause of approximately 5 s (time dependence of FVC). Ob-jective: In the present study, we investigated the influence of thesetwo manoeuvres on PEF and FEV

1 in asthmatic patients during

methacholine challenge testing. Methods: Thirteen patients whowere positive according to routine (non-standardized) metha-choline challenge tests (PD20£1.57 mg) were studied. Theiraverage(SD) lung function data were: FVC%pred=94(15),FEV

1%pred=76(17) and FEV

1/FVC%=68(12). The patients per-

formed the two types of FVC manoeuvres in random order beforeand at the last methacholine dose. Results: Using the standardizedFVC manoeuvres (fast before/fast after and slow before/slow af-ter), only 10 patients (77%) had a positive test, while all 13 pa-tients were positive with the routine test. Conclusion: These dataindicate that different results can be obtained, if instead of thestandardized, the non-standardized manoeuvres during metha-choline challenge tests are used. The use of non-standardized FVCmanoeuvres may lead to over-, or at least theoretically, to under-estimation of patients with bronchial hyperresponsiveness. There-fore, standardization of FVC manoeuvres during airway challengetesting is required. Pneumon 2002, 15(2)168-175.

INTRODUCTION

Extensive guidelines have been provided for the measurement proce-dure of airway responsiveness1-5. In these guidelines, however, the inspira-tory manoeuver preceding the expiratory effort has not been standardized.Thus, in practice, the FVC manoeuvres performed during challenge test-ing may be preceded by: 1) maximal inspirations made at different speeds,

N.G. Koulouris,J. Milic-Emili*,M. Gaga,A. Rassidakis,A. Koutsoukou,P. Latsi,J. Dimitroulis,P. Rapakoulias,J. Jordanoglou

Correspondence:Dr. N.G. Koulouris MD, PhD (London), RespiratoryFunction Laboratory, Department of RespiratoryMedicine, University of Athens, �Sotiria� Hospitalfor Diseases of the Chest, 152 Messoghion Ave,Athens, GR-115 27, Greece, Tel: +30-10-777 8827,Fax: +30-10-777 0423, E-mail: [email protected]

Clinical Study

Respiratory Function Laboratory, Department of Res-piratory Medicine, University of Athens Medical School,�Sotiria� Hospital, Athens, Greece, and *Meakins-Christie Laboratories, McGill University, Montreal,Quebec, Canada

Key Words: spirometry, standardization, lung me-chanics, asthma, methacholine challenge, airwayresponsiveness.


and 2) variable pauses at full inspiration. However, sev-eral studies have shown that in normal subjects6-9 andpatients with chronic obstructive pulmonary disease9,10,asthma8,9 and lung restriction11 the peak expiratory flow(PEF), FEV1, and maximal expiratory flows at differentlung volumes are significantly higher if the FVC manoeu-ver is performed after a rapid lung inflation without anend-inspiratory pause (manoeuver 1; fast) than after aslow inspiration with a 4-6 s end-inspiratory pause (ma-noeuver 2; slow). This time dependence is probably mainlycaused by stress relaxation and time constant inequali-ties within the lung6-14. These results dictate standardiza-tion of the inspiratory time history prior to the FVCmanoeuver.

In the present study we have performed a routinemethacholine challenge in 13 patients with a history ofasthma. As it is common practice, during this procedurethe volume and time history prior to the FVC manoeu-ver were not standardized. Additionally, before the rou-tine test and at the dose of methacholine at which FEV1

decreased by at least 20% (positive test), we measuredFEV1 using the standardized FVC manoeuvres 1 and 2.We hypothesized that our results might indicate that dif-ferent responses can be obtained with the routine (non-standardized) as compared to standardized methacholinetesting.

METHODS

We studied 13 consecutive patients (7 females) witha history of asthma diagnosed in the past according tothe American Thoracic Society criteria15. These werereferred to our laboratory for routine methacholine chal-lenge testing having no absolute contraindication for thetest. Their anthropometric characteristics and baselinelung function data are given in table 1. All subjects werein a stable clinical and functional state for at least 4 weekspreceding the study and were receiving their usual medi-cation. Subjects on treatment refrained from any drug(i.e., inhaled bronchodilators and/or corticosteroids) atleast from the day before testing. All patients had previ-ous experience with respiratory manoeuvres and werenon-smokers. Forced spirometry was measured with ascreen pneumotachograph (Screenmate; Erich JaegerGmbH & Co., Höchberg, Germany). The total lung ca-

Table 1. Anthropometric and pulmonary function data of 13 asth-matic patients

Age, yr 31 (11)Weight, kg 69 (11)Height, cm 169 (10)Gender 6M, 7FPEF, %pred 98 (24)FVC, %pred 94 (15)FEV1, %pred 76 (17)FEV1/FVC, % 68 (12)MMEF, %pred 61 (26)TLC, %pred n=10 96 (9)FRC, %pred 103 (21)RV, %pred 100 (31)TL, CO, %pred 96 (7)KCO, %pred 112 (16)

Values are mean(SD). PEF: peak expiratory flow; FVC: forcedvital capacity; FEV1: forced expiratory volume in one second;MMEF: forced expiratory flow between 25 and 75% of FVC;TLC: total lung capacity; FRC: functional residual capacity;RV: residual volume; TLCO: diffusing capacity for carbonmonoxide; KCO: transfer coefficient.

pacity (TLC) and its subdivisions were assessed by thehelium dilution method, carbon monoxide transfer fac-tor (TLCO) and transfer coefficient (KCO) by the singlebreath-hold method (P. K. Morgan, Kent, UK). The pre-dicted spirometric values, static lung volumes, TLCO andKCO are from the European Coal and Steel Communi-ty1,2. The study had the approval of the hospital�s ethicalcommittee and informed consent was obtained from allpatients. The patients were not aware of the specific aimof the study.

For the routine methacholine challenge testing theEuropean Community Respiratory Health Survey�s(ECRHS) short protocol16,17 was employed. During themethacholine test FEV1 and FVC were measured with aBiomedin spirometer (Biomedin srl, Padova, Italy). Thisdevice involves insertion of the mouthpiece into themouth after inhalation to TLC, therefore does not allowrecording of inspiratory manoeuvres preceding the FVC.Mefar MB3 Dosimeter (Mefar srl, Bovezzi, Italy) wasused for the administration of methacholine solutions.Methacholine solutions were made up from lyophilizedmethacholine chloride (Provocholine, Hoffman La Ro-


were urged to maintain the maximal expiratory effortsfor a similar duration7-11 (Table 2); and 4) all subjectswere studied at nearly the same time of the day20. Beforethe methacholine challenge (phase A) each subject ran-domly performed two types of FVC manoeuvres (Table2): a) fast: after a fast inspiration (mean flow of 2.59 l/s)without an end-inspiratory pause (manoeuver 1), and b)slow: after a slow inspiration (mean flow of 0.53 l/s) withan end-inspiratory pause lasting ~5s (manoeuver 2). Itshould be noted that closely similar results would havebeen obtained with a shorter (more realistic) pause asthe stress relaxation phenomena (see discussion) arecompleted within 2s. However, the two manoeuvres wereselected as such, in order to have comparable results withthe previous reports6-11. Each FVC manoeuver was initiat-ed from resting end-expiratory lung volume (FRC) aftera period of tidal breathing through the screen pneumo-tachograph. All patients had been trained to performthese two manoeuvres prior to this study. For both ma-noeuvres, at least three FVC curves were obtained thatfulfilled the ATS criteria19. The largest FVC and FEV1

were selected from all the acceptable curves, while PEFwas chosen from the acceptable curve that exhibited thelargest sum of FVC plus FEV1 (�best� test)19.

A short period after completing phase A, the patientsunderwent the standard routine methacholine challengetest17,18 with an independent member of the laboratorystaff (chest physician). In this case the time history priorto the FVC manoeuvres was not controlled. Since dur-ing the routine methacholine challenge the FEV1 wasmeasured with a device (Biomedin Spirometer) which

che, Basel, Switzerland) by standard procedures16,17.During phase A and B for the standardized mano-

euvres (see below), flow (V̂ ) was measured at the mouth,through the heated (30o C) Screenmate pneumotacho-graph. In contrast to Biomedin spirometer, the use ofthe latter device allows the recording of the inspiratorymanoeuvres prior to FVC. The response of the pneumo-tachograph, which was calibrated at the above tempera-ture along with the Biomedin spirometer with the same2L volume syringe, was linear over the range of flowsused. The calibration factor was corrected for the fall intemperature (6-7o C) of the expired air on passingthrough the cooler pneumotachograph18. The flow sig-nal was sampled at a rate of 100 Hz, using a data acqui-sition system with a built-in 16-bit analog-to-digital con-verter (AT-Codas; DATAQ Instruments, Inc., Akron,OH, USA) controlled by a computer (Toshiba T5200/100; Toshiba Inc., Tokyo, Japan). Volume (V) was ob-tained by numerical integration of the flow signal aftercorrection for drift. The resulting maximal expiratoryvolume-time (tFVC) and MEFV curves were used forsubsequent analysis.

Procedure

On the study day, all subjects were studied seated witha nose-clip on. To minimize variations of the maximalexpiratory volume-time curves19,20: 1) the first two ma-noeuvres were disregarded except the ones in phase B(see below), thus making the volume history of the sub-sequent curves about the same7-11; 2) care was taken tokeep the neck at a fixed neutral position21; 3) all subjects

Table 2. Variables characterizing the fast and slow forced vital capacity manoeuvres before and at last methacholine dose (n=13)

Phase A (before challenge) Phase B (last methacholine dose)manoeuver 1 manoeuver 2 manoeuver 1 manoeuver 2

fast slow fast slow

IC, l 2.61 (0.73) 2.58 (0.72) 2.21 (0.62) 2.24 (0.72)tI, s 1.04 (0.19) 5.31 (1.48) 1.15 (0.22) 4.83 (2.00)VT/tI, l/s 2.59 (0.87) 0.53 (0.22) 2.04 (0.78) 0.58 (0.41)tp, s 0.07 (0.09) 4.99 (0.90) 0.04 (0.05) 4.92 (1.05)tE, s 10.93 (1.28) 11.06 (1.31) 11.09 (2.07) 11.14 (2.23)

Values are mean(SD). IC: inspiratory capacity at which inspiration started; tI: duration of inspiration; VT/tI: mean inspiratoryflow; tp: duration of end-inspiratory pause; tE: duration of expiratory effort. There was no significant difference in IC and tEbetween manoeuvres 1 and 2.


involves insertion of the mouthpiece into the mouth af-ter inhalation to TLC, the subjects necessarily exhibitedan end-inspiratory pause of variable time, depending ontheir coordination. Similarly, since the speed of inspira-tion to TLC was not standardized, the duration of themaximal inspiration prior to the FVC manoeuvre wasnecessarily variable. The routine challenge was stoppedat the cumulative methacholine dose at which FEV1 de-creased by at least 20% (PD20) from baseline (positivetest)17,18. Immediately thereafter, the patients proceed-ed to phase B of the study. In contrast to phase A, thisconsisted in randomly performing fewer acceptable FVCmanoeuvres, i.e., 1 slow and 1 fast, in order to maintainthe bronchoconstrictor effect of methacholine.

In phases A and B the following variables were as-sessed from the maximal inspiration preceding the FVCmanoeuvre: 1) inspiratory capacity (IC), 2) duration ofinspiration (tI), 3) mean inspiratory flow (VT/tI), 4) du-ration of end-inspiratory pause (tp), and 5) duration offorced expiration (tE). The variables characterizing thefast and slow FVC manoeuvres during phase A and Bare presented in Table 2.

Statistical analysis

Values reported are means (SD). The values of the

various variables were compared using the paired Stu-dent t-test. A value of p£0.05 was taken as statisticallysignificant. Linear regression analysis was performedusing the least squares method (Sigma Stat 2.03, JandelScientific, San Rafael, CA, USA).

RESULTS

The PD20 of the patients amounted to 0.28±0.44 mg(range: 0.01-1.57) and in all of them was consistent withairway hyper-responsiveness17,18.

The values of PEF and FEV1 of the 13 patients weresignificantly higher with manoeuvre 1 than 2 both be-fore and after methacholine challenge (Tables 3 & 4), inline with previous observations7-11. Furthermore, as pre-viously reported for asthmatic patients9, there were nosignificant differences in the percent changes of PEF andFEV1 obtained before and after methacholine adminis-tration (Table 4).

In line with previous reports8,9, both before and atthe last methacholine dose the difference in FEV1 be-tween the fast and slow FVC manoeuvres, expressed asa percentage of FEV1 slow, were similarly correlated toFEV1 slow, expressed as percent of predicted FEV1 (Fig-ure 1).

Table 3. Individual values of FEV1, l measured during the routine test, and manoeuvres 1 and 2 before and at last methacholine dose

Phase A Phase B(before challenge) routine test (at last methacholine dose)

Patient manoeuver 1 manoeuver 2 manoeuver 1 manoeuver 2 # fast slow baseline last methacholine dose fast slow

1 2.80 2.14 2.54 1.72 1.65 1.332 2.80 2.58 2.73 1.90 1.98 1.743 4.56 4.26 4.14 2.78 3.14 2.924 3.23 2.90 3.08 1.67 2.39 2.205 2.63 2.21 2.71 2.15 1.87 1.566 4.28 3.95 3.26 2.56 3.67 3.27 2.73 2.49 2.79 2.18 1.92 1.858 4.06 3.77 3.84 2.26 3.15 2.989 1.71 1.51 1.78 1.32 1.13 0.99

10 2.52 2.41 2.80 2.08 2.00 1.5211 3.24 2.77 3.27 2.62 2.97 2.5812 4.43 4.34 4.46 2.66 3.34 3.4413 1.31 0.98 1.33 1.04 1.12 0.81

mean (SD) 3.10 (1.01) 2.79 (1.03) 3.04 (0.92) 2.07 (0.53) 2.33 (0.84) 2.09 (0.87)


Table 4. PEF and FEV1 with manoeuvres 1 and 2 before and at last methacholine dose (n=13)

Phase A (before challenge) Phase B (last methacholine dose)manoeuver 1 manoeuver 2 % change p manoeuver 1 manoeuver 2 % change p

fast slow fast slow

PEF, l/s 7.00 (2.12) 5.69 (1.74) 24 (13) 0.001 5.56 (1.91) 4.65 (1.53) 20 (16) 0.001FEV1, l 3.10 (1.01) 2.79 (1.03) 13 (10) 0.001 2.33 (0.84) 2.09 (0.87) 15 (11) 0.001

Values are mean (SD). %change, (fast-slow)/slow%. PEF: peak expiratory flow; FEV1: forced expiratory volume in one second.

Figure 1. Relationship of %ÄFEV1 (fast-slow)/slow and severity of airways obstruction (slow FEV

1 %pred) before methacholine chal-

lenge (left) and at the last dose of methacholine testing (right).

Based on the standardized (see below) FVC manoeu-vres only 10 patients (77%) had a positive test (Table 5).Therefore, three patients (#6, 11, 13) who had a positiveresponse during the routine (non-standardized) test, werenot positive during the standardized tests. Furthermore,the patients with a positive test were the same using ei-ther the fast or slow FVC manoeuver. Except in patient#10, the difference in % change in FEV1 between thestandardized fast (fast before/fast after) and slow (slowbefore/slow after) combination of FVC manoeuvres wasless 4.7% (Figure 2).

DISCUSSION

In the present study we found that by using the stand-ardized FVC manoeuvres only 10 patients (77%) had apositive methacholine test1-5,16-18 i.e., a fall in FEV1 ³ 20%

(Tables 3 & 5). Furthermore, the same 10 patients had apositive test using either the fast or slow standardizedFVC manoeuvres (Figure 2). Similarly, three patients(#6, 11, 13) who were positive with the routine test, werenot positive during both fast and slow standardized FVCmanoeuvres at the same methacholine dose. These re-sults indicate that using non-standardized as comparedto standardized methacholine testing different results canbe obtained.

An argument may arise on the small sample size ofthe study. However, the behavior of these 3 differentpatients must be explained even when a much bigger sam-ple with no new different patients would have been ob-tained. Therefore, the authors considered unethical tocontinue the study.

Table 5 shows the percentage decrease in FEV1 afterthe last dose of methacholine using various combinations


Table 5. Percentage fall in FEV1 and number of positive tests according to various combinations of fast and slow manoeuvres performedbefore and at the last dose of methacholine administration (n=13)

% fall in FEV1 positive tests positive tests, (%)

(Fast Before-Fast After)/Fast Before 25 (9) 10/13 77(Slow Before-Slow After)/Slow Before 26 (9) 10/13 77(Fast Before-Slow After)/Fast Before 34 (9) 13/13 100(Slow Before-Fast After)/Slow Before 15 (13) 6/13 46Routine test (non standardized) 30 (9) 13/13 100

Values are mean (SD)

Figure 2. Bars: %change in FEV1 at the end of the routine (non-standardized) methacholine test in each patient. Open circles: %change

in FEV1 with fast FVC manoeuvres; open triangles; %change in FEV

1 with slow manoeuvres with standardized tests. Dotted line: 20%

fall in FEV1 (positive test).

between fast and slow manoeuvres, and the number ofpositive tests that would have occurred with each combi-nation. As previously noted, if the fast or slow FVC ma-noeuver were made both before challenge and at the lastdose of methacholine, 10 patients would have been la-belled as positive responders at that dose. However, witha slow baseline manoeuver and a fast at the last metha-choline dose, only 6 patients would have exhibited a fallin FEV1 ³20%. In contrast, with the fast manoeuver be-fore and the slow after, all 13 patients would have beenreported as responders, as was the case during the rou-tine challenge test. Although we have no direct proof, itis likely that patients (#6, 11 and 13) exhibited such afast-slow combination of FVC manoeuvres during theroutine challenge test. In fact, as it is common practice,

in the latter condition the FEV1 was measured with adevice which required insertion of the mouthpiece intothe mouth after inhalation to TLC. This necessarily in-volves an obligatory end-inspiratory pause which lasts avariable time, depending on the coordination of the sub-ject. Furthermore, during the routine challenge test thespeed of inspiration to TLC was not controlled, and henceit was also axiomatically variable. Since the speed of in-spiration to TLC and the duration of the end-inspiratorypause were not controlled false responses to metha-choline challenge would be expected.

The three patients (#6, 11 and 13), who were not re-sponders with the standardized manoeuvres at the lastmethacholine dose, could have been positive at a higherdose. However, accurate determination of PD20 is a pre-


requisite for serial measurements of methacholine re-sponsiveness22-24. Indeed, changes in PD20 play an im-portant role in the follow up of the effects of treatmentand are used to predict when a reduction in treatmentmight be tried. Furthermore, serial measurements ofPD20 are commonly used to determine whether occupa-tional exposure is the cause of workers asthma and toassess the effects of immunotherapy. Therefore, stand-ardization of FVC manoeuvres during airway responsive-ness should be mandatory.

At the start and at the end of the challenge the stand-ardized and non-standardized manoeuvres were meas-ured by different observers. Examining the data report-ed in Table 5, they do not seem to be far from the 20%fall and figure 2 shows that only one patient had a reallybig difference in response with the standardized manoeu-vres from that with the routine test. In other words, thedifferent results seem only a slight variation in PD20FEV1. However, the differences in FEV1 (Table 3 & 4)can not be explained on the variability of the measure-ment alone, as in all instances but one the values withthe fast manoeuvres were higher. Although, there areseveral potential mechanisms6-14,25-30 which might explainthe higher values of PEF and FEV1 with manoeuver 1relative to 2 (differences in TLC, differences in expira-tory effort, gas compression artifacts, gas density and gascomposition, airway and parenchymal hysteresis, andtime constant inequality within the lungs) the time de-pendence of the FVC manoeuver appears to be mainlycaused by differences in lung recoil due to viscoelasticbehaviour (stress relaxation) of the pulmonary tissue6-14.

The concept of PD20 FEV1 may be an overly simplis-tic one if we want to diagnose the disease exclusively onit. Many scientists would be more interested on whetherthe routine not standardized tests may affect the entirebronchial dose-response curve rather than a single pa-rameter like PD20FEV1, which may sometimes be mis-leading. Further studies are required to quantify the ef-fect of the aforementioned factors on the time depend-ence of FVC during the entire procedure of bronchialchallenge testing.

In conclusion, the results of the present study indi-cate that assessment of airway hyper-responsiveness andaccurate determination of PD20 require standardizationof the FVC manoeuvres in order to minimize their vari-ability.

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ÊëéíéêÞ ÌåëÝôç

Â. ÔóÜñá,Â. Ëáæáñßäçò*,Â. Ðáó÷ßäïõ,Å. ÓÝñáóëç,Ð. ÊáêáâÝëáòÐ. ×ñéóôÜêç

ÐÅÑÉËÇØÇ. Óå ìÝëç (56,7% óýæõãïò, 33,3% ðáéäß) ôùí ïéêïãå-íåéþí 32 áóèåíþí ìå Xñüíéá ÁíáðíåõóôéêÞ ÁíåðÜñêåéá õðü ×ñü-íéá Ïîõãïíïèåñáðåßá Þ êáé Ìç÷áíéêü Áåñéóìü, åêôéìÞèçêå ç áíôé-êåéìåíéêÞ êáé õðïêåéìåíéêÞ åðéâÜñõíóç êáé ç øõ÷éêÞ êáôÜóôáóç(Äåßêôçò ÃåíéêÞò Õãåßáò). Ç ìÝóç äéÜñêåéá óõìâßùóçò ìå ôïíáóèåíÞ Þôáí 29,7 ÷ñüíéá êáé ç óõ÷íüôçôá êáèçìåñéíÞò åðáöÞò96%. ̧ êäçëç áíôéêåéìåíéêÞ åðéâÜñõíóç óôéò êïéíùíéêÝò äñáóôç-ñéüôçôåò ðáñïõóßáóáí 57,7% ôùí ïéêïãåíåéþí, óôç äéá÷åßñéóç íïé-êïêõñéïý 46,7%, óôá ïéêïíïìéêÜ 43,3%, óôçí åñãáóéáêÞ áðáó÷ü-ëçóç 30% êáé óôçí éáôñéêÞ ðëçñïöüñçóç 27,6%. Ç õðïêåéìåíéêÞåðéâÜñõíóç áíôßóôïé÷á Þôáí äéáöïñïðïéçìÝíç óå ìéêñüôåñá ðï-óïóôÜ. Ïé óôñáôçãéêÝò ðñïóáñìïãÞò ôùí ïéêïãåíåéþí Þôáí: Åðá-íáðñïóäéïñéóìüò ôùí óôü÷ùí 90%, ðáñáßôçóç 86,1%, ðáèçôéêü-ôçôá êáé åëðßäá 50% åíþ åíï÷ïðïßçóç 16,6% êáé áìöéèõìßá 17%.Ï Äåßêôçò ÃåíéêÞò Õãåßáò Þôáí >4 óôï 69,7% ôùí óõããåíþí êáéåß÷å óçìáíôéêÞ óõó÷Ýôéóç ìå ôçí áíôéêåéìåíéêÞ åðéâÜñõíóç óôéòêïéíùíéêÝò äñáóôçñéüôçôåò (r=0,61, p<0,05) êáé óôçí åñãáóéá-êÞ áðáó÷üëçóç (r=0,70, p<0,01) åíþ õðïêåéìåíéêÜ ìå ôç äéá÷åß-ñéóç íïéêïêõñéïý (r=0,78, p<0,01) êáé ôá ïéêïíïìéêÜ (r=0,76,p<0,01). Ïé ïéêïãÝíåéåò ôùí áóèåíþí ìå ×ÁÁ öáßíåôáé íá Ý÷ïõíìåãÜëá ðñïâëÞìáôá (Ýêäçëç åðéâÜñõíóç) óôéò êïéíùíéêÝò ôïõòó÷Ýóåéò êáé óôçí ïéêïíïìéêÞ êáôÜóôáóç, áëëÜ äå âéþíïõí ôçí åðé-âÜñõíóç ðïõ êáôáãñÜöåôáé, êáé ÷ñçóéìïðïéïýí õãéåßò óôñáôçãé-êÝò ðñïóáñìïãÞò óôçí êáôÜóôáóç. Ç áíáðñïóáñìïãÞ ôçò æùÞòôïõò êáé ç õðïóôÞñéîç óôïí áóèåíÞ öáßíåôáé üôé Ý÷åé êüóôïò, áöïýóôï Äåßêôç ÃåíéêÞò Õãåßáò êáôáãñÜöåôáé ìåãÜëï ðïóïóôü åðé-êéíäõíüôçôáò. Ðíåýìùí 2002, 15(2)176-182.

ÅÉÓÁÃÙÃÇ

Ç ïéêïãÝíåéá åßíáé ç êïéíùíéêÞ äïìÞ óôçí ïðïßá óõíÞèùò óôçñßæåôáéç áíáãêáßá ìáêñï÷ñüíéá áãùãÞ ôïõ áóèåíïýò ìå ÷ñüíéá íüóï. Éäéáßôåñá

Â' ÐíåõìïíïëïãéêÞ ÊëéíéêÞ, Ã.Ð.Í.Ã. ÐáðáíéêïëÜïõ,*ÏìÜäá Øõ÷ïêïéíùíéêÞò ÓôÞñéîçò Åðáñ÷éáêïý Ôý-ðïõ 2, Øõ÷éáôñéêü Íïóïêïìåßï Èåóóáëïíßêçò

ËÝîåéò ÊëåéäéÜ: ×ñüíéá ÁíáðíåõóôéêÞ ÁíåðÜñ-êåéá, Ìç÷áíéêüò Áåñéóìüò, ×ñüíéá Ïîõãïíïèå-ñáðåßá, ÅðéâÜñõíóç, ÏéêïãÝíåéá, ÃåíéêÞ Õãåßá.


ãéá ôïõò áóèåíåßò ìå ×ñüíéá ÁíáðíåõóôéêÞ ÁíåðÜñêåéá(×ÁÁ), ×ñüíéá ÁðïöñáêôéêÞ ÐíåõìïíïðÜèåéá (×ÁÐ)Þ ðåñéïñéóôéêïý ôýðïõ ðíåõìïíéêÞ ðÜèçóç, ç ïéêïãÝ-íåéá åßíáé óçìáíôéêü óôÞñéãìá óôï ðñüãñáììá áðïêá-ôÜóôáóçò. Åðùìßæåôáé Ýíá óçìáíôéêü ìÝñïò ôçò èåñá-ðåõôéêÞò êáé õðïóôçñéêôéêÞò áãùãÞò ãéá ôïí áóèåíÞ ìå×ÁÁ, ç ïðïßá óõíÞèùò óôá ôåëåõôáßá óôÜäéá ôçò íü-óïõ ðåñéëáìâÜíåé ôç ÷ñÞóç óõóêåõþí õøçëÞò ôå÷íïëï-ãßáò (ð.÷. áíáðíåõóôÞñåò, íåöåëïðïéçôÝò, ðçãÝò ðáñï-÷Þò ïîõãüíïõ ê.ëð.) ðïõ áðáéôïýí ãíþóåéò êáé éêáíüôç-ôåò ãéá ôç ÷ñÞóç ôïõò. Êáèþò ôåëåõôáßá áíáðôýóóåôáéóõíå÷þò ç ôÜóç ãéá ôç öñïíôßäá ôïõ áóèåíïýò ìå ÷ñü-íéï íüóçìá óôï óðßôé, ãéá ëüãïõò ïéêïíïìéêïýò êáé êïé-íùíéêïýò, ç ïéêïãÝíåéá ôïðïèåôåßôáé áõôüìáôá óå èÝóçåõèýíçò ÷ùñßò ðïëëÝò öïñÝò íá ðñïåôïéìÜæåôáé ïõóéá-óôéêÜ ãé´ áõôü1-3.

¸÷ïíôáò õðüøç ôï óçìáíôéêü ñüëï ôçò ïéêïãÝíåéáòóôçí áðáéôçôéêÞ áðü Üðïøç ÷ñüíïõ êáé êüðïõ öñïíôß-äá ôïõ ÷ñüíéïõ áóèåíïýò, èåùñïýìå üôé ç ãíþóç ôçòåðéâÜñõíóçò ðïõ ðñïêáëåßôáé óôïõò äéÜöïñïõò ôïìåßòôùí äñáóôçñéïôÞôùí ôçò, èá ìðïñïýóå íá óõìâÜëëåé óôçóùóôÞ áîéïðïßçóÞ ôçò. Ìå áõôü ôï óôü÷ï, Ýãéíå ç åêôß-ìçóç ôçò áíôéêåéìåíéêÞò êáé ôçò õðïêåéìåíéêÞò åðéâÜ-ñõíóçò êáèþò êáé ôïõ Äåßêôç ÃåíéêÞò Õãåßáò ôùí ïéêï-ãåíåéþí áóèåíþí ìå ×ÁÁ.

ÕËÉÊÏ ÊÁÉ ÌÅÈÏÄÏÉ

Ï ðëçèõóìüò ôçò ìåëÝôçò Þôáí ïé ïéêïãÝíåéåò 32 åîù-ôåñéêþí áóèåíþí ìå ×ÁÁ õðü Ìç÷áíéêü Áåñéóìü óôïóðßôé (ÌÁ) Þ/êáé ×ñüíéá Ïîõãïíïèåñáðåßá (×ÏÈ)ôïõëÜ÷éóôïí åðß 6 ìÞíåò (3,8 ± 2,7 Ýôç). ¼ëïé ïé áóèå-íåßò åêôüò áðü 3 ðïõ åß÷áí ôñá÷åéïóôïìßá, Þôáí õðü ìçåðåìâáôéêÞ ìç÷áíéêÞ õðïóôÞñéîç ôçò áíáðíïÞò (óõ-óêåõÝò BiPAP S/T ìå ñéíéêÞ Þ ñéíïóôïìáôéêÞ ìÜóêá).Ï ÷ñüíïò ôïõ ÌÁ êáé ôçò ×ÏÈ, ïé ìåñéêÝò ðéÝóåéò áå-ñßùí áßìáôïò êáé ïé óðéñïìåôñéêÝò ôéìÝò êáôÜ ôçí ðñï-ãñáììáôéóìÝíç åðßóêåøç, öáßíïíôáé óôïí Ðßíáêá 1. Ïéáóèåíåßò äéáöïñïðïéÞèçêáí áíÜëïãá ìå ôï áßôéï ôçò×ÁÁ óå ôñåéò ïìÜäåò: 1. ×ñüíéá ÁðïöñáêôéêÞ Ðíåõ-ìïíïðÜèåéá (13 áóèåíåßò, 40,6%). 2. ÍåõñïìõúêÞ ðÜ-èçóç (íüóïò Êéíçôéêïý Íåõñþíá, ìõïðÜèåéá Duchenneê.ëð., 8 áóèåíåßò, 25%) êáé 3. ÄéÜöïñåò ðáèÞóåéò (ðá-÷õóáñêßá, õðïáåñéóìüò, êõöïóêïëßùóç, ìåôÜ ÔÂ áíá-ðíåõóôéêÞ áíåðÜñêåéá ê.ëð., (11 áóèåíåßò, 34,3%).

Ðßíáêáò 1. ÄéÜñêåéá èåñáðåßáò êáé áíáðíåõóôéêÞ ëåéôïõñ-ãßá áóèåíþí ìå ×ÁÁ

ÄéÜñêåéáÈåñáðåßáò FEV 1 FVC PaÏ2 PaCÏ2

(÷ñüíéá) (% ðñ) (% ðñ) mmHg mmHg

3,8 ± 2,7 45±19,4 53±19 63,3±15,5 43±6,5

ÅîçãÞèçêå ï óôü÷ïò ôçò ìåëÝôçò ôüóï óôïí áóèåíÞüóï êáé óôï ìÝëïò ôçò ïéêïãÝíåéáò ðïõ ôïí öñïíôßæåé,êáé æçôÞèçêå ðñïöïñéêÞ óõãêáôÜèåóç ãéá ôç óõìðëÞ-ñùóç ôùí åñùôçìáôïëïãßùí óôïí ßäéï ÷ñüíï ðïõ ïéáóèåíåßò åß÷áí ôçí ðñïãñáììáôéóìÝíç åîÝôáóç ðáñá-êïëïýèçóçò. Óõìðëçñþèçêå åéäéêü Ýíôõðï äçìïãñáöé-êþí óôïé÷åßùí, ôüóï ãéá ôïí áóèåíÞ üóï êáé ãéá ôï óõã-ãåíÞ ó÷åôéêÜ ìå ôï åêðáéäåõôéêü åðßðåäï, ôçí åñãáóßáêáé ôçí ïéêïãåíåéáêÞ êáôÜóôáóç.

Ç åðéâÜñõíóç ôçò ïéêïãÝíåéáò åêôéìÞèçêå ùò áíôé-êåéìåíéêÞ (äçëáäÞ áõôÞ ðïõ áíôéêåéìåíéêÜ êáôáãñÜöå-ôáé) êáé ùò õðïêåéìåíéêÞ (äçëáäÞ áõôÞ ðïõ ôåëéêÜ âéþ-íåôáé) áðü óõíÝíôåõîç ôïõ ìÝëïõò ôçò ðïõ áó÷ïëåßôáéðåñéóóüôåñï ìå ôïí áóèåíÞ. ×ñçóéìïðïéÞèçêå ôï Fam-ily Burden Questionnaire ôçò G. Fadden4, ôñïðïðïéç-ìÝíï êáôÜ É. Ìðßìðïõ5. Ïé åñùôÞóåéò áöïñïýí óå ðÝ-íôå ðåñéï÷Ýò, ðïõ ðåñéëáìâÜíïõí ôçí åñãáóéáêÞ áðá-ó÷üëçóç, ôç äéá÷åßñéóç íïéêïêõñéïý, ôçí ïéêïíïìéêÞ êá-ôÜóôáóç, ôéò êïéíùíéêÝò äñáóôçñéüôçôåò, ôïí åëåýèåñï÷ñüíï êáé ôçí ðëçñïöüñçóç êáé éêáíïðïßçóç áðü ôéòõðçñåóßåò õãåßáò. Áðü ôéò ðåñéï÷Ýò áõôÝò Ýãéíå ç åêôß-ìçóç ôçò áíôéêåéìåíéêÞò êáé ôçò õðïêåéìåíéêÞò åðéâÜ-ñõíóçò. Åðßóçò ôï åñùôçìáôïëüãéï ðåñéëáìâÜíåé åñù-ôÞóåéò ðïõ áöïñïýí óôéò ðåñéï÷Ýò ôçò ðáèçôéêüôçôáò,ôçò áìöéèõìßáò, ôçò åíï÷ïðïßçóçò, ôçò åëðßäáò, ôçò ðá-ñáßôçóçò êáé åðáíáðñïóäéïñéóìïý ôùí óôü÷ùí, áðü ôéòïðïßåò Ýãéíå ç åêôßìçóç ôçò äõíáôüôçôáò ðñïóáñìïãÞò(coping strategies) ôçò ïéêïãÝíåéáò óôç íÝá êáôÜóôáóç.

¸ãéíáí 32 óõíåíôåýîåéò óå Þóõ÷ï ðåñéâÜëëïí áðüåîïéêåéùìÝíïõò ìå ôï åñùôçìáôïëüãéï ãéáôñïýò, ãíù-óôïýò óôïí áóèåíÞ êáé ôçí ïéêïãÝíåéÜ ôïõ.

Ãéá ôçí åêôßìçóç ôçò áôïìéêÞò êáôÜóôáóçò ôïõ åðé-öïñôéóìÝíïõ ìÝëïõò ôçò ïéêïãÝíåéáò ãéá ôç öñïíôßäáôïõ áóèåíïýò, óõìðëçñþèçêå ôï åñùôçìáôïëüãéï Ãåíé-êÞò Õãåßáò (General Health Questionnaire 28)6. Ôï åñù-


ïéêéáêÜ (44,8%). Ôá äçìïãñáöéêÜ óôïé÷åßá ôùí áóèå-íþí êáé ôùí óõããåíþí öáßíïíôáé óôïí ðßíáêá 2.


ÁíôéêåéìåíéêÞ åðéâÜñõíóç: Ðïóïóôü 57,7% ôùí ïé-êïãåíåéþí ðáñïõóßáóáí Ýêäçëç áíôéêåéìåíéêÞ åðéâÜ-ñõíóç óôéò êïéíùíéêÝò ôïõò äñáóôçñéüôçôåò (äçëáäÞóôçí Ýîïäï ãéá äéáóêÝäáóç, óôéò åðáöÝò êáé åðéóêÝøåéòôùí ößëùí ê.ëð.), 46,6% óôç äéá÷åßñéóç íïéêïêõñéïý,43,3% óôá ïéêïíïìéêÜ êáé 30% óôçí åñãáóéáêÞ áðá-ó÷üëçóç. Óôçí éáôñéêÞ öñïíôßäá êáé ðëçñïöüñçóç çåðéâÜñõíóç Þôáí Ýêäçëç ìüíï óôï 27,6% ôùí ïéêïãå-íåéþí.

ôçìáôïëüãéï åêôéìÜ ìå 28 åñùôÞóåéò óå ôÝóóåñéò êëßìá-êåò ôá óùìáôéêÜ óõìðôþìáôá, ôï Üã÷ïò êáé ôçí áûðíßá,ôçí êïéíùíéêÞ äõóëåéôïõñãßá êáé ôç óïâáñÞ êáôÜèëé-øç. Ç âáèìïëüãçóÞ ôïõ (Äåßêôçò ÃåíéêÞò Õãåßáò, ÄÃÕ)ðåñéóóüôåñï áðü 4 êáôáôÜóóåé ôïí åñùôþìåíï óå ïìÜ-äá õøçëïý êéíäýíïõ ãéá ôçí åêäÞëùóç ôçò øõ÷éêÞò ðÜ-èçóçò. Ôï åñùôçìáôïëüãéï óõìðëçñþèçêå áðü 16 ìÝëçïéêïãÝíåéáò, óå Þóõ÷ï ÷þñï áöïý äüèçêáí ïé êáôÜëëç-ëåò ïäçãßåò.

Ç óôáôéóôéêÞ áíÜëõóç Ýãéíå ìå ôï ðáêÝôï SPSS.

ÄÇÌÏÃÑÁÖÉÊÁ ÓÔÏÉ×ÅÉÁ

Ôá ìÝëç ôçò ïéêïãÝíåéáò ðïõ óõììåôåß÷áí óôç óõíÝ-íôåõîç Þôáí êõñßùò óýæõãïé (56,7%) êáé ðáéäéÜ (33,3%)ôïõ áóèåíïýò åíþ óå ìéêñüôåñï ðïóïóôü åß÷áí Üëëç óõã-ãåíéêÞ ó÷Ýóç. Ç ìÝóç äéÜñêåéá óõìâßùóçò Þôáí 29,7±10÷ñüíéá, êáé ôï 96% ôùí ìåëþí åß÷å êáèçìåñéíÞ åðáöÞìå ôïí áóèåíÞ. Ïé áóèåíåßò Þôáí ðåñéóóüôåñï çëéêéù-ìÝíïé (62,7±15,2 ÷ñüíéá) óå ó÷Ýóç ìå ôá ìÝëç ôçò ïéêï-ãÝíåéáò (49,2±15,2 ÷ñüíéá).

Ç ðëåéïøçößá ôùí áóèåíþí Þôáí óõíôáîéïý÷ïé(77,8%), ðáíôñåìÝíïé (83,3%), ìå åêðáßäåõóç äçìïôé-êïý ó÷ïëåßïõ (78,6%). ÐáíôñåìÝíá Þôáí ôá ðåñéóóüôå-ñá ìÝëç ôùí ïéêïãåíåéþí (86,7%), êõñßùò ìå åêðáßäåõ-óç äçìïôéêïý åðéðÝäïõ (50%) êáé óå ìéêñüôåñï ðïóï-óôü ìå ìÝóç Þ áíþôåñç/ áíþôáôç. Ôá ìéóÜ ðåñßðïõ áðüôá ìÝëç ôçò ïéêïãÝíåéáò äÞëùóáí ùò áðáó÷üëçóç ôá

ÄéÜãñáììá 1. ÕðïêåéìåíéêÞ êáé áíôéêåéìåíéêÞ åðéâÜñõíóçóôéò ïéêïãÝíåéåò áóèåíþí ìå ×ÁÁ.

Ðßíáêáò 2. ÄçìïãñáöéêÜ óôïé÷åßá ïéêïãåíåéþí êáé áóèåíþíìå ×ÁÁ

Áóèåíåßò ÏéêïãÝíåéá(n=32) (n=32)

ÏéêïãåíåéáêÞ êáôÜóôáóç (%)ÐáíôñåìÝíïé 83,3 86,7Áíýðáíôñïé 10 13,3×çñåßá 6,7Åêðáßäåõóç (%)Äçìïôéêü 78,6 50ÃõìíÜóéï-Ëýêåéï 17,9 36,7Áíþôåñç-Áíþôáôç 3,5 13,3ÅðáããåëìáôéêÞ ÊáôÜóôáóç (%)Óõíôáîéïý÷ïé 77,8 20ÏéêéáêÜ 11,1 44,8¢ëëï 11,1 35,2

ÕðïêåéìåíéêÞ åðéâÜñõíóç: ¸êäçëç õðïêåéìåíéêÞåðéâÜñõíóç ðáñïõóßáóå óáöþò ìéêñüôåñï ðïóïóôü ïé-êïãåíåéþí óå êÜèå ðåñéï÷Þ áíôßóôïé÷á. ¸êäçëç õðï-êåéìåíéêÞ åðéâÜñõíóç ðáñïõóßáóáí 31% ôùí ïéêïãå-íåéþí óôçí åñãáóéáêÞ áðáó÷üëçóç, 30% óôá ïéêïíïìé-êÜ, 26,6% óôï íïéêïêõñéü êáé 23,3% óôéò êïéíùíéêÝòäñáóôçñéüôçôåò.

Ç ðáñáóôáôéêÞ áðåéêüíéóç ôçò áíôéêåéìåíéêÞò êáéõðïêåéìåíéêÞò åðéâÜñõíóçò ôùí ïéêïãåíåéþí öáßíåôáéóôï äéÜãñáììá 1.

Ç åðéâÜñõíóç ôùí ïéêïãåíåéþí óôçí ðåñéï÷Þ ôçòåñãáóéáêÞò áðáó÷üëçóçò, äéáöïñïðïéÞèçêå áíÜëïãáìå ôçí ïìÜäá ðïõ áíÞêå ï áóèåíÞò ôïõò. ÓõãêåêñéìÝ-íá, ïé ïéêïãÝíåéåò ôùí áóèåíþí ôçò 2çò ïìÜäáò åß÷áíóçìáíôéêÜ ìåãáëýôåñç åðéâÜñõíóç óôçí åñãáóéáêÞáðáó÷üëçóç ôüóï áíôéêåéìåíéêÜ (x2(2)=7,293, p<0,02)üóï êáé õðïêåéìåíéêÜ (x2(2)=11,072, p<0,05) óå ó÷Ýóç


ìå ôéò ïéêïãÝíåéåò ôùí Üëëùí äýï ïìÜäùí áóèåíþí.Óå ó÷Ýóç ìå ôçí ðñïóáñìïãÞ, ïé ïéêïãÝíåéåò äÞëù-

óáí êáôÜ 90% üôé åðáíáðñïóäéïñßæïõí ôïõò óôü÷ïõòôïõò ãéá íá áíôáðïêñéèïýí óôéò áíÜãêåò ôùí áóèåíþí,áëëÜ 86,1% äÞëùóáí ðáñáßôçóç áðü ôçí åëðßäá ïñé-óôéêÞò ãéáôñåéÜò êáé 50% ðáèçôéêüôçôá óôçí áðïäï÷Þôçò ÷ñüíéáò áóèÝíåéáò. Åðßóçò 50% ôùí ïéêïãåíåéþíäÞëùóå üôé Ý÷åé åëðßäá ãéá óïâáñÞ âåëôßùóç ôçò êáôÜ-óôáóçò ôïõ áóèåíïýò åíþ åíï÷ïðïßçóç êáé áìöéèõìßáãéá ôçí áóèÝíåéá äÞëùóå ôï 16,6% êáé 17% áíôßóôïé÷á(ÄéÜãñáììá 2). ÐáñáôçñÞèçêå ìéá ôÜóç äéáöïñïðïßç-óçò ùò ðñïò ôïí åðáíáðñïóäéïñéóìü ôùí óôü÷ùí, áíÜ-ëïãá ìå ôçí êáôçãïñßá íüóïõ ôùí áóèåíþí. Ç åëðßäáãéá ïñéóôéêÞ Þ ìåãÜëç âåëôßùóç ôçò êáôÜóôáóçò ôïõáóèåíïýò åêöñÜóôçêå êõñßùò áðü ôéò ïéêïãÝíåéåò ôùíáóèåíþí ôçò äåýôåñçò ïìÜäáò (íåõñïìõúêÝò íüóïé) êáéðïëý ëéãüôåñï áðü ôéò ïéêïãÝíåéåò ôùí õðïëïßðùí áóèå-íþí.

ÓÕÆÇÔÇÓÇ

Ç ðáñïõóßá åíüò áóèåíÞ ìå ÷ñüíéá íüóï åðéâáñý-íåé ôçí ïéêïãÝíåéá, ðïõ áíáãêÜæåôáé íá áëëÜîåé ôñüðïæùÞò ãéá íá êáëýøåé ôéò áíÜãêåò ôïõ, êáèþò áíáëáì-âÜíåé Ýíá ìåãÜëï ìÝñïò ôçò åõèýíçò ãéá ôç öñïíôßäáôïõ. Ç ïéêïãÝíåéá áóèåíïýò ìå ×ÁÁ áíáëáìâÜíåé åõ-èýíåò ãéá ôç ëåéôïõñãßá óõóêåõþí õøçëÞò ôå÷íïëïãßáò(áíáðíåõóôÞñáò, íåöåëïðïéçôÞò, óõìðõêíùôÞò ê.ëð.)ðïõ ÷ñçóéìïðïéïýíôáé óôï óðßôé ãéá ôïí áóèåíÞ. Óå âá-ñýôåñåò êáôáóôÜóåéò ÷ñçóéìïðïéïýíôáé êáé Üëëåò óõ-óêåõÝò Þ õëéêÜ ðïõ äåí Ý÷ïõí ó÷Ýóç ìå ôçí áíáðíåõóôé-êÞ ðÜèçóç, áëëÜ åßíáé áðáñáßôçôá ãéá ôá ðñïâëÞìáôáðïõ ðñïêýðôïõí (ð.÷. óõóêåõÝò áíáññïöÞóåùí, ãåñá-íïß ìåôáêßíçóçò, óôñþìáôá ðñüëçøçò êáôáêëßóåùíê.ëð.). ÁõôÞ ç êáôÜóôáóç äçìéïõñãåß Üã÷ïò êáé áíáóöÜ-ëåéá éäéáßôåñá ôï ðñþôï äéÜóôçìá ðïõ âñßóêïíôáé ìåôïí áóèåíÞ óôü óðßôé, Ýîù áðü ôï ðñïóôáôåõôéêü íïóï-êïìåéáêü ðåñéâÜëëïí7.

Ïé áóèåíåßò ìáò åß÷áí óïâáñÞ áíáðíåõóôéêÞ áíå-ðÜñêåéá êáé áíÜãêç ìç åðåìâáôéêÞò ìç÷áíéêÞò õðïóôÞ-ñéîçò ôçò áíáðíïÞò, åêôüò áðü 3 áóèåíåßò ìå íåõñïìõú-êÞ ðÜèçóç, ðïõ åöÜñìïæáí ìç÷áíéêÞ õðïóôÞñéîç ôçòáíáðíïÞò, ìÝóù ôñá÷åéïóôïìßáò, åíþ óå ðñüóèåôç ÷ñü-íéá ïîõãïíïèåñáðåßá Þôáí êõñßùò ïé áóèåíåßò ôçò ðñþ-ôçò êáé ôñßôçò ïìÜäáò.

Åßíáé ãíùóôü üôé ïé áóèåíåßò ìå ×ÁÐ êáé áíáðíåõ-óôéêÞ áíåðÜñêåéá Ý÷ïõí êáêÞ ðïéüôçôá æùÞò8 ðïõ öáß-íåôáé üôé ó÷åôßæåôáé ìå ôçí áíéêáíüôçôá êéíçôïðïßçóçòêáé ôç äéÜñêåéá ôùí íïóçëåéþí9. Áíôßèåôá ïé áóèåíåßòìå íåõñïìõúêÞ ðÜèçóç, áí êáé Ý÷ïõí ìåãÜëåò êéíçôéêÝòäõóêïëßåò, äçëþíïõí êáëÞ ðïéüôçôá æùÞò áêüìá êáéüôáí âñßóêïíôáé õðü ìç÷áíéêÞ õðïóôÞñéîç ôçò áíá-ðíïÞò10. ¼ìùò ïé ïéêïãÝíåéåò ôùí áóèåíþí áõôþí åê-äçëþíïõí óçìáíôéêÞ åðéâÜñõíóç óôéò êïéíùíéêÝò õðï-÷ñåþóåéò êáé óôá ïéêïíïìéêÜ11. ÁíÜëïãåò ìåëÝôåò ôçòåðéâÜñõíóçò ôçò ïéêïãÝíåéáò ìå ÷ñüíéï áóèåíÞ óôïõòêüëðïõò ôçò, Ý÷ïõí ãßíåé óôç ÷þñá ìáò ãéá ôïõò øõ÷ù-óéêïýò áóèåíåßò12,13. Åßíáé ç ðñþôç öïñÜ ðïõ ãßíåôáé çåêôßìçóç ôçò ïéêïãåíåéáêÞò åðéâÜñõíóçò ðáñÜëëçëá ìåôçí åêôßìçóç ôïõ Äåßêôç ÃåíéêÞò Õãåßáò óå ïéêïãÝíåéåòáóèåíþí ìå ×ÁÁ.

Ïé ïéêïãÝíåéåò ðïõ áîéïëïãÞèçêáí, áíáãíùñßæïõíüôé åðéâáñýíïíôáé óçìáíôéêÜ áðü ôçí ðáñïõóßá ôïõáóèåíïýò ìå ×ÁÁ. Ç åðéâÜñõíóç åßíáé õðáñêôÞ óå üëåò

ÄéÜãñáììá 2. ÓôñáôçãéêÝò áíôéìåôþðéóçò ôçò êáôÜóôáóçòáðü ôéò ïéêïãÝíåéåò áóèåíþí ìå ×ÁÁ.

Ï Äåßêôçò ÃåíéêÞò Õãåßáò ôùí åðéöïñôéóìÝíùí ìåôç öñïíôßäá ôïõ áóèåíïýò ìåëþí ôçò ïéêïãÝíåéáò, Þôáíóå ðïóïóôü 69,7% ìåãáëýôåñïò áðü 4. Ï ÄÃÕ ôùí ïé-êïãåíåéþí óõó÷åôßóôçêå óçìáíôéêÜ ìå äýï ðåñéï÷Ýò ôçòáíôéêåéìåíéêÞò åðéâÜñõíóçò êáé óõãêåêñéìÝíá, ôéò êïé-íùíéêÝò äñáóôçñéüôçôåò (r=0,61, p<0,05) êáé ôçí åñãá-óéáêÞ áðáó÷üëçóç (r=0,70, p<0,01) êáé ìå äýï ðåñéï-÷Ýò ôçò õðïêåéìåíéêÞò åðéâÜñõíóçò üðùò ôç äéá÷åßñéóçíïéêïêõñéïý (r=0,78, p<0,01) êáé ôçí ïéêïíïìéêÞ êá-ôÜóôáóç (r=0,76, p<0,01).


ôéò ðåñéï÷Ýò ðïõ åîåôÜóôçêáí ìå ðñïåîÜñ÷ïõóåò áõôÝòôùí êïéíùíéêþí åêäçëþóåùí êáé ôçò ïéêïíïìéêÞò êáôÜ-óôáóçò. ¼ìùò ç åðéâÜñõíóç ðïõ ôåëéêÜ áéóèÜíïíôáé,åßíáé ðïëý ìéêñüôåñçò Ýíôáóçò áðü áõôÞ ðïõ áíáãíù-ñßæïõí üôé ðñáãìáôéêÜ õðÜñ÷åé, üðùò öáßíåôáé áðü ôïìéêñü ðïóïóôü ôùí ïéêïãåíåéþí ðïõ åêäÞëùóáí êáéõðïêåéìåíéêÞ åðéâÜñõíóç. Ç äéáöïñÜ áõôÞ ßóùò ó÷åôß-æåôáé ìå ôçí éó÷õñÞ ôÜóç áíáðñïóáñìïãÞò ôùí óôü÷ùíðïõ åêäçëþèçêå áðü ôéò ïéêïãÝíåéåò, áí êáé óå äéáöï-ñåôéêü âáèìü, óôéò ðåñéóóüôåñåò ðåñéï÷Ýò ðïõ åêôéìÞ-èçêáí.

Ç õðïêåéìåíéêÞ åðéâÜñõíóç Þôáí éäéáßôåñá áéóèçôÞãéá ôéò ïéêïãÝíåéåò, óôéò ðåñéï÷Ýò ôçò åñãáóßáò êáé ôùíïéêïíïìéêþí. Ç óõíå÷Þò ðáñïõóßá ðïõ áðáéôåßôáé áðüôçí ïéêïãÝíåéá ãéá ôç öñïíôßäá ôïõ áóèåíïýò, åßíáé äõ-íáôüí íá äçìéïõñãÞóåé ðñïâëÞìáôá óôéò åñãáóéáêÝòõðï÷ñåþóåéò éäéáßôåñá áí ï áóèåíÞò ðñÝðåé íá åðéóêå-öôåß ôï íïóïêïìåßï Þ ÷ñåéÜæåôáé ðïëõÞìåñç íïóçëåßá.Ôá ðñïâëÞìáôá ðïõ åìöáíßæïíôáé óôçí åñãáóßá äéáöï-ñïðïéïýíôáé áíÜìåóá óôéò ïéêïãÝíåéåò áíÜëïãá ìå ôçíõðïêåßìåíç ðÜèçóç ôùí áóèåíþí. Ðåñéóóüôåñåò ïéêï-ãÝíåéåò áóèåíþí ôçò äåýôåñçò ïìÜäáò äçëþíïõí üôéåðéâáñýíïíôáé óôçí åñãáóßá, óõãêñéôéêÜ ìå ôéò ïéêïãÝ-íåéåò ôùí äýï Üëëùí ïìÜäùí áóèåíþí. ÅðéðëÝïí ç ïé-êïíïìéêÞ åðéâÜñõíóç ðïõ õößóôáíôáé ïé ïéêïãÝíåéåò ãéáôç ÷ñüíéá öñïíôßäá ôïõ áóèåíïýò, öáßíåôáé íá åßíáé óç-ìáíôéêÞ. Ïé ðåñéï÷Ýò ðïõ åêäçëþèçêå óçìáíôéêÞ äõóöï-ñßá áðü ôéò ïéêïãÝíåéåò, ôá ïéêïíïìéêÜ, ïé ó÷Ýóåéò åñ-ãáóßáò êáé ç äéá÷åßñéóç ôïõ íïéêïêõñéïý, åßíáé ôïìåßòðïõ ç áíôéìåôþðéóç ôùí ðñïâëçìÜôùí åßíáé ßóùò ðåñéó-óüôåñï óõëëïãéêÞ (êïéíùíéêÞ) ðáñÜ áôïìéêÞ êáé ìðï-ñïýí íá ðåñéëáìâÜíïíôáé óôçí ïñãÜíùóç êáé åöáñìï-ãÞ ôùí ðñïãñáììÜôùí áðïêáôÜóôáóçò êáé öñïíôßäáòóôï óðßôé ôïõ áóèåíïýò.

Åßíáé óçìáíôéêü üôé ç ïéêïãÝíåéá äåí öáßíåôáé íáâéþíåé õðïêåéìåíéêÜ ôç äéáðéóôùìÝíç áíôéêåéìåíéêÞ åðé-âÜñõíóç, óå üëïõò áíåîáßñåôá ôïõò ôïìåßò ôùí äñáóôç-ñéïôÞôùí ôçò. Ðáñ' üëï ðïõ ïé äñáóôçñéüôçôåò åðéâá-ñýíïíôáé, ïé ïéêïãÝíåéåò öáßíåôáé íá áðïäÝ÷ïíôáé ôçíêáôÜóôáóç áõôÞ êáé áíáðñïóáñìüæïõí ôïí ôñüðï æùÞòôïõò. Ôá äçìïãñáöéêÜ óôïé÷åßá äåß÷íïõí üôé ïé ðåñéó-óüôåñïé áóèåíåßò åßíáé ðáíôñåìÝíïé, ìå ÷áìçëïý åðéðÝ-äïõ ãñáììáôéêÝò ãíþóåéò. Áõôü õðïäçëþíåé ßóùò üôéðñüêåéôáé ãéá "ðáñáäïóéáêÝò" ïéêïãÝíåéåò ðïõ ç öñï-íôßäá ôïõ ìÝëïõò ìå ÷ñüíéá ðÜèçóç åßíáé çèéêü êáèÞ-

êïí êáé ü÷é Ýíá "âÜñïò" îÝíï ðñïò ôéò êáèçìåñéíÝò ôïõòõðï÷ñåþóåéò. Ïé ðåñéóóüôåñïé óõããåíåßò åßíáé ãõíáß-êåò (óýæõãïé) ðïõ ï ðáñáäïóéáêüò ôïõò ñüëïò åßíáé íáöñïíôßæïõí, Üñá äåí íéþèïõí Üó÷çìá (õðïêåéìåíéêÞåðéâÜñõíóç), ìéáò êáé èåùñïýí üôé ç áðáó÷üëçóÞ ôïõòìå ôïí áóèåíÞ áðïôåëåß óõóôáôéêü ôçò æùÞò ôïõò.

¼ìùò ç óõíå÷Þò öñïíôßäá ÷ùñßò ïõóéáóôéêÞ óôÞñé-îç, ìðïñåß íá ðñïêáëÝóåé ðñïâëÞìáôá óôçí øõ÷éêÞõãåßá ôçò ïéêïãÝíåéáò. Ôï ðïóïóôü ôùí ïéêïãåíåéþí ìåÄÃÕ > 4, åßíáé óçìáíôéêÜ õøçëüôåñï áðü áõôü ôïõ ãå-íéêïý ðëçèõóìïý, ðïõ äå îåðåñíÜ ôï 30%6. ̧ ôóé ïé ïé-êïãÝíåéåò ôùí áóèåíþí ôïðïèåôïýíôáé óôçí ïìÜäá õøç-ëïý êéíäýíïõ ãéá ôçí åìöÜíéóç Üã÷ïõò, êáôÜèëéøçò, øõ-÷ïóùìáôéêþí åêäçëþóåùí Þ êïéíùíéêÞò äõóëåéôïõñ-ãßáò. Óå ó÷Ýóç ìå ôéò ïìÜäåò ôùí áóèåíþí, ìåãáëýôåñçåðéâÜñõíóç åß÷å ï ÄÃÕ ôùí ïéêïãåíåéþí ìå áóèåíåßòðïõ áíÞêïõí êõñßùò óôçí ðñþôç êáé ôñßôç ïìÜäá. Åßíáéãíùóôü üôé ïé áóèåíåßò ìå âáñéÜ ×ÁÐ óõ÷íÜ åìöáíß-æïõí êáôÜèëéøç14, ðïõ åðçñåÜæåé ôçí ðïéüôçôá æùÞò ôïõòêáé åíäå÷ïìÝíùò ôï ïéêïãåíåéáêü ðåñéâÜëëïí. Áíôßèå-ôá, ç êáëÞ øõ÷éêÞ êáôÜóôáóç ôïõ áóèåíïýò êáé ç ðá-ñïõóßá ôïõ Þ ôçò óõæýãïõ, öáßíåôáé üôé Ý÷ïõí èåôéêÞåðßäñáóç óôçí åðéâßùóç áõôþí ôùí áóèåíþí15. Åßíáéëïéðüí ëïãéêü ü÷é ìüíï íá áíáãíùñßæåôáé ç åðéâÜñõí-óç ôçò ïéêïãÝíåéáò áëëÜ êáé íá åðéäéþêåôáé üóï åßíáéäõíáôü ç áíôéóôÜèìéóÞ ôçò.

ÔÝëïò, ç éáôñéêÞ öñïíôßäá êáé åíçìÝñùóç ãéá üôéáöïñÜ óôç íüóï êáé ôç èåñáðåõôéêÞ áãùãÞ, êñßèçêå éêá-íïðïéçôéêÞ áðü ôïõò óõããåíåßò ôùí áóèåíþí êáèþò çáðïõóßá åðéâÜñõíóçò óôçí ðåñéï÷Þ áõôÞ Þôáí óçìáíôé-êÞ. Ç åêôßìçóç áõôÞ üìùò äåí ìðïñåß íá ãåíéêåõôåß, ãéáôßüëïé ïé áóèåíåßò Þôáí õðü óõóôçìáôéêÞ ðáñáêïëïýèç-óç êáé åß÷å ãßíåé ðñïóðÜèåéá åíçìÝñùóçò êáé åêðáß-äåõóçò áõôþí êáé ôçò ïéêïãÝíåéáò.

Áðü ôá ìÝ÷ñé ôþñá áðïôåëÝóìáôá, ç Ýêäçëç áíôé-êåéìåíéêÞ åðéâÜñõíóç ôçò ïéêïãÝíåéáò áóèåíþí ìå×ÁÁ, ðïõ äéáðéóôþèçêå óå üëåò ôéò ðåñéï÷Ýò ðïõ áîéï-ëïãÞèçêáí, öáßíåôáé íá áíôéóôáèìßæåôáé áðü ôéò äïìÝòêáé ôéò çèéêÝò áîßåò ðïõ áêüìá éó÷ýïõí ãéá ôçí ïéêïãÝ-íåéá óôçí êïéíùíßá ìáò. Ç êáôáãñáöÞ ôïõ õøçëïý ðï-óïóôïý åðéêéíäõíüôçôáò óôï Äåßêôç ÃåíéêÞò Õãåßáò óôéòïéêïãÝíåéåò áõôÝò äåß÷íåé üôé ç ðñïóðÜèåéá áíôéóôÜè-ìéóçò ôïõ âÜñïõò ðïõ ðñïêáëåßôáé áðü ôç óõìâßùóç ìåôïí áóèåíÞ, ãßíåôáé ìå õøçëü êüóôïò. Ç ðáñáðÝñá äéå-ñåýíçóç ôçò åðéâÜñõíóçò ôùí ïéêïãåíåéþí, áíÜëïãá ìå


ôçí õðïêåßìåíç ðÜèçóç ôïõ áóèåíïýò üðùò êáé ôçò åðé-êéíäõíüôçôáò óôï Äåßêôç ÃåíéêÞò Õãåßáò, åßíáé áðáñáß-ôçôç. ¼ìùò áðü ôá ìÝ÷ñé ôþñá äåäïìÝíá åßíáé öáíåñüüôé óôçí ïéêïãÝíåéá ôïõ áóèåíïýò ìå ×ÁÁ, äçìéïõñ-

ãïýíôáé óçìáíôéêÜ ðñïâëÞìáôá êáé ÷ñåéÜæåôáé óôÞñéîçãéá íá ìðïñåß áõôÞ íá áíôáðåîÝëèåé, ç äå óôÞñéîç áõôÞìüíï èåôéêÞ åðßðôùóç èá Ý÷åé óôïí ÷ñïíßùò ðÜó÷ïíôááóèåíÞ.

SUMMARY

Burden imposed on the families of patients with chronic ïbstructive insufficiency

V. Tsara, V. Lazarides, V. Paschidou, E. Serasli, P. Kakavelas, P. Christakis

Ôhe objective and subjective burden imposed on the families of patients under LTOT and MV, as wellas their General Health Score was estimated in 32 family members (56.7% husband /wife, 33.3%child) with mean duration of common life of 29.7 years and daily contact rate of 96%. A profoundobjective burden was revealed in the field of social activities in 57.7% of the families, home caremanaging in 46.7%, financial condition in 43.3%, occupation activities in 30% and satisfaction withmedical services in 27.6% of the families. The subjective burden rates were respectively lower. Thestrategies adopted by the families in order to cope with the imposed burden were: reevaluation of theiraims in 90% of the families, resignation 86.1%, passivity in 50%, hopefulness in 50%, guilt in 16.6%and ambivalence in 17% of the families. General Health Score was >4 in 69.7% of the relatives andit was significantly related with the objective burden imposed on social activities (r=0.61, p<0.05)and occupation activities (r=0.70, p<0.01), as well as with the subjective burden on home care man-aging (r=0.78, p<0.01) and financial condition (r=0.76, p<0.01). The families of patients with CRIseem to face major problems (severe burden) in their social relations and financial condition. On thecontrary, they seem to be satisfied (absence of burden) with the provided medical services. Families donot seem to experience subjectively the burden that is objectively recorded. In their vast majority, theyadopt healthy coping strategies. Nevertheless, a high rate of them is estimated to be in great risk ofdeveloping mental disorders. Pneumon 2002, (2):176-182.

Key words: Chronic Obstructive Insufficiency, Mechanical Ventilation, Long-term Oxygen Ôherapy,Burden, Family, General Health.


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ÅíáëëáêôéêÝò ìéêñïâéïëïãéêÝò ìÝèïäïé óôç äéÜãíùóçôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò

ËÝîåéò-ÊëåéäéÜ: ÐíåõìïíéïêïêêéêÞ ðíåõìïíßá,åíáëëáêôéêÝò ìéêñïâéïëïãéêÝò ìÝèïäïé, ðïëõóáê-÷áñéäéêü êáøéäéáêü áíôéãüíï -PCA, ðïëõóáê÷á-ñéäéêü ôåé÷ùìáôéêü áíôéãüíï -PnC, ôá÷åßá ìÝèï-äïò áíïóï÷ñùìáôïãñáößáò ìåìâñÜíçò

Aëëçëïãñáößá:Óïößá ÊáíáâÜêç, Áíáðë. Äéåõèýíôñéá Ìéêñïâéï-ëïãéêïý Åñãáóôçñßïõ, Íïóïêïìåßï �Óùôçñßá�,11527 Ë. Ìåóïãåßùí 152, ÁèÞíá

Ó. ÊáíáâÜêç,Ó. ÊáñÜìðåëá,Ì. Ìáêáñþíá,Ó. Ôñéáíôáöýëëïõ,Å. ÅõóôáèéÜäïõ,Å. Öáâßïõ

Ìéêñïâéïëïãéêü ÅñãáóôÞñéï ÍÍÈÁ

ÐÅÑIËÇØÇ. Ç ðíåõìïíéïêïêêéêÞ ðíåõìïíßá áðïôåëåß óõ÷íÜ ìßáéäéáßôåñá âáñåéÜ ëïßìùîç, ç áíôéìåôþðéóç ôçò ïðïßáò ðñïûðïèÝ-ôåé Ýãêáéñá êáé áêñéâÞ åñãáóôçñéáêÜ áðïôåëÝóìáôá üðùò êáé êá-ôÜëëçëç èåñáðåõôéêÞ áãùãÞ. Ïé êëáóóéêÝò ìéêñïâéïëïãéêÝò ìÝ-èïäïé äåí áíôáðïêñßíïíôáé ðÜíôá ó�áõôÝò ôéò ðñïûðïèÝóåéò äå-äïìÝíïõ üôé, ç äéåîáãþãç ôïõò áðáéôåß ó÷åôéêÜ ìåãÜëï ÷ñïíéêüäéÜóôçìá, ôá äå áðïôåëÝóìáôá óõ÷íÜ äåí åßíáé éäéáßôåñá óáöÞ.Ãéá ôçí áíôéìåôþðéóç áõôïý ôïõ ðñïâëÞìáôïò áíáðôý÷èçêáíäéÜöïñåò åíáëëáêôéêÝò ìÝèïäïé, ïé ïðïßåò óôï÷åýïõí êõñßùò óôçíáíß÷íåõóç ôïõ ðïëõóáê÷áñéäéêïý êáøéäéáêïý áíôéãüíïõ ôïõ ðíåõ-ìïíéïêüêêïõ (Polysaccharide capsular antigen-PCA), óå âéïëïãé-êÜ äåßãìáôá. ´Ïìùò, äéÜöïñïé ëüãïé Ý÷ïõí óõíôåëÝóåé, þóôå ïéìÝèïäïé áõôÝò íá ìçí Ý÷ïõí ôý÷åé êïéíÞò áðïäï÷Þò. ÐáñïõóéÜ-æïõìå ôá âéâëéïãñáöéêÜ äåäïìÝíá êáé ôçí åìðåéñßá ìáò, áðü ôçíåöáñìïãÞ ìéáò íÝáò ìåèüäïõ, ôçò ôá÷åßáò áíïóï÷ñùìáôïãñáößáòìåìâñÜíçò (Immunochromatographic Test �ICT), ãéá ôçí áíß÷íåõ-óç ôïõ ðïëõóáê÷áñéäéêïý êáøéäéáêïý áíôéãüíïõ ôïõ ðíåõìïíéï-êüêêïõ (Pneumococcus C polysaccharide-PnC) óôá ïýñá, èåùñþ-íôáò üôé, áõôÞ áðïôåëåß ìßá áîéüëïãç åíáëëáêôéêÞ ìÝèïäï, ðïõèá ðñÝðåé íá ðåñéëáìâÜíåôáé áðáñáßôçôá óôï öÜóìá ôùí ìéêñï-âéïëïãéêþí åîåôÜóåùí ñïõôßíáò ïé ïðïßåò åöáñìüæïíôáé ãéá ôçíáéôéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò. Ðíåý-ìùí 2002, 15(2)189-195.

ÅÉÓÁÃÙÃÇ

Ç ìéêñïâéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò, ìåôçí åöáñìïãÞ ôùí ãíùóôþí êëáóóéêþí ìåèüäùí, óõ÷íÜ áðïäåéêíýåôáé÷ñïíïâüñá êáé áíáðïôåëåóìáôéêÞ. Ç áðïìüíùóç ôïõ ðíåõìïíéïêüêêïõ,éäéáßôåñá ìåôÜ áðü ÷ïñÞãçóç áíôéâéïôéêÞò áãùãÞò åßíáé äýóêïëç, åíþ çâáñýôçôá ôçò ëïßìùîçò êáé ðñïâëÞìáôá óôç èåñáðåõôéêÞ, ìå óçìáíôéêü-

KëéíéêÞ ÌåëÝôç


âáêôçñßïõ.ã) Ïýñá. Ãéá ôçí áíß÷íåõóç ôïõ áíôéãüíïõ PnC ôïõ

ðíåõìïíéïêüêêïõ, åöáñìüóèçêå ç ôá÷åßá ìÝèïäïò ôçòáíïóï÷ñùìáôïãñáößáò ìåìâñÜíçò. ×ñçóéìïðïéÞèçêåôï áíôéäñáóôÞñéï Binax NOW Streptococcus pneumon-iae Urinary Antigen Test, ôçò åôáéñåßáò Binax. Óôç ðñáã-ìáôéêüôçôá, ðñüêåéôáé ãéá ìßá äéÜôáîç, óôçí ïðïßá anti-S. pneumoniae áíôéóþìáôá êïíßêëïõ (rabbit anti-S. pn-eumoniae) áðïññïöþíôáé óå ìåìâñÜíç íéôñïêõôôáñß-íçò (ãñáììÞ åîåôáóôÝïõ -èÝóç Ã), åíþ áíôéóþìáôá êá-ôóßêáò (goat anti-rabbit IgG) áðïññïöþíôáé ðÜíù óôçíßäéá ìåìâñÜíç, óå äåýôåñï óçìåßï (ãñáììÞ ìÜñôõñïò-èÝóç Ä). ¸íá äåýôåñï set áíôéóùìÜôùí rabbit anti-S.pneumoniae, óõíäåäåìÝíùí ìå óùìáôßäéá êïëëïåéäïýò÷ñõóïý åßíáé áðïññïöçìÝíá óå éíþäåò õðüóôñùìá, ôïïðïßï åßíáé ðñïóáñìïìÝíï óôç ìåìâñÜíç (èÝóç Â) êáéóå óõíäõáóìü ìå áõôÞ, óõíèÝôåé ôçí üëç äéÜôáîç. Ï óôõ-ëåüò, ï ïðïßïò Ý÷åé ðñïçãïõìÝíùò åìâáðôéóèåß óôï äåßã-ìá ôùí ïýñùí, ôïðïèåôåßôáé óå õðïäï÷Þ (èÝóç Á) (Ó÷Þ-ìá 1). Ðñïóôßèåíôáé ëßãåò óôáãüíåò ñõèìéóôéêïý äéáëý-ìáôïò êéôñéêþí áëÜôùí ãéá íá âïçèçèåß ç ìåôáêßíçóçôïõ áíôéãüíïõ ðÜíù óôç ìåìâñÜíç. Ôá áíôéóþìáôá rab-

ôåñï áõôü ôçò áíôï÷Þò óôçí ðåíéêéëëßíç, åðéâÜëëïõíÜìåóç êáé áîéüðéóôç áðÜíôçóç áðü ôï ìéêñïâéïëïãéêüåñãáóôÞñéï. Ç áíß÷íåõóç ôïõ ðíåõìïíéïêïêêéêïý áíôé-ãüíïõ PnC óôá ïýñá, ìå åöáñìïãÞ ôçò ôá÷åßáò ìåèü-äïõ áíïóï÷ñùìáôïãñáößáò ìåìâñÜíçò áðïôåëåß ìßááîéüëïãç åíáëëáêôéêÞ ëýóç, ãéá ãñÞãïñç êáé áóöáëÞìéêñïâéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞò ðíåõ-ìïíßáò1.

ÕËÉÊÏ ÊÁÉ ÌÅÈÏÄÏÓ

ÌÝóá óôá ðëáßóéá ôçò áéôéïëïãéêÞò äéåñåýíçóçò 66ðåñéðôþóåùí âáñåéÜò åîùíïóïêïìåéáêÞò ðíåõìïíßáòáãíþóôïõ áéôéïëïãßáò, ðïõ áíôéìåôùðßóôçêáí óôï Íï-óïêïìåßï �Óùôçñßá� êáôÜ ôï ÷ñïíéêü äéÜóôçìá ìåôáîýÉïõíßïõ 2001 - Öåâñïõáñßïõ 2002, ðñáãìáôïðïéÞèçêåÝëåã÷ïò ãéá ôçí ðéèáíÞ óõììåôï÷Þ ôïõ ðíåõìïíéïêüê-êïõ, ùò ìéêñïâéáêïý áéôßïõ ôùí ðíåõìïíéþí áõôþí.

Óôï Ìéêñïâéïëïãéêü ÅñãáóôÞñéï åîåôÜóèçóáí ôáåîÞò åßäç äåéãìÜôùí: á) ðôýåëá, óôïõò 64/66 áóèåíåßòãéá êáëëéÝñãåéá êáé ÷ñþóç Gram. â) êáëëéÝñãåéåò áß-ìáôïò, áåñüâéåò êáé áíáåñüâéåò óôïõò 36/66 áóèåíåßò.Ãéá êÜèå áóèåíÞ åóôÜëçóáí ôïõëÜ÷éóôïí äýï æåýãç áé-ìïêáëëéåñãåéþí. ã) äåßãìáôá ïýñùí óôïõò 66/66 áóèå-íåßò, ãéá áíß÷íåõóç ôïõ ðíåõìïíéïêïêêéêïý áíôéãüíïõPnC. Ç åñãáóôçñéáêÞ ìåèïäïëïãßá ç ïðïßá åöáñìü-óèçêå ãéá êÜèå Ýíá åßäïò äåßãìáôïò Þôáí ç áêüëïõèç:

á) Ðôýåëá: ÐñáãìáôïðïéÞèçêå ÷ñþóç Gram êáéêáëëéÝñãåéá ðôõÝëùí ãéá ôçí áíÜäåéîç êáé áðïìüíùóçôïõ ðíåõìïíéïêüêêïõ. Ìå âÜóç ôï Üìåóï êáôÜ Gramðáñáóêåýáóìá Ýãéíå áîéïëüãçóç ãéá ôï âáèìü áîéïðé-óôßáò ôïõ äåßãìáôïò ôùí ðôõÝëùí. Áîéüðéóôá èåùñÞèç-óáí ôá äåßãìáôá, üðïõ óôç ìåãÝíèõóç X 10 õðÞñ÷áíåðéèçëéáêÜ êýôôáñá < 10 êïð êáé ðõïóöáßñéá >25 êïð.¸ãéíå åðéóÞìáíóç ãéá ôçí åðéêñÜôçóç Þ ìç ðíåõìïíéï-êüêêïõ óôï Üìåóï ðáñáóêåýáóìá Ãéá ôçí êáëëéÝñãåéáôùí ðôõÝëùí ÷ñçóéìïðïéÞèçêå áéìáôïý÷ï êáé MacCo-nkey Üãáñ, áåñïâßùò, êáèþò êáé óïêïëáôïý÷ï êáé FildesÜãáñ ãéá êáëëéÝñãåéá óå áôìüóöáéñá CO2 10%.

â) Ãéá ôéò êáëëéÝñãåéåò áßìáôïò ÷ñçóéìïðïéÞèçêåôï áõôüìáôï óýóôçìá Bactec 9240 ôçò åôáéñåßáò BectonDickinson. Óôéò ðåñéðôþóåéò ðïõ ôï ìç÷Üíçìá ÝäùóåèåôéêÞ Ýíäåéîç, Ýãéíáí ðáñáóêåõÜóìáôá êáé áíáêáë-ëéÝñãåéåò óå áéìáôïý÷ï êáé MacConkey Üãáñ áåñïâßùòêáé óå áéìáôïý÷ï áíáåñïâßùò, ãéá ôçí áðïìüíùóç ôïõ

Ó÷Þìá 1. Ó÷çìáôéêÞ áðåéêüíéóç ôçò ôá÷åßáò ìåèüäïõ áíïóï-÷ñùìáôïãñáößáò ìåìâñÜíçò (ICT) ãéá ôçí åíß÷íåõóç ôïõ áíôé-ãüíïõ PnC ôïõ ðíåõìïíéïêüêêïõ óôá ïýñá. (á) Åðéóêüðçóçåê ôùí Üíù, (â) Óå êÜèåôç ôïìÞ.

Á: ÈÝóç äåßãìáôïò, Â: ÈÝóç óõíäåäåìÝíïõ ìå óùìáôßäéáêïëëïåéäïýò ÷ñõóïý, áíôéóþìáôïò êïíßêëïõ anti-S. Pneumo-niae, Ã: ÃñáììÞ åîåôáóôÝïõ, Ä: ÃñáììÞ ìÜñôõñá, Å: Ìåì-âñÜíç íéôñïêõôôáñßíçò


bit anti S. pneumoniae, ðïõ åßíáé óõíäåäåìÝíá ìå óù-ìáôßäéá êïëëïåéäïýò ÷ñõóïý óôç èÝóç Â, óõíäÝïíôáé ìåôá áíôéãüíá ôïõ ðíåõìïíéïêüêêïõ, åö�üóïí áõôÜ õðÜñ-÷ïõí óôï äåßãìá ôùí ïýñùí êáé ôï óýìðëåãìá áíôéãü-íïõ-óõíäåäåìÝíïõ áíôéóþìáôïò äåóìåýåôáé áðü ôá áêé-íçôïðïéçìÝíá áíôéóþìáôá êïíßêëïõ anti-S. pneumoni-ae, óôç èÝóç Ã, ó÷çìáôßæïíôáò ôç ãñáììÞ ôïõ åîåôá-óôÝïõ. Åðß ðëÝïí, ôá áêéíçôïðïéçìÝíá áíôéóþìáôá êá-ôóßêáò anti-rabbit IgG äåóìåýïõí ôçí ðåñßóóåéá ôïõóõíäåäåìÝíïõ áíôéóþìáôïò, ó÷çìáôßæïíôáò ôç ãñáììÞôïõ ìÜñôõñá, óôç èÝóç Ä. Ôï áðïôÝëåóìá åßíáé ïñáôüóå 15´. ÅÜí åßíáé èåôéêü ó÷çìáôßæïíôáé äýï ñïæ ãñáì-ìÝò, ìßá óôç èÝóç ôïõ åîåôáóôÝïõ êáé ìßá óôç èÝóç ôïõìÜñôõñá, åíþ åÜí åßíáé áñíçôéêü, ó÷çìáôßæåôáé ìßáãñáììÞ ìüíï, óôç èÝóç ôïõ ìÜñôõñá. ÅÜí ôï áðïôÝëå-óìá äåí åßíáé åõäéÜêñéôï, óõíéóôÜôáé ç åðáíåêôßìçóçìåôÜ áðü 45´, äçëáäÞ óõíïëéêÜ óå 1þñá áðü ôçí áñ÷Þôçò åöáñìïãÞò ôçò ìåèüäïõ.


Ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò, öáßíïíôáé óôïõòðßíáêåò 1 êáé 2 êáé Ý÷ïõí áíáëõôéêÜ ùò åîÞò: á) Ðôýå-ëá: Áîéüðéóôá Þôáí ôá 45/64 (70,3%) äåßãìáôá. ÅìöáíÞåðéêñÜôçóç ðíåõìïíéïêüêêïõ óôï Üìåóï ðáñáóêåýá-óìá ðáñïõóßáæáí ôá 7/45 (10,9%) äåßãìáôá ðôõÝëùí,åíþ áðïìïíþèçêå ðíåõìïíéüêïêêïò óôá 3/45 (14,7%)åî áõôþí (Ðßíáêáò 1).

â) ÊáëëéÝñãåéåò áßìáôïò. Èåôéêü áðïôÝëåóìá óç-ìåéþèçêå ìüíï óå ìßá áðü ôéò 36 ðåñéðôþóåéò áóèåíþí(2,7%). ¼ ðíåõìïíéüêïêêïò áðåìïíþèç êáé óôá äýïæåýãç öéáëéäßùí ôïõ áóèåíïýò, áåñïâßùò êáé áíáåñï-âßùò (Ðßíáêáò 1).

ã) Ïýñá ãéá áíß÷íåõóç ôïõ PnC áíôéãüíïõ ôïõ ðíåõ-ìïíéïêüêêïõ. Áðü ôá 66 äåßãìáôá, ðïõ áíôéóôïé÷ïýóáíóå êÜèå ìßá áðü ôéò 66 ðåñéðôþóåéò âáñåéÜò åîùíïóï-êïìåéáêÞò ðíåõìïíßáò ðïõ ìåëåôÞóáìå, ôï áíôéãüíï PnC

áíé÷íåýèçêå óå 14/66 (21,2%) ðåñéðôþóåéò. Ôï áðïôÝ-ëåóìá åëÞöèåé óå 15´, èÝôïíôáò Üìåóá ôç ìéêñïâéïëïãé-êÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò. ÔïáðïôÝëåóìá êñßèçêå áðüëõôá óõìâáôü, ôüóï ìå ôçí êëé-íéêÞ, üóï êáé ìå ôçí áêôéíïëïãéêÞ åéêüíá ôùí áóèåíþí(Ðßíáêáò 1).

Ïé õðüëïéðåò ìéêñïâéïëïãéêÝò, êëáóóéêÝò åîåôÜóåéòóôéò 14 áõôÝò âÝâáéåò ðåñéðôþóåéò ðíåõìïíéïêïêêéêÞòðíåõìïíßáò, Ýäåéîáí üôé 11/14 (78,5%) äéÝèåôáí áîéüðé-óôï äåßãìá ðôõÝëùí, åìöáíÞ åðéêñÜôçóç ôïõ ðíåõìï-íéïêüêêïõ óôï Üìåóï ðáñáóêåýáóìá óçìåéþèçêå óå 3/14 (29,4%), åíþ áðïìüíùóç ôïõ ìéêñïâßïõ óôç êáëëéÝñ-ãåéá, óå 2/14 (14,3%) ðåñéðôþóåéò. Áîéïóçìåßùôï åßíáéüôé, óå ìßá ìüíï ðåñßðôùóç ç áéìïêáëëéÝñãåéá Þôáí èå-ôéêÞ (7,1%) (Ðßíáêáò 2).

ÓÕÆÇÔÇÓÇ

Ç ðíåõìïíßá ôçò êïéíüôçôáò, áñêåôÜ óõ÷íÜ, áðïôå-ëåß ìßá óïâáñÞ êáé äýóêïëç ëïßìùîç, ôüóï áðü ÜðïøçäéáãíùóôéêÞ, üóï êáé èåñáðåõôéêÞ. Ï ðíåõìïíéüêïêêïòåîáêïëïõèåß íá èåùñåßôáé ôï óõ÷íüôåñï ìéêñïâéáêüáßôéï ôçò åîùíïóïêïìåéáêÞò ðíåõìïíßáò, üìùò ç ìéêñï-âéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáòìå ôçí åöáñìïãÞ ôùí êëáóóéêþí ìéêñïâéïëïãéêþí ìå-èüäùí, ðïëëÝò öïñÝò áðïäåéêíýåôáé áíåðáñêÞò, áíå-ðéôõ÷Þò êáé ÷ñïíïâüñá. ÄéÜöïñïé ðáñÜãïíôåò óõìâÜë-ëïõí ó� áõôü, ìå óçìáíôéêüôåñïõò, ôçí áäõíáìßá ðáñá-ãùãÞò áîéüðéóôïõ êëéíéêïý äåßãìáôïò, ôïí áðïéêéóìü ôïõóôïìáôïöÜñõããá, êáèþò êáé ôçí áäõíáìßá áðïìüíù-óçò ôïõ ìéêñïâßïõ åî�áéôßáò ðñïçãçèåßóáò áíôéâéïôéêÞòáãùãÞò. ÐáñÜ ôéò äõóêïëßåò ðïõ óõ÷íÜ ðñïêýðôïõí áðüôç ìéêñïâéïëïãéêÞ åîÝôáóç ôùí ðôõÝëùí, ôá ðôýåëá ðá-ñáìÝíïõí ôï äåßãìá ðñþôçò ãñáììÞò, äåäïìÝíçò ôçòåõêïëßáò ìå ôçí ïðïßá ðáñÜãïíôáé. ÄéÜöïñåò ðáñåì-âáôéêÝò ôå÷íéêÝò åîáóöáëßæïõí áóöáëþò äåßãìáôá ìå-ãáëýôåñçò áîéïðéóôßáò, üðùò åßíáé ôï âñïã÷ïêõøåëéäé-

Ðßíáêáò 1. ÁðïôåëÝóìáôá ìéêñïâéïëïãéêïý åëÝã÷ïõ óå ðåñéðôþóåéò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò

Åßäïò Áñéèìüò äåéãìÜôùí/ Áîéïðéóôßá ÌéêñïóêïðéêÞ Áðïìüíùóç PnC (-) PnC (+)äåßãìáôïò Áóèåíåßò Áñéèìüò % Áñéèìüò % Áñéèìüò % Áñéèìüò % Áñéèìüò %

Ðôýåëá 64/66 45 70,3 7 10,9 3 14,7Áßìá 36/66 1 2,7Ïýñá 66/66 52 78,8 14 21,2


Ðßíáêáò 2. ÅñãáóôçñéáêÜ áðïôåëÝóìáôá áðü ôçí åöáñìïãÞ êëáóóéêþí ìéêñïâéïëïãéêþí ìåèüäùí óôéò ðåñéðôþóåéòèåôéêÞò áíß÷íåõóçò ðíåõìïíéïêïêêéêïý áíôéãüíïõ (PnC) óôá ïýñá

Áóèåíåßò Á/Á Áîéïðéóôßá ÌéêñïóêïðéêÞäåéãìÜôùí ÅîÝôáóç Áðïìüíùóç Áéìïê/á PnC (+)

1 + - - - +2 + - - - +3 + - - + +4 + - - - +5 + - - - +6 - - - - +7 + + + - +8 + - + - +9 + + - - +10 - - - - +11 - - - - +12 + - - - +13 + - - - +14 + + - - +

ÓÕÍÏËÏ 11 3 2 1 14 % 78,5 29,4 14,3 7,1 100

êü Ýêðëõìá (Broncho Alveolar Lavage-BAL), ôï äåßã-ìá ðñïóôáôåõìÝíçò âïýñôóáò (Protected Brush Speci-men-PBS), êáèþò êáé ôï äåßãìá áðü äéáôñá÷åéáêÞ áíáñ-ñüöçóç (Trans Tracheal Aspiration-TTA). ¼ìùò, çåöáñìïãÞ áõôþí ôùí ìåèüäùí áðáéôåß ðñïãñáììáôé-óìü, åìðåéñßá ðñïóùðéêïý êáé åéäéêü åîïðëéóìü, åíþðÜíôá óõíõðÜñ÷åé ç ðéèáíüôçôá áíåðéèýìçôùí åíåñ-ãåéþí. Ç êáëëéÝñãåéá áßìáôïò, ðáñÜ ôïõ üôé åîáóöáëß-æåé ôï ðëÝïí áîéüðéóôï áðïôÝëåóìá, äåí áðïäåéêíýåôáééäéáßôåñá ÷ñÞóéìç óôçí ðñÜîç, äéüôé ôï 70-80% ôùí ðå-ñéðôþóåùí ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò åßíáé ìçâáêôçñéáéìéêÝò, ç äå ÷ïñÞãçóç áíôéâéïôéêþí, åëáôôþ-íåé áêüìç ðåñéóóüôåñï ôçí ðéèáíüôçôá áðïìüíùóçò ôïõìéêñïâßïõ1,2.

Ãéá ôïõò ëüãïõò áõôïýò, åäþ êáé áñêåôÜ ÷ñüíéá ãß-íïíôáé ðñïóðÜèåéåò åöáñìïãÞò åíáëëáêôéêþí ìåèüäùíãéá ôç ìéêñïâéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêé-êÞò ðíåõìïíßáò. Óçìáíôéêüôåñç åßíáé áõôÞ, ôçò áíß÷íåõ-óçò ôïõ ðïëõóáê÷áñéäéêïý êáøéäéáêïý áíôéãüíïõ PCAôïõ ðíåõìïíéïêüêêïõ óå âéïëïãéêÜ äåßãìáôá, üðùòðôýåëá, áßìá êáé ïýñá, ìå åöáñìïãÞ óõãêïëëçôéíïá-íôßäñáóçò (Latex), áíïóïçëåêñïöüñçóçò (CIE), Þ áíï-óïåíæõìéêÞò ìåèüäïõ (EIA). ¼ìùò äéáöïñÝò óôçíáíôéãïíéêüôçôá ôïõ PCA óôïõò äéáöüñïõò ïñïôýðïõò

ôïõ ðíåõìïíéïêüêêïõ êáé áðïêëßóåéò ðïõ êáôáãñÜöï-íôáé, ùò ðñïò ôçí åõáéóèçóßá êáé ôçí åéäéêüôçôá ôùí ùòÜíù ìåèüäùí óôá äéÜöïñá åßäç äåéãìÜôùí, ìåôáîý ôùíåñåõíçôþí, Ý÷ïõí ùò áðïôÝëåóìá íá ìçí Ý÷ïõí ôý÷åéêïéíÞò áðïäï÷Þò êáé ç åöáñìïãÞ ôïõò óôçí êáèçìåñéíÞðñÜîç íá åßíáé ðåñéïñéóìÝíç. ̧ ôóé, ãéá ôçí áíß÷íåõóçôïõ PCA óôá ðôýåëá,ðåñéóóüôåñï áîéüðéóôç ìÝèïäïòèåùñåßôáé ç óõãêïëëçôéíïáíôßäñáóç, åíþ ãéá ôá ïýñá,ç CIE1-6. Ç åöáñìïãÞ ôçò ÅÉÁ óôá ïýñá ãéá ôçí áíß-÷íåõóç ôïõ PCA äåí Ý÷åé áðïäåé÷èåß éäéáßôåñá åðéôõ-÷Þò êáé áõôü áðïäßäåôáé óôï ãåãïíüò üôé, ôï PCA ôùíïýñùí åßíáé åëáöñþò ôñïðïðïéçìÝíï, åðåéäÞ öáßíåôáéüôé äéáèÝôåé ëéãüôåñåò äåóìåõôéêÝò èÝóåéò, åíþ ÜëëïéåðéðëÝïí ðáñÜãïíôåò, üðùò ôï Ph ôùí ïýñùí êáé ç óõ-ãêÝíôñùóç ôïõ ëåõêþìáôïò, öáßíåôáé üôé åðéäñïýí áñ-íçôéêÜ óôçí áíôßäñáóç áíôéãüíïõ-áíôéóþìáôïò1,7.

Åêôüò üìùò áðü ôï êáøéäéáêü áíôéãüíï PCA, åíäéá-öÝñïí Ý÷åé ðñïêáëÝóåé êáé ôï ôåé÷ùìáôéêü áíôéãüíï ôïõðíåõìïíéïêüêêïõ PnC, ôï ïðïßï ðñïÝñ÷åôáé áðü ôá ôåé-÷ïúêÜ ïîÝá ôïõ ôïé÷þìáôïò êáé ôï ïðïßï óå áíôßèåóç ìåôï PCA åßíáé êïéíü óå üëïõò ôïõò ïñïôýðïõò1. Ãéá ôçíáíß÷íåõóç ôïõ PnC, åöáñìüæïíôáé ç óõãêïëëçôéíïáíôß-äñáóç Latex, ç CIE êáé ç ÅÉÁ, óå ðôýåëá, áßìá êáé ïýñá,ìÝèïäïé ðïõ üìùò, üðùò óçìâáßíåé êáé ãéá ôï PCA, óôå-


ñïýíôáé êïéíÞò áðïäï÷Þò êáé äåí êáôÜöåñáí íá áðïôå-ëÝóïõí éó÷õñü åíáëëáêôéêü ôñüðï ìéêñïâéïëïãéêÞò äéÜ-ãíùóçò ôïõ ðíåõìïíéïêüêêïõ1.

ÐñÝðåé íá óçìåéùèåß üôé ôï äåßãìá ôùí ïýñùí ðñï-êáëåß óôáèåñÜ ôï åíäéáöÝñïí óôç äéáãíùóôéêÞ ðñïóÝã-ãéóç áñêåôþí ëïéìþîåùí ôá ôåëåõôáßá ÷ñüíéá, äéüôéüðùò åßíáé ãíùóôü, äéáëõôÜ áíôéãüíá äéáöüñùí ìéêñï-âéáêþí ðáñáãüíôùí åêêñßíïíôáé êáé óõãêåíôñþíïíôáéó�áõôÜ, óå ìåãÜëåò ðïóüôçôåò, åî�áéôßáò ôçò öõóéêÞòóõìðõêíùôéêÞò éêáíüôçôáò ôùí íåöñþí8.

Åßíáé áîéïóçìåßùôï üôé, ôüóï ôï PCA üóï êáé ôï PnCáíé÷íåýïíôáé óôá ïýñá, ôüóï óôç âáêôçñéáéìéêÞ, üóï êáéóôç ìç âáêôçñéáéìéêÞ ðíåõìïíßá, äéüôé ç êõêëïöïñßáôïõò äåí åßíáé áðïêëåéóôéêÜ áðïôÝëåóìá âáêôçñéáéìßáò,áëëÜ ãåíéêüôåñçò áðåëåõèÝñùóçò áõôþí, åî�áéôßáò ôçòëïßìùîçò. Ç áíß÷íåõóç ôùí áíôéãüíùí áõôþí, ôüóï ìååöáñìïãÞ CIE, üóï êáé ìå ICT åßíáé äõíáôÞ, áêüìç êáéüôáí ç áðïìüíùóç ôïõ âáêôçñßïõ äåí åßíáé åöéêôÞ, äå-äïìÝíïõ üôé äåí áðáéôïýí æþíôåò ïñãáíéóìïýò1,9. Ç áíß-÷íåõóç ôïõ PCA óôá ïýñá ìå ôçí åöáñìïãÞ ôçò CIEÝ÷åé äþóåé ðñÜãìáôé áñêåôÜ éêáíïðïéçôéêÜ áðïôåëÝóìá-ôá, ìå åõáéóèçóßá êáé åéäéêüôçôá ðåñßðïõ 62%. Ç ìÝ-èïäïò ôçò ôá÷åßáò áíïóï÷ñùìáôïãñáößáò ìåìâñÜíçòãéá ôçí áíß÷íåõóç ôïõ PnC åßíáé óáöþò ðëåïíåêôéêüôå-ñç, äéüôé óå áíôßèåóç ìå ôç CIE åßíáé ôá÷ýôåñç, ìå áðáé-ôïýìåíï ÷ñüíï ìüëéò 15´, äåí áðáéôåß åéäéêü åîïðëéóìü,ïýôå åìðåéñßá ðñïóùðéêïý, Ý÷åé õøçëÞ åõáéóèçóßá êáéåéäéêüôçôá, 80,4% êáé 97,2% áíôßóôïé÷á, Ý÷åé äå ÞäçðÜñåé Ýãêñéóç áðü ôïí ïñãáíéóìü ôñïößìùí êáé öáñ-ìÜêùí (Food and Drug Administration-FDA) ôùí Çíù-ìÝíùí Ðïëéôåéþí1. ÅðéðëÝïí, ôá áðïôåëÝóìáôá ôçò ICTäåí åðçñåÜæïíôáé áðü ôïí áðïéêéóìü ôïõ óôïìáôïöÜ-ñõããá, äåäïìÝíïõ üôé ôï ìéêñïâéáêü öïñôßï óôçí ðåñß-ðôùóç ôïõ áðïéêéóìïý åßíáé ðïëý ìéêñüôåñï, áðü áõôüóå ðåñßðôùóç ëïßìùîçò êáé ðÜíôùò äåí åßíáé åðáñêÝòãéá íá äþóåé øåõäþò èåôéêÜ áðïôåëÝóìáôá1,10,11.

Áóöáëþò, üôáí ç óõãêÝíôñùóç ôïõ áíôéãüíïõ åßíáéìåãÜëç, ôï èåôéêü áðïôÝëåóìá åßíáé ðåñéóóüôåñï åõäéÜ-êñéôï. Ãé� áõôü åöéóôÜôáé ç ðñïóï÷Þ, óôéò ðåñéðôþóåéòüðïõ ç óõãêÝíôñùóç ôïõ áíôéãüíïõ åßíáé ìéêñÞ êáé ôïáðïôÝëåóìá äåí åßíáé Ýíôïíï, íá ìç äßäïíôáé øåõäþòáñíçôéêÜ áðïôåëÝóìáôá. ¢ëëùóôå, üðùò Þäç áíáöÝñ-èçêå, ç êáôáóêåõÜóôñéá åôáéñåßá ðñïôåßíåé ôçí ðáñÜ-ôáóç ôïõ ÷ñüíïõ áíÜãíùóçò ôïõ áðïôåëÝóìáôïò óôç 1þñá óõíïëéêÜ, üôáí õðÜñ÷åé áìöéâïëßá1. ¸íá Üëëï

óçìáíôéêü ðëåïíÝêôçìá ôçò ìåèüäïõ åßíáé üôé äåí öáß-íåôáé íá åðçñåÜæåôáé éäéáßôåñá áðü ôç ÷ïñÞãçóç áíôé-âéïôéêþí. Ðáñ� üëá áõôÜ, ç åöáñìïãÞ ôçò ICT óõíéóôÜ-ôáé ôéò ðñþôåò çìÝñåò áðü ôçí åéóáãùãÞ ôïõ áóèåíïýòóôï Íïóïêïìåßï1 Ìéêñü ìåéïíÝêôçìá ôçò ìåèüäïõ åß-íáé ðéèáíÝò äéáóôáõñïýìåíåò áíôéäñÜóåéò ìå óôñåðôü-êïêêïõò ôçò ïìÜäáò S.oralis (S. oralis, S. mitis êáé S.pneumoniae). ¼ìùò óôç ðñÜîç, áõôü äåí áðïôåëåß óï-âáñü ìåéïíÝêôçìá, áöïý ôï áíôéãüíï PnC åõñßóêåôáéóå ðïëý ìåãáëýôåñåò óõãêåíôñþóåéò óôï ðíåõìïíéüêïê-êï, óå ó÷Ýóç ìå ôïõò Üëëïõò óôñåðôüêïêêïõò ôçò ïìÜ-äáò. ¢ëëùóôå, ï ðíåõìïíéüêïêêïò åßíáé ôï óõ÷íüôåñïáßôéï ôçò ðíåõìïíéïêïêêéêÞò ðíåõìïíßáò, åíþ ï S.mitisäåí ó÷åôßæåôáé åðéäçìéïëïãéêÜ ìå áõôÞ1,12.

Áîßæåé íá áíáöåñèåß üôé, ç ßäéá ìÝèïäïò åöáñìüæå-ôáé êáé ãéá ôç ìéêñïâéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéï-êïêêéêÞò ìçíéããßôéäáò, óå äåßãìáôá ÅÍÕ, ìå åõáéóèç-óßá êáé åéäéêüôçôá 100%13.

Óýìöùíá ìå ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò, ó÷å-ôéêÜ ìå ôçí åöáñìïãÞ ôçò ôá÷åßáò ìåèüäïõ ICT ãéá ôçíáíß÷íåõóç ôïõ áíôéãüíïõ PnC ôïõ ðíåõìïíéüêïêêïõ óôáïýñá, óôéò 66 ðåñéðôþóåéò âáñåéÜò åîùíïóïêïìåéáêÞòðíåõìïíßáò áãíþóôïõ áéôéïëïãßáò ðïõ ìåëåôÞèçóáí,êáôÝóôç äõíáôüí íá äïèåß Üìåóç ìéêñïâéïëïãéêÞ áðÜ-íôçóç ùò ðñïò ôï ðáèïãüíï áßôéï, óå 14 ðåñéðôþóåéò,äçëáäÞ óå ðïóïóôü 21,2% êáé íá êáèïñéóèåß ôá÷ýôáôáüôé, ðñÜãìáôé åðñüêåéôï ãéá ðíåõìïíéïêïêêéêÞ ðíåõìï-íßá. Áîéïóçìåßùôï åßíáé üôé, óôéò 14 áõôÝò ðíåõìïíéï-êïêêéêÝò ðíåõìïíßåò, ìüíï ìßá (7,1%) Ýäùóå èåôéêüáðïôÝëåóìá óôçí áéìïêáëëéÝñãåéá, åðéâåâáéþíïíôáòôçí ìéêñÞ ôçò áîßá óôç ðñÜîç. Ìå ôçí åöáñìïãÞ ôùíêëáóóéêþí ìåèüäùí, åíäåéîç ãéá ðéèáíÞ óõììåôï÷Þ ôïõðíåõìïíéïêüêêïõ óçìåéþèçêå ìüíï óôéò 5/14 (35,7%)ðåñéðôþóåéò êáé óõãêåêñéìÝíá ìå ìéêñïóêïðéêÞ åîÝôá-óç óå 3/14 êáé ìå áðïìüíùóç óå 2/14, åíþ óå 9/14(64,3%) ðåñéðôþóåéò áðü ôéò âÝâáéåò áõôÝò ðíåõìïíéï-êïêêéêÝò ðíåõìïíßåò, äåí óçìåéþèçêå êáíÝíá èåôéêüáðïôÝëåóìá õðÝñ ôïõ ðíåõìïíéïêüêêïõ, ìå êáìßá áðüôéò êëáóóéêÝò ìéêñïâéïëïãéêÝò ìåèüäïõò ðïõ åöáñìü-óôçêáí (Ðßíáêåò 1, 2). Ç áíß÷íåõóç ôïõ PnC óôá ïýñáìå åöáñìïãÞ ôçò ôá÷åßáò ìåèüäïõ áíïóï÷ñùìáôïãñá-ößáò ìåìâñÜíçò, èåùñåßôáé áðïëýôùò áóöáëÞò êáé áîéü-ðéóôç ìÝèïäïò ãéá ôç äéÜãíùóç ôçò ðíåõìïíéïêïêêéêÞòðíåõìïíßáò. Ç õøçëÞ åõáéóèçóßá êáé åéäéêüôçôá ôçòìåèüäïõ, óå óõíäõáóìü ìå ôïí åëÜ÷éóôï ÷ñüíï ðïõ


áðáéôåß, êáèþò êáé ç äõíáôüôçôá íá åîáóöáëßæåé èåôé-êÜ áðïôåëÝóìáôá, üôáí ç áðïìüíùóç ôïõ ìéêñïâßïõ äåíåßíáé äõíáôÞ, ôçí êáèéóôïýí áîéüëïãç åíáëëáêôéêÞ ëýóçãéá ôç ìéêñïâéïëïãéêÞ äéÜãíùóç ôçò ðíåõìïíéïêïêêé-

êÞò ðíåõìïíßáò. Ãéá ôïõò ëüãïõò áõôïýò äåí ðñÝðåé íáðáñáëåßðåôáé áðü ôï öÜóìá ôùí ìéêñïâéïëïãéêþí åîå-ôÜóåùí ñïõôßíáò ðïõ åöáñìüæïíôáé óå áíôßóôïé÷åò ðå-ñéðôþóåéò.

SUMMARY

Alternative microbiologic methods for the diagnosis of pneumococcal pneumonia

S. Kanavaki, S. Karabela, M. Makarona, S. Triantafillou, E. Eustathiadou, E. Faviou

Microbiology Department, �Sotiria� Hospital

Streptococcus pneumoniae is the most frequent cause of community acquired pneumonia (CAP).Conventional diagnostic methods are frequently not rapid nor sensitive enough, to guide initial antibi-otic therapy. A new method of a rapid immunochromatographic test (ICT), Binax NOW Streptococ-cus Pneumoniae Urinary Antigen Test, by Binax, increases the diagnostic yield for pneumococci inpatients with CAP. The sensivity and specifitidy of the test is 80,4% and 97,2% respectively, results aregiven in 15´, it is technically simple and it does not require any special equipment. We performed theICT test for the detection of PnC antigen of pneumococcus in urine, in 66 patients with CAP. PnCwas detected in 14/66 (21,2%) of cases. In only 1/14 case (7,1%) there was a positive result in theblood culture, while in 9/14 (64,3%) of cases, all results were negative by conventional methods. Inconclusion, the ICT method for the detection of S.pneumoniae antigen in urine, with the Binax NOWpneumococcus Urinary Antigen Test, in patients with CAP, allows a rapid diagnosis of a pneumococ-cal infection and increases the efficiency of conventional methods. Pneumon 2002, (2):189-195.

Key words: pneumococcal pneumonia, PCA, PnC, alternative diagnostic methods, Immunochroma-tographic assay-ICT


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Eéäéêü ¢ñèñï

ÌÝèïäïò ðïéïôéêÞò âåëôßùóçò óôçí êëéíéêÞ éáôñéêÞ

A.A. ×áñáëÜìðïõò

Áíáðëçñþôñéá Äéåõèýíôñéá Ì.Å.È. Éððïêñáôåßïõ

ÅÉÓÁÃÙÃÇ

Ïé ìÝèïäïé ôïõ Ðïéïôéêïý ÅëÝã÷ïõ ðïõ ðáñáäïóéáêÜ ÷ñçóéìïðïéïý-íôáé óôç âéïìç÷áíßá åäþ êáé 50 êáé ðëÝïí ÷ñüíéá, Ý÷ïõí ùò áðïôÝëåóìáôçí åðßôåõîç ôïõ Üêñùò åðéèõìçôïý æçôïýìåíïõ, äçëáäÞ ôç âåëôßùóç ôçòðáñáãùãÞò (ðïéïôéêÜ êáé ðïóïôéêÜ). ÐïëëÝò öïñÝò ìÜëéóôá åßíáé äõíá-ôÞ êáé ç ìåßùóç ôïõ êüóôïõò êáé ãåíéêüôåñá ç áñôéüôåñç ïñãÜíùóç ïëü-êëçñçò ôçò äéáäéêáóßáò ç ïðïßá îåêéíÜåé áðü ôçí ðñþôç ýëç êáé êáôáëÞ-ãåé óôï ôåëéêü ðñïúüí.

Ôá ôåëåõôáßá 2-3 ÷ñüíéá ç ìåèïäïëïãßá áõôÞ, Ýãéíå ðñïóðÜèåéá íáåöáñìïóèåß êáé óôïí ôïìÝá ôçò õãåßáò1-5, ðïõ êáôÜ ðáñÜäïóç åßíáé áíôé-ðáñáãùãéêüò êáé ðïëõðáñáãïíôéêüò. Ôá áðïôåëÝóìáôá Þôáí èåáìáôéêÜêáé õðÜñ÷åé âéâëéïãñáößá ç ïðïßá åðéóõíÜðôåôáé. Åðßóçò èá ðñÝðåé íáåðéóçìáíèåß üôé ðáñÜ ôç äéáöïñåôéêüôçôá ôùí äýï ôïìÝùí (Õãåßá - Âéï-ìç÷áíßá) ç ìåèïäïëïãßá äåí äéáöÝñåé ïõóéáóôéêÜ êáé äåí ìïéÜæåé ìå ôïõòãíùóôïýò ôñüðïõò Ýñåõíáò êáé åöáñìïãÞò ðñùôïêüëëùí ôùí ðáñáäï-óéáêþí åñåõíçôþí óôçí éáôñéêÞ.

Óôç óõíÝ÷åéá èá ãßíåé ðñïóðÜèåéá ãéá ëåðôïìåñåéáêÞ áíÜëõóç ôçòìåèüäïõ, üðùò áõôÞ ðåñéãñÜöåôáé óôï Üñèñï ôïõ Paul E. Plsek. MS ðïõäçìïóéåýôçêå óôï ðåñéïäéêü �Pediatrics, Vol. 103, No. I� ôïí ÉáíïõÜñéïôïõ 1999. Èá åðé÷åéñçèåß ç ðáñïõóßáóç áõôÞ íá êÜíåé êáôáíïçôÞ ôç ìÝ-èïäï óå ðïëëÝò åéäéêüôçôåò ðïõ áðáó÷ïëïýíôáé óôïí ôïìÝá ôçò õãåßáò.ÅîÜëëïõ, Ýíá áðü ôá ÷áñáêôçñéóôéêÜ ôçò åßíáé ç óõíåñãáóßá äéáöüñùíåéäéêïôÞôùí êáé ç áíôáëëáãÞ áðüøåùí êáé åìðåéñéþí äéáöüñùí ôìçìÜ-ôùí. Ôï æçôïýìåíï, ðÜíôá, ôåëéêþò åßíáé ôá êáëëßôåñá áðïôåëÝóìáôá óåüëïõò ôïõò ôïìåßò üðùò ð.÷.:ü Óôçí ðáñï÷Þ êáëëßôåñçò ðåñßèáëøçò óôïõò áññþóôïõòü Óôï ìéêñüôåñï äéÜóôçìá ðáñáìïíÞò ôïõò óôá íïóïêïìåßáü Óôï ìéêñüôåñï íïóçëåõôéêü êüóôïòü Óôç ìåßùóç ôçò èíçóéìüôçôáòü Óôçí êáëëßôåñç ðáñáêïëïýèçóÞ ôïõò (ìåôÜ ôçí Ýîïäü ôïõò)ü Óôçí êáëëßôåñç óõììüñöùóÞ ôïõò ùò ðñïò ôçí áãùãÞ ðïõ èá áêïëïõ-

èÞóïõí.

ËÝîåéò-ÊëåéäéÜ: Ðïéüôçôá, ðïéïôéêüò Ýëåã÷ïò,êëéíéêÞ éáôñéêÞ


Ïé ðáñáðÜíù ôïìåßò ðåñéëáìâÜíïíôáé óå Ýíáí êá-ôÜëïãï ÷ùñßò ôÝëïò, ìå Üðåéñåò ðñïåêôÜóåéò áêüìá êáéóå êñáôéêïýò êïéíùíéêïýò öïñåßò êáé ðïëéôéêÝò ðïõåöáñìüæïíôáé êáôÜ êáéñïýò óôï ÷þñï ôçò õãåßáò, åíþåßíáé ðïëý óçìáíôéêü êáé ðñÝðåé íá áíáöåñèåß üôé:Ø ç ìÝèïäïò áõôÞ ÷áñáêôçñßæåôáé áðü áðëüôçôá êáé

ìåèïäéêü ó÷åäéáóìü,Ø äåí øÜ÷íåé ðïéïò öôáßåé, áëëÜ ôé öôáßåé êáé ðñïóðá-

èåß ìå ãñÞãïñï ôñüðï íá äéïñèþóåé ôá ëÜèç êáé íáöÝñåé ôá÷åßá âåëôßùóç êáé êáëëßôåñç áðïôåëåóìá-ôéêüôçôá.

ÌÅÈÏÄÏÉ ÊÁÉ ÅÑÃÁËÅÉÁ ÐÏÕ ×ÑÇÓÉÌÏÐÏÉÏÕÍÔÁÉ ÓÔÇÂÉÏÌÇ×ÁÍÉÁ ÊÁÉ ÐÏÕ ÌÐÏÑÏÕÍ ÍÁ ÅÖÁÑÌÏÓÔÏÕÍÃÉÁ ÔÏÍ ÐÏÉÏÔÉÊÏ ÅËÅÃ×Ï ÊÁÉ ÓÔÏÍ ÔÏÌÅÁ ÔÇÓÕÃÅÉÁÓ

Ï ðïéïôéêüò Ýëåã÷ïò óôçí ðáñáãùãéêÞ âéïìç÷áíßá6,7,åßíáé ãíùóôüò êáé ùò �Ç åðéóôÞìç ôçò ðïéïôéêÞò äéá÷åß-ñéóçò êáé ôçò óõíå÷ïýò âåëôßùóçò ôçò ðáñáãùãéêÞò äéá-äéêáóßáò�.

ÁõôÞ ç åðéóôÞìç åßíáé ìéá åêëåêôéêÞ óõëëïãÞ êáéóýæåõîç ôå÷íéêþí êáé óõóôçìÜôùí ðïõ äáíåßæåôáé áðüäéÜöïñåò èåùñßåò êáé ðñáêôéêÝò åðéóôçìþí, üðùò çÓôáôéóôéêÞ, ç Ìç÷áíïëïãßá, ç Øõ÷ïëïãßá êáé ðïëëÝòÜëëåò, ÷ñçóéìïðïéåßôáé äå üðùò áíáöÝñèçêå áñ÷éêÜ,åäþ êáé 50 ÷ñüíéá óôç Âéïìç÷áíßá ìå Üñéóôá áðïôåëÝ-óìáôá.

ÌÅÈÏÄÏÉ ÂÅËÔÉÙÓÇÓ ÊÁÉ ÏÌÁÄÅÓ ÅÑÃÁÓÉÁÓ ÐÏÕ ÔÉÓÓ×ÅÄÉÁÆÏÕÍ ÊÁÉ ÔÉÓ ÅÖÁÑÌÏÆÏÕÍ

Ðñþôïò ï Joseph Juran8, ôï 1930, ðÜíôá óôï Âéïìç-÷áíéêü ÔïìÝá, äçìéïýñãçóå êáé äïýëåøå ìå ôçí ðñþôçïìÜäá âåëôßùóçò, ôçí ïðïßá ïíüìáóå �Ïé Åéäéêïß óôçíÐïéüôçôá�, ìå ðïëý êáëÜ áðïôåëÝóìáôá. ̧ êôïôå ç ìå-èïäïëïãßá áõôÞ ôùí ïìÜäùí âåëôßùóçò ôçò ðïéüôçôáòõéïèåôÞèçêå êáé Ýãéíå êáèçìåñéíÞ ðñáêôéêÞ.

Ïé ïìÜäåò áõôÝò áðïôåëïýíôáé, óõíÞèùò, áðü 3 Ýùò9 Üôïìá äéáöüñùí åéäéêïôÞôùí ôá ïðïßá åñãÜæïíôáé ãéáôç ëýóç ôïõ ðñïâëÞìáôïò. ÐáñÜäåéãìá êëáóéêü óôïíéáôñéêü ôïìÝá áðïôåëåß ç ïìÜäá �ÓõíåñãÜôåò Õãåßáò�9,ôçò Minneapolis ç ïðïßá êáôüñèùóå íá áõîÞóåé ôï ñõè-ìü áíïóïðïßçóçò óôçí ðáéäéêÞ çëéêßá êáé ç ïðïßá áðï-ôåëïýíôáí áðü äýï ðáéäéÜôñïõò, Ýíáí ïéêïãåíåéáêü ãéá-

ôñü, ìéá õðåýèõíç íïóçëåýôñéá, Ýíá äéåõèýíïíôá êëéíé-êÞò êáé Ýíá óõíôïíéóôÞ.

Ïé ïìÜäåò áõôÝò, ëïéðüí, âáóßæïíôáé óôç óõíåñãá-óßá äéáöïñåôéêþí áôüìùí ìå äéáöïñåôéêÝò åéäéêüôçôåòêáé åßíáé ðëÝïí îåêáèáñéóìÝíï üôé ç ðïéïôéêÞ âåëôßùóçêáé óôçí Õãåßá äåí ìðïñåß óå êáìéÜ ðåñßðôùóç íáðñïÝëèåé áðü ôçí ðñïóðÜèåéá åíüò êáé ìüíï áôüìïõ,üóï åéäéêüò, éêáíüò êáé ìå êáëÞ ðñüèåóç êáé áí åßíáé.

ÊËÁÓÉÊÏ ÌÏÍÔÅËÏ Ó×ÇÌÁÔÉÊÏÕ Ó×ÅÄÉÁÓÌÏÕ ÊÁÉÏÑÃÁÍÙÓÇÓ ÔÇÓ ÄÏÕËÅÉÁÓ

¸íá êëáóéêü ìïíôÝëï ó÷çìáôéêïý ó÷åäéáóìïý êáéïñãÜíùóçò ôçò äïõëåéÜò üðùò ôï åìðíåýóèçêå êáé ôïðñáãìáôïðïßçóå ï ãíùóôüò ðëÝïí Joseph Juran, åßíáéáõôü ðïõ öáßíåôáé óôïí ðßíáêá 1.

¼ðùò öáßíåôáé óôïí ðßíáêá 1, ôá âÞìáôá ãéá ôçíåðßëõóç åíüò ðñïâëÞìáôïò ðñÝðåé íá åßíáé:� Áíáãíþñéóç êáé ïñéóìüò ôïõ ðñïâëÞìáôïò� ÊáôáãñáöÞ ôïõ ðñïâëÞìáôïò� ÁíáæÞôçóç ôùí áéôßùí ôïõ ðñïâëÞìáôïò� Åðßëõóç ôïõ ðñïâëÞìáôïò� Åðéêýñùóç ôçò âåëôßùóçò ìåôÜ ôçí åöáñìïãÞ ôùí

ëýóåùí, êáé� Êáôï÷ýñùóç ôùí âåëôéþóåùí þóôå íá åöáñìüæïíôáé

åöåîÞò.Ãéá ôçí ðñüïäï áðü óôÜäéï óå óôÜäéï, áðáéôåßôáé ç

óõììåôï÷Þ, üðùò ðñïáíáöÝñèçêå äéáöüñùí áôüìùí,äéáöüñùí åéäéêïôÞôùí, ðïõ èá óõíåñãáóôïýí óôåíÜ êáéðéèáíþò ïé åìðåéñßåò ïé ïðïßåò èá ðñïêýøïõí èá áðï-ôåëÝóïõí åñãáëåßá ãéá ðåñáéôÝñù âåëôßùóç.

ÅÑÃÁËÅÉÁ ÃÉÁ ÔÇÍ ÐÅÑÉÃÑÁÖÇ ÌÉÁÓ ÏÐÏÉÁÓÄÇÐÏÔÅÄÉÁÄÉÊÁÓÉÁÓ ÂÅËÔÉÙÓÇÓ

Äýï áðü ôá ðëÝïí ãíùóôÜ êáé êïéíþò ÷ñçóéìïðïéïý-ìåíá åñãáëåßá ðïéïôéêÞò âåëôßùóçò åßíáé:� Ôï ÄéÜãñáììá ÑïÞò, êáé� Ôï ÄéÜãñáììá Áßôéïõ-ÁðïôåëÝóìáôïò

Ôé åßíáé ôï ÄéÜãñáììá ÑïÞò;

Áðïôåëåß ìéá ó÷çìáôéêÞ áðåéêüíéóç ôùí âçìÜôùíìéáò äéáäéêáóßáò êáôÜ ÷ñïíïëïãéêÞ óåéñÜ. Ð.÷. ðáñá-ôçñþíôáò ðñïóåêôéêÜ êáé áíáëýïíôáò áõôÞ ôç äéáäéêá-óßá ìðïñåß íá åðéóçìáíèåß üôé ôá âÞìáôá áõôÜ äåí ãß-


Ðßíáêáò 1. Ó÷åäéáóìüò êáé ÏñãÜíùóç

Ïñéóìüò ôïõ ðñïâëÞìáôïò êáé ïñãÜíùóç - ÊáôáãñáöÞ ôùí ðñïâëçìÜôùí êáôÜ óåéñÜ ðñïôåñáéüôçôáòôçò äéåñåýíçóÞò ôïõ - ÅðéëïãÞ åíüò ðñïâëÞìáôïò êáé óõãêñüôçóç ôçò ïìÜäáò äïõëåéÜò

ÄéÜãíùóç êáé êáôáãñáöÞ ôùí ðñïâëçìÜôùí - ÁíÜëõóç ôùí óõìðôùìÜôùí ôïõ ðñïâëÞìáôïòÞ ôïõ ðñïâëÞìáôïò - ÊáôáãñáöÞ ôùí ðéèáíþí áéôßùí ôïõ ðñïâëÞìáôïò

- Áíáãíþñéóç ôùí ðñáãìáôéêþí áéôßùí ôïõ ðñïâëÞìáôïò

Óýíïëï ôùí äéïñèùôéêþí êéíÞóåùí - ÁíáæÞôçóç åíáëëáêôéêþí ëýóåùí- Ó÷åäéáóìüò åðéëýóåùí êáé åëÝã÷ùí- ÊáôáãñáöÞ ôùí áíôéññÞóåùí óôï ó÷åäéáóìü áëëáãÞò- ÅöáñìïãÞ ôùí ëýóåùí êáé ôùí ôñüðùí åëÝã÷ïõ

ÐñïóðÜèåéá êáôï÷ýñùóçò ôùí íÝùí äéïñèùôéêþí - ¸ëåã÷ïò ôùí áðïôåëåóìÜôùí ìåôÜ ôéò äéïñèþóåéòêéíÞóåùí óôï ìÝëëïí - Ðáñáêïëïýèçóç ôçò áðïôåëåóìáôéêüôçôáò ôçò ìåèüäïõ

Ó÷Þìá 1. ÄéÜãñáììá ñïÞò ôçò åéóáãùãÞò åíüò áóèåíÞ óôï íïóïêïìåßï

íïíôáé ìå ôç óùóôÞ ÷ñïíïëïãéêÞ óåéñÜ Þ üôé ãßíïíôáéÜóêïðåò åíÝñãåéåò Þ üôé èá ìðïñïýóáí íá óõíôïìåõ-èïýí (óõã÷ùíåõèïýí) äýï Þ ðåñéóóüôåñá âÞìáôá Þ ïôé-äÞðïôå Üëëï ó÷åôéêü ìå ôç äéáäéêáóßá (Ó÷Þìá 1).

Ôé åßíáé ôï ÄéÜãñáììá Áßôéïõ-ÁðïôåëÝóìáôïò;

Åßíáé ç äéáãñáììáôéêÞ áðåéêüíéóç, óå ìïñöÞ øá-ñïêüêêáëïõ, åíüò óýíèåôïõ ðñïâëÞìáôïò üðïõ �ôï êå-öÜëé ôïõ øáñéïý� åßíáé ôï õðü ìåëÝôç ðñüâëçìá êáé çñá÷ïêïêêáëéÜ ôïõ ïé ðáñÜãïíôåò - áßôéá ðïõ ôï åðçñ-ñåÜæïõí (Ó÷Þìá 2).

ÅÑÃÁËÅÉÁ ÓÕËËÏÃÇÓ ÓÔÏÉ×ÅÉÙÍ

Ç áíôéêåéìåíéêüôçôá óôç óêÝøç êáé óôï ó÷åäéáóìü÷áñáêôçñßæïõí ôïí Ðïéïôéêü ̧ ëåã÷ï êáé ôçí ÐïéïôéêÞÁíáâÜèìéóç. Ãé� áõôü ïé ïìÜäåò åñãáóßáò èá ðñÝðåé íáâÜæïõí óõãêåêñéìÝíá åñùôÞìáôá óôá ïðïßá èá ðñïóðá-èïýí íá äþóïõí ìéá áíôéêåéìåíéêÞ áðÜíôçóç. Ç óõëëï-

ãÞ óôïé÷åßùí ãéá íá äïèåß áõôÞ ç áðÜíôçóç åßíáé ç ðå-ìðôïõóßá ôïõ ðïéïôéêïý åëÝã÷ïõ êáé ôçò ðïéïôéêÞò áíá-âÜèìéóçò êáé óôïí ôïìÝá ôçò éáôñéêÞò.

Ï ôñüðïò ðïõ óõëëÝãïíôáé ôá óôïé÷åßá êáé ç óõóôç-ìáôéêÞ êáôáãñáöÞ ôïõò ìðïñåß íá åßíáé áðü ðïëý áðëüòìÝ÷ñé éäéáßôåñá óýíèåôïò18.

Ï ôñüðïò áõôüò äõíáôüí íá áðïôåëåß áðëÞ êáôáãñá-öÞ óôïé÷åßùí üðïõ ìéá ïìÜäá ð.÷. ðïõ åñãÜæåôáé ãéá íáìåéþóåé ôç óõ÷íüôçôá ðíåõìïèþñáêá óôá íåïãíÜ ìéáòóõãêåêñéìÝíçò êëéíéêÞò èá ðñÝðåé íá áíáñùôçèåß ðüóïåðß ôïéò åêáôü áðü ôá íåïãíÜ ðïõ ãåííÞèçêáí óôçí êëé-íéêÞ ðñüùñá (30 åâäïìÜäùí êýçóç) ðÞñáí ðñïöõëá-êôéêÜ surfactant (åðéöáíåéïäñáóôéêü ðáñÜãïíôá). Áöïýç ïìÜäá óõëëÝîåé êáé êáôáãñÜøåé áõôÜ ôá óôïé÷åßá, èáðñïôåßíåé ôñüðïõò äïõëåéÜò þóôå íá åßíáé äõíáôü üëáôá ðñüùñá íá ìðïñïýí íá ðÜñïõí surfactant. Óôçí ðå-ñßðôùóç áõôÞ ç óõëëïãÞ ôùí óôïé÷åßùí èá ãßíåé áðü ôïõòöáêÝëëïõò ôçò êëéíéêÞò (óðïõäáéüôçôá ôïõ óùóôÜ ôç-ñïýìåíïõ áñ÷åßïõ). Åðßóçò åßíáé äõíáôüí ç êáôáãñá-

ÅÍÄÅÉÎÇ


Ó÷Þìá 3. ÄéáãñÜììáôá ÄéáóðïñÜò

öÞ ôùí óôïé÷åßùí óå ó÷åäéÜãñáììá íá äþóåé ôç ãñáöé-êÞ ðáñÜóôáóç (êáìðýëç) ôçò óõ÷íüôçôáò ðíåõìïèþñá-êá, ç áíÜëõóç ôçò ïðïßáò ìðïñåß íá áðïêáëýøåé, ðå-ñáéôÝñù, ÷ñÞóéìåò ðëçñïöïñßåò.

¢ëëïò ôñüðïò åßíáé ç ÷ñïíïëïãéêÞ êáôáãñáöÞ óôïé-÷åßùí üðùò ð.÷. ìéá ïìÜäá ç ïðïßá åñãÜæåôáé ãéá íáêáôáãñÜøåé êáé óôç óõíÝ÷åéá íá âåëôéþóåé ôïí ôñüðïìå ôïí ïðïßï ÷ïñçãåßôáé ç èñïìâüëõóç óôïõò áóèåíåßòìå ðüíï óôï èþñáêá, ðïõ ðñïóÝñ÷ïíôáé óôá åîùôåñéêÜéáôñåßá (åðåßãïíôá). Èá ðñÝðåé íá ãßíåé Ýíá äéÜãñáì-ìá üðïõ ï ïñéæüíôéïò Üîïíáò ôùí × èá åßíáé ÷ùñéóìÝ-íïò óå äéáóôÞìáôá ôùí 10 ëåðôþí ìÝ÷ñé ôá 180 ëåðôÜ(ðïõ åßíáé ï éäáíéêüò ÷ñüíïò ÷ïñÞãçóçò ôçò èñïìâüëõ-óçò) êáé óôïí Üîïíá ôùí Ø ï áñéèìüò ôùí ðñïóåñ÷ïìÝ-íùí áóèåíþí.

Óôç óõíÝ÷åéá ìéá õðåýèõíç íïóçëåýôñéá Þ íïóçëåõ-ôÞò èá óçìåéþíåé ìå ìéá êïõêßäá (ãéá êÜèå Üññùóôï)ôï ÷ñüíï ðïõ ìåóïëÜâçóå áðü ôçí ÜöéîÞ ôïõ ìÝ÷ñé ôçóôéãìÞ ôçò ÷ïñÞãçóçò ôçò èñïìâüëõóçò. ÁõôÞ ç öáéíï-ìåíéêÜ áðëÞ äéáäéêáóßá ìåôÜ áðü êÜðïéï ÷ñïíéêü äéÜ-óôçìá ðïõ èá Ý÷åé äçìéïõñãèåß Ýíá éóôüãñáììá, äßíåéðïëýôéìåò ðëçñïöïñßåò êáé ãéá ôçí ïñèüôçôá áëëÜ êáéãéá ôçí ôá÷ýôçôá ôùí ÷åéñéóìþí. Åðßóçò èá Þôáí äõíá-ôü íá ðñïóôåèåß êáé ç ðáñÜìåôñïò ôçò éêáíïðïßçóçò ôùíáóèåíþí, êÜíïíôÜò ôïõò êÜðïéåò åñùôÞóåéò ìåôÜ ôçíåîáöÜíéóç ôïõ ðüíïõ. ÅðéðëÝïí, èá ìðïñïýóå íá áîéï-ëïãçèåß áí ôï äéÜóôçìá ðïõ ãßíïíôáé êÜðïéåò äéáãíù-óôéêÝò åîåôÜóåéò ìÝ÷ñé íá ÷ïñçãçèåß ç èñïìâüëõóç, åß-íáé éêáíïðïéçôéêü Þ ðñÝðåé íá óõíôïìåõèåß. Áêüìá, åé-

äéêüôåñá, áí èá ðñÝðåé íá óõíôïíéóèïýí êáëëßôåñá ïéêéíÞóåéò ôùí èåñáðüíôùí éáôñþí êáé ôïõ ðáñáúáôñéêïýðñïóùðéêïý Þ áí óå äéÜóôçìá 6 ìçíþí ðáñïõóßáæïíôáéêÜðïéåò åëëåßøåéò, ð.÷. óå õëéêü (Ó÷Þìá 3).

ÅÑÃÁËÅÉÁ ÃÉÁ ÔÇÍ ÁÍÁËÕÓÇ ÔÙÍ ÓÕËËÅÃÅÍÔÙÍ ÓÔÏÉ-×ÅÉÙÍ

Ôï åðüìåíï âÞìá ìåôÜ ôç óõëëïãÞ êáé ôçí êáôáãñá-öÞ ôùí óôïé÷åßùí åßíáé ç áíÜëõóÞ ôïõò. Ç áíÜëõóç áõôÞìðïñåß íá åßíáé Ýñãï åéäéêþí áíáëõôþí óôáôéóôéêïëü-ãùí, ìðïñåß üìùò íá åßíáé êáé áðëÞ üðùò ç ðáñáôÞñç-óç ìéáò êáìðýëçò, åíüò éóôïãñÜììáôïò Þ ç óõ÷íüôçôá Þï ìÝóïò üñïò ìéáò ðñÜîçò ðïõ åðáíáëáìâÜíåôáé. Åéäé-êÜ ãéá ôïí ðïéïôéêü Ýëåã÷ï óôïí ôïìÝá ôçò õãåßáò, üðïõïé ïìÜäåò åñãáóßáò áðïôåëïýíôáé áðü åéäéêüôçôåò ðïõäåí èá ìðïñïýóáí åýêïëá íá êáôáíïÞóïõí ìéá ðåñß-

Ó÷Þìá 2. ÐáñÜäåéãìá äéáãñÜììáôïò áéôßïõ - áðïôåëÝóìáôïò


ðëïêç óôáôéóôéêÞ ìÝèïäï, ðñïôéìþíôáé ôá áðëÜ åñãá-ëåßá áíÜëõóçò üðùò ïé êáìðýëåò, ôá äéáãñÜììáôá ñïÞò,ôá éóôïãñÜììáôá, ôá äéáãñÜììáôá áßôéïõ êáé áðïôåëÝ-óìáôïò, ê.ëð.

Åßíáé ôåëéêÜ óçìáíôéêü êáé ðñÝðåé íá ôïíéóèåß, üðùòðñïôåßíåé ï Berwick19, üôé üôáí åðé÷åéñåßôáé ðïéïôéêüòÝëåã÷ïò êáé áíáâÜèìéóç óôçí Õãåßá, èá ðñÝðåé íá ëáì-âÜíåôáé õðüøç üôé ðñüêåéôáé ãéá ìéá íÝá ìåèïäïëïãßááðüêôçóçò ãíþóçò, ç ïðïßá äåí öéëïäïîåß íá áíôéêáôá-óôÞóåé ôçí êëáóéêÞ Ýñåõíá, ïýôå üìùò áñêåßôáé óôçíåðéóÞìáíóç áðëþò êÜðïéùí äéáäéêáóéþí ðïõ ãßíïíôáéìå ëáíèáóìÝíï Þ áíåðáñêÞ ôñüðï. Ï ôåëéêüò ôçò óêï-ðüò åßíáé ç óõíå÷Þò áíáâÜèìéóç-âåëôßùóç óå üëá ôáåðßðåäá.

Ïé ìåôáâëçôïß ðáñÜãïíôåò óôï ÷þñï ôçò õãåßáò åß-íáé ðÜñá ðïëëïß, ï äå ðñïóäéïñéóìüò ôïõò åßíáé ðïëýðéo ðåñßðëïêïò áð� ü,ôé óôïí Âéïìç÷áíéêü ÔïìÝá. Ãé�áõôü ç óõëëïãéêÞ åñãáóßá, ç óõíåñãáóßá êáé ç åðéêïé-íùíßá áðïôåëïýí åñãáëåßá åê ôùí �ùí ïõê Üíåõ�24. Ãéááõôü, ç ðïéïôéêÞ áíÜëõóç êáé âåëôßùóç ùò ìÝèïäïò äá-íåßæåôáé áñ÷Ýò êáé ëåéôïõñãßåò áðü ðïëëïýò ôïìåßò êáéðñïóðáèåß ìå ôç âïÞèåéÜ ôïõò íá ãåííÞóåé êõñéïëåêôé-êÜ éäÝåò, íá ôéò åöáñìüóåé êáé íá êáôï÷õñþóåé ôçí (ðé-èáíþò) åðéôõ÷çìÝíç åöáñìïãÞ ôïõò25-27.

Ç ÄÉÁÄÉÊÁÓÉÁ ÔÏÕ ÅÐÁÍÁÓ×ÅÄÉÁÓÌÏÕ ¹ ÔÏÕ ÍÅÏÕÓ×ÅÄÉÁÓÌÏÕ

Óôç âéïìç÷áíéêÞ ðáñáãùãÞ ðëÝïí äåí ÷ñçóéìï-ðïéïýíôáé ìüíï ïé ùò Üíù áíáöåñüìåíåò ìÝèïäïé ôçòðñïóðÜèåéáò äéüñèùóçò ôùí ðáñáãùãéêþí äéáäéêá-óéþí. Óå áñêåôÝò ðåñéðôþóåéò åðé÷åéñåßôáé åîáñ÷Þò ó÷å-äéáóìüò Þ áíáó÷åäéáóìüò äéáäéêáóéþí28-31 êáé ôá âÞìá-ôá ðïõ áêïëïõèïýíôáé åßíáé ðáñüìïéá. Êáô� áñ÷Þí ïñß-æåôáé ôï áíôéêåßìåíï, óôç óõíÝ÷åéá áíáëýïíôáò ôá äå-äïìÝíá ôùí áíáãêþí ôùí ðåëáôþí êáôáãñÜöïíôáé êáéáñ÷ßæåé ï ó÷åäéáóìüò ðñïò åðßëõóÞ ôïõò. Óôïí ôñüðïáõôü ðñÝðåé íá äßíåôáé ìåãÜëç ðñïóï÷Þ óôéò ðéèáíüôç-ôåò áðïôõ÷ßáò ôçò ëåéôïõñãéêüôçôáò ôïõ ó÷åäéáóìïý (ôïëåãüìåíï Failure Mode and Effects Analysis, FMEA), ïïðïßïò åßíáé Ýíáò åðéóôçìïíéêÜ êáôï÷õñùìÝíïò ôñüðïòâáèìïëüãçóçò áðü ôï 1 Ýùò ôï 10 Þ ìå ôï 1, 3, 9, ôùíðéèáíïôÞôùí áðïôõ÷ßáò ôùí âçìÜôùí ðïõ áêïëïõèïý-íôáé ãéá ôç ëýóç åíüò ðñïâëÞìáôïò Þ ãéá ôçí åðßôåõîçåíüò óêïðïý. ÅÜí ôï Üèñïéóìá ôçò âáèìïëïãßáò ôïõ

êÜèå âÞìáôïò åßíáé 120 êáé ðÜíù Þ 6 êáé ðÜíù áíáëü-ãùò ôïõ ôñüðïõ âáèìïëüãçóçò, ôüôå ôï âÞìá ðñÝðåé íááëëÜîåé Þ íá ëçöèïýí ìÝôñá ãéá íá ìåéùèåß ç ðéèáíü-ôçôá áðïôõ÷ßáò.

Äýï ëáìðåñÜ ðáñüìïéá ðáñáäåßãìáôá áðü ôïí éá-ôñéêü ÷þñï åßíáé:1. Ôïõ Gustafson êáé óõíåñãáôþí32, ïé ïðïßïé ÷ñçóé-

ìïðïéþíôáò ðáñüìïéá ìåèïäïëïãßá, ôçí ïðïßá ïíü-ìáóáí ÓôéãìÝò ÁíáëõôéêÞò ÁëÞèåéáò (Moments ofTruth Analysis), åðáíáó÷åäßáóáí ôïí ôñüðï ìå ôïíïðïßï åäßäïíôï ðëçñïöïñßåò êáé óõìâïõëÝò óôïõòðÜó÷ïíôåò áðü êáñêßíï ôïõ ìáóôïý, óôï Ðáíåðéóôç-ìéáêü ÊÝíôñï Winsconsin (Madison, Wi).

2. Ôïõ Niles êáé óõíåñãáôþí33, ïé ïðïßïé ÷ñçóéìïðïßç-óáí ïìÜäåò åñãáóßáò ãéá íá îáíáó÷åäéÜóïõí ôçíëåéôïõñãßá ôïõ ôìÞìáôïò �Öñïíôßäá ôçò ÊáñäéÜò�(Cardiac Care Center) óôï Dart-Month-HitchcockMedical Center (Lebanon, NH).ÔåëéêÜ êáé óôéò 2 åñãáóßåò áêïëïõèÞèçêå ï ãíùóôüò

ôñüðïò êáé ç ìåèïäïëïãßá ôïõ ðïéïôéêïý åëÝã÷ïõ ðïõöáßíåôáé óôï ó÷Þìá 4.

Ðñüêåéôáé äçëáäÞ ãéá ìéá õøçëïý åðéðÝäïõ ìåèï-äïëïãßá ìå êýñéï áíôéêåßìåíï ôç ëýóç ôùí ðñïâëçìÜ-ôùí ìéáò óõãêåêñéìÝíçò êáôçãïñßáò áññþóôùí35-36, çïðïßá ïíïìÜóôçêå Critical Paths Þ Care Maps áëëÜ êáéìå Üëëåò ïíïìáóßåò, ç ïðïßá ôåëéêÜ êáé ôç öñïíôßäá ôùíáóèåíþí áíáâáèìßæåé, êáé ãéá ôç ìéêñüôåñç ðáñáìïíÞôïõò óôá íïóïêïìåßá öñïíôßæåé, êáé ôç óùóôüôåñç åìðëï-êÞ ôùí óõããåíþí ôïõò êáôáöÝñíåé.

ÔÁ×ÅÉÓ ÊÕÊËÏÉ ÂÅËÔÉÙÓÇÓ ÓÔÇÍ ÕÃÅÉÁ

Ãéá ôçí åðéôÜ÷õíóç ôùí äéáäéêáóéþí ôïõ ðïéïôéêïýåëÝã÷ïõ êáé ìÜëéóôá óôçí õãåßá ï Allemi êáé óõíåñãÜ-ôåò43, êáé õðü ôïí ïñéóìü �Rapid Cycle Improvement�,

Ó÷Þìá 4. Ìåèïäïëïãßá ðïéïôéêïý åëÝã÷ïõ


ôçò åíäïêïéëéáêÞò áéìïññáãßáò (IVH) êáôÜ 50% óåíåïãíÜ 501-1500 g (óôü÷ïò).

2. Ôá óçìåñéíÜ ðïóïóôÜ ìðïñïýí íá áëëÜîïõí;3. Ðïéåò áëëáãÝò èá ìðïñïýóáí íá ïäçãÞóïõí óôï óôü-

÷ï; (Ðåñéóóüôåñåò ãõíáßêåò õøçëïý êéíäýíïõ ãéáðñüùñï ôïêåôü, íá ðÜñïõí ðñïëçðôéêÜ êïñôéêïóôå-ñïåéäÞ.)

4. Ôé èá ìðïñïýóå íá ãßíåé ãéá ôçí ðñïëçðôéêÞ ÷ïñÞ-ãçóç êïñôéêïóôåñïåéäþí;

5. Íá åíçìåñùèïýí üëïé ïé éäéþôåò ãõíáéêïëüãïé ôùíéäéùôéêþí éáôñåßùí áëëÜ êáé ïé êñáôéêÝò ãõíáéêï-ëïãéêÝò êëéíéêÝò ðñïêåéìÝíïõ íá óõíäåèïýí êáé íáðáñáðÝìðïõí ôéò õøçëïý êéíäýíïõ Ýãêõåò óôï �Åèíé-êü Éíóôéôïýôï Õãåßáò ãéá ôçí ðñï ôïêåôïý ÷ïñÞãçóçóôåñïåéäþí�46.Öáßíåôáé äçëáäÞ åäþ üôé ç óêÝøç íá óõíäåèïýí üëï

êáé ðåñéóóüôåñá ãõíáéêïëïãéêÜ éäéùôéêÜ éáôñåßá áëëÜêáé êñáôéêÝò êëéíéêÝò ìå ôï �Åèíéêü ÊÝíôñï ÁíáöïñÜò�ãéá ôçí ðñï ôïõ ôïêåôïý ÷ïñÞãçóç óôåñïåéäþí åßíáé çðéï áðïôåëåóìáôéêÞ êßíçóç ãéá ôçí åðßôåõîç ôïõ óêï-ðïý, ðïõ åßíáé, ç ìåßùóç êáôÜ 50% ôïõ RDS êáé ôçò åí-äïêïéëéáêÞò áéìïññáãßáò óå ðñüùñá âñÝöç 501-1500 g.

Óôïõò Ôá÷åßò Êýêëïõò Âåëôßùóçò ç ìÝèïäïò áõôÞëÝãåôáé �ÁëëáãÞ Ôçò ÃåíéêÞò ÉäÝáò� Þ �ÁëëáãÞ Ôáêôé-êÞò� êáé áðïôåëåß ôï êáèïñéóôéêü âÞìá óôïõò ãñÞãï-ñïõò êýêëïõò âåëôßùóçò ðïõ èá äþóåé áðáíôÞóåéò óôï3ï ìÝñïò ôïõ ðñïçãïýìåíïõ ó÷Þìáôïò êáé áðáíôÜ óôçíåñþôçóç �Ðïéåò áëëáãÝò ìðïñïýìå íá êÜíïõìå ãéá íáâåëôéùèïýìå óáöþò;�.

Ïé Íolan êáé Schall53, ãñÜöïõí üôé ç áëëáãÞ áõôÞôçò ãåíéêÞò éäÝáò Þ ôçò ôáêôéêÞò, ìðïñåß íá ðñïêýøåéáðü ðÜñá ðïëëÝò ðçãÝò, üðùò:1. ÊñéôéêÝò óêÝøåéò ðÜíù óôçí ôáêôéêÞ ðïõ áêïëïõèåß-

ôáé ôþñá2. ÄçìéïõñãéêÝò óêÝøåéò ðÜíù óôï õðü âåëôßùóç èÝìá3. ÓôåíÞ ðáñáôÞñçóç ôçò äéáäéêáóßáò ðïõ áêïëïõèåß-

ôáé ôþñá4. Ìéá ðñïáßóèçóç Þ ìéá Ýìðíåõóç5. Ìéá éäÝá áðü ôçí åðéóôçìïíéêÞ âéâëéïãñáößá6. Ìéá ãíþóç Þ åìðåéñßá ðïõ êáôáêôÞèçêå áðü êÜðïéï

ôåëåßùò äéáöïñåôéêü ôïìÝá7. Ìéá êáôÜêôçóç áðü êÜðïéïõò Üëëïõò, ìå åõñýôáôç

áðÞ÷çóç üìùò, ðïõ Ý÷åé ïäçãÞóåé óå óáöåßò âåëôéþ-óåéò.Öáßíåôáé, ëïéðüí, üôé ç áëëáãÞ ôçò ãåíéêÞò éäÝáò

óõíéóôïýí íá áêïëïõèïýíôáé êÜðïéïé óõãêåêñéìÝíïéêáíüíåò:1. Ïé óôü÷ïé íá åßíáé ðïëý ðñïóåêôéêïß, áêñéâåßò, óõ-

ãêåêñéìÝíïé êáé áðüëõôá îåêáèáñéóìÝíïé.2. Ïé óõíåäñéÜóåéò ôùí ïìÜäùí åñãáóßáò íá åßíáé áðï-

ôåëåóìáôéêÝò ìÝóá óå ðïëý óõãêåêñéìÝíï ÷ñüíï.3. Íá áðïöåýãïíôáé ëåðôïìåñåßò áíáëýóåéò ãéá Üëëá

èÝìáôá äéáöïñåôéêÜ áðü ôï èÝìá ôïõ óôü÷ïõ.4. Íá óõëëÝãïíôáé êáé íá áíáëýïíôáé äåäïìÝíá êáé

óôïé÷åßá ìüíï áõóôçñþò óõíäåäåìÝíá ìå ôï óôü÷ï.5. ÊáôÜ ôç äéÜñêåéá ôùí åñãáóéþí êáé êáèþò áõôÝò

ðñïïäåõôéêÜ ðñï÷ùñïýí êáé ðéèáíþò åîÜãïíôáéêÜðïéá ìåñéêÜ óõìðåñÜóìáôá êáé ìåñéêÝò ëýóåéò,íá ãßíïíôáé ãíùóôÜ êáé óôïí åõñýôåñï ÷þñï êáé óôáÜôïìá ðïõ áöïñÜ ï ôåëéêüò óôü÷ïò (Ó÷Þìá 5).Åíþ ï Allemi êáé óõíåñãÜôåò43, üðùò áíáöÝñèçêå,

ðñïôåßíïõí êÜðïéïõò êáíüíåò ãéá ãñÞãïñç âåëôßùóç, ïNolan, o Langley êáé óõíåñãÜôåò44-45, ó÷çìáôïðïßçóáíôï 1996 ôïõò êáíüíåò áõôïýò. Áõôïß ëïéðüí ïé ìéêñïßêáé ãñÞãïñïé êýêëïé äïõëåéÜò ãéá ôç âåëôßùóç üðùò êáéç åðáíÜëçøÞ ôïõò ìðïñïýí íá ëýóïõí ðïëëÜ ðñïâëÞ-ìáôá êáé óôçí éáôñéêÞ.

¸íá êëáóéêü ðáñÜäåéãìá äïõëåéÜò ìå áõôÞ ôç ìå-èïäïëïãßá åßíáé ôï åîÞò:1. Ìåßùóç ôïõ RDS (respiratory distress syndrome) êáé

Ó÷Þìá 5. Ôá÷åßò Êýêëïé Âåëôßùóçò (Rapid Cycle Improvement)


ìðïñåß íá åßíáé áðü êÜôé ðïëý óõãêåêñéìÝíï (ð.÷. çóýíäåóç ìå ôï Åèíéêü ÊÝíôñï ÁíáöïñÜò óôï ðéï ðÜíùðáñÜäåéãìá), ìÝ÷ñé êÜôé ðïëý áöçñçìÝíï (ð.÷. ìéáÝìðíåõóç), ðïõ èá ÷ñåéáóèåß ßóùò êÜðïéïò êüðïò êáé÷ñüíïò ãéá íá õëïðïéçèåß.

Ôï æçôïýìåíï óå êÜèå ðåñßðôùóç åßíáé íá ìçí õðÜñ-÷åé åöçóõ÷áóìüò, ï óôü÷ïò íá åßíáé ðÜíôá ç áëëáãÞ ðñïòôï êáëëßôåñï, ïñãáíùìÝíç êáé ìå óýóôçìá åñãáóßá, ìååðéìïíÞ êáé õðïìïíÞ. ÐñÝðåé íá äéåñåõíÜôáé ç äõíáôü-ôçôá åöáñìïãÞò áðïäåäåéãìÝíùí åðéôåõãìÜôùí ÜëëùíôïìÝùí óôçí Õãåßá êáé íá õðÜñ÷åé áíôáëëáãÞ óêÝøåùíêáé ìåèüäùí üðùò êáé åðéèõìßá ãéá ãïñãÞ åðßôåõîç ôïõóôü÷ïõ.

Óõã÷ñüíùò, ç óõììåôï÷Þ ðñÝðåé íá äéåõñýíåôáé óõ-íå÷þò êáé ôá åðéôåýãìáôá íá êáôï÷õñþíïíôáé ìÝóù ôçòåõñåßáò óõììåôï÷Þò. ÓõíÞèùò äåí õðÜñ÷ïõí Üôïìá ðïõäåí ìðïñïýí íá ðñïóöÝñïõí êÜôé. Ç äçìéïõñãßá åíüòåõ÷Üñéóôïõ êëßìáôïò äïõëåéÜò êáé óõíåñãáóßáò åßíáéêëåéäß óôéò äéáäéêáóßåò ôïõ ðïéïôéêïý åëÝã÷ïõ êáé ôçòðïéïôéêÞò áíáâÜèìéóçò. ÊáëÞ ðñïáßñåóç êáé äéÜèåóçóõíÞèùò õðÜñ÷ïõí áñêåß íá áíáêáëõöèïýí êáé íá áîéï-ðïéçèïýí. Ç ðåßñá Ýäåéîå üôé êáé ïé ðéï äýóðéóôïé óôïôÝëïò ðåßèïíôáé êáé ïé åëÜ÷éóôåò åîáéñÝóåéò áðëþò åðé-âåâáéþíïõí ôïí êáíüíá êáé äåí åßíáé éêáíÝò íá áíá-óôåßëïõí ôçí ðñüïäï, áñêåß ç ìÝèïäïò äïõëåéÜò íá åß-íáé óùóôÞ êáé íá âáóßæåôáé óôç óõììåôï÷Þ êáé óõíåñ-ãáóßá üëùí.

ÕðÜñ÷ïõí ðïëëÜ ðáñáäåßãìáôá ðïõ áíáöÝñïíôáéóôç âéâëéïãñáößá, üðïõ ïìÜäåò äïõëåéÜò êáôÜöåñáí íáìåéþóïõí óçìáíôéêÜ ôç óõ÷íüôçôá åéóáãùãÞò óôá íï-óïêïìåßá áññþóôùí ìå ÷ñüíéåò ðáèÞóåéò (ð.÷. Üóèìá),ôéò õðïôñïðÝò áññþóôùí ðïõ íïóçëåýèçêáí óå ÌÅÈ Þíá ìåéþóïõí ôï êüóôïò íïóçëåßáò óå äéÜöïñá ôìÞìá-ôá64.

Äåí åßíáé ðïôÝ ðåñéôôü íá åðáíáëáìâÜíåôáé, üôé çðåßñá áðü èåôéêÝò êáé áðïôåëåóìáôéêÝò ëýóåéò èá ðñÝ-ðåé íá äéáóðåßñåôáé êáé íá äéáäßäåôáé åõñÝùò ãéáôß áõ-ôüò åîÜëëïõ åßíáé êáé ï ìåëëïíôéêüò óêïðüò ôïõ ðïéïôé-êïý åëÝã÷ïõ. Ç ìåñéêÞ ôñïðïðïßçóç, åðßóçò, áðïôåëå-óìáôéêþí ëýóåùí áíáëüãùò ôùí ôïðéêþí áíáãêþí êÜèåöïñÜ åßíáé êáé áõôü Ýíáò ÷ñõóüò êáíüíáò. ÅðïìÝíùò,áöïý ç áíÜãêç âåëôßùóçò ôùí óõóôçìÜôùí õãåßáò åßíáéôåñÜóôéá, ç åöáñìïãÞ ôùí ìÝ÷ñé óÞìåñá ãíùóôþí åðé-ôõ÷çìÝíùí ìåèüäùí ðïéïôéêïý åëÝã÷ïõ êáé áíáâÜèìé-óçò, èá ðñÝðåé íá åöáñìüæåôáé ÷ùñßò êáèõóôåñÞóåéò

êáé íá äéáäßäåôáé åðßóçò ÷ùñßò êáèõóôåñÞóåéò, åíþ çãíþìç ôùí åéäéêþí êáé Ýìðåéñùí (üóùí õðÜñ÷ïõí óÞ-ìåñá óôïí ôïìÝá ôçò Õãåßáò) èá ðñÝðåé íá åéóáêïýãå-ôáé65. ÅðéðñïóèÝôùò, ç åêðáßäåõóç íÝùí óôåëå÷þí ðñÝ-ðåé íá åßíáé ðñùôáñ÷éêÞ ìÝñéìíá üóùí áóêïýí ïðïéáó-äÞðïôå ìïñöÞò äéïßêçóç. Áêüìç ï ôáêôéêüò Ýëåã÷ïò ôçòáðïôåëåóìáôéêüôçôáò ôùí íÝùí ìåèüäùí, èá åîáóöá-ëßæåé üôé ïé äéáäéêáóßåò äåí èá åßíáé åðéêéíäýíùò ÷ñï-íïâüñåò êáé áêñéâÝò êáé èá áíôÝ÷ïõí óôï ÷ñüíï, Ýôóéþóôå ïé êáëÝò éäÝåò êáé ç åöáñìïãÞ ôïõò íá áíáâáèìß-æåé ôçí ðáñï÷Þ õãåßáò óå üëïõò êáé óõíå÷þò!!!

ÔåëéêÜ, ìéá íÝá öéëïóïößá ìåôñÞóåùí êáé áîéïëüãçóçòãåííéÝôáé

Ìïëïíüôé ç åðéóôÞìç ôïõ ðïéïôéêïý åëÝã÷ïõ êáé áíá-âÜèìéóçò ÷ôßæåé ðÜíù óôéò ðáñáäïóéáêÝò ìåèüäïõò ìå-ôñÞóåùí êáé åëÝã÷ùí, åí ôïýôïéò 3 íÝá âáóéêÜ óçìåßááíáäýïíôáé êáé ÷áñáêôçñßæïõí ôïí ðïéïôéêü Ýëåã÷ï óôçíÕÃÅÉÁ:1. Ðïéüôçôá óôçí õãåßá äåí ðñÝðåé íá èåùñåßôáé ìüíï

ç åöáñìïãÞ ôçò ãíþìçò ôùí åéäéêþí êáé åðáããåëìá-ôéþí Þ üóùí áóêïýí äéïßêçóç, áëëÜ êáé ç ãíþìç ôùíáóèåíþí êáé ôùí óõããåíþí ôïõò (óôï ìÝôñï ðïõ ôïõòáíáëïãåß).

2. Ïé ìåôñÞóåéò êáé ç áîéïëüãçóç ôçò ðïéüôçôáò ÷ñåéÜ-æïíôáé ôç óõíåñãáóßá üëùí ôùí ôïìÝùí êáé ôïõ äéïé-êçôéêïý êáé ôïõ éáôñéêïý êáé ôïõ íïóçëåõôéêïý êáéÜëëùí.

3. Áõôü ðïõ ðáñáäïóéáêÜ ãßíåôáé ìÝ÷ñé óÞìåñá ìå ôïõòåëÝã÷ïõò ôçò ðïéüôçôáò üðïõ óõíå÷þò áíáæçôþíôáéôá �óÜðéá ìÞëá�, üðùò ÷áñáêôçñéóôéêÜ áíáöÝñåé ïBerwick66 óôï Üñèñï ôïõ êáé óôç óõíÝ÷åéá ôéìùñïý-íôáé Þ åðáéíþíôáé ìåìïíùìÝíá Üôïìá, ìÜëëïí ðñÝ-ðåé íá áíáèåùñçèåß. Ôï ìõóôéêü âñßóêåôáé áëëïý êáéóõãêåêñéìÝíá óôïí ðñïãñáììáôéóìü êáé óôéò ìåèü-äïõò ðïõ áêïëïõèïýíôáé. Óôç âéïìç÷áíéêÞ ðáñáãù-ãÞ áõôü Ý÷åé ãßíåé êáôáíïçôü áðü ôá ìÝóá ôïõ ðñïç-ãïýìåíïõ áéþíá.¼ìùò, ðþò ãßíåôáé áõôüò ï Ýëåã÷ïò;

ÅËÅÃ×ÏÓ ÌÅ ÔÁ ÄÉÁÃÑÁÌÌÁÔÁ ÅËÅÃ×ÏÕ

Ôá äéáãñÜììáôá áõôÜ åßíáé Ýíá åéäéêü åñãáëåßï ôïõðïéïôéêïý åëÝã÷ïõ êáé ôçò ðïéïôéêÞò áíáâÜèìéóçò ðïõ÷ñçóéìïðïéåßôáé óÞìåñá êáé óôçí Õãåßá67-69.


¸íá ôÝôïéï äéÜãñáììá åßíáé ìéá ãñáììéêÞ ãñáöéêÞðáñÜóôáóç óôçí ïðïßá õðÜñ÷ïõí ôïðïèåôçìÝíá 2 ïñé-æüíôéá üñéá (ôï Áíþôåñï êáé ôï Êáôþôåñï) ðïõ ðñïó-äéïñßæïíôáé åîáñ÷Þò óôáôéóôéêþò, üðùò öáßíåôáé óôïó÷Þìá 6.

ÁõôÜ ôá üñéá ðñïóäéïñßæïõí ôï ìÝãåèïò ôçò ìåôá-âëçôüôçôáò ðïõ ìðïñåß êÜðïéïò íá áíáìÝíåé ìÝóá óôïðëáßóéï ìéáò äéáäéêáóßáò. Áí ïé ôéìÝò ðïõ ìåôñÜåé áíÜôáêôÜ ÷ñïíéêÜ äéáóôÞìáôá ðÝöôïõí ìÝóá óôá üñéá, ôüôåèá ìðïñåß íá ðåé üôé ç äéáäéêáóßá ðïõ áêïëïõèåßôáéÝ÷åé ìéá ìåôáâëçôüôçôá ðïõ êáëåßôáé �ÌåôáâëçôüôçôáÊïéíÞò Áéôßáò Þ ÅóùôåñéêÞò Áéôßáò�(�Common CauseVariation�). Áõôü åîáóöáëßæåé ìéá óôáèåñüôçôá êáé ìéáðñïâëåøéìüôçôá óôï óýóôçìá Ýôóé þóôå íá ôï êáèéóôÜöåñÝããõï ùò ðñïò ôá áðïôåëÝóìáôÜ ôïõ.

Åðßóçò ç óôáèåñüôçôá áõôÞ åîáóöáëßæåé üôé ðåñáé-ôÝñù âåëôßùóç áõôÞò ôçò äéáäéêáóßáò óçìáßíåé ôçí áë-ëáãÞ ôçò åê âÜèñùí ïðüôå ðéèáíþò íá ðñïêýøåé Ýíáôåëåßùò äéáöïñåôéêü ðñïúüí. Ãéá ðáñÜäåéãìá, áíôßäñá-óç óôéò åîÜñóåéò êáé óôéò õöÝóåéò ôùí ëïéìþîåùí êáé

ôçò êáôáíÜëùóçò áíôéâéïôéêþí ãéá ôïõò áóèåíåßò ìéáòÌÅÈ óôï ðëáßóéï åíüò ìçíüò ìå ðáñáôçñÞóåéò óôï ðñï-óùðéêü, äåí ùöåëåß êáé åßíáé áíôéðáñáãùãéêü70-71, áíáõôÝò äåí îåðåñíïýí êÜðïéá ðñïêáèïñéóìÝíá üñéá ðïõðéèáíþò Ý÷åé ïñßóåé ìéá åðéôñïðÞ ëïéìþîåùí.

Áí üìùò êÜðïéåò åîÜñóåéò âãáßíïõí åêôüò ôùí ðñï-êáèïñéóìÝíùí ïñßùí, ôüôå ðñáãìáôéêÜ êÜôé óïâáñüóõìâáßíåé êáé èá ðñÝðåé íá åõñåèåß, íá áðïìïíùèåß êáéíá áðïâëçèåß áðü ôç äéáäéêáóßá.

Ïé Carey êáé Lloyd72, óôï Üñèñï ôïõò äßíïõí ðïëëÜðáñáäåßãìáôá ìåëÝôçò ðåñéóôáôéêþí ìå äéáãñÜììáôáåëÝã÷ïõ üðùò:

�Ï ÷ñüíïò ðïõ áðáéôåßôáé ãéá ìéá åñãáóôçñéáêÞ åîÝ-ôáóç �Turn Around Time�. ÄçëáäÞ ï ÷ñüíïò ðïõáðáéôåßôáé áðü ôç óôéãìÞ ôçò áéìïëçøßáò ìÝ÷ñé ôçóôéãìÞ ôçò áíáãñáöÞò ôïõ áðïôåëÝóìáôïò.

�Ç óõ÷íüôçôá ôïõ ðåóßìáôïò áðü ôï êñåââÜôé áóèå-íþí êáé Üëëá.Ï Nelson êáé ïé óõíåñãÜôåò ôïõ73, äßíïõí ðáñáäåßã-

ìáôá äéáãñáììÜôùí åëÝã÷ïõ, ãéá ôï ÷ñüíï íïóçëåßáò

Ó÷Þìá 6. ÄéÜãñáììá åëÝã÷ïõ


áóèåíþí, ãéá ôç äéÜñêåéá ôçò áãùãÞò ôçò ðíåõìïíßáòôçò êïéíüôçôáò ê.ëð. ÐáñïõóéÜæïõí åíäéáöÝñïí ïé åñ-ãáóßåò ìå äéáãñÜììáôá åëÝã÷ïõ74-78, ôïõ Laffel êáé ôùíóõíåñãáôþí ôïõ ãéá ôï ðþò ðïëëÝò öïñÝò óôéò ÌÅÈëüãù êáêÞò áîéïëüãçóçò ôùí ôéìþí, ôçò óõíå÷ïýò êá-ôáãñáöÞò (Continuous Monitoring), ïé ãéáôñïß ðñïâáß-íïõí óå õðåñâïëéêÝò èåñáðåõôéêÝò åíÝñãåéåò (Over-Medicating).

BENCHMARKING - Ç ÌÅÈÏÄÏÓ ÔÇÓ ÓÕÃÊÑÉÓÇÓ ËÅÉ-ÔÏÕÑÃÉÁÓ ÏÄÇÃÅÉ ÓÔÇ ÂÅËÔÉÙÓÇ

Ç ìåèïäïëïãßá áõôÞ áíáðôý÷èçêå êáôÜ ôç äåêáå-ôßá ôïõ �80 áðü ôçí Xerox. Ðñüêåéôáé ãéá ìéá ìÝèïäï çïðïßá óõãêñßíåé ìåôáîý ôïõò ðñáêôéêÝò ðïõ áêïëïõèïý-íôáé áðü äéÜöïñïõò ãéá ôç ëýóç ôïõ ßäéïõ ðñïâëÞìá-ôïò79-81, êáé êáôáëÞãåé óôï ðïéá áðü áõôÝò åßíáé ç êáëëß-ôåñç êáé ç ðéï áðïäïôéêÞ.

Óôç óõíÝ÷åéá, áí åßíáé äõíáôü, åðé÷åéñåßôáé ç ôõðï-ðïßçóç ôçò ìåèüäïõ êáé áí èÝëåé êÜðïéïò íá åìâáèýíåéáêüìá ðåñéóóüôåñï, ðñïóðáèåß íá äþóåé óõãêåêñéìÝ-íåò áðáíôÞóåéò óôï ãéáôß êáé ðïý õðåñÝ÷åé áõôÞ ç ìÝèï-äïò. ÁíôéëáìâÜíåôáé ëïéðüí êáíåßò üôé ç äéáäéêáóßááõôÞ áðáéôåß ðïëý ìåèïäéêÞ, áíáëõôéêÞ êáé áðïôåëåóìá-ôéêÞ äïõëåéÜ êáé üôé ç åöáñìïãÞ ôçò óôïí ðïëõðáñáãï-íôéêü ôïìÝá ôçò Õãåßáò ÷ñåéÜæåôáé áêüìá ìåãáëýôåñçäüóç áðü ôéò ðéï ðÜíù áñåôÝò (O�Conner and Coll)82.

ÐåñéãñÜöïíôáé óôç âéâëéïãñáößá 3 äéáöïñåôéêÝòìÝèïäïé Benchmarking.1) Ç ðñþôç ìÝèïäïò ãßíåôáé ìå áíôáëëáãÞ åðéóêÝøåùí

óôá íïóïêïìåßá êáé óôá åðéìÝñïõò ôìÞìáôá êáé êëé-íéêÝò. Ìå áõôüí ôïí ôñüðï êáé áðü ôá ìÝëç ôïõÍorthern New England Cardiovascular Disease StudyGroup83 õëïðïéÞèçêå Ýíá åêôåôáìÝíï ðñüãñáììáêáôÜ ôï ïðïßï ðñáãìáôïðïßçóáí ôïðéêÝò åðéóêÝøåéòãéá íá ðáñáêïëïõèÞóïõí êáñäéï÷åéñïõñãéêÝò åðåì-âÜóåéò. Óôç óõíÝ÷åéá ïìÜäåò áðïôåëïýìåíåò áðüäéÜöïñåò åéäéêüôçôåò, ÷åéñïõñãïýò, íïóçëåýôñéåò,ôå÷íéêïýò êáé ìç÷áíéêïýò óõóêÝöèçêáí ìåôáîý ôïõòêáé êáôÝëçîáí óå áõôü ðïõ ï Kasper êáé ïé óõíÜ-äåëöïß ôïõ84, ðåñéãñÜöïõí ùò åéëéêñéíÝò êáé õøç-ëïý ðåñéå÷ïìÝíïõ óõìðÝñáóìá. Ôï áðïôÝëåóìá Þôáí24% ìéêñüôåñç åíäïíïóïêïìåéáêÞ èíçôüôçôá ìåôÜáðü åã÷åßñçóç by-pass ðïõ ðñáãìáôïðïßçóáí 23êáñäéï÷åéñïõñãïß (p= <0,001), åíþ óôç âéâëéïãñá-

ößá áíáöÝñïíôáé êáé Üëëá ó÷åôéêÜ ðáñáäåßãìáôá85-

86.2) Ç äåýôåñç ìÝèïäïò Benchmarking, ç ïðïßá èåùñåß-

ôáé üôé õðåñÝ÷åé ôçò ðñþôçò ùò ðñïò ôï ÷ñüíï êáé ôïêüóôïò åßíáé áõôÞ ðïõ áêïëïýèçóå ç Sun Health Al-liance, ìéá óõíåñãáóßá ìåôáîý 200 íïóïêïìåßùí óôéòÇÐÁ. ÓõãêñïôÞèçêå Ýíá äéïéêçôéêü óõìâïýëéï áðüõðáëëÞëïõò áõôþí ôùí íïóïêïìåßùí87, ôï ïðïßï áíÝ-ëáâå íá óõëëÝîåé ðëçñïöïñßåò ãéá ôéò ìåèüäïõò ðïõáêïëïõèïýíôáé êáé íá èÝóåé óõãêåêñéìÝíåò åñùôÞ-óåéò ãéá äéÜöïñåò äéáäéêáóßåò êáé ðñáêôéêÝò. ÓôçóõíÝ÷åéá, ôï åí ëüãù óõìâïýëéï áðü ìéá ïìÜäá 10íïóïêïìåßùí ìå ôéò ÷åéñüôåñåò, ìÝôñéåò áëëÜ êáé ôéòêáëëßôåñåò ìåèüäïõò, üñéóå ìéá ïëéãïÞìåñç óõíÜ-íôçóç áíôéðñïóþðùí, ïé ïðïßïé êáôÝëçîáí ìåôÜ áðüåêôåíÞ óõæÞôçóç ãéá ôï ðïéÜ, áðïäåäåéãìÝíá, åßíáéç êáëëßôåñç ìåèïäïëïãßá ãéá êÜèå óõãêåêñéìÝíïèÝìá. Ôá èÝìáôá Þôáí ðïëëÜ üðùò: ÐñïâëÞìáôá óôïêõêëïöïñéáêü óýóôçìá áðü êáèåôÞñåò, íïóïêïìåéá-êÞ ðíåõìïíßá, ïëéêÞ áñèñïðëáóôéêÞ éó÷ßïõ, ïîý Ýì-öñáãìá ôïõ ìõïêáñäßïõ, áããåéïðëáóôéêÞ, ê.ëð.88-89

3) Ç ôñßôç ìÝèïäïò Benchmarking ÷ñçóéìïðïéåß ðëÞ-ñïõò êáé áðïêëåéóôéêÞò áðáó÷üëçóçò óôåëÝ÷ç ôáïðïßá åíôïðßæïõí ôéò êáëëßôåñåò ìåèüäïõò ëåéôïõñ-ãßáò êáé óôç óõíÝ÷åéá ïñãáíþíïõí åðéóêÝøåéò êáôÜôüðïõò þóôå íá ãßíåé äõíáôÞ ç õéïèÝôçóÞ ôïõò áðüÜëëïõò90. ÐáñÜäåéãìá ôÝôïéïõ åßäïõò äïõëåéÜò Ýãé-íå áðü ôçí Uni-Health ãéá ôï ðïéá åßíáé ç êáëëßôåñçìåèüäåõóç ãéá ôçí áíôéêáôÜóôáóç ðñïèÝóåùí óôéòáñèñþóåéò. Ïé åñåõíçôÝò êáôÝëçîáí üôé:

� ÐñÝðåé íá ãßíåôáé áðü íùñßò öõóéïèåñáðåßá.� Íá ãßíïíôáé êáô� ïßêïí åðéóêÝøåéò áðü ôïõò åéäéêïýò

ðñéí ôçí åéóáãùãÞ óôï íïóïêïìåßï êáé� Íá ôõðïðïéçèåß ç ÷åéñïõñãéêÞ ìÝèïäïò ðïõ áêïëïõ-

èåßôáé91. Ôá áðïôåëÝóìáôá Þôáí êáôÜ 50% ìéêñüôå-ñïò ÷ñüíïò ðáñáìïíÞò óôá íïóïêïìåßá êáé êáôÜ2.000 äïëëÜñéá ìåßùóç ôïõ êüóôïõò áíÜ áóèåíÞ.Ôï ðïéá áðü ôéò ôñåéò ìåèüäïõò �Benchmarking� èá

áêïëïõèçèåß åßíáé èÝìá éäéáéôÝñùí óõíèçêþí êáé äõ-íáôïôÞôùí ðïõ åðéêñáôïýí óå êÜèå ïñãáíéóìï Þ óýóôç-ìá õãåßáò Þ íïóïêïìåßï, ê.ëð.

Èá ðñÝðåé ôÝëïò íá ôïíéóèåß üôé ôï åñãáëåßï ôïõ�Benchmarking� óôïí ðïéïôéêü Ýëåã÷ï êáé óôçí ðïéïôé-êÞ áíáâÜèìéóç åßíáé ìüíïí Ýíá åñãáëåßï êáé ü÷é ðáíÜ-êåéá. ÌåñéêÝò öïñÝò ßóùò íá áðïäåé÷èåß ðïëõÝîïäï êáé


÷ñïíïâüñï, Üëëåò öïñÝò üìùò ìðïñåß íá áðïôåëåß ôçìüíç ëýóç. Åßíáé ãíùóôü üôé üôáí êÜðïéïò áíáæçôÜåéüóï ôï äõíáôü êáëëßôåñåò ðñáêôéêÝò êáé ëýóåéò èá ðñÝ-ðåé íá Ý÷åé ôçí éêáíüôçôá êáé ìåñéêÝò öïñÝò êáé ôç äéáß-óèçóç Þ ôçí Ýêôç áßóèçóç, íá åíôïðßæåé êáé ôéò ðéï åíäå-äåéãìÝíåò ìåèüäïõò. Èá ðñÝðåé íá åßíáé ôïëìçñüò óôïíá äïêéìÜæåé, óõíåôüò óôï íá áðïöáóßæåé, äõíáìéêüò óôïíá åöáñìüæåé, íá Ý÷åé öáíôáóßá, íá ìçí äéóôÜæåé íááðïðïéçèåß ðáëéÝò ðñáêôéêÝò êáé íá ïìïëïãåß ôõ÷üíëÜèç ðïõ Ýãéíáí óôï ðáñåëèüí. Óôçí ÐïéïôéêÞ ÁíáâÜè-ìéóç äïêéìÜæïõìå ìå ãíþóç êáé óýíåóç ðáñáêïëïõèþ-íôáò ôéò åîåëßîåéò, âåëôéùíüìáóôå óõíå÷þò êáé óõíåñ-ãáæüìáóôå óå åéëéêñéíÞ âÜóç ó÷åäüí ìå üëïõò.

Ç ÐÏÉÏÔÉÊÇ ÁÍÁÂÁÈÌÉÓÇ ÌÅÓÁ ÁÐÏ ÔÇ ÓÕÍÅÑÃÁ-ÓÉÁ ÌÅ ÊÏÉÍÏÕÓ ÓÔÏ×ÏÕÓ

ÁõôÞ áðïôåëåß ìéá íÝá êáôÜêôçóç ôçò ðïéüôçôáò92

êõñßùò óôçí Õãåßá, åðåéäÞ ï ÷þñïò áõôüò ðñïóöÝñåôáéðïëý ðåñéóóüôåñï ãéá óõíåñãáóßåò áðü üôé ï âéïìç÷á-íéêüò.

ÁõôÝò ïé óõíåñãáóßåò ìðïñïýí íá óõëëÝîïõí Ýíáðïëý ìåãÜëï áñéèìü ðëçñïöïñéþí áðü ðïëõÜñéèìåòðçãÝò, íá äéäá÷èïýí áðü ôçí åìðåéñßá ôçò åöáñìïãÞòóôçí ðñÜîç êáéíïôïìéþí, íá óêåöèïýí Ýîù êáé ðÝñá áðüôá óôåíÜ ðëáßóéá ôïõ ÷þñïõ ôïõò êáé íá áíáêáëýøïõíôç äýíáìç ðïõ ðñïóäßäåé ç óùóôÞ óõíåñãáóßá ãéá ôçíåðßôåõîç äýóêïëùí áëëÜ êïéíþí óôü÷ùí. Íá äéáðéóôþ-óïõí áêüìá üôé ïé äéáöïñåôéêÝò éäÝåò êáé ðñáêôéêÝò äåíåßíáé ôñï÷ïðÝäç, áëëÜ áíôéèÝôùò áðïôåëïýí áðáñáßôç-ôç ðñïûðüèåóç ãéá ìéá óùóôÞ óõíåñãáóßá ðïõ èá öÝ-ñåé Ýíá áðïôÝëåóìá ÷ôéóìÝíï ìå ôï áðáýãáóìá ôùíóùóôþí åðéìÝñïõò ìåèüäùí ôïõ êáèåíüò.

¸ôóé ëïéðüí, ôá êëåéäéÜ ôçò êáëÞò óõíåñãáóßáò óôïðëáßóéï ôïõ ðïéïôéêïý åëÝã÷ïõ êáé ôçò ðïéïôéêÞò áíá-âÜèìéóçò óýìöùíá ìå ôç âéâëéïãñáößá93, ðåñéãñÜöï-íôáé óôïí ðßíáêá 2.

ÐÑÏÓÖÁÔÁ ÁÐÏÔÅËÅÓÌÁÔÁ ÊÁÉ ÌÅËËÏÍÔÉÊÅÓ ÔÁÓÅÉÓ

Ôï áðïôÝëåóìá ôçò óõíåñãáóßáò ôïõ Northern NewEngland Cardiovascular Study Group Þôáí ôï ðñþôïìåãÜëï áíáöåñüìåíï áðïôÝëåóìá êáé óõãêåêñéìÝíá,êáôÜ 24% ìåßùóç ôçò åíäïíïóïêïìåéáêÞò èíçôüôçôáòìåôÜ áðü åã÷åéñÞóåéò êáñäéÜò94.

Ðßíáêáò 2. Ôá êëåéäéÜ ôçò êáëÞò óõíåñãáóßáò

1. Èá ðñÝðåé íá õðÜñ÷åé äéáöïñåôéêüôçôá ìåèüäùí,áðüøåùí êáé éäåþí ìåôáîý ôùí óõíåñãáôþí ìéáò êáéáðü ôïí ßóï óïõ äåí ìáèáßíåéò, ìá ïýôå êáé ìðïñåßòíá ôïõ äéäÜîåéò êÜôé.

2. ÊáëÞ äéÜèåóç íá ìïéñáóôåß êáíåßò äéêÜ ôïõ áëëÜêáé îÝíá ðñÜãìáôá.

3. ÓùóôÜ óõíôïíéóìÝíï �Benchmarking�4. Óôü÷ïò ïé üóï ôï äõíáôü êáëëßôåñåò ìÝèïäïé êáé

ðñáêôéêÝò5. Ôõðïðïßçóç ôùí åðéôõ÷çìÝíùí áðïôåëåóìÜôùí6. Ìåôñçóéìüôçôá ôùí åðéôõ÷çìÝíùí áðïôåëåóìÜôùí

êáé7. ¼ôáí êÜðïéïò óõíåñãÜæåôáé ðñÝðåé íá îå÷íÜåé ôçí

áõôïðñïâïëÞ, íá ìðïñåß íá êÜíåé áõôïêñéôéêÞ, íáðáñáäÝ÷åôáé ôá ëÜèç ôïõ êáé íá Ý÷åé êáôáíüçóç ãéáôá ëÜèç ôùí Üëëùí.

8. ÔÝëïò, ç åðéôõ÷ßá ðñÝðåé íá åïñôÜæåôáé.

×ñåéÜæåôáé, äçëáäÞ ìå ëßãá ëüãéá, áëëáãÞ íïïôñïðßáò.

Ôï Üñèñï ôïõ Kilo95, ðáñÝ÷åé óáöåßò ðëçñïöïñßåòãéá ôï ðþò åðéôåý÷èçêå èåáìáôéêÞ ìåßùóç ôïõ ÷ñüíïõáíáìïíÞò óôá éáôñåßá ãéá ôïõò áóèìáôéêïýò, óôç óõ÷íü-ôçôá ôùí êáéóáñéêþí ôïìþí, óôçí êáëëßôåñç ëåéôïõñãßáôùí ÌÅÈ êáé óôç ìåßùóç ôùí ðáñåíåñãåéþí ôùí ÷ïñç-ãïõìÝíùí öáñìÜêùí. Ïìïßùò ïé Horbar, Rogowiski êáéPlsek96, ðåñéãñÜöïõí óçìáíôéêÞ ìåßùóç óôç óõ÷íüôçôáôùí ðáñïîõóìþí óå áññþóôïõò ìå ×ÁÐ óå 10 ðíåõìï-íïëïãéêÜ êÝíôñá (The Vermont-Oxford Network NIC/Q Project Collaborative).

Ï áíôáãùíéóìüò ìåôáîý ôùí éáôñþí óôç �Âéïìç÷á-íßá� ôçò Õãåßáò êáé ç õðïôéèÝìåíç êáôï÷ýñùóç ôçò ðíåõ-ìáôéêÞò ðåñéïõóßáò (áöïý ïõóéáóôéêÜ åßíáé áðïôÝëå-óìá óõëëïãéêÞò äïõëåéÜò, ãéáôß ðïôÝ êÜðïéïò ôåëåßùòìüíïò ôïõ äåí êáôüñèùóå íá êÜíåé èáýìáôá) äåí ðñÝ-ðåé íá ãßíïõí ôñï÷ïðÝäç óôçí áíÜðôõîç ôïõ ðïéïôéêïýåëÝã÷ïõ êáé ôçò ðïéïôéêÞò áíáâÜèìéóçò. Ôá êáëÜ áðï-ôåëÝóìáôá áöïñïýí óå üëïõò, êáé ôïõò áóèåíåßò êáé ôïõòãéáôñïýò (ðïõ ìå ôçí óåéñÜ ôïõò ìðïñåß íá áóèåíÞóïõí)êáé ôï ðáñáúáôñéêü ðñïóùðéêü êáé ôá íïóïêïìåßá êáéôá áóöáëéóôéêÜ ôáìåßá êáé ôç äçìüóéá äéïßêçóç êáé ôïÊñÜôïò ãåíéêþò. Ìüíï ïé åêìåôáëëåõôÝò óôï ÷þñï ôçòÕãåßáò èá ðñÝðåé íá ðñïâëçìáôéóèïýí.


ÓÕÌÐÅÑÁÓÌÁÔÁ - ÔÅÓÓÅÑÉÓ ÁÑÅÔÅÓ ÂÅËÔÉÙÓÇÓ

Óôï ÷þñï ôçò Õãåßáò ç åöáñìïãÞ ôïõ ðïéïôéêïý åëÝã-÷ïõ êáé ôçò ðïéïôéêÞò áíáâÜèìéóçò åßíáé ó÷åôéêÜ íÝáêáôÜêôçóç. Õðüó÷åôáé ðïëëÜ, ðáñÜëëçëá üìùò ÷ñåéÜ-æåôáé ðïëý ðñïóðÜèåéá, õðïìïíÞ êáé åðéìïíÞ. Ç åîá-ôïìßêåõóç ìåñéêÝò öïñÝò ôùí áðïôåëåóìÜôùí áíáëüãùòìå ôéò óõíèÞêåò ðïõ åðéêñáôïýí åßíáé åðéâåâëçìÝíç, ÜñáõðÜñ÷ïõí ðïëëÝò ìåôáâëçôÝò êáé ÷ñåéÜæåôáé óýíåóç êáéðñïóåêôéêÞ, õðåýèõíç êáé åðéóôçìïíéêÞ äïõëåéÜ. Ìå-ñéêÝò öïñÝò ôá ðñÜãìáôá ÷ôßæïíôáé êáé áíáìïñöþíï-íôáé ðÜíù óôá ðáñáäïóéáêÜ, Üëëåò áëëÜæïíôáé åê èå-ìåëßùí. ¼ðùò êáé íá Ý÷åé, ðÜíôùò, ðñÝðåé íá áðïêôç-èïýí 4 áñåôÝò:1. Ç êëéíéêÞ ðñáêôéêÞ ðñÝðåé íá áíôéìåôùðßæåôáé ùò

äéáäéêáóßá óå óõíå÷Þ åîÝëéîç2. Íá êáôáâÜëëïíôáé óõíå÷åßò ðñïóðÜèåéåò ãéá áðï-

äåäåéãìÝíá êáëëßôåñç ëåéôïõñãßá, ìå óåâáóìü êáéóôçí ðáñÜäïóç

3. Óõíåñãáóßá ìå üëïõò. Ç äéáñêÞò áíáæÞôçóç åßíáéðÜíôïôå êáëëßôåñç áðü ôçí Üìõíá ãéá ôá êåêôçìÝíá

4. ÐñÝðåé íá åðéäéþêåôáé ç óõíå÷Þò âåëôßùóç. Ç íïï-ôñïðßá ôïõ �åãþ Ý÷ù ìÜèåé íá ôï êÜíù Ýôóé� åßíáéóõíþíõìï ôçò ìåôñéüôçôáò, Çorber97 (Vermont-Ox-ford Network Evidence-Based Quality ImprovementCollaborative for Neonatology).


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46. NIH consensus development panel on the effect of cor-ticosteroids for fetal maturation on perinatal outcomes.JAMA 1995, 273: 413-418.

47. Shewhart WA. Economic Control of Quality of Manu-factured Product. New York, NY: Van Nostrand, 1931.

48. Deming WE. Out of the Crisis. Cambridge, MA: Centerfor Advanced Engineering Study, 1986.

49. Schon DA. Educating the Reflective Practitioner. To-ward a New Design for Teaching and Learning in theProfessions. San Francisco, CA: Jossey-Bass, 1988.

50. Kolb DA. Experiencial Learning. Experience as theSource of Learning and Development. Englewood Cliffs,NJ: Prentice Hall, 1984.

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52. Alemi et al. óp. cit.53. Nolan TW, Schall MW. óp. cit.54. Provost LP, Langley GJ. The importance of concepts in

creativity and improvement. Quality Progress 1998, 31:31-38.

55. Plsek PE. Creativity, Innovation, and Quality. Milwau-kee, WI: ASQ Quality Press, 1997.

56. US Dept of Health and Human Services. Public HealthService. Clinician�s Handbook of Preventative Services:Put Prevention into Practice. Washington, DC: US Gov-ernment Printing Office, 1994.

57. Langley GJ, Nolan KM, Nolan TW, Norman CL, Prov-ost LP. The Improvement Guide: A Practical Approachto Enhancing Organizational Performance. San Francis-co, CA: Jossey-Bass, 1996.

58. Altov H. The Art of Inventing: And Suddenly the In-ventor Appeared. Translated and adapted by LeeShulyak. Worcester. MA: Technical Innovation Center,1994.

59. Leape LL. Error in medicine. JAMA 1994, 272: 1851-1857.

60. Nolan TW, Schall MW. Reducing Delays and WaitingTimes Throughout the Healthcare System. Boston. MA:Institute for Healthcare Improvement, 1996.

61. Weiss KB, Mendoza G, Schall MW, Berwick DM, Roess-ner J. Improving Asthma Care in Children and Adults.Boston, MA: Institute for Healthcare Improvement,1997.

62. Rainey TG, Kabcenell A, Berwick DM, Roessner J.Reducing Costs and Improving Outcomes in Adult In-


tensive Care. Boston, MA: Institute for Healthcare Im-provement, 1996.

63. Weiss et al, óp. cit.64. Rainey et al, óp. cit.65. Guyatt HG, Sackett DL, Sinclair JC, et al. User�s guide

to the medical literature. IX. A method for grading healthcare recommendations. JAMA 1995, 274: 1800-1804.

66. Berwick DM. Continuous improvement as an ideal inhealth care. N Engl J Med 1989, 320: 53-56.

67. Shewhart W. óp. cit.68. Plsek PE. Introduction to control charts. Quality Man-

agement in Health Care 1992, 1: 65-74.69. Carey RG, Lloyd RC. Measuring Quality Improvement

in Healthcare: A Guide to Statistical Process ControlApplications. New York, NY: Quality Resources, 1995.

70. Deming WE. óp. cit.71. Berwick DM. Continuous improvement as an ideal in

health care. N Engl J Med 1989, 320: 53-56.72. Carey, Lloyd, óp. cit.73. Nelson EC, Splaine ME, Batalden PB, Plume SK. Build-

ing measurement and data collection into medical prac-tice. Ann Intern Med 1998, 128: 460-466.

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K, Olson LG, Saltos N. Using quality-control analysis ofpeak expiratory flow recordings to guide therapy for asth-ma. Ann Intern Med 1995, 123: 488-492.

76. Nelson EC, Splaine ME, Batalden PB, Plume SK. Build-ing measurement and data collection into medical prac-tice. Ann Intern Med 1998, 128: 460-466.

77. Oniki TA, Clemmer TP, Arthur LK, Linford LH. Usingstatistical quality control techniques to monitor bloodglucose levels. Proc Ann Symp Comput Appl Med Care1995, 586-590.

78. Laffel G, Luttman R, Zimmerman S. Using controlcharts to analyze serial patient-related data. QualityManagement in Health Care 1994, 3: 70-77.

79. Tucker FG, Zivan SM, Camp R. How to measure your-self against the best. Harvard Bus Rev 1987, 65: 8-10.

80. Camp RC. Benchmarking: The Search for Industry BestPractices That Lead to Superior Performance. Milwau-

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Collaborative Approach. New York. NY: AmericanHospital Publishing: 1994.

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ries to improve the quality of care. Am J Infect Control1997, 25: 85-95.

93. ibid.94. O� Connor GT, Plume SK, Olmstead EM, et al. óp. cit.95. Kilo C. Improving care through collaboration. Pediat-

rics 1999, 03(suppl): 384-393.96. Horbar JD, Rogowski J, Plsek PE, et al. óp. cit.97. Horbar JD. The Vermont-Oxford Network: evidence-

based quality improvement for neonatology. Pediatrics1999, 103(suppl): 350-359.

Öáñìáêïåðáãñýðíçóç.Ìýèïò Þ áíÜãêç;ÅÐÉÔÑÏÐÇ ÖÁÑÌÁÊÏÅÐÁÃÑÕÐÍÇÓÇÓ ÅÏÖ

Åð. Êáè. Ðáèïëïãßáò

Ç ðñüóöáôç áíáöïñÜ óïâáñþí áíåðéèýìçôùí åíåñãåéþí, êáèþò êáéåíüò èáíÜôïõ ðéèáíþò ó÷åôéæüìåíïõ ìå ôç óåñéâáóôáôßíç êÜíåé ðÜñá ðïëýåðßêáéñï ôï èÝìá ôçò öáñìáêïåðáãñýðíçóçò. Ùò öáñìáêïåðáãñýðíçóçïñßæåôáé ç óõíå÷Þò ðñïóðÜèåéá ãéá ôçí áíß÷íåõóç, åêôßìçóç êáé ðñüëç-øç áíåðéèýìçôùí åíåñãåéþí Þ ïðïéïõäÞðïôå Üëëïõ ðñïâëÞìáôïò ðéèá-íþò ó÷åôéæüìåíïõ ìå ôç ÷ïñÞãçóç öáñìÜêùí1. Ï ïñéóìüò áõôüò, êáèþòêáé ïé áñ÷Ýò óôéò ïðïßåò âáóßæåôáé êáé ïé ôñüðïé ìå ôïõò ïðïßïõò åöáñìü-æåôáé ç öáñìáêïåðáãñýðíçóç Ý÷ïõí áðáó÷ïëÞóåé åðáíåéëçììÝíá ôïíÐáãêüóìéï Ïñãáíéóìü Õãåßáò (ÐÏÕ) êáé ðåñéëáìâÜíïíôáé óå êáôåõèõ-íôÞñéá ïäçãßá ðïõ åßíáé äçìïóéåõìÝíç óôç äéáäéêôõáêÞ óåëßäá (ôüðï)ôïõ ðñïáíáöåñèÝíôïò ïñãáíéóìïý. Ç ðñïóðÜèåéá Üñ÷éóå êáôÜ ôç äéÜñ-êåéá ôçò äåêáåôßáò ôïõ '60, ìåôÜ áðü ôç èëéâåñÞ éóôïñßá ôçò èáëéäïìßäçò,êáé ï ôåëéêüò óôü÷ïò Þôáí êáé åßíáé ç õéïèÝôçóç áóöáëïýò êáé ïñèïëïãé-êÞò ÷ñÞóçò ôùí öáñìÜêùí. Êýñéï åñãáëåßï ãéá ôçí åðßôåõîç ôïõ óôü÷ïõáõôïý Þôáí ç äçìéïõñãßá ôïðéêþí (åèíéêþí) êÝíôñùí öáñìáêïåðáãñý-ðíçóçò, óõíåñãáæüìåíùí ìåôáîý ôïõò, ðïõ èá äçìéïõñãïýóáí ìéá ðá-ãêüóìéá âÜóç äåäïìÝíùí, ìÝóù ôçò ïðïßáò èá Þôáí äõíáôÞ ç ðñþéìç,áðïôåëåóìáôéêÞ êáé ôåêìçñéùìÝíç áíß÷íåõóç ôùí áíåðéèýìçôùí åíåñ-ãåéþí ôùí öáñìÜêùí êáé, áðü ôá äåäïìÝíá áõôÜ, ç åíçìÝñùóç ôùí ÷ñç-óôþí, Ýôóé þóôå ç ÷ñÞóç ôùí öáñìáêåõôéêþí ïõóéþí íá åêëïãéêåõôåß êáéíá ãßíåé ðéï áóöáëÞò.

Ôï ðñüâëçìá Þôáí êáé åßíáé ðþò ç âÜóç äåäïìÝíùí èá âñßóêåé üëåòôéò áíáãêáßåò ðëçñïöïñßåò. ÌÝ÷ñé óÞìåñá ôïõëÜ÷éóôïí, üëï ôï óýóôçìáóôçñéæüôáí óôçí áõèüñìçôç áíáöïñÜ áíåðéèýìçôùí åíåñãåéþí2. Ç áõ-èüñìçôç áíáöïñÜ áíåðéèýìçôùí åíåñãåéþí ãéá ëüãïõò ðïõ èá óõæçôç-èïýí ðáñáêÜôù åßíáé ðéï áðïäïôéêüò ôñüðïò óõëëïãÞò ðëçñïöïñéþí,áëëÜ ãéá íá Ý÷åé ôçí áðïôåëåóìáôéêüôçôá ðïõ èá ðåñßìåíå êáíåßò, ïé áíá-öïñÝò ðñÝðåé íá åßíáé óõ÷íÝò êáé íá öôÜíïõí ôçí åôÞóéá óõ÷íüôçôá ôùí300 áíáöïñþí áíÜ åêáôïììýñéï ðëçèõóìïý, ôï äå 30% íá áöïñÜ óïâá-ñÝò áíåðéèýìçôåò åíÝñãåéåò ó÷åôéæüìåíåò ìå öÜñìáêá3. Ç óõ÷íüôçôá áõôÞ

Í. ÃáëáíÜêçò

Åðßêáéñá ÈÝìáôá


êáé ãéá ôéò öáñìáêåõôéêÝò åôáéñåßåò. Óôo ðáñáðÜíùðëáßóéo, ôï Äéïéêçôéêü Óõìâïýëéï ôïõ ÅÏÖ åðÝâáëåðñüóôéìá ôüóï óôïõò ãéáôñïýò ðïõ äåí õðÝâáëáí Ýãêáé-ñá ôéò áíáöïñÝò ôïõò üóï êáé óôéò åôáéñåßåò-ðáñáãù-ãïýò ôùí ðéèáíþò ó÷åôéæüìåíùí ìå ôéò áíåðéèýìçôåòåíÝñãåéåò öáñìÜêùí, äéüôé êáé áõôÝò êáèõóôÝñçóáí ôçíåíçìÝñùóç ôïõ ÅÏÖ ùò äéïéêçôéêïý ïñãÜíïõ öáñìÜ-êïõ, üðùò åß÷áí õðï÷ñÝùóç åê ôïõ íüìïõ.

Ç áíÜãêç ýðáñîçò ðëçñïöïñéþí ðïõ áöïñïýí óôçíáóöÜëåéá ôùí öáñìÜêùí Þ áêüìç êáé ôçí åëëéðÞ äñá-óôéêüôçôá, Ý÷åé èåùñçèåß áðü áõèåíôßåò åðß ôïõ èÝìá-ôïò ùò ðñüâëçìá öáñìáêïåðáãñýðíçóçò5-8 êáé Ý÷åéáíáãíùñéóôåß ðáãêïóìßùò. ÐåíÞíôá Ýîé êñÜôç óõíåñ-ãÜæïíôáé ìÝóá óôï ðëáßóéï ôïõ ÐÏÕ, ìåôáîý ôùí ïðïßùíêáé ôï äéêü ìáò, êáé äßäïõí ôéò óõãêåíôñïýìåíåò áðü ôáÅèíéêÜ ÊÝíôñá Öáñìáêïåðáãñýðíçóçò ðëçñïöïñßåòóôç âÜóç äåäïìÝíùí ðïõ Ý÷åé äçìéïõñãÞóåé ï ÐÏÕ óôçíÏõøÜëá ôçò Óïõçäßáò êáé åßíáé ãíùóôÞ ùò Collaborat-ing Center For International Drug Monitoring Þ ùò Upp-sala Monitoring Centre (UMC). To êÝíôñï äÝ÷åôáé ðå-ñßðïõ, êáôÜ ìÝóï üñï, 150.000 áíáöïñÝò åôçóßùò6,7. Ïáñéèìüò ôùí ÷ùñþí ðïõ æçôïýí íá ìåôÜó÷ïõí óôçí ðñï-óðÜèåéá óõíå÷þò áõîÜíåôáé êáé áñêåôÝò ÷þñåò óõììå-ôÝ÷ïõí ÷ùñßò íá Ý÷ïõí ìÝ÷ñé óôéãìÞò êáôïñèþóåé íá ïñ-ãáíþóïõí êáëþò ëåéôïõñãïýíôá åèíéêÜ êÝíôñá öáñìá-êïåðáãñýðíçóçò. Ç óõãêÝíôñùóç óôïé÷åßùí ÷ùñßò óõ-ãêåêñéìÝíç ìåèïäïëïãßá êáé êáèïñéóìÝíïõò óêïðïýò,üðùò êáé óå üëåò ôéò åêöÜíóåéò ôçò áíèñþðéíçò æùÞò,äåí èá åß÷å êáìéÜ áîßá. Ôá ðñïâëÞìáôá ìåèïäïëïãßáòäåí Ý÷ïõí ëõèåß ìÝ÷ñé óÞìåñá, áëëÜ Ý÷åé õðÜñîåé áñêå-ôÞ ðñüïäïò êáé óå ðïëëÜ èÝìáôá Ý÷åé åðÝëèåé ïìïöù-íßá êáé åíáñìüíéóç ôùí ôñüðùí Ýñåõíáò êáé ôùí óôü-÷ùí ôçò öáñìáêïåðáãñýðíçóçò. Ãéá ôç óõëëïãÞ ôùíóôïé÷åßùí ÷ñçóéìïðïéïýíôáé ç Þäç áíáöåñèåßóá áõôü-ìáôç áíáöïñÜ, ç ðáñáêïëïýèçóç ôçò óõíôáãïãñáößáò,ç ðáñáêïëïýèçóç ôùí öáêÝëùí ôùí áóèåíþí, êáèþòêáé ç åðéôÞñçóç ôùí ðåñéðôþóåùí (case control surveil-lance) Þ ç ðáñáêïëïýèçóç ôùí åõðáèþí ïìÜäùí (co-hort studies)2.

Áðü ôéò áíáöåñèåßóåò ìåèüäïõò, ç áõôüìáôç áíá-öïñÜ åßíáé ç äçìïöéëÝóôåñç, äéüôé: (á) Ý÷åé ìåãÜëï åý-ñïò åöáñìïãÞò, óôï ïðïßï ðåñéëáìâÜíïíôáé áíåðéèý-ìçôåò åíÝñãåéåò ôýðïõ Á êáé Â êáé áëëçëåðéäñÜóåéò ìåÜëëá öÜñìáêá êáé áöïñÜ üëá ôá öÜñìáêá êáé üëïõòôïõò áóèåíåßò, (â) åßíáé áðïôåëåóìáôéêÞ, (ã) åßíáé ôá-

åßíáé äýóêïëï íá åðéôåõ÷èåß áêüìç êáé óå ÷þñåò ìåðáñÜäïóç óôïí ôïìÝá áõôü, üðùò ç Ïëëáíäßá, ç ïðïßáÝ÷åé ðåñßðïõ 1.000 áíáöïñÝò ôï ÷ñüíï, äçëáäÞ ðåñß-ðïõ 70 áíáöïñÝò áíÜ åêáôïììýñéï êáôïßêùí4. Óôç ÷þñáìáò, ðïõ ç óõíÞèåéá ôçò áíáöïñÜò ôùí áíåðéèýìçôùíåíåñãåéþí êÜèå Üëëï ðáñÜ äéáäåäïìÝíç åßíáé êáé ïéáíáöïñÝò áõôÝò äåí áðïôåëïýí áíôéðñïóùðåõôéêü äåßã-ìá ôçò ÷þñáò, äéüôé óõíÞèùò ðñïÝñ÷ïíôáé áðü óõãêå-êñéìÝíá êÝíôñá, ç êáôÜóôáóç åßíáé áêüìç ÷åéñüôåñç. Çáñìüäéá åðéôñïðÞ ôïõ ÅÏÖ äÝ÷åôáé ðåñßðïõ 500 áíá-öïñÝò ôï ÷ñüíï Þ 50 áíÜ åêáôïììýñéï ðëçèõóìïý.

Ïé ëüãïé ãéá ôç ìéêñÞ óõ÷íüôçôá áõôüìáôçò áíáöï-ñÜò åßíáé ðïëëïß. Åêôüò áðü ôçí åëáôôùìÝíç åõáéóèç-óßá, ôçí Ýëëåéøç êáôÜëëçëçò åêðáßäåõóçò êáé ðñïçãïý-ìåíçò åìðåéñßáò, ôçí ïëéãùñßá, ôçí Ýëëåéøç ÷ñüíïõ, ôéòäõóêïëßåò áðïóôïëÞò ôçò áíáöïñÜò, áíáöÝñåôáé êáé ïöüâïò ôùí áíáöåñüíôùí ãéá êïéíïëüãçóç ôïõ ïíüìá-ôïò ôïõò Þ ôïõ ïíüìáôïò ôïõ áóèåíïýò Þ, áêüìç ÷åéñü-ôåñá, ôùí ðëçñïöïñéþí áðü ôï éóôïñéêü ôïõ áóèåíïýò,ãåãïíüò ðïõ áðïôåëåß ðáñáâßáóç ôïõ éáôñéêïý áðïñ-ñÞôïõ. Ïé öüâïé áõôïß åßíáé Üäéêïé êáé õðåñâïëéêïß^ üëáôá áíáöåñüìåíá óôïé÷åßá åßíáé áðïëýôùò áðüññçôá êáéïõäåßò Ý÷åé ðñüóâáóç óå áõôÜ. Ç áíùíõìßá êáé ç áóöÜ-ëåéá ôùí óôïé÷åßùí åßíáé âáóéêÞò óçìáóßáò ãéá ôçí êáëÞëåéôïõñãßá ôïõ óõóôÞìáôïò. Ôï áðüññçôï, åêôüò áðü ôïüôé åîáóöáëßæåé ôç äéáöýëáîç õøßóôùí áãáèþí, üðùòôá ðñïóùðéêÜ äåäïìÝíá, ðñïöõëÜóóåé êáé áðü ôïí áèÝ-ìéôï áíôáãùíéóìü ôçò öáñìáêïâéïìç÷áíßáò, ôç ãêñßæáäéáöÞìéóç ê.ëð.

Ôá ðáñáðÜíù êáôÝóôçóáí ôçí áõèüñìçôç áíáöïñÜëéãüôåñï áõèüñìçôç êáé ôç ìåôÝôñåøáí óå áõôüìáôç êáéõðï÷ñåùôéêÞ óôéò ðåñéóóüôåñåò ÅõñùðáúêÝò ÷þñåò.¼ëåò ïé öáñìáêåõôéêÝò åôáéñåßåò åßíáé õðï÷ñåùìÝíåòíá Ý÷ïõí ôìÞìáôá öáñìáêïåðáãñýðíçóçò êáé íá áíá-öÝñïõí ïðïéïäÞðïôå ðñüâëçìá åìöáíßóïõí ôá ðñïúü-íôá ôïõò ìåôÜ ôçí ÜäåéÜ ôïõò óôá áñìüäéá êÝíôñá öáñ-ìáêïåðáãñýðíçóçò. Ãéá ôï óõíôïíéóìü ôçò äñÜóçò êáéôçí åíáñìüíéóç ìåôáîý ôùí ÷ùñþí ìåëþí ôçò ̧ íùóçò,õðåýèõíï üñãáíï åßíáé ôï European Agency for theEvaluation of Medicinal Products (FMEA), ôï ïðïßïåäñåýåé óôï Ëïíäßíï êáé óõíåñãÜæåôáé óå èÝìáôá öáñ-ìáêïåðáãñýðíçóçò ìå ôï FDA (Food and Drug Admin-istration). Åðßóçò, áñêåôÝò ÷þñåò ôçò ¸íùóçò Ý÷ïõíêáôáóôÞóåé õðï÷ñåùôéêÞ ôçí áíáöïñÜ ôùí áíåðéèýìç-ôùí åíåñãåéþí ôüóï ãéá ôïõò åðáããåëìáôßåò õãåßáò üóï


÷åßá, (ä) åßíáé óõíå÷Þò êáé (å) ïéêïíïìéêÞ. ÁëëÜ, üðùòêÜèå åöáñìïãÞ, Ý÷åé ôá ìåéïíåêôÞìáôá êáé ôïõò ðåñéï-ñéóìïýò ôçò. ÁõôÜ óõíßóôáíôáé óôï üôé: (á) óõíÞèùò áäõ-íáôåß íá áðïäåßîåé ôçí áéôéþäç óõíÜöåéá ôçò áíåðéèý-ìçôçò åíÝñãåéáò ìå Ýíá öÜñìáêï, êáé üôé ïé áíáöïñÝòäåí åßíáé áðñïêáôÜëçðôåò, (â) áäõíáôåß íá êÜíåé ðïóï-ôéêÝò ìåôñÞóåéò (ùò åê ôïýôïõ, óõãêñßóåéò ìåôáîý ôùíöáñìÜêùí åßíáé äýóêïëåò, áí ü÷é áäýíáôåò) êáé (ã) áäõ-íáôåß íá áíé÷íåýóåé áíåðéèýìçôåò åíÝñãåéåò ôýðïõ C2.

Óêüðéìï åßíáé óôï óçìåßï áõôü, ãéá ôçí êáëýôåñçêáôáíüçóç ôïõ èÝìáôïò, íá ãßíåé êÜðïéá ðñïóðÜèåéáäéåõêñßíéóçò ìåñéêþí åðéóôçìïíéêþí üñùí. Ïé áíåðé-èýìçôåò åíÝñãåéåò åßíáé ðïëõðïßêéëëåò, åôåñïãåíåßò êáé,óôéò ðåñéóóüôåñåò ôùí ðåñéðôþóåùí, ìç áíáìåíüìåíåòêáé áóõíÞèåéò. Ó÷çìáôéêÜ äéáêñßíïíôáé óå ôñåéò ôýðïõò:Á, Â êáé C. Ï ôýðïò Á åßíáé åêåßíïò ðïõ ó÷åôßæåôáé ìåôç ìåãéóôïðïéçìÝíç öáñìáêïëïãéêÜ äñÜóç ôïõ öáñìÜ-êïõ êáé ôåßíåé íá åßíáé éäéáßôåñá óõ÷íüò êáé äïóïåîáñ-ôþìåíïò. Ç áíåðéèýìçôç åíÝñãåéá ôÝôïéïõ ôýðïõ èáìðïñïýóå íá áðïöåõ÷èåß, áí Þôáí äõíáôÞ ç åîáôïìß-êåõóç ôçò äüóçò. Ôõðéêü ðáñÜäåéãìá ôÝôïéïõ ôýðïõáíôßäñáóçò åßíáé ç äõóêïéëéüôçôá ðïõ ðñïêáëåßôáé áðüïðéïý÷á. Ï ôýðïò Â åßíáé óõíÞèùò áëëåñãéêÞ Þ éäéïóõ-ãêñáóéáêÞ áíôßäñáóç, åðéóõìâáßíåé ó÷åôéêÜ óðÜíéá(< 1/1.000) êáé åßíáé óõíÞèùò ìç áíáìåíüìåíç êáé áðñü-âëåðôç. Ó÷åäüí ðïôÝ äåí åßíáé äïóïåîáñôþìåíï öáéíü-ìåíï êáé, åðåéäÞ õðÜñ÷åé ÷ñïíéêÞ óõó÷Ýôéóç ãéá ôç ëÞøçôïõ öáñìÜêïõ, åßíáé åýêïëïò ï óõó÷åôéóìüò áíåðéèý-ìçôçò åíÝñãåéáò-öáñìÜêïõ. Ï ôüðïò C áöïñÜ áëëáãÞôçò êëéíéêÞò åéêüíáò ôïõ íïóÞìáôïò åðß ìáêñï÷ñüíéáòèåñáðåßáò Þ äçìéïõñãßá íÝïõ ðñïâëÞìáôïò õãåßáò ùòáðïôÝëåóìá ìáêñï÷ñüíéáò öáñìáêåõôéêÞò áãùãÞò.Ôõðéêü ðáñÜäåéãìá åßíáé ç áíÜðôõîç èñïìâïöëåâßôé-äáò åðß ìáêñï÷ñüíéáò áãùãÞò ìå áíôéóõëëçðôéêÜ äé-óêßá3.

Ïé õðüëïéðåò ìÝèïäïé óõëëïãÞò óôïé÷åßùí Ý÷ïõíìåãáëýôåñåò äõóêïëßåò, åßíáé ÷ñïíïâüñåò, Ý÷ïõí õøç-ëü êüóôïò êáé ãéá ôï ó÷åäéáóìü ôïõò ÷ñåéÜæåôáé ç óõì-ìåôï÷Þ öáñìáêïåðéäçìéïëüãïõ óôçí ïìÜäá. Ç óõììå-ôï÷Þ ôïõ ôåëåõôáßïõ èåùñåßôáé áðáñáßôçôç áêüìç óôçíáîéïëüãçóç êáé áíÜëõóç ôùí óôïé÷åßùí ôçò áõôüìáôçòáíáöïñÜò2. Ëüãù ôùí åêôåèÝíôùí ðáñáðÜíù, äåí Ý÷ïõíôý÷åé åõñåßáò åöáñìïãÞò áêüìç êáé óå ÷þñåò ìå ðïëýêáëü åðßðåäï öáñìáêïåðáãñýðíçóçò9. Óôç ÷þñá ìáò,äåí Ý÷ïõí åöáñìïóôåß êáèüëïõ Üëëåò ìÝèïäïé. Óõëëï-

ãÞ óôïé÷åßùí ÷ùñßò áîéïëüãçóç êáé áíáöïñÜ ôïõò óôçíåðéóôçìïíéêÞ êïéíüôçôá èá Þôáí ìéá ÷ñïíïâüñá êáéêïõñáóôéêÞ äéáäéêáóßá ÷ùñßò êáìßá áîßá. Ç ìåèïäï-ëïãßá ôçò áîéïëüãçóçò ôùí óôïé÷åßùí áðïôåëåß óçìåßïäéáöùíßáò êáé ìÝ÷ñé óÞìåñá äåí Ý÷åé åðÝëèåé óõìöù-íßá ãéá ôïí êáëýôåñï ôñüðï áíÜëõóçò ôùí óôïé÷åßùí.Ðáñ' üëá ôáýôá, ïé ãíþóåéò ìáò ãéá íÝá öÜñìáêá áõîÞ-èçêáí óå ðïëý ðåñéóóüôåñá óçìåßá áðü åêåßíá ðïõ Þäçãíùñßæáìå áðü ôéò êëéíéêÝò ìåëÝôåò. ÖÜñìáêá ðïõ åß-÷áí êñéèåß ùò áóöáëÞ êáé áðïôåëåóìáôéêÜ êáé ôïõò åß÷å÷ïñçãçèåß Üäåéá, áðïóýñèçêáí áðü ôçí áãïñÜ, äéüôéêñßèçêáí ùò ìç áóöáëÞ. ÔÝôïéá öÜñìáêá Þôáí ç ôåìï-öëïîáóßíç, ç öëåñïîáóßíç êáé ç óåñéâáóôáôßíç. Ç öáñ-ìáêïåðáãñýðíçóç ìáò Ýêáíå ãíùóôÝò êáé áíåðéèýìç-ôåò åíÝñãåéåò ëéãüôåñï åðéêßíäõíåò, áëëÜ ìåãÜëçò óçìá-óßáò ãéá ôçí õãåßá ôùí áóèåíþí, ðïõ äå ìáò Þôáí ãíù-óôÝò áðü ôéò êëéíéêÝò ìåëÝôåò. Ôõðéêü ðáñÜäåéãìá åßíáéç õðåñëéðéäáéìßá ðïõ ðñïêáëïýí êÜðïéá öÜñìáêá êáôÜôïõ AIDS.

Ç ÷ñÞóç ôùí õðïëïãéóôéêþí óõóôçìÜôùí êáé ôïõäéáäéêôýïõ Ýêáíå ôç öáñìáêïåðáãñýðíçóç ó÷åôéêÜåýêïëç õðüèåóç, ü÷é ìüíï áðü Üðïøç óõëëïãÞò óôïé-÷åßùí êáé äçìéïõñãßáò âÜóçò äåäïìÝíùí, áëëÜ êõñßùòáðü ôçí Üðïøç åðéêïéíùíßáò ôùí åðáããåëìáôéþí õãåßáòìå ÅèíéêÜ ÊÝíôñá Öáñìáêïåðáãñýðíçóçò, áëëÜ êáé ìåôá ó÷åôéêÜ Ðáãêüóìéá ÊÝíôñá10. Ç åõêïëßá áõôÞ óÞìå-ñá êáèçìåñéíÜ áõîÜíåôáé êáé êÜíåé ôçí áìößäñïìç ðëç-ñïöüñçóç ìåôáîý åðáããåëìáôéþí õãåßáò êáé êÝíôñùíöáñìáêïåðáãñýðíçóçò áðïôåëåóìáôéêüôåñç, áëëÜ ðñï-ðáíôüò ôá÷ýôåñç, ìå ôåëéêü áðïôÝëåóìá ôçí êáëýôåñçãíþóç ãéá ôï öÜñìáêï.

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the management of parapneumonic effusions and empyema · logic characteristics of the effusion, the...

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