上海交通大学医学院儿科学临床医学五年制课件 儿童呼吸系统感染性疾病

上海交通大学医学院附属新华医院儿科 鲍一笑,Infection Diseases of Respiratory System in Children,Introduction,High Morbidity Rate High Mortality Rate,Each year, respiratory infection diseases cause about 15 million deaths among children younger than age 5 year through the world. Pediatric pulmonary infection accounts for about 63.89% of all hospitalizations of children, in which 44.6 percent are pneumonia.,Cricoid cartilage,Upper respiratory tract nose, paranasal sinuses,pharynx, eustachian tube, epiglottis, larynx,Lower respiratory tract: trachea, bronchi, bronchioles, alveolus,Anatomy,Anatomy,Upper respiratory tract,Short Nasal passages, nasolacrimal duct and eustachian tube,Significance :These characters make nasal cavity easy to become hyperemia, edema, and congestion which will induce infection. Local infection can spread to nearby organs and tissues easily and cause dyspnea, hoarseness and apnea.,Nasal mucosa Is soft,More vascular,Nasal cavity is short and narrow,Anatomy,Narrowed airway Soft mucous menbrane More vascular Softer and more compliant,Clinical significance: Easy to become hyperemia, edema, and congestion which will induce infection Complication: Pulmonary emphysema and atelectasis,Lower respiratory tract,Physiology,The younger the child The quicker the frequency The less regular the rhythm,Vital capacity (VC) Tidal volume Total lung capacity (TLC),Respiratory frequency and rhythm ： The respiratory frequency is inversely related to age . neonate : 4050 bpm；612mo: 30-35 bpm； 1-3 yr : 2530 bpm；49 yr : 20-25 bpm； 8-14 yr :1820 bpm。 (2) Some young infants present with irregular rhythm or apnea due to immature respiratory center.,Small,Immune System,Low level of sIgA , IgG on Respiratory Mucosa Low level of Th1 function,Acute Upper Respiratory Tract Infection “Common cold”,Acute Upper Respiratory Infection,Introduction,80-90% proportion of visit to clinic. spread to nearby organs and tissues (otitis media, conjunctivitis, lymphadenitis, lymphadenitis and pneumonia) Bronchial asthma, nephritis, myocarditis, measles and pertussis may also follow AURI,90% of AURI are caused by viral infection,Etiology,Rhinovirus Echo virus Coxsackievirus Parainfluenza Influenza Adenovirus RSV(Respiratory Syncytial Virus),Pneumococcus Moraxelle catarrhalis,Haemophilus influenzae Staphylococcus aureus,Bacteria,Mycoplasma Chlamydia Other Microorganisms,Others,Mild symptom Nasal congestion, rhinorrhea, sneezing, sore throat Severe symptom High fever, convulsion, anorexia, frequency cough,Clinical Manifestation,Symptoms of URI in children of different ages,The pharynx is red Retropharyngeal folliculosis Erythematous enlarged tonsils Enlarged lymph nodes Enterovirus illnesses may be associated with a wide variety of skin rashes,Physical Sign,Herpangina Coxsackievirus A Most often occurs in summer and autumn More often in infants（0-3 yr of age） Characterized by sudden onset of fever, sore throat and dysphagia Characteristic lesions, present on the posterior pharynx, are discrete vesicles and ulcers Duration of illness is usually 7 days,Two Special Types,Occurs typically with type 3,7 adenovirus Most often occurs in spring and summer Children （3 yr ） more often affected Features include: A high temperature that lasts 45 days, pharyngitis, conjunctivitis, cervical lymphadenopathy, and rhinitis. Duration of illness is usually 1-2 weeks,Pharyngoconjunctival Fever,Otitis media Cervical lymphadenitis Bronchitis Pneumonia Septicemia,Complication,Viral Infection Viral Myocarditis Viral Encephalitis Bacterial Infections（streptococcus) Acute Nephritis Rheumatic Fever,Diagnosis,Symptoms sighs,The differential diagnosis of the URl includes other acute infectious disease. In patient with febrile convulsion, central nervous system Infections should also considered. Patients with abdominal pain may have acute abdomen.,Differential diagnosis,Difference Between Mesenteric Lymphadenitis and Acute appendicitis,Prophylaxis,Increase outdoor activities. Improve physical fitness. Enhance immunity function. Patients in collective institutions should be isolated.,General treatment Etiological treatment Anti-virus：Ribavirin Avoid the abuse of antibiotics Symptomatic treatment Severe nasal obstruction Irritability-restlessness High fever Pharyngeal portion ulcer Conjunctivitis,Treatment,Upper respiratory infection is the most common disease in childhood, most of which are caused by viral infections. The severity of clinical manifestations is related to age of the patients. Infants present mild local symptoms and severe systemic symptoms, while older children present on the contrary. A stuffy, congested nose may exist in infants younger than 3 months of age. Treatment for the common cold should be mainly symptomatic. Antibiotics should not be used unless in those young, infant patients which are suspected to complicate bacterial infections.,Summary,Acute bronchitis is inflammation of the tracheobronchial epithelium . Trachea is usually involved，so acute bronchitis is also called acute tracheobronchitis. Acute bronchitis is commonly secondary to an acute viral infection, or just one manifestation of acute infectious disease.,Acute Bronchitis,Infectious factors：viral, bacterial or other pathogen infections Characters of respiratory tract of infants: The mucous become edema and hyperemia which make the bronchus narrower when inflammation. Other factors：immunodeficiency, nutritional diseases, specific body constitution.,Etiology,Clinical Manifestation,Begins as an URI Cough is a significant signs nonproductive cough productive The systemic symptoms is usually severe in infants including fever, vomiting and diarrhea Medical examination： Respiratory rudeness Diffuse or scattered rales No dyspnea CXR : may be normal or thickening lung markings,Acute bronchitis is an inflammation of the major conducting airways within the lung which caused by viral or bacteria, and is most often in infants. Cough is the most significant clinical manifestation. Fever, vomiting and diarrhea are frequent in infants. Respiratory sounds are rough and scattered rales are heard on auscultation. Radiographic examination of the chest may show a mild increase in bronchovascular markings. Antibiotics are indicated if a bacterial infection of the airway is suspected or proven. Corticosteroids are recommended in severe cases.,Summary,Pneumonia is an inflammation of the parenchyma of the lungs. Most cases of pneumonia are caused by microorgnanisms, but there are several noninfectious causes, which include aspiration of food or gastric acid, foreign bodies and so on.,Acute Pneumonia,Season of onset Age of onset Morbidity rate Mortality rate,Epidemiology,Classified according to the infecting organism: Viral pneumonia, bacterial Pneumonia, mycoplasma Pneumonia. Classified according to Pathology: Bronchopneumonia, lobar pneumonia,interstitial pneumonia. Classified according to duration of disease: Acute pneumonia( 3mo). Classified according to severity of disease: Mild pneumonia and severe pneumonia.,Category,Etiology,Age,More often in infants,Disease,Environment,Malnutrition, Congenital heart disease, Immunodeficiency disease,wetness, stuffiness and crowding.,Inducement,Patients with the following problems are particularly predisposed to this disease:,Hyperemia, edema and inflammatory infiltration of lung tissues Alveolar exudate Patchy Inflammation focus, and consolidation Atelectasis and emphysema of lung,Pathology,fever,cough,tachypnea,Rales,four,symptoms,Clinical Manifestion,Pneumonia,Apart from the general features of bronchopneumonia, severe pneumonia also present with systemic toxic symptoms in respiratory system circulatory system nervous system digestive system,Severe Pneumonia,Circulatory system,Myocarditis, heart failure Microcirculation disturbance,Digestive system,Gastrointestinal dysfunction, enteroplegia Alimentary tract hemorrhage,Nervous system,Intracranial hypertension Encephaledema,Water-Electrolyte Balance,Mixed acidosis, dehydration Hyponatremia,Extrapulmoanry presentations,Suddenly onset of tachypnea, R60 bpm, increased pulmonary rales. Tachycardia that can not be explained by high fever or tachypnea, HR180 bpm Irritability and cyanosis Gallop rhythm or dull heart sound , distension of jugular vein and enlarged cardiac Increased liver with tenderness, 1.5cm. Oliguria or anuria that present with edema of eyelid or lower extremities.,Myocardial failure,Empyema of pleura Purulent pneumothorax Bullae of lung Septicemia Purulent pericarditis,Complication,Peripheral blood examination White cell count CRP (C-reactive protein) Nitroblue tetrazolium test Etiological examination Bacteriological examination ：Bacterial culture Virological examination： Viral isolation Examination of mycoplasma： Specific immunity examination,Laboratory Examination,Lobular pneumonia (Bronchopneumonia),Pathogen Streptococcus pneumoniae Haemophilus influenzae Pathology Pathological changes such as hyperemia and edema of bronchiolar wall, exudation of pulmonary lobule, and bronchiolar obstruction are scattered surround bronchus. Clinical manifestation Hyperpyrexia, cough, tachypnea and dyspnea More common in infants, aged people and weak people,Increase lung markings,Diffuse bilateral Patchy infiltrates and consolidation scattered throughout both lungs,Atelectasis, hyperinflation, bullae of lung and pyothorax,Chest radiographic findings in bronchopneumonia,Chest radiographic findings in bronchopneumonia,Frontal views : Patchy infiltrates and consolidation at the inner zone and middle zone of bilateral lower lobes, with or without hyperinflation,Segmental atelectasis,Frontal views : It is a segmental atelectasis at the right superior lobe. The transversa fissure is displaced toward the airless lobe. There is a sector high density shadow with the apex toward the hilum of lung. The diaphragm is elevated and the mediastinum is shifted to the side of involvement.,Lobar pneumonia,Pathogen: maily streptococcus pneumoniae Pathology : inflammtion infiltrates throughout a whole lobe or segment of the lung. Main clinical manifestation: More common in adolescence, rare in young children. Hyperpyrexia, cough, and rusty sputum X-ray findings Change after changes of clinical symptoms.,Lobar pneumonia at middle lobe of right lung,Frontal views : A consolidation within the transverse fissure and oblique fissure can be seen at the middle lobe of right lung,viral disease, RSV (85%). aged 2-6 months. airway obstruction is due to pathological changes include swelling and distension of bronchioles, secretions blockage.,Bronchiolitis,expiratory wheezing tachypnea, nasal flaring Cyanosis fine rales emphysema The duration of illness is 4 7 days,Clinical Manifestation,Hyperexpansion is commonly present Peribronchial cuffing Increased interstitial markings Patchy infiltrates,Chest radiographic findings,Frontal views of CXR: Ground-glass opacity Decreased lung markings Patchy infiltrates in innner and middle zone Acquired hyperinflation,RSV Pneumonia,Escherichia coli is the most common pathogen in neonate. In young infants 1 week, mainly pathogen are staphylococcus aureus and hemolytic streptococcus. Some patients may present only with signs of generalized toxicity. Patient uauslly present no cough or fever. Rales are seldom heard on ausculation. Clinical manifestation may be milk-resistant, drowsiness, low response, and tachypnea. Cyanosis, foaming at mouth, nodding respiration or apnea may present in severe cases. Respiratory signs is rare.,Pneumonia of newborn,Chest X-ray,Frontal views : There is patchy shadows and infiltrates at right lung field.,Adenovirus pneumonia,Type 3,7 adenovirus Young children（6 mo-2 yr ）are more often affected Acute onset of high fever, toxic symptoms and pale face. Sometimes present with cardiac dysfunction and symptom of nervous system Severe cough, dyspnea and wheezing Respiratory signs such as fine rales occur after 3-4 days Patchy infiltrates and consolidation with hyperinflation.,Adenovirus pneumonia,Frontal views : Chest radiographs reveals diffuse interstitial and patchy alveolar infiltrates, peribronchial thickening, and focal consolidation throughout both lung field.,Staphylococcal pneumonia,More common in neonate and infants Present a sudden onset and progress quickly Signs include: rashes, severe toxic symptoms, digestive symptoms, convulsion and shock Signs vary with stage of disease Consolidation of lung is obvious Chest X-ray reveals infiltrates, abscess and bullae of lung,Abscess of lung,Frontal views : Multiple round high density shadow in both sides,Pyopneumothorax,Encapsulated pleural effusion,Pulmonary Bulla,Female，7 day，hyperpyrexia and no crying CXR: multiple giant air-containing cavity,Common cause of symptomatic pneumonia in older children Fever, dry cough are common symptoms Extrapulmonary complications sometimes occur Chest radiographs are untypical, usually demonstrate interstitial or bronchopneumonic infiltrates,Mycoplasma pneumonia,Interstitial infiltrates in Mycoplasma pneumonia,A 5-year-old boy complain of fever and cough. MP antibody (+) Frontal views of CXR: Increased lung markings Diffuse patchy infiltrates Volume loss of lower lobes of bilateral lung Enlarged hilar shadow,Peak age of onset Clinical manifestation Laboratory examination X-ray examination Others,Diagnosis,Acute bronchitis Pulmonary tuberculosis Foreign body in bronchus,Differential Diagnosis,Nursing and supporting therapy Symptomatic treatment： Oxygen supply Conscious sedation P