课件：郑湘榕肺炎课件上课用.ppt

同学们好！,呼吸系统疾病 Respiratory System Disease,湘雅医院儿科 郑湘榕,婴幼儿上感、2种特殊类型上感的特点 支气管肺炎临床表现、重症肺炎特点 支气管肺炎的诊断、治疗 支气管哮喘的临床表现、诊断和治疗,重点,Introduce,In pediatric outpatient, 6o% patients are acute respiratory infections. In pediatric ward, 25% patients are Pneumonia. The first cause of childrens death in China is Pneumonia. Pneumonia is the worlds leading cause of death among children. It kills nearly two million children under age five every year.,Why children are so susceptible to acute respiratory infections,?,breathed in (inspired) breathed out (expired) Nasopharynx Orapharynx Larynx Epiglottis Trachea Right bronchi Left bronchi Alveoli,anatomic physiological features,The childrens respiratory lumens are narrow, blood flow is abundant. The childrens repertory ability is low. The childrens local immunity is low.,Children Respiratory System Physiologic Feature,Respiratory rate,Neonate 40-44/min 1year 30/min 2-3years 24/min 4-7years 22/min 8-14years 20/min,Children Respiratory System Physiologic Feature,Respiratory type,Abdominal respiration Thoracic abdominal respiration,hysical examination inspection Change of respiratory rate Cyanosis Three depressions sign uscultation,Examine Method,uscultation 吸气喘鸣（inspiratory strider） 呼气喘息（expiratory wheeze） 哮鸣音 中、粗湿罗音 细湿罗音,Examine Method,急性上呼吸道感染（AURI） Acute Upper Respiratory Infection,Etiology,irus： ccupy 90% acteria： econdary Streptococus pyogens Pneumococcu aemophilus influenzae,Common AURI,Local symptom is mild,In infant and toddler,Systemic symptom is severe,Complications are common,Clinical Manifestations,School age,Tympanitis, sinusitis,Abscess of pharynx posterior-wall,Laryngitis, bronchitis,Infant , toddler,Pneumonia,Glomerulonephritis,Rheumatic fever,Complications,Common AURI,hysical examination,Congestion of pharyngeal portion, antiadoncus (咽部充血，扁桃体肿大) Lymphadenectasis in submaxilla (有时下颌、淋巴结肿大) Rash when enterovirus infection (肠道病毒感染时可出现皮疹),Clinical Manifestations,Special AURI,柯萨奇病毒A组感染 夏秋好发 高热、咽痛、流涎 咽腭弓、软腭处有疱疹 疱疹破溃后可形成溃疡 病程 1 周左右,Clinical Manifestations,Herpangina 疱疹性咽峡炎,Pharyngo- conjunctival fever 咽结合膜热,腺病毒 3，7 型所致 春夏发病，可小流行 发热、咽炎、结合膜炎 咽部充血、结合膜充血，颈部、 耳后淋巴结肿大 病程 12 周,Clinical Manifestations,Special AURI,Antivirus drugs,中药,Ribovirin,3-5 days,Antibiotics,Penicillin,Cephalosporin Macrocyclic lactone,3-5 days,Sever symptomatic;,Secondary bacteria affection,Treatment,Defervesce,Drugs：对乙酰氨基酚，布洛芬,Physics methods,Febril convulsion,Calm,Stop convulsion,Defervesce,Treatment,中国0-5岁儿童急性发热诊断处理指南 2008,婴幼儿上感、2种特殊类型上感的特点 支气管肺炎临床表现、重症肺炎特点 支气管肺炎的诊断、治疗 支气管哮喘的临床表现、诊断和治疗,重点,Pneumonia,肺 炎,Children familiar disease,Introduction,Pneumonia affects 156 million children under the age of 5 yrs Leading cause of mortality in under 5 yrs Most of these deaths preventable Most effective intervention-Early diagnosis and appropriate management The hospitalization number of infant and toddler is 39.5 times of school age,Williams et al. Lancet Infect Dis, 2002,Worlds biggest killer,Introduction,Pneumonia (18%) and diarrhea(15%) are the leading killers in children. They took nearly 3 million children lives in 2008 alone. (两种疾病在2008年一年就夺走三百万儿童的生命) In children ages 0-59 months: 0-59月的儿童 Pneumonia caused nearly 1.6m deaths Diarrhea caused more than 1.3m deaths,Black et al, Lancet 2010,Pneumonia is an inflammation of the parenchyma of the lungs,It is caused by microorganisms or noninfectious causes,Manifested by fever,cough, tachypnea , respiratory distress and rales,Definition,On course of illness,Acute： 3 months Deferred：13 months,Classification 1,On the etiology,Mycoplasma,Chlamydia, parasites ,fungi,Noninfections causes,Classification 3,On the severity of illness,Mild symptomatic,Severe symptomatic Besides symptoms of respiratory system, concomitant manifestations of other organ systems are present,Classification 4,on typical of clinical manifestation,Typical pneumonia,untypical pneumonia Severe acute respiratory syndrome, (SARS) coronavirus,Classification 5,On Occurrence Region,Community Acquired Pneumonia CAP,Hospital Acquired Pneumonia HAP,Classification 6,支气管肺炎,Bronchopneumonia,Etiology,virus,Main cause of pneumonia in developed country RSV,bacteria,Main cause of pneumonia in developing country S. pneumoniae,Pathology,Pathologic physiology,气道炎症,循环系统,神经系统,水电解质,消化系统,肺A压增高,中毒性 心肌炎,心衰,代酸,中毒性 肠麻痹,胃肠粘膜 屏障功能,脑水肿,颅压,呼酸,K+,水钠储留,毒血症,通气不足 PaO2,PaCO2 换气障碍 PaO2,Clinical manifestation,Mild symptomatic,respiratory system,fever,respiratory distress nasal flaring, retractions,cyonosis,tachypnea,cough,rales,5 years RR30次/分,Rapid breathing,Clinical manifestation,5 years RR30次/分,Clinical manifestation,Severe symptomatic,circular system symptom,Cardiac muscle inflammation,Heart failure,Clinical manifest,Severe symptomatic,Heart failure,呼吸突然加快，60次/分 心率突然增快 婴儿180次/分幼儿160次/分 突然烦躁不安、面色发灰 心音明显低钝，奔马率，颈静脉怒张 肝大肋下3cm以上 尿少、下肢浮肿,Clinical manifest,nerval system,Light hypoxia： irritability，lethargy,Sever hypoxia： hydrocephalus,digestive system,alimentary canal bleeding,Poisoning intestine palsy,Severe symptomatic,Clinical manifest,DIC,Bp,四肢凉，脉速弱， 出血,SLADH,Na + 130mmol/L 渗透压 270mOsm/L,Edema,Severe symptomatic,Complications,Complication,pneumatocele,pyopneumothorax,empyema,2019/8/31,45,可编辑,Laboratory data,Blood,blood routine,bacteria infect：WBC、N left shift of nucleus virus infect：WBC、L abnormal lymph cell,bacteria infect ： CRP virus infect ：CRP normal,CRP,NBT,bacteria infect ： 10% virus infect ： 10%,Pathogeny,virus separate,Germiculture,sputum for Gram stain and culture,Laboratory data,X-ray,shadow of dot and spote,emphysema atelectasis,支气管肺炎,正常胸片,大叶性肺炎,正常胸片,fever,cough, tachypnea , respiratory distress and rales,X-ray,diagnosis,Differentiation,foreign bodies in bronchi,history of foreign bodies、sudden cough、 respiratory distress、lower of breath tone or wheezing,Treatment,general treatment,Balance of water and electrolyte 3%Nacl 12ml/LNa+10mmol/L,Temperature 18-20 Humidity 60% Food nutritive,Treatment,Control infection,virus：no ideal drug like virozol,mycoplasma、chlamydia select erythromycin,bactrria：the principle of sensitivity efficiency、full period of treatment, first select Peniccilin,Treatment,抗生素 使用原则,根据药敏选药 adopt sensitive drugs on the basis of pathogenic bacterium 用下呼吸道浓度高的药物 adopt drugs which can finally infiltrate lung tissue 足量足疗程重症静脉给药 in severe case,drugs should be administed by vein , full dose, full period,Bacteria, the commonest pathogen,Despite variation in study results, S. Pneumoniae ,Staph aureus, H influenzae Identified as major pathogens in developing countries,Pneumonia : Microorganisms,Pneumonia : microorganisms,Mixed infection : 8-40% (Viral / bacterial or more than 1 bacteria) Most common combination S pneumoniae + RSV or S pneumoniae + Mycoplasma,Kabir ARML. Aetiology of ALRTI in infancy2003,Organism isolation rate : 11.69% Staph aureus (42%) Strep Pneumoniae (20%) H Influenzae (7%) P aeroginosa (5.3%) coming up- previously not recognized,Severe pneumonia Evaluation Antimicrobial Research (SPEAR)2007,All were susceptible to 3rd gen cephalosporin,Treatment,full period of treatment,after temperature normal 5 7days or clinical symptom disappearing 3 days Mycoplasma pneumonia： 23 weeks Staphylococus aureus ： after temperature normal 2 weeks ， full period is 6 weeks,treat against symptoms,Treatment,oxygen treat,PaO2：dyspnea、 cyanosis、asthma suppress、“toxic appearance,“ methods: by nose canal 0.5 1 L /min，40%； by veil 24 L/min,50%60% mechanism ventilate （ respire failture）,holding respiratory tract unobstructed,remove sputum、 pulverization 、 relieve spasm ensure liquid absorb,Treatment,treat of other symp,defervesce calm,treat of windy,supply Kalium Poisoning intestine palsy：fasting、decompress of stomach and intestine 酚妥拉明 0.5 mg/kg ivgtt 10%GS 20 ml,treat against symptoms,Treatment,treat of Heart failure,镇静 给氧 强心：西地兰 减轻心脏负荷,treat against symptoms,Treatment,中毒性脑病 治疗,脱水：甘露醇 改善通气 扩血管药物：酚妥拉明，654-2 止痉：安定，鲁米那 糖皮质激素：地塞米松 神经营养,treat against symptoms,Treatment,糖皮质激素 应用,适应症： 喘憋重,呼吸衰竭 全身中毒症状重 感染性休克 脑水肿,琥珀酸氢化可的松5 10 mg/kg.d 地塞米松0.1 0.3 mg/kg.d ivgtt 23 次/日35 天 甲基强的松龙 2 4 mg/kg.次,Response to treatment in otherwise uncomplicated CAP?,Fever- falls in 2 days Leucocytosis- decreases in 4 days Physical findings persist slightly longer Chest radiographic abnormalities may take 4-12 weeks to resolve,What if patients fails to recover?,You should consider-,Noninfectious condition Resistance to drug New nosocomial pathogen,病毒性 肺炎,呼吸道合胞病毒肺炎,腺病毒肺炎,2岁，2 6月多见 喘憋、呼吸困难，可合并 呼衰、心衰 哮鸣音，细湿罗音 小点片状影，肺气肿肺不张 间质性肺炎,6月 2岁 中毒症状重，稽留热， 咳剧，喘憋，呼吸困难 出现晚，湿罗音或肺实变 胸片改变出现早，肺气 肿，片状影或融合,年龄,症状,胸片,体征,细菌性 肺炎,葡萄球菌肺炎,新生儿，婴幼儿 急、重、快，弛张热或稽留热， 咳嗽，呼吸困难，呻吟，易致 迁徒化脓病灶，并发脓胸，脓 气胸，肺大疱 中细湿罗音，出现早，皮疹 浸润影，持续时间较长，易变， 可见多发性肺脓肿，脓胸，脓气 胸等,4岁 慢，重，发热，痉挛性 咳嗽，呼吸困难，发绀。 易致迁徒化脓病灶，易并 发脓胸 湿罗音或实变 大叶性肺炎、支气管肺炎、 肺实变,年龄,症状,体征,胸片,革兰阴性杆菌肺炎,肺炎支原体肺炎,年长儿，婴幼儿 发热、刺激性咳嗽，多系统病变 不明显，婴幼儿可有呼吸困难， 喘憋，哮鸣音，湿罗音 肺门影增浓；支气管肺炎改变； 间质性肺炎；均一实变影,6月 起病慢，无发热，先URI 症状后咳、喘、气促，部 分伴结膜炎 湿罗音，持续时间长 间质性炎症，过度充气、 片状影，持续时间长,年龄,症状,体征,胸片,沙眼衣原体肺炎,支衣原体 肺炎,支原体 肺炎,支气管哮喘 bronchial asthma,发展史,asthma-喘息，2000年前就有对哮喘的详细描述 过去认为是一种平滑肌功能异常性疾病 80年代以来通过支气管黏膜活检， 认识到哮喘是气道慢性炎症性疾病,Definition,chronic airway inflammation,airway hyperreactivity(AHR) reversible airway obstruction,manifested by wheezing, respiratory distress ,cough,特征,气道慢性炎症：此为哮喘主要特征 可逆性的气流受限：指气流受限可被支气管 扩张剂所逆转 气道高反应性：对正常气道无反应或很小反 （AHR） 应的刺激产生收缩反应,pathology,naked eye：emphysema,mucus blot scope: inflammatory cell infiltrate， gland hyper plasia basal membrance thickening,病理生理,急性支气管痉挛：速发型哮喘反应（IgE依赖） 气道壁肿胀：迟发型哮喘反应（炎症诱导） 粘液栓形成：难治疗的气流受限 气道重塑：不可逆的气道狭窄,核心,气流受限,atopy,是指对普通环境中常见的变应原产生IgE介导反应的易感性，有明显的家族遗传倾向。,特应性,哮喘、过敏性鼻炎、湿疹、食物过敏等,导致哮喘发生最确定的危险因素,pathogenesis,immunity factor,atopy,IgE ,nerve energy factor,- adrenal gland nerve, - adrenal gland nerve,Pneumogastric nerve,various inflammatory cells into airway,AHR,Inherit factor,genetic disease,family history,Clinical manifest,older children sensitizin induce infant and toddler viral infection induce,period of onset symptoms of bronchial spasm- cough ,gasp catabasis may no signs and symptoms,rapid serious attack, reasonable utilize para-sympathesis drug cannot relief in 24 hours,status asthmaticus,auxiliary examination,X-ray,lung function,skin test,FEV1/FVC （一秒用力呼气容积/ 用力肺活量 ，低于70-75提示气流受限）,PEFR （呼气风流速，其日间变异率20%,使用支扩剂后增加20% 可诊断哮喘）,Diagnose of children asthma,gasp recurrent attacks lung wheezing rales reversible airway obstruction exclude other disease that can cause gasp,cough4 weeks,antibiotics treat is invalid bronchodilators can relieve cough hypersensitive history or allergi