郑湘榕肺炎上课用

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)NasopharynxOrapharynxLarynxEpiglottisTrachea Right bronchiLeft bronchiAlveoli,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/min60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,Laboratory data,Blood,blood routine,bacteria infect：WBC、N left shift of nucleus virus infect：WBC、Labnormal 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 electrolyte3%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 sensitivityefficiency、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 infiltratelung tissue 足量足疗程重症静脉给药in severe case,drugs should be administedby 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 periodof treatment,after temperature normal 5 7days or clinical symptom disappearing 3 daysMycoplasma pneumonia： 23 weeksStaphylococus aureus ： after temperature normal 2 weeks ， full period is 6 weeks,treat against symptoms,Treatment,oxygentreat,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 spasmensure liquid absorb,Treatment,treat ofother symp,defervesce calm,treat ofwindy,supply KaliumPoisoning 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 ofHeart 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 ivgtt23 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 daysLeucocytosis- decreases in 4 days Physical findings persist slightly longerChest radiographic abnormalities may take4-12 weeks to resolve,What if patients fails to recover?,You should consider-,Noninfectious conditionResistance to drugNew 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,20%,使用支扩剂后增加20% 可诊断哮喘）,Diagnose of children asthma,gasp recurrent attackslung wheezing ralesreversible airway obstructionexclude other disease that can cause gasp,cough4 weeks,antibiotics treat is invalidbronchodilators can relieve coughhypersensitive history or allergia family historyairway is hyperreactivityexclude other cough disease,Diagnose of cough variant asthma,therapy,Principle: long-term 、 persistence、standard、individuationPeriod of onset:antiinflammatory、calm gaspcatabasis:long-term 、 antiinflammatory、avoid trigger factor、self-careto spread Global Initiative for Asthma，GINA(全球哮 喘防治创议),drug,glucocorticoid-first select bronchodilators immunosuppressant other drug,inhale：beclometasone 100 g，24times/day oral：prednisone12 mg/kg/day，17daysevere casepersisten