内科学-肺炎-胡必杰

5/31/2020,Dr.HUBijie,1,RespiratoryDiseasesPneumonia肺炎,Dr.BijieHU（胡必杰）ZhongshanHospitalofFudanUniversityShanghai,5/31/2020,Dr.HUBijie,2,SeminRespirInfect9(3):140-52，1994,mortality(per10000),MortalityTrendswithPneumoniafrom1900to1990inUSA,0,20,40,60,80,100,120,140,160,180,200,1900,1910,1920,1930,1940,1950,1960,1970,1980,1990,Pneumoniaisnotthe“captainofdeath”anymore?,5/31/2020,Dr.HUBijie,3,2002年9月歌手高枫因卡氏肺孢子虫肺炎（PCP）不治身亡,5/31/2020,Dr.HUBijie,4,5/31/2020,Dr.HUBijie,5,5/31/2020,Dr.HUBijie,6,19902020CardiovasculardiseaseCerebrovasculardiseasesLowerrespiratoryinfectionsDiarrheaPerinataldiseaseCOPDTuberculosisMorbilliTrafficaccidentsLungcancer,GastriccancerHIVsuicide,Editorial,Lancet,1997,349:1263.,MortalityForecastbyWHO,5/31/2020,Dr.HUBijie,7,Whatispneumonia?,Tothepathologistaninfectionofthealveoli,distalairways,andinterstitiumofthelungincreasedweightofthelungs,consolidationalveolifilledwithWBC,RBC,andfibrinTotheclinicianfever,chills,cough,pleuriticchestpain,sputumproduction,hyper-orhypothermia,increasedrespiratoryrate,dullnesstopercussion,bronchialbreathing,egophony,crackles,wheezes,pleuralfrictionrubopacityonchestradiography,5/31/2020,Dr.HUBijie,8,Definition,Pneumoniaistheinflammationoflowerrespiratorytractsincludingalveoli,interstitialtissues,andbronchiolebythemicroorganisms,chemicalirritationsorbyanimmunologicalprocess,5/31/2020,Dr.HUBijie,9,Classifications?,Lobar(segmental)lobular(bronchopneumonia)interstitial,5/31/2020,Dr.HUBijie,10,Classifications183S-187S,5/31/2020,Dr.HUBijie,21,IsolationRatesofVariousPathogens,Hubijie,etal.EpidemiologicalSurveyonthePathogenicSpectrumofCAPinChina,2005,5/31/2020,Dr.HUBijie,22,259BacterialStrainsIsolatedfromCAP,Bacterianame,#strains,proportion%,Hubijie,etal.EpidemiologicalSurveyonthePathogenicSpectrumofCAPinChina,2005,5/31/2020,Dr.HUBijie,23,PathogensofAtypicalPneumonia,LegionellasppMycoplasmapneumoniaeChlamydiapneumoniaeChlamydiapsittaciCoxiellaburnetiiFrancisellatularensisPCPPneumocystiscariniipneumoniaInfluenzaA/BRSVrespiratorysyncytialvirusCMVcytomegalovirusAdenovirusSARSCoronavirusSARS,FileTMJr,etal.InfectDisClinNorthAm.1998;12:572.LevisonME.HarrisonsPrinciplesofInternalMedicine.McGraw-Hill;1998:1439.BartlettJG,etal.ClinInfectDis.1998;26:821,Table9.,5/31/2020,Dr.HUBijie,24,ProportionofAtypicalPathogensinCAP,Hubijie,etal.EpidemiologicalSurveyonthePathogenicSpectrumofCAPinChina,2005,5/31/2020,Dr.HUBijie,25,Manifestation,SystematicoftenprecededbyaURIsuddenonset,shakingchill,Feverother:nausea,vomiting,malaise,andmyalgiasLocalpainwithbreathingontheaffectedside(pleurisy)Cough：(dryinitiallybutusuallybecomesproductive,dyspnea,andsputumproduction）SignT:3840.5;pulseisusually100to140beats/min;respirationsaccelerateto20to45breaths/min.lobarconsolidation;crackles;pleuraleffusion,5/31/2020,Dr.HUBijie,26,Independentriskfactors,alcoholism(RR9)asthma(RR4.2)immunosuppression(RR1.9)ageof70years(RR1.5vs.anageof60to69years)pneumococcalpneumonia:dementia,seizures,congestiveheartfailure,cerebrovasculardisease,tobaccosmoking,alcoholism,COPD,HIVLegionnairesdisease:malegender,currenttobaccosmoking,diabetes,hematologicmalignancy,cancer,end-stagerenaldisease,andHIVinfectionGNB:probableaspiration,previoushospitaladmission,previousantimicrobialRx,bronchiectasis,heavydrinkers,5/31/2020,Dr.HUBijie,27,Modifyingfactorsthatincreasetheriskofinfectionwithspecificpathogens,5/31/2020,Dr.HUBijie,28,GeneralLabExaminations,Bloodtests：leukocytosiswithashifttothelefthypoxemiarespiratoryalkalosis,5/31/2020,Dr.HUBijie,29,5/31/2020,Dr.HUBijie,30,DiagnosisClinical,Fever380CNewcough,sputum,hemoptysis+PleuriticchestpainWBC10109or25neutrophilsand85yr40%Untreated50%-90%,5/31/2020,Dr.HUBijie,39,PatientPointscharacteristicsassignedDemographicfactorsAge:malesage(inyrs)femalesage(inyrs)-10Nursinghomeresident+10ComorbidillnessesNeoplasticdisease+30Liverdisease+20Congestiveheartfailure+10Cerebrovasculardisease+10Renaldisease+10,PhysicalexaminationfindingsAlteredmentalstatus+20Respiratoryrate30/min+20Systolicbloodpressure125/min+10LaboratoryfindingspH10.7mmol/L+20Sodium13.9mmol/L+10Hematocrit30/minPaO2/FiO2ratio250mmHgDiffusebilateralinvolvementormultiplelobesB.P.90mmHgsystolicB.P.2yrandadultsatincreasedriskforpneumococcaldiseaseoritscomplications;olderadultsdurationofprotection:5yr(revaccinatedin1billiondollars/yearinUS.Hospitalstayincreasesby7-9days；,5/31/2020,Dr.HUBijie,60,Pathogenesis,Invasionofthelowerrespiratorytractby:Aspirationoforopharyngeal/GIorganismsInhalationofaerosolscontainingbacteriaHematogenousspread,5/31/2020,Dr.HUBijie,61,ColonizationAspiration,HAP,MRSA*,5/31/2020,Dr.HUBijie,62,AcinetobacteronlyinfectshighlydebilitatedpatientsWithrelativelylowmortality8-12%H.RichetICAAC2004Abstract#403,Noantibioticsincaseofcolonization,5/31/2020,Dr.HUBijie,63,RiskFactors,HostFactorsExtremesofage,severeillnesses,immunosupression,coma,alcoholism,malnutrition,COPD,DMEnhanceoropharynxandstomachcolonizationICU,antibiotics,endotrachealintubation,etc.FavoringaspirationorrefluxSupineposition,depressedconsciousness,endotrachealintubation,insertionofnasogastrictubeMechanicalventilationImpairedmucociliary,secretionpoolinginsubglotticarea,contaminatedequipmentandhandsofHCWsImpedeadequatepulmonarytoiletHeadandnecksurgery,trauma,sedationetc.,5/31/2020,Dr.HUBijie,64,EtiologicAgents,S.aureusEnterobacteriaceaeP.aeruginosaAcinetobactersp.PolymicrobialAnaerobicbacteriaLegionellasp.Aspergillussp.Viral,5/31/2020,Dr.HUBijie,65,EtiologicAgents,MildtomoderateHAPorearlysevereHAPStreptococcuspneumoniaeHaemophilusinfluenzaMSSAKlebsiellaPneumoniaeEnterobacter,Ecoli,Proteus,SerratiaSevereHAPPseudomonasAcinetobacterMRSA,5/31/2020,Dr.HUBijie,66,BugsofHosp-acquiredpneumonia,5/31/2020,Dr.HUBijie,67,Diagnosis,Clinicalfever;coughwithpurulentsputumRadiographicneworprogressiveinfiltratesonCXR,LaboratorialleukocytosisorleukopeniaMicrobiologicSuggestivegramstainandpositiveculturesofsputum,trachealaspirate,BAL,PSB,pleuralfluidorbloodQuantitativecultures,5/31/2020,Dr.HUBijie,68,Differentialdiagnosis,ARDSPulmonaryedemaPulmonaryembolismAtelectasisAlveolarhemorrhageLungcontusion,5/31/2020,Dr.HUBijie,69,AntimicrobialTherapy,0%,20%,40%,60%,80%,100,%,Luna,1997,Ibrahim,2000,Kollef,1998,Harbarth,2003,Rello,1997,Alvarez-Lerma,1996,Initialadequatetherapy,Initialinadequatetherapy,Alvarez-LermaFetal.IntensiveCareMed1996;22:387-394.RelloJetal.AmJRespirCritCareMed1997;156:196-200.HarbarthSetal.AmJMed2003;115:529-535.KollefMHetal.Chest1998;113:412-420.IbrahimEHatal.Chest2000;118:146-155.LunaCMetal.Chest1997;111:676-685.VallesJetal.Chest2003;123:1615-1624.,Mortality,Valles,2003,MortalityinCriticallyIllICUPatients,5/31/2020,Dr.HUBijie,70,RatesofResistanceAmongNosocomialInfectionsReportedinIntensiveCareUnitPatientsComparisonof2002withHistoricalData,Vancomycin/enterococciMethicillin/S.aureusMethicillin/CNS3rdCeph/E.coli*3rdCeph/K.pneumoniae*Imipenem/P.aeruginosaQuinolone/P.aeruginosa3rdCeph/P.aeruginosa3rdCeph/Enterobacterspp.,1997-2001(+/-standarddeviation)*,January-December,2002,27.5%,57.1%,89.1%,6.3%,14.0%,32.2%,30.2%,22.3%,32.8%,%Resistance,/ncidod/hip/NNIS,5/31/2020,Dr.HUBijie,71,NPRSSummaryofResults