肺炎的诊断治疗

Pneumonia肺炎问鼎不治之症1919流感大流行1950s青霉素发现之前1976嗜肺军团菌1990s年PRSP1999禽流感2003年SARS冠状病毒肺炎当前：超级细菌DefinitionPneumoniaisaninflammationofthelungs(pulmonaryparenchyma)causedbyaninfectionMechanismofinfectionAspirationMicroaspirationoforopharyngealcontentsduringsleepGrossaspirationnormallyoccursonlyinthosewithalteredsensorium,depressedconsciousnessInhalationofaerosolizeddropletBloodstreamspread三种解剖分型

6interstitialpneumonia百草枯中毒04.11.04百草枯中毒04.11.10百草枯中毒04.11.17EtiologicalClassificationBacterialpneumoniaAtypicalpneumoniaViralpneumoniaFungalpneumoniaOthersClassificationbytheSiteofInfectionCommunity-acquiredpneumonia(CAP)Hospital-acquiredpneumonia(HAP)orNosocomialpneumonia(NP)Healthcareassociatedpneumonia(HCAP)Pneumoniainimmunocompromisedhosts9CommonpathogensofCAP其他卡他10%流感25%肺链40%1.RussellW.Steel.InfectionsinMedicine.Vol.14(suppl.)PP9-11199710Spneumoniaethemostcommoncauseofbacterialpneumonia11HinfluenzaePneumoniafromHinfluenzaeoftenisassociatedwithdebilitatingconditionssuchasasthma,COPD,smoking,andacompromisedimmunesystem.12MycoplasmapneumoniaeMpneumoniaeisacommoncauseofmildpneumoniaandusuallyaffectspeopleyoungerthan40.Variousstudiessuggestthatitcauses15-50%ofallpneumoniainadultsandanevenhigherpercentageofpneumoniainschool-agedchildren.Peopleathighestriskformycoplasmapneumoniaincludethoselivingorworkingincrowdedareassuchasschoolsandhomelessshelters,althoughmanypeoplewhocontractmycoplasmapneumoniahavenoidentifiableriskfactor.

13Legionella

Legionnaire'sdiseasewasfirstdescribedin1976afteranoutbreakoffatalpneumoniaataLegionnairesconvention.ThenewlydescribedorganismwhichcausedthediseasewasnamedLegionellapneumophila,showninthispicture.(ImagecourtesyoftheCentersforDiseaseControlandPrevention.)ClinicalManifestationsPrecursorysymptomCoughSputumDyspneaFeverAtypicalinelderlyorinImmunocompromisedhost

15Additionalsymptomspleuriticchestpain，abdominalpain，

consciousnessdisorders

-------pneumococcalinfectionheadaches,malaise,nausea,vomiting,anddiarrhea-------Legionella,Chlamydia,orMycoplasmaspecies.

16重要表现及并发症重要表现气急紫绀病变广泛、ARDS

出血点DIC、败血症巩膜黄染败血症低血压休克并发症休克、胸膜炎、脓胸心包炎、脑膜炎和关节炎

ClinicalManifestationsinspectionpalpationpercussionAusculation

18实验室和其它检查血液检查(血常规、炎性指标、血清学、血培养)痰涂片及痰培养(痰、纤支镜)尿抗原实验经皮细针穿刺细胞学或肺活检影像学1920LobarPneumoniaStaphylococcusPneumoniaViralPneumoniaAconed-downviewofthechestdemonstratesfinetomediumheterogeneousreticularopacitiesinbothlowerlobes.ThispatternisthemosttypicalseenwithcytomegalovirusPneumocystisCariniiPneumoniaWithPneumothorax香港SARS病例26细菌性肺炎诊断标准主要标准次要标准胸片：新出现或进展性浸润影发热或体温不升呼吸道症状体征：叩诊浊音、管状呼吸音、罗音白细胞，N%27病情评估年龄、基础病、意识障碍高热或低温、R>30,P>125,BP<90/60mmHgWBC、PLT、PH<7.3,PO2<60mmHg,BUN及Cr升高，X线多叶病变或胸水，菌血症或肺外病灶中国CAP指南重症肺炎判断出现下列征象中1项或以上者意识障碍呼吸频率≥30次/minPaO2＜60mmHg,PaO2/FiO2＜300,需行机械通气动脉收缩压＜90mmHg并发脓毒性休克胸片双侧或多肺叶受累，或入院48h内病变扩大≥50％尿＜20ml/h,或＜80ml/4h，或并发急性肾功衰需要透析29aSARSpatient4daysafteronsetofsymptomstwodayslater

30鉴别诊断

31结核中毒症状肺实变历久不消散，多位于肺尖伴空洞，肺内播散肺结核(干酪性肺炎)32TUBERCULOSIS33LUNGCANCER34pulmonaryembolism35ForeignBodyAspiration36Bronchiectasis37LungAbscess38其他鉴别疾病间质性肺炎肺水肿肺血管炎社区获得性肺炎的治疗CAPguidelinesAustralia2000InformationtobeupdatedCanada2000CanadianInfectiousDiseasesSociety/CanadianThoracicSocietyChina1999/2006中华医学会呼吸病学分会France2001FrenchSocietyofInfectiousDiseasesGermany2000GermanRespirAssociation/PaulEhrlichSocietyforChemotherHongKong2001HongKongUniversityandHongKongHospitalAuthorityJapan2001/2005JapanRespirSocietyCAPTreat.GuidelineCreationCommitteeLatinAmerica2002AsociaciónLatinoamericanadelTóraxThePhilippines1998PhilippineSocietyforMicrobiologyandInfectiousDiseasesPortugal2000PortugueseRespiratorySocietySingapore2000PhysiciansAcademyofMedicineofSingaporeSouthAfrica1996SouthAfricanPulmonarySociety/AntibioticStudyGroupSouthAmerica2001ConsenSurSouthAmericanWorkingGroupSpain2001SpanishRespiratorySociety/SpanishSocietyofChemotherapyUK2001BritishThoracicSocietyUSA98/03/05/07ATS/CDC/IDSAEtiologyofCAP国家/年度,样本量S.Pneumoniae(%)Hflu(%)M.Pneumoniae(%)C.Pneumoniae(%)瑞典/2003,n=17732.028.018.05.0芬兰/2001,n=30441.13.99.99.9西班牙/1999,n=22823.92.31.313.5西班牙/1999,n=22729.011.05.07.0阿根廷/2000,n=34624.012.013.08.0加拿大/2005*,n=5075.94.915.012.0中国台湾/2005，n=16823.84.814.37.1中国大陆/2006，n=61010.39.220.76.6*Ambulatorypatients中华医学会呼吸分会06年CAP指南

推荐初始经验性应用抗生素－门诊治疗青壮年&无基础疾病老年人/有基础疾病青霉素/阿莫西林多西环素大环酯第I/II代头孢呼吸喹诺酮第II代头孢±大环酯b内酰胺/酶抑制剂±大环酯呼吸喹诺酮43有基础疾病或有危险因素的社区获得性肺炎β-内酰胺类加大环内酯、或加呼吸氟喹诺酮药物当有铜绿假单胞菌感染危险因素时（如结构性支气管异常），可选用抗铜绿假单胞菌β-内酰胺类联合环丙沙星或联合氨基糖甙及呼吸氟喹诺酮/大环内酯。CAP的简化治疗方案肺炎链球菌不典型致病菌肺结构异常肺结构正常铜绿假单胞菌PRSPPSSP/PISP阿莫西林+/-BLI2ndGCs或曲松呼吸喹诺酮高级大环酯呼吸喹诺酮抗铜绿假单胞b-内酰胺呼吸奎诺酮，氨基糖苷吸入性肺炎克林霉素或阿莫西林+/-BLI45重症肺炎

强效、足量、联合重症CAP:

-内酰胺＋新大环/呼吸喹诺酮

-内酰胺过敏：呼吸喹诺酮±克林霉素

抗生素疗程和静脉-口服转换欧美指南关注抗生素疗程和静脉-口服转换抗生素疗程至少5天，通常为7～14天，军团菌肺炎至少14天静脉-口服转换时机(LevelII证据)血液动力学稳定临床状况改善胃肠道功能正常47短期治疗不佳时应考虑几点细菌耐药，未能覆盖致病菌其它特异性感染，如TB、真菌、病毒等并发症、或基础病未控制误诊、误治药物热等48治疗（2）支持治疗休息，能量补充监测体温、血压、尿量等对症治疗并发症治疗49院内肺炎(HAP)入院时不存在、也不处于潜伏期于入院48小时后发生VAP：机械通气后48h50院内肺炎的病原谱克雷伯杆菌绿脓杆菌不动杆菌肠杆菌大肠杆菌葡萄球菌MRSA/MRSE其它：真菌肺炎球菌卡氏肺囊虫军团病…51HAP的抗生素选择抗铜绿假单胞的b内酰胺/酶抑制or碳氢酶烯+呼吸奎诺酮or氨基糖苷类MDR的球菌--万古霉素/替考拉宁/利赖唑胺53Staphylococcuspneum