儿科学理论课七年制肺炎

1、Pediatrics,Childhood pneumonia,Zhi-min Chen 陈志敏 Dept. Pediatric Pulmonology Email: zmchen,Allergic disorders asthma Congenital anomalies Obstructive sleep apnea Foreign body aspiration Neoplastic diseases,Infections,Others,Respiratory diseases in children,Respiratory infections,-Infections of the up

2、per respiratory tract Cold(nasopharyngitis) Sinusitis Uvulitis Tonsillitis Pharyngitis Laryngitis,Respiratory infections -infections of lower respiratory tract, Bronchitis Bronchiolitis Pneumonia,Childhood Pneumonia,Pediatrics,Importance of childhood pneumonia,Four to five million annual deaths bein

3、g reported in children younger than 5 yrs, Ranking among the most frequent causes of both mortality and morbidity, especially in developing countries.,China had the highest number !,Bull WHO,2008;86(5):408,Bull WHO,2008;86(5):408,Pneumonia: the leading cause of death!,Pneumonia is the leading cause

4、of death in young children in China,中华预防医学杂志，2005;39(4):260,Definition,Pneumonia inflammation of the lung tissue with the common features of fever, cough, dyspnea, tachypnea and fine moist rales on auscultation.,Classification,Pneumonia can be classified by presumed or proven etiology Bacterial, Vir

5、alor noninfectious by source Community-acquired pneumonia(CAP) Hospital-acquired pneumonia(HAP) or Nasocomial pneumopnia(NP),Classification,Definition: CAP pneumonia occurring 48 hr of hospital admission ( untreated and immunocompetent) HAP pneumonia occurring 48 hr after hospital admission (with ri

6、sk factors for MDR bacteria),Classification,Pneumonia can also be classified by Duration as acute(3m) Severity as mild or severe Pathology as lobar, bronchopneumonia or interstitial pneumonia,Etiology,Childhood Pneumonia,Common pathogens of pneumonia,Atypical pathogeens,Mycoplasma: Mycoplasma pneumo

7、niae(MP) Chlamydia: Chlamydia trachomatis(CP) Chlamydia pneumoniae(CT) Legionella: Legionella pneumophilia(LP),Different pathogens in,Different countries or regions Different seasons Different ages Different bases (immunologic),Microbial agents of CAP, according to age,0-20d 4m-4y Group B streptococ

8、cus RSV/IFV/PIV/ADV/RV Gram negative bacilli Streptococcus pneumonia Cytomegalovirus Hemophilus influenza Listeria monocytogenes Mycoplasma pneumoniae 3w-3m Mycobacterium tuberculosis C. Trachomatis 5y-15y RSV/PIV-3 Mycoplasma pneumoniae Streptococcus pneumonia C.pneumoniae Bordetella pertussis Stre

9、ptococcus pneumonia Staphylococcus aureus Mycobacterium tuberculosis,N Engl J Med, 2002,346:429,Predisposing Factors,Bull WHO,2008;86(5):408,Pathophysiology,Childhood Pneumonia,Pathogens Inflammation of Inflammation conducting airway of alveoli airway obstruction thickening of respiratory membranes,

10、 atelectasis obstructive ventilation V/Q imbalance, dysfunction impaired diffusion Toxemia Hypercapnia Hypoxia,Pathophysiology,Toxemia Hypercapnia Hypoxia Respiratory acidosis Metabolic acidosis SIADH Respiratory insufficiency Respiratory failure Pulmonary hypertension Heart failure Toxic myocarditi

11、s Cerebral edema Shock,DIC, etc. Toxic encephalopathy Gastrointestinal failure (Paralytic ileus, GI bleeding, etc.),Pathophysiology,Toxic myocarditis,Pulmonary hypertension,Heart failure,Clinical manifestation,Childhood Pneumonia,Typical pneumonia,Fever (Hypothermia),Cough,Tachypnea,Dyspnea,Rales,Ta

12、chypnea,Normal RR Tachypnea 2m 4045 /min 60/min 12m 3040 /min 50/min 4y 2530 /min 40/min 4y 1825 /min 30/min,Dyspnea,Inspiratory Dyspnea nasal flarings suprasternal ,intercostal and subcostal retractions nodding respiration Expiratory Dyspnea prolonged expiratory time wheezing,Severe pneumonia,Respi

13、ratory failure or insufficiency Heart failure Toxic encephalopathy Cerebral edema Paralytic ileus Gastrointestinal bleeding,Definition of respiratory failure or insufficiency,Respiratory failure PaO250mmHg Respiratory insufficiency PaO245mmHg,Diagnostic criteria of heart failure,Abruptly increased t

14、achypnea 60/m ; Tachycardia 160180 bpm ; Abruptly increased cyanosis, irritability which cannot be explained by Decreased heart sounds and gallop rhythm; Hepatomegaly ; Oligouria and edema,Atelectasis Emphysema Pneumatocele Empyema Pyopneumothorax,Acute Complication,Suggestive signs for acute compli

15、cation,Persistent fever or recurrent fever despite of adequate antibiotic therapy Abruptly deteriorative dyspnea or tachypnea,Long-term complication or sequela,Bronchiectasis due to adenoviral pneumonia Wheezing disorders or asthma afer RSV infection,Laboratory examination,Etiologic examination Non-

16、specific examination Blood gas analysis,Etiologic diagnosis for viral pneumonia: gold standard,Samples Methods NPA or sputum Virus isolation Blood Serology (double samples) (IgG titres increased4 times) NPA: Nasopharyngeal Aspirate,Etiologic diagnosis for viral pneumonia: rapid diagnosis,Samples Met

17、hods NPA or sputum Virus antigen detection (ELISA,CIE, COA,LA,RIA) Virus DNA or RNA (PCR,RT-PCR, Gene probe) Blood Blood sIgM (IgM capture, IFA),Etiologic diagnosis for bacterial pneumonia,Methods: Smear gram-stain and Culture Samples： Lung puncture and biopsy Blood Pleural effusion Tracheal aspirat

18、es or BAL Sputum Throat swab,Etiologic diagnosis for MP: gold standard,Samples Methods NPS or sputum MP isolation Blood Serology (double serum antibody) NPS: Nasopharyngeal Secretion,Etiologic diagnosis for viral pneumonia: rapid diagnosis,Samples Methods NPS or sputum MP antigen detection MP DNA de

19、tection Blood Blood MP-sIgM,Nonspecific examination,Blood WBC +DC Alkaline phosphatase (AKP) activity Enhanced phagocytosis of neutrophils as shown by nitroblue tetrazolium test(NBT) Acute reactants (C-Reactive Protein,CRP) Blood CGA,Blood gas analysis,Determining the severity Instructing management

20、 Predicting outcome,Blood gas analysis,Hypoxemia: PaO245mmHg Metabolic acidosis: pH and BE Respiratory acidosis: pH and PaCO2 Hyponatremia and hypokalemia,Roentgenographic examination,Early changes：increased and hazy lung markings. Typical: small, focal infiltrative lesions to patchy consolidation O

21、thers: emphysema, atelectasis, segmental or lobar consolidation,Diagnosis and differential diagnosis,Childhood Pneumonia,Diagnosis,Preliminary diagnosis is based on clinical features: fever, cough, tachypnea, dyspnea and fine moist rales. It can be confirmed by roentgenographic examination.,Differen

22、tial diagnosis,Bronchitis Pulmonary Tuberculosis Foreign bodies in trachea and bronchus,Differential diagnosis,bronchitis No tachypnea or dyspnea Different feature of rales In infants, it is difficult to differentiate Chest X ray,Differential diagnosis,Foreign body aspiration History of aspiration I

23、mmediate choking and cough Relatively latent period followed with occasional cough, slight wheezing, recurrent lobar pneumonia. Chest X ray: positive shadow, bronchial obstruction sign(atelectasis or emphysema), mediastinum swing.,Foreign body aspiration,Atelectasis,Emphysema,Differential diagnosis,

24、Tuberculosis History of contact with patient No rales chest film PPD test Therapeutic response,Pneumonia with different etiology,RSV Adenovirus Staphylococcus Mycoplasma Chlamydia,RSV: pathology,Bronchioles(75300m) damaged and obstructed: diffuse emphysema and patchy atelectasis,Ciliary epithelium n

25、ecrosis Submucosa edema Lymphocyte infiltration Smooth muscle spasm,RSV: Epidemiology (data from childrens hospital, zhejiang university school of medicine,2000-2001）,Season 3y Cold 39.6 (n=192) 3.6 (n=33) Hot 0.0 (n=83) 0.0 (n=66) total 39.6 (n=275) 3.6 (n=99),RSV: Clinical features-Bronchiolitis,2

26、 year with peak incidence 26 m Peak incidence in cold seasons No fever or low to moderate fever Rhinorrhea and pharyngitis followed by nonproductive cough episodic wheezing (Bronchiolitis) Signs of expiratory dyspnea： prolonged expiratory time and wheezing Heart failure and respiratory failure,RSV:

27、assistant examination,Nonspecific: normal WBC count and L. predominance, normal CRP BGA: hypoxemia, hypercapnia,and acidosis Chest X ray: emphysema Specific: RSV Ag(+), or RSV-RNA(+) RSV-IgM(+),Emphysema,Adenoviral pneumonia: pathology,Characteristic microscopic changes include In severely affected

28、cases, confluent, diffuse infiltrates, necrosis of mucosa with large amounts of exudates and bronchial obliteration may occur.,dense lymphocytic infiltrates, epithelium destruction, focal necrosis of mucous glands, hyaline membrane formation.,Adenoviral pneumonia: Clinical features,Peak incidence 6

29、m2 y Abrupt onset and continued high fever Toxic with neurological disturbances early Severe cough, dyspnea and wheezing Rales and wheezing not detectable until 3 to 7 days after the onset of high fever.,Adenoviral pneumonia: complication,Acute phase: Long-term sequelae:,Heart failure Toxic encephal

30、opathy Pleurisy Secondary bacterial infection,Lung dysfunction Bronchiectasis and COPD,Adenoviral pneumonia: assistant examination,Nonspecific: normal WBC count and L. predominance BGA: hypoxemia, hypercapnia,and acidosis Chest X ray: Specific: Adv Ag(+), or Adv-DNA(+) Adv-IgM(+),More: lung markings

31、, emphysema, large lesions and confluent lesion Less: circular lesion, pneumatocele, effusion Consistent: clinic and X ray,Adenoviral pneumonia,Staphylococcal aureus: Pathology and pathogenesis,Hematogenous or aspiration Confluent bronchopneumonia,Characterized by extensive areas of hemorrhagic necr

32、osis and multiple small abscesses.,Staphylococcal aureus: clinical features,Peak incidence in infants Abrupt onset and rapid progression High fever, dyspnea and toxic appearance Some accompanied by gastrointestinal disturbance, scarlet fever-like rash Scattered rales being detectable early,Staphyloc

33、occal aureus: complications,Lung abscess, empyema, pyopneumothorax, Pneumatoceles and air leak: pneumothorax, subcutaneous and mediastinal emphysema Multiple metastatic abscesses in soft tissue, purulent pericarditis and meningitis,Staphylococcal aureus: assistant examination,Nonspecific: Leucocytos

34、is with PMN predominance BGA: hypoxemia, hypercapnia,and acidosis Chest X ray: Specific: Bacterial culture,Not in accordance with symptoms Rapid progression Multiple complications Slow absorbance,Staphylococcal pneumonia,Mycoplasma pneumoniae(MP): pathology and pathogenesis,Adhering to epithelium Se

35、creting toxic substances Damaging ciliary epithelium Producing self-antibody to some tissues,MP:Epidemiology (data from childrens hospital, zhejiang university school of medicine,2000-2001）,Season 3y Total Cold 9/192 15/33 24/225 （ 4.7） （45.5） Hot 1/83 19/66 20/149 （ 1.2） （28.8） total 10/275 34/99 4

36、4/374 （ 3.6） （34.3） (11.8%),MP: clinical features,Peak incidence in school-aged children Gradual onset of fever, rhinorrhea, and sore throat followed by cough Persistent fever and irritative, nonproductive cough with frothy white sputum Fine rales usually lacking in older children. Severe dyspnea,wh

37、eezing in infants and toddlers,MP: Complication,Multi-system involvement: Accompanied by or preceding respiratory symptoms,myocarditis, pericarditis, hepatitis, pancreatitis, erythema multiformae, Stevens-Johnson syndrome, meningoencephalitis, hemolysis with positive Coombs test, etc.,MP: assistant

38、examination,Nonspecific: normal WBC count and PMN predominating, CRP and ESR Chest X ray: Specific: MP Ag(+), or MP-DNA(+) MP-IgM(+),Interstitial pneumonia Bronchopneumonia Dense hilar shadow Consolidation infiltrates,MP: interstitial,MP: hilar & segmental,MP: lobar,Chlamydial pneumonia,Chlamydia tr

39、achomatis is one of the important pathogens causing afebrile pneumonia in infants (5y).,Treatment,Childhood Pneumonia,Nursing and supportive care Antimicrobial therapy Symptomatic therapy Management of complications,Principles of treatment,Nursing and supportive care,Bed rest in the acute phase Main

40、tenance of fluid and acid-base balances Avoidance of cross-infection,Antimicrobial therapy: principles for severe bacterial infection,Intelligent selection based on etiology Prompt intravenous administration Combination Good penetration into lower RT Enough doses and duration,Antimicrobial therapy:

41、drugs of choice for bacteria,Pneumococcus Penicillin G Cefotaxime, Ceftriaxone S. aureus Oxacillin, Vancomycin H. influenza Ampicillin -lactam/-lactamase inhibitors Cephalosporins MP/CP/CT Erythromycin, Roxithromycin Azithromycin, Clarithromycin,Empirical treatment recommended,Age clinic hospitalize

42、d Hospitalized (mild) (severe) * 20d admission Ampicllin or Ampicllin and +Cefotaxime Cefotaxime 3w3m Macrolides Macrolides or Cefotaxime admission +Cefotaxime 4m4y Amoxycillin No antibiotics Cefotaxime or Ampicillin Cefuroxime 515y Macrolides Macrolides or Cefotaxime or +Ampicillin Cefuroxime or +M

43、acrolides,* Purulent, alveolar infiltration or pleural effusion,Antimicrobial therapy: appropriate duration,Not discontinued until the patient is afebrile for 57 days with disappearance of symptoms for 3 days. At least 23 weeks for MP,CP infections 6 weeks for S. aureaus with normal temperature for

44、at least 2 weeks.,Antimicrobial therapy: consideration for virus infections,No indication for antibacterial RSV: Ribavirin inhalation, RSV-IVIG, Palivizumab (RSV monoclone antibody) Influenza: Oseltavir IVIG, Interferon ,Symptomatic therapy,Oxygen therapy Humidification and inhaled medication Chest

45、physiotherapy (CPT),Symptomatic therapy: indication for humidified oxygen,Cyanosis PaO260mmHg Irritability Tachycardia Dyspnea Tachypnea,Symptomatic therapy: notice for oxygen therapy,Humidified to prevent damaging to ciliary epithelium condensation of sputum Monitored to prevent unsatisfactory oxygenation oxygen toxicity,Symptomatic therapy: