兒科學(xué)理論課七年制肺炎

1、Pediatrics,Childhood pneumonia,,Zhi-min Chen 陳志敏Dept. Pediatric PulmonologyEmail: zmchen@zju.edu.cn,Allergic disorders asthmaCongenital anomaliesObstructive sleep apnea Foreign body aspir

2、ation Neoplastic diseases,Infections,Others,Respiratory diseases in children,Respiratory infections,---Infections of the upper respiratory tractCold(nasopharyngitis)SinusitisUvulitisTonsillitisPharyngitisLaryngiti

3、s,Respiratory infections---infections of lower respiratory tract,,,¤ Bronchitis¤ Bronchiolitis¤ Pneumonia,,Childhood Pneumonia,Pediatrics,Importance of childhood pneumonia,Four to five million annual d

4、eaths being 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,Bul

5、l WHO,2008;86(5):408,Pneumonia: the leading cause of death!,Pneumonia is the leading cause of death in young children in China,,中華預(yù)防醫(yī)學(xué)雜志，2005;39(4):260,Definition,Pneumonia ¤ inflammation of the lung tissue

6、64; 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, Viral…or noninfe

7、ctiousby source Community-acquired pneumonia(CAP) Hospital-acquired pneumonia(HAP) or Nasocomial pneumopnia(NP),Classification,Definition:CAP pneumonia occurring ≤48 hr

8、of hospital admission ( untreated and immunocompetent)HAP pneumonia occurring >48 hr after hospital admission (with risk factors for MDR bacteria),Classification,Pneumonia ca

9、n 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 pneumo

10、nia,Atypical pathogeens,Mycoplasma: Mycoplasma pneumoniae(MP)Chlamydia: Chlamydia trachomatis(CP) Chlamydia pneumoniae(CT)Legionella: Legionella pneumophilia(LP),Different pathogens

11、in,Different countries or regions Different seasons Different ages Different bases (immunologic…),Microbial agents of CAP, according to age,0-20d 4m-4yGroup B streptococcusRSV/

12、IFV/PIV/ADV/RVGram negative bacilliStreptococcus pneumoniaCytomegalovirusHemophilus influenzaListeria monocytogenesMycoplasma pneumoniae3w-3mMycobacterium tuberculosisC. Trachomatis 5

13、y-15yRSV/PIV-3Mycoplasma pneumoniaeStreptococcus pneumoniaC.pneumoniaeBordetella pertussisStreptococcus pneumoniaStaphylococcus aureusMycobacterium tuberculosis,N Engl J Med, 2002,346:429,Predisposing Factors,Bul

14、l WHO,2008;86(5):408,,Pathophysiology,Childhood Pneumonia,Pathogens Inflammation of Inflammation conducting airway　　 of alveoli　　　　　　 airway

15、obstruction thickening of respiratory membranes, atelectasis　　 obstructive ventilation V/Q

16、 imbalance, dysfunction impaired diffusion 　　　　　　　 　　 Toxemia Hypercapnia Hypoxia,,,,,,,,,,,Pathophysiology,Toxemi

17、a Hypercapnia HypoxiaRespiratory acidosisMetabolic acidosisSIADH Respiratory insufficiency

18、 Respiratory failurePulmonary hypertensionHeart failureToxic myocarditis Cerebral edemaShock,DIC, etc. Toxic encephalopat

19、hy Gastrointestinal failure (Paralytic ileus, GI bleeding, etc.),,,,,,,,,,Pathophysiology,Toxic myocarditis,Pulmonary hypertension,,,Heart failure,,,Cli

20、nical manifestation,Childhood Pneumonia,,,,,,,Typical pneumonia,,Fever (Hypothermia),Cough,Tachypnea,Dyspnea,Rales,Tachypnea,Normal RR Tachypnea~2m 40~45 /min >60/min~12m 30~40 /min

21、 >50/min~4y 25~30 /min >40/min>4y 18~25 /min >30/min,Dyspnea,Inspiratory Dyspnea nasal flarings suprasternal ,intercostal and subcostal

22、 retractions nodding respirationExpiratory Dyspnea prolonged expiratory time wheezing,Severe pneumonia,Respiratory failure or insufficiencyHeart failureToxic encephalopathy Cerebra

23、l edemaParalytic ileusGastrointestinal bleeding,Definition of respiratory failure or insufficiency,Respiratory failure PaO250mmHgRespiratory insufficiency PaO245mmHg,Diagnostic criteria

24、of heart failure,Abruptly increased tachypnea >60/m ;Tachycardia > 160~180 bpm ;Abruptly increased cyanosis, irritability which cannot be explained by …Decreased heart sounds and gallop rhythm;Hepatomegaly ;Ol

25、igouria and edema,Atelectasis Emphysema Pneumatocele Empyema Pyopneumothorax,Acute Complication,Suggestive signsfor acute complication,Persistent fever or recurrent fever despite of adequ

26、ate antibiotic therapyAbruptly deteriorative dyspnea or tachypnea,Long-term complication or sequela,Bronchiectasis due to adenoviral pneumonia Wheezing disorders or asthma

27、 afer RSV infection,Laboratory examination,Etiologic examinationNon-specific examinationBlood gas analysis,Etiologic diagnosis for viral pneumonia: gold standard,Samples Methods NPA or

28、sputum Virus isolation Blood Serology (double samples) (IgG titres increased>4 times) NPA: Nasopharyngeal Aspirate,,,,Etiologic diagnosis for viral

29、 pneumonia: rapid diagnosis,Samples MethodsNPA or sputum Virus antigen detection (ELISA,CIE, COA,LA,RIA) Virus DNA or RNA

30、 (PCR,RT-PCR, Gene probe)Blood Blood sIgM (IgM capture, IFA),,,,Etiologic diagnosis for bacterial pneumonia,Methods: Smear gram-stain a

31、nd CultureSamples： Lung puncture and biopsy Blood Pleural effusion Tracheal aspirates or BAL Sputum Throat swab,Etiologic diagnosis for MP:

32、 gold standard,Samples Methods NPS or sputum MP isolation Blood Serology (double serum antibody) NPS: Nas

33、opharyngeal Secretion,,,,Etiologic diagnosis for viral pneumonia: rapid diagnosis,Samples MethodsNPS or sputum MP antigen detection MP DNA detecti

34、onBlood Blood MP-sIgM,,,,Nonspecific examination,Blood WBC +DC Alkaline phosphatase (AKP) activity Enhanced phagocytosis of neutrophils as shown by nitroblue tetraz

35、olium test(NBT) Acute reactants (C-Reactive Protein,CRP)Blood CGA,Blood gas analysis,Determining the severityInstructing managementPredicting outcome,Blood gas analysis,Hypoxemia: PaO245mmHgMetabolic acidosis: pH

36、and BE Respiratory acidosis: pH and PaCO2Hyponatremia and hypokalemia,,,,,Roentgenographic examination,Early changes：increased and hazy lung markings.Typical: small, focal infiltrative lesions to patchy consolidat

37、ionOthers: emphysema, atelectasis, segmental or lobar consolidation,Diagnosis and differential diagnosis,Childhood Pneumonia,Diagnosis,Preliminary diagnosis is based on clinical features: fever, cough,

38、 tachypnea, dyspnea and fine moist rales.It can be confirmed by roentgenographic examination.,Differential diagnosis,Bronchitis Pulmonary TuberculosisForeign bodies in trachea and bronchus,Differ

39、ential diagnosis,bronchitis No tachypnea or dyspneaDifferent feature of ralesIn infants, it is difficult to differentiate Chest X ray,Differential diagnosis,Foreign body aspiration History of aspirationImmediate ch

40、oking and coughRelatively latent period followed with occasional cough, slight wheezing, recurrent lobar pneumonia. Chest X ray: positive shadow, bronchial obstruction sign(atelectasis or emphysema), mediastinum swing.

41、,Foreign body aspiration,Atelectasis,Emphysema,Differential diagnosis,TuberculosisHistory of contact with patientNo raleschest film PPD testTherapeutic response,,Pneumonia with different etiology,RSVAdenovirusStap

42、hylococcusMycoplasmaChlamydia,RSV: pathology,Bronchioles(75~300?m) damaged and obstructed:diffuse emphysema and patchy atelectasis,Ciliary epithelium necrosis Submucosa edema Lymphocyte infiltration Smoot

43、h muscle spasm,RSV: Epidemiology (data from children’s hospital, zhejiang university school of medicine,2000-2001）,Season 3yCold 39.6％ (n=192) 3.6％ (n=33) Hot 0.0％

44、 (n=83) 0.0％ (n=66)total 39.6％ (n=275) 3.6％ (n=99),,,,,RSV: Clinical features-Bronchiolitis,<2 year with peak incidence 2~6 mPeak incidence in cold seasonsNo fever or low to moderate feverRhi

45、norrhea and pharyngitis followed by nonproductive cough episodic wheezing (Bronchiolitis)Signs of expiratory dyspnea： prolonged expiratory time and wheezingHeart failure and respirato

46、ry failure,RSV: assistant examination,Nonspecific: normal WBC count and L. predominance, normal CRPBGA: hypoxemia, hypercapnia,and acidosisChest X ray: emphysemaSpecific: RSV Ag(+), or RSV-RNA(+)

47、 RSV-IgM(+),Emphysema,Adenoviral pneumonia:pathology,Characteristic microscopic changes include In severely affected cases, confluent, diffuse infiltrates, necrosis of mucosa with large amounts of exudates and bro

48、nchial obliteration may occur.,dense lymphocytic infiltrates, epithelium destruction, focal necrosis of mucous glands, hyaline membrane formation.,Adenoviral pneumonia:Clinical features,Peak incidence 6 m~2 yAbrupt ons

49、et and continued high fever Toxic with neurological disturbances earlySevere cough, dyspnea and wheezingRales and wheezing not detectable until 3 to 7 days after the onset of high fever.,Adenoviral pneumonia:complica

50、tion,Acute phase:Long-term sequelae:,Heart failure Toxic encephalopathyPleurisy Secondary bacterial infection,Lung dysfunctionBronchiectasis and COPD,Adenoviral pneumonia:assistant examina

51、tion,Nonspecific: normal WBC count and L. predominanceBGA: hypoxemia, hypercapnia,and acidosisChest X ray:Specific: Adv Ag(+), or Adv-DNA(+) Adv-IgM(+),More: lung markings, emphysema,

52、 large lesions and confluent lesion Less: circular lesion, pneumatocele, effusion Consistent: clinic and X ray,,,Adenoviral pneumonia,Staphylococcal aureus:Pathology and pathogenesis,Hematogenous or asp

53、irationConfluent bronchopneumonia,Characterized by extensive areas of hemorrhagic necrosis and multiple small abscesses.,Staphylococcal aureus:clinical features,Peak incidence in infantsAbrupt onset and rapid progress

54、ionHigh fever, dyspnea and toxic appearanceSome accompanied by gastrointestinal disturbance, scarlet fever-like rashScattered rales being detectable early,Staphylococcal aureus:complications,Lung abscess, empyema, py

55、opneumothorax,Pneumatoceles and air leak: pneumothorax, subcutaneous and mediastinal emphysemaMultiple metastatic abscesses in soft tissue, purulent pericarditis and meningitis,Staphylococcal aureus:assistant examina

56、tion,Nonspecific: Leucocytosis with PMN predominance BGA: hypoxemia, hypercapnia,and acidosisChest X ray: Specific: Bacterial culture,,Not in accordance with symptomsRapid progressionMultiple complicationsSl

57、ow absorbance,Staphylococcal pneumonia,Mycoplasma pneumoniae(MP):pathology and pathogenesis,Adhering to epitheliumSecreting toxic substancesDamaging ciliary epitheliumProducing self-antibody to some tissues,MP:Epidem

58、iology (data from children’s hospital, zhejiang university school of medicine,2000-2001）,Season 3y TotalCold 9/192 15/33 24/225 （ 4.7％） （45.5％

59、）Hot 1/83 19/66 20/149 （ 1.2％） （28.8％）total 10/275 34/99 44/374 （ 3.6％） （34.3％） (11.8%),,,,,MP: clinical

60、 features,Peak incidence in school-aged childrenGradual onset of fever, rhinorrhea, and sore throat followed by coughPersistent fever and irritative, nonproductive cough with frothy white sputumFine rales usually lack

61、ing in older children. Severe dyspnea,wheezing in infants and toddlers,MP: Complication,Multi-system involvement:Accompanied by or preceding respiratory symptoms,myocarditis, pericarditis, hepatitis, pancreatitis,

62、erythema multiformae, Stevens-Johnson syndrome, meningoencephalitis, hemolysis with positive Coombs test, etc.,MP: assistant examination,Nonspecific: normal WBC count and PMN predominating, CRP and ESRChest X ray:Sp

63、ecific: MP Ag(+), or MP-DNA(+) MP-IgM(+),,Interstitial pneumoniaBronchopneumoniaDense hilar shadow Consolidation infiltrates,MP: interstitial,MP: hilar & segmental,MP: lobar,Chlamydial pneumoni

64、a,Chlamydia trachomatis is one of the important pathogens causing afebrile pneumonia in infants (5y).,Treatment,Childhood Pneumonia,Nursing and supportive care Antimicrobial therapySymptomatic therapy Management of

65、complications,Principles of treatment,Nursing and supportive care,Bed rest in the acute phaseMaintenance of fluid and acid-base balancesAvoidance of cross-infection,Antimicrobial therapy:principles for severe bacteria

66、l infection,Intelligent selection based on etiologyPrompt intravenous administrationCombinationGood penetration into lower RTEnough doses and duration,Antimicrobial therapy:drugs of choice for bacteria,Pneumococcus

67、 Penicillin G Cefotaxime, CeftriaxoneS. aureus Oxacillin, Vancomycin H. influenza

68、 Ampicillin ?-lactam/?-lactamase inhibitors CephalosporinsMP/CP/CT Erythromycin, Roxithromycin

69、 Azithromycin, Clarithromycin,Empirical treatment recommended,Age clinic hospitalized Hospitalized (mild)

70、(severe) *~20d admission Ampicllin or Ampicllin and +Cefotaxime Cefotaxime 3w~3m Macrolides Macrolide

71、s or Cefotaxime admission +Cefotaxime 4m~4y Amoxycillin No antibiotics Cefotaxime or Ampicillin Cefuroxime5~1

72、5y Macrolides Macrolides or Cefotaxime or +Ampicillin Cefuroxime or