儿科学教学课件：8 肺炎七年制-2013年-C

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1、Respiratory DisordersTopicsv Respiratory disordersv Respiratory infectionsv PneumoniaTopicsv Respiratory disordersv Respiratory infectionsv Pneumoniav 50%of consultation with general practitioners or acute illness in young children and a third of consultations in older childrenv 25-30%of acute pedia

2、tric admissions to hospital,some of which are life-threateningv Acute respiratory tract infections form a major part of pediatric practicev Asthma is the most common chronic illness of childhoodv Cystic fibrosis is the most common inherited disorder in Caucasians causing chronic diseaseRespiratory D

3、isordersTopicsv Respiratory disordersv Respiratory infectionsv PneumoniaRespiratory Infectionsv The most frequent infections of childhood:6-8/yearv Pathogens:viruses,bacterial,other pathogensv Host and environmental factorsv Classification of respiratory infectionsClassification of Respiratory Infec

4、tionsAccording to the level of the respiratory tree most involved:v Upper respiratory tract infectionv Lower respiratory tract infectionCase-1Jack,age four months,is sent at home by his general practitioner because of two days of cough,rapid,laboured breathing and poor feeding.He was born at 27 week

5、s gestation,birth weight 979g and was discharged home at three months of age.On examination he was a fever of 37.4C and a respiratory rate of 60 breaths/min.His chest is hyperinflated with marked intercoastal recession.On auscultation there are generalized fine crackles and wheezes.QuestionDo you ha

6、ve any comments or what do you conclude anything from this case?Case-1Jack,age four months,is sent at home by his general practitioner because of two days of cough,rapid,laboured breathing and poor feeding.He was born at 27 weeks gestation,birth weight 979g and was discharged home at three months of

7、 age.On examination he was a fever of 37.4C and a respiratory rate of 60 breaths/min.His chest is hyperinflated with marked intercostal recession.On auscultation there are generalized fine crackles and wheezes.PneumoniaQuestionWhat is pneumonia?Pneumonia is an inflammation of the parenchyma of the l

8、ungs.Typical manifestations:cough,fever,tachypnea（气促）（气促）,cyanosis（紫绀）（紫绀）,rales（湿啰音）（湿啰音）DefinitionQuestionHow about the prevalence of pneumonia?v Pneumonia accounts for approximately 15%of all respiratory tract infectionsv Worldwide,about 3 million children die each year from pneumonia,with the ma

9、jority of these deaths occurring in developing countriesv Pneumonia remains the most common cause of morbidity in ChinaIncidenceThe Global burden of Childhood Diseases Mortality:Main causes U5(Professor and Chair,Department of International Health,Johns Hopkins Bloomberg School of Public Health,USA)

10、Globally,more than 10 million children under five years of age die each year,usually due to:19%Pneumonia18%Diarrhoea10%Neonatal sepsis/pneumonia 8%Malaria-preterm delivery asphyxia at birthQuestionHow to classify pneumonias clinically?v Anatomyv Pathogensv Severityv Duration v Onset siteClassificati

11、onv Bronchopneumonia（支气管肺炎）v Lobar or Lobular Pneumonia（大叶性或节 段性肺炎）v Interstitial Pneumonia（间质性肺炎）Based on anatomy or X-ray manifestation Based on etiologyv Bacterial Pneumoniav Viral Pneumoniav Mycoplasma Pneumoniav Chlamydia Pneumoniav Acute Pneumoniav Prolonged Pneumoniav Chronic PneumoniaBased o

12、n the course of pneumoniav Mild Pneumoniav Severe PneumoniaBased on the severity of pneumoniav Community Acquired Pneumonia(CAP)v Hospital Acquired Pneumonia(HAP)Based on the onset site of pneumoniaCommon pathogens in community and hospital infectionCommunity-acquired infectionViruses Streptococcus

13、pneumoniae（肺炎链球菌）Haemophilus influenzae（流感嗜血杆菌）Mycoplasma pneumoniae（肺炎支原体）Chylamidia（衣原体）Staphyloccocus aureus（金黄色葡萄球菌）Hospital-acquired infectionGram-negative bacteriaPseudomonas aeruginosa（铜绿假单胞菌）Klebsiella pneumoniae（肺炎克雷伯菌）Escherichia coli（大肠杆菌）Streptococcus pneumoniaeStaphylococcus aureusAnaer

14、obes（厌氧菌）Fungi（真菌）BronchopneumoniaQuestionWhy are children likely have bronchopneumonia?v Characters of childhood airway anatomic structure and their respiratory physiologyv Immune function of childhoodv High risk factors:premature baby,underlying disordersQuestionWhat cause bronchopneumonia?Bacteri

15、a:Streptococcus pneumoniae,Haemophilus influenzae,Moraxellacatarrhalis（卡他莫拉菌），Staphyloccocus aureus Viruses:RSV,IV,ADV,MPV,et al.MycoplasmaCauses of Bronchopneumonia Bacteria:Streptococcus pneumoniae,Haemophilus influenzae,Moraxellacatarrhalis（卡他莫拉菌），Staphyloccocus aureus Viruses:RSV MycoplasmaCause

16、s of BronchopneumoniaPathology of PneumoniaNormalPneumoniaInflammaory exudateInflammaory exudatePathology of PneumoniaQuestionWhat are the pathophysiology of pneumonia?PathogensURTIBronchitisPneumoniaInflammatory exudateObstruction of airwayGas exchange abnormalVentilation abnormalhypoxemia(低氧血症）低氧血

17、症）hypercapnia（高碳酸血症）（高碳酸血症）toxinemia（毒血症）（毒血症）tachypneacyanosisralesfevercoughSevere PneumoniaRespiratory failure PO2 6.67 kPa PCO2 6.67 kPaToxic carditis and DICToxic encephalopathy（中毒性脑病）Digestive system symptom abdomen distension bloody diarrheaDisturbances of fluid and electrolyte metabolic acid

18、osis respiratory acidosis hyponatremiaQuestionWhat are the signs and symptoms of pneumonia?The clinical signs and symptoms of pneumonia depend primarily on the age of the patient,the causative organism,and the severity of the diseaseFeverCoughCyanosisTachypeneaRalesAge rangeDefinition of“fast breath

19、ing”Up to 2 months60 breaths/minute 2-12 months50 breaths/minute 1-5 years 40 breaths/minuteAge-realted respiratory rates indicative of a lower respiraotry tract infection out breathing inWith inspiration,the side of the nostrils flares outwardsNasal Flaring（鼻扇）（鼻扇）With inspiration,the lower chest w

20、all moves inLower Chest Wall Indrawing out breathing inFeverCoughCyanosisTachypeneaRalesv Classic findings of pneumonia that occur in adults and older children,such as fever,cough and rales,are often absent in infants and toddlers v Generally present with nonspecific signs and symptoms including let

21、hargy,irritability,poor feeding,vomitingv If it appear respiratory failure or other abnormality of other system-severe pneumonia.Important PointsSevere PneumoniaRespiratory failure PO2 6.67 kPa PCO2 6.67 kPaToxic carditis and DIC tachycardia pale ECG abnormalToxic encephalopathy irritability letharg

22、y vomiting seizurelDigestive system symptom abdomen distension bloody diarrheaComplicationsv Empyema（脓胸）v Pyopneumothorax（脓气胸）v Pneumatocele（肺大疱）v Lung abscesses（肺脓肿）v Atelectasis（肺不张）Laboratory Examination v White blood cell count and C-reaction proteinv Pathogens examination:1)Sputum cultures 2)Bl

23、ood cultures 3)Rapid screening tests for virus or bacterialv Bronchoscopyv Blood gas analysis:hypoxia and/or hypercapniaRadiograph Evaluation v Typical X-ray manifestation of bronchopneumonia is patchy infiltrates bilaterallyv Complication:lung abscesses,empyema,pyopneumothorax,pneumatocele,atelecta

24、sisv CT Normal chest X-rayPatchy infiltratesConsolidation脓气胸脓气胸pyopneumothorax肺脓肿肺脓肿lung abscesses肺大疱肺大疱pneumatocele 左侧肺不张左侧肺不张atelectasisQuestionHow to diagnosis pneumonia clinically?v According to the typical clinical manifestation of bronchopneumoniav According to X-ray manifestation v Pay attent

25、ion to the atypical manifestation of infantsv Evaluate the severity of pneumoniav Find the etiology of pneumoniaDifferential Diagnosis v Bronchitisv Foreign Body Aspirationv Tuberculosisv AsthmaQuestionHow is pneumonia treated?Managementv Supportive carev Antimicrobials therapyv Hospitalization in s

26、elected cases Supportive Carev Respiratory care may range from oxygenation,bronchodilators for wheezing,humidification or mist,suctioning,and postural drainage,intubation and mechanical ventilationv Hydration(sometimes intravenous)v Control of fever:brufen,acetaminophenv Management of complicationsA

27、ntimicrobial TherapyOrganismAntimicrobialS.pneumoniae Penicillin(if not resistant).third-generation cephalosporin e.g.cefotaximeceftriaxone(if resistant to penicillin)H.influenzae Azithromycin or Amoxicillin(if not resistant)B e t a lactamase Cefuroxime or third-generation cephalosporin(if beta lact

28、amase and resistant)S.aureusMethicillin(if not resistant)Vancomycin(if MRSA-methicillin resistant S.aureus)if penicillin allergy:vancomycin,clindamycin Chlamydia Azithromycin(other macrolides e.g erythromycin);alternative,sulfa drugs MycoplasmaAzithromycin(other macrolides);alternative,tetracycline(

29、if older than 8 years)RSV Ribavirin(optional)InfluenzaAmantadine(if severe)BacteriaAtypicalVirusesAge Group Bacterial Viral Empiric TherapyNeonate(0-28 days)Group B streptococcus,gram-negative enteric E.coli,Klebsiella,Listeria monocytogenes,S.aureus,other gram-positive)Cytomegalovirus Herpes simple

30、xAmpicillin and aminoglycoside(gentamicin or tobramycin or amikacin,or third-generation cephalosporin).Note:Avoid ceftriaxone 2 to bilirubin Infants 3-16 weeks;afebrile pneumonia infancy Chlamydia trachomatis Ureaplasma urealyticum CytomegalovirusPneumocystis cariniiErythromycin SulfonamideInfants f

31、ebrile or ill appearing age 1-3 monthsSame organisms as for neonate plus S.pneumoniae,H.influenzae,S.aureusNot applicableAntibiotic(nafcillin,oxacillin,or methacillin)Broad-spectrum cephalosporin(e.g.,cefotaxime)Toddler or preschool ageS.pneumoniae,H.influenzae M.pneumoniae,ChlamydiaRSV Parainfluenz

32、a Adenovirus InfluenzaAzithromycinAmoxacillin-clavulanate:not active against atypical organisms(Mycoplasma,Chlamydia)Organisms Causing Pneumonia and Empiric Therapy in Pediatric BacteriaAntibioticsDurationG+coccusPenicillin，1st and 2nd cephalosporin 710 daysG-bacillus2nd and 3rd cephalosporin12 week

33、s S.aureus Piperacillin Sodium，Vancomycin 34 weeksM.pneumoniaeMacrolides 23 weeksQuestionHow about the clinical course of pneumonia?v With treatment,pneumonia caused by bacteria can usually be cured in 1 or 2 weeksv Pneumonia caused by a virus often lasts longerClinical CourseSeveral Pneumoniasp Bro

34、nchiolitis is the most common serious respiratory infection of infancyp Two to three per cent of all infants are admitted to hospital with the disease each year during annual winter epidemicsp Respiratory syncytial virus(RSV)is the pathogen in 75-80%cases p Clinical features:1.Age:2-6 month2.Season3

35、.Wheezing4.X-rayDuration:7-10 daysBronchiolitisHyperinflation of the lungs with flattening of diaphragmInvestigations v RSV can be identified rapidly using a fluorescent antibody test on nasopharyngeal secretionsv The chest X-ray shows hyperinflation of the lungs due to small airways obstruction and

36、 air trapping v Blood gas analysis,which is required in only the most severe cases,shows lowered arterial oxygen and raised CO2 tension Management v Supportive.Humidified oxygen is delivered into a head-box v Mist,antibiotics and steroids are not helpful v Nebulised bronchodialators do not reduce th

37、e severity or duration of the illness v The antiviral drug ribavirin only marginally shortens viral excretion and clinical symptoms,and should be considered only for infants with underlying cardiopulmonary disorders or immunodeficiency v Fluids may need to be given by nasogastric tube or intravenous

38、lyv Mechanical ventilation is required in about 2%of infants admitted to hospital p There are over 60 types of adenoviruses,which account for 2-10%of all respiratory illnessesp Adenoviral infections are common early in life,it is especially common in less than 2 year-oldp Epidemic respiratory diseas

39、e occurs in winter and springp High grade fever,severe symptoms of systemic poisoning,and multiple organ damage.Symptoms persist for 2-4 weeksp Chest X-rear show bilateral peribronchial and interstitial infiltratesp Adenoviral pneumonia can be necrotizing and cause permanent lung damage,especially b

40、ronchiectasisp There is no specific treatment Adenoviral PneumoniaStaphylococcus aureus Pneumoniav S.aureus is an uncommon but important cause of pneumonia that can occur in any age groupv S.aureus is a rapidly progressive fulminant illness v S.aureus pneumonia easily occurs complicationsv Blood cul

41、tures are positive in 20-30%of patientsv The pleural effusions should be drained by thoracentesis or,if large,by a chest tubev Pneumatoceles are also common and are found in 45-60%of patients with S.aureus pneumoniav Methicillin or vancomycin should be administered for 3-4weeksMycoplasma Pneumonia v

42、 M pneumoniae is a common cause of symptomatic pneumonia in older childrenv Endemic and epidemic infection can occur v The incubation period is long(2-3weeks),and the onset of symptoms is slowv Although the lung is the primary infection site,extrapulmonary complications sometimes occurClinical Featu

43、res v Fever,cough,headache,and malaise are common symptoms as the illness evolvesv Rales are frequently present on chest examination,decreased breath sounds or dullness to percussion over the involved area may be presentLaboratory findings v The total and differential white blood cell counts are usu

44、ally normalv The cold hemagglutinin titier should be determined,because it may be elevated during the acute presentation.A titer of 1:64 or higher supports the diagnosisImaging Chest x-rays usually demonstrate intersititial or bronchopneumonic infiltrates,frequently in the middle or lower lobes.Pleu

45、ral effusions are extremely uncommon.Complications v Extrapulmonary involvement of the blood,CNS,skin,heart,or joints can occur v Direct Coombs-positive autoimmune hemolytic anemia,Coagulation defects and thrombocytopenia can also occurv A wide variety of skin rashes including erythema multiforma an

46、d Stevens-Johnson syndromeTreatment v Antibiotic therapy with erythromycin or Azithromycin for 7-10 days usually shortens the course of illness v Supportive measures,including hydration,antipyretics,and bed rest,are helpfulChlamydial Pneumonia v Pulmonary disease due to C trachomatis usually evolves

47、 gradually as the infection descends the respiratory tractv Infants may appear quite well despite the presence of significant pulmonary illness v Appropriate age:2-12 weeksv Inclusion conjunctivitis,eosinophilia,and elevated immunoglobulins can be seen Clinical Features v About 50%of patients with c

48、hlamydial pneumonia have active inclusion conjunctivitis or a history of itv Rhinopharyngitis with nasal discharge or otitis media may have occurred or may by currently presentv Cough is usually present.It can have a staccato character and resemble the cough of pertussisv The infant is usually tachy

49、penic.Scattered inspiratory rales are commonly heard,but wheezes rarelyv Significant fever suggests a different or additional diagnosisLaboratory findings v Although patients may frequently be hypoxemic,CO2 retention is not commonv Peripheral blood eosinphilia has been observed in about 75%of patien

50、tsv Serum immunloglobulins are usually abnormal.IgM is virtually always elevated,IgG is high in many,and IgA is less frequently abnormalv C trachomatis can usually be identified in nasopharyngeal washings using fluorescent antibody or culture techniquesImaging Chest x-rays usually reveal diffuse int

51、erstitial and patchy alveolar infiltrates,peribronchial thickening,or focal consolidation.A small pleural reaction can be present.Despite the usual absence of wheezes,hyperexpansion is commonly present Treatment v Erythromycin or sulfisoxazole therapy should be administered for 14 daysv Oxygen thera

52、py may be required for prolonged periods in some patientsSummary v Pneumonia in pediatric patients encompasses a wide spectrum of etiologies and illness from mild to severe and life threateningv Therapy should include an antibiotic if a bacteria or atypical bacteria(chlamydia or mycoplasma)is suspec

53、ted.No antibiotics are necessary for viral pneumoniav Supportive therapy also includes fever control,maintenance of hydration and respiratory carev Close follow-up is necessary in order to detect any secondary bacterial infection or the development of complicationsKey Issues v Etiology of pneumoniav

54、 Pathophysiology of pneumoniav Clinical feature of pneumoniav Diagnosis and differential diagnosis of pneumoniav Management of pneumoniav Several special pneumoniasReferences v Nelson Textbook of Paediatricsv Pneumonia(Sharon E.Mace,MD,FACEP,FAA)v Current Pediatric Diagnosis and Treatmentv Mosby”s Crash Coursev PediatricsEmail address:Telephone:86-23-63632386Address:Childrens Hospital,CMU