提高对老年性肺炎的认识课件

1、提高对老年性肺炎的认识济南军区总医院呼吸内科刘书盈A 1960s article in Time magazine speculated that “bacterial and viral diseases will have been virtually wiped out” by the year 2000.Into the new millennium, pneumonia is still a significant public health problem in the world. Not only has the incidence of pneumonia increased

2、, but new threats have emerged with highly virulent pathogens with epidemic potential, such as the Coronavirus (SARS) and avian influenza.About PneumoniaMuthiah MP. Pneumonia in the Elderly: Whose Friend Is It Anyway? Southern Medical Journal, 2008 ,101(11):1084-1085.In old age pneumonia may be late

3、nt, . . . coming on without a chill, the cough and expectoration are slight, . . . The physical findings ill-defined and changeable . . . And the constitutional symptoms out of proportion to the extent of the local lesion. pneumonia was the friend of the aged that often allowed patients with advance

4、d illness to die peacefully-William Osler,In 1892About geriatric pneumoniaMalin. A. Pneumonia in old age. Chronic Respiratory Disease. 2011, 8(3): 207210.老年性肺炎（geriatric pneumonia，pneumonia in the elderly）不是一个标准的诊断术语，但将之单纯看作是发生在老年人的“肺炎”是不合适的。老年性肺炎在病因、发病及临床表现各个方面有其特殊性，与一般成人肺炎相差较大。对其缺乏认识或错误认识，或重视不够，将导

5、致误诊、误治或延误治疗。概念和认识研究发现，人类生命的两端是肺炎的高发年龄段，呈V字形或倒钟形，在60岁后发病率明显升高，且老年人肺炎较为严重。老年性肺炎发病情况Malin. A. Pneumonia in old age. Chronic Respiratory Disease. 2011, 8(3): 207210.易感因素是老年性肺炎的一个重要特点。各种生理机能的进行性衰退，年龄本身即是一个重要的易感因素，其机理涉及诸多方面：各系统功能降低，尤其是免疫功能的下降，粒细胞、淋巴细胞、NK细胞及抗原呈递细胞功能降低，使其更容易罹患肺炎。近年研究发现，脾脏的边缘区与肺炎球菌的清除和T细胞依赖的

6、抗体产生有关，65岁及以上老年人脾脏功能降低，致使其易患肺炎球菌肺炎。易感因素 1、Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(11):1141-1145.2、Birjandi S, Witte P. Why are the elderly so susceptible to pneumonia? Expert R

7、ev. Respir. Med. 2011, 5(5), 593595.呼吸系统退行性变患者肺脏弹性回缩力减弱肺泡腔扩大（老年性肺气肿）呼吸肌乏力支气管纤毛功能降低呼吸道分泌性IgA减少咳嗽反射减弱、咳嗽无力诸多因素都使之易于受到感染，且容易发生呼吸衰竭。易感因素 1、Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(1

8、1):1141-1145.2、Birjandi S, Witte P. Why are the elderly so susceptible to pneumonia? Expert Rev. Respir. Med. 2011, 5(5), 593595.老年性肺炎并不是“老年人的肺炎”，常常缺乏肺炎的表现。没有呼吸道症状咳嗽反射减弱、对缺氧和高二氧化碳刺激不敏感、排痰功能降低极易被家属，乃至医生忽视，造成漏诊、误诊，从而延误治疗。表现为“肺外”症状或以“肺外”表现发病精神萎靡、神智淡漠，甚至意识模糊，乃至昏迷等神经系统症状，达21%-73%；心功能不全、心律失常、血压下降等心血管系统症状，

9、高达70%；恶心、呕吐、腹泻、食欲减退等消化系统症状；不明原因的电解质紊乱，虚弱乏力、甚至莫名跌倒。临床上因跌倒就诊发现肺炎的病例并不少见。因此，临床医生对老年患者的以上表现一定要注意。老年性肺炎的特点一“隐匿性”Falcone M, Blasi F and Menichetti F,et al. Pneumonia in frail older patients: an up to date. Intern Emerg Med. 2012, 7:415424.“低体温”：患者体温反应不同于其他人群，常常表现不明显，体温不高，甚至低体温。个别患者可以向另一个极端发展，即持续性高热，高热不退预示

10、预后不良；“低血象”：即患者血白细胞常常不升高，甚至降低，但中性粒细胞可增高，此时C反应蛋白可能较之更敏感；“低治疗反应”：即对治疗反应慢，即使敏感抗生素，用药后起效也慢或根本无效，因此，抗菌药物不宜频繁更换，一般至少3天以上。“低耐受性”：患者各种器官功能降低，处于临界状态，对各种药物毒副作用耐受性低，极易出现治疗作用尚未达到，毒副作用已经出现的现象，因此，药物选择及剂量要慎重。老年性肺炎的特点二“低反应性”由于患者抵抗力降低，老年性肺炎极易向重症进展，尤其是漏诊、误诊病例，因延误治疗，易发展至重症状态，病死率高。国外报道，在家庭护理和医院相关性感染患者，病死率高达44%-57%，社区获得性

11、肺炎病死率高达30%。老年性肺炎是老年人最常见的死亡原因之一。老年性肺炎的特点三“高致死性”Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(11):1141-1145.CURB65评分：精神异常;尿素氮升高大于7mmol/L；呼吸频率30次/分；血压下降收缩压低于90mmHg或/和舒张压60mmHg；年龄超过65岁。每

12、项1分，0-1分为低严重度，死亡风险3%，2分为中度严重度，死亡风险为9%，而3分以上为高严重度，死亡风险达15%-40%。老年性肺炎严重性评估 Chong CP, Street,PR. Pneumonia in the Elderly: A Review of Severity Assessment, Prognosis, Mortality, Prevention, and Treatment. Southern Medical Journal. 2008, 101(11):1134-1140.Myint等研究发现，精神异常和尿素氮升高在老年患者非常普遍，对肺炎严重程度的预计作用较小，氧合

13、状况是最好的预计指标。提出了SOAR标准：收缩压90mmHg；氧合指数（PaO2/FiO2 ）250；年龄65岁呼吸30次/分每项1分，并建议将其作为老年患者的评估工具。老年性肺炎严重性评估最新研究发现，老年性肺炎病死率与宿主因素如年龄和体能状况等密切相关，而与肺炎的严重程度和对耐药菌治疗失败无关。我们临床上也发现，老年性肺炎即使病原菌对药物敏感，抗菌药物完全覆盖也照样无效，此时其抵抗力降低可能是主要因素。老年性肺炎的死亡问题Komiya K, Ishii H and Okabe E, et al. Risk factors for unexpected death from suffocat

14、ion in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int. 2013, 13: 388392.近年发现，感染所导致的全身炎性反应综合征可能为促进患者死亡的重要原因，即使抗感染有效，细菌死亡所导致的内毒素释放可能成为促进病情加重的“最后一根稻草”。因此，抗炎、抗毒素治疗应该受到重视。研究发现，延误诊断和治疗可能与其高死亡率有关。老年性肺炎的死亡问题老年性肺炎患者的非预期性死亡是临床上一个重要问题，且可能是引起纠纷的重要因素，但常常被忽视或不被重视。国际卫生组织将老年性肺炎非预期性死亡定义为：临床治疗成功或进入

15、恢复期（如症状、体征、化验检查和影像学改善）；死亡前1周生命体征稳定（血压波动在20mmHg以内，心率波动在10次/分，血氧饱和度波动在5%以内，体温低于37.5）；窒息后24小时内死亡；气管内吸出吸入物。吸入物主要为呕吐物和口咽部分泌物。老年性肺炎的非预期死亡问题Komiya K, Ishii H and Okabe E, et al. Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int. 2013, 13

16、: 388392.最新研究发现，胃管鼻饲可能增加窒息所致非预期性死亡的危险可能与胃-食道反流及胃-唾液反射所致口咽部分泌物增多有关。加强口咽部护理对防止老年患者非预期性死亡具有重要意义。心脑血管意外导致患者意外死亡也是老年性肺炎住院期间非预期性死亡的重要原因，应该予以重视。老年性肺炎的非预期死亡问题家庭护理相关性肺炎（Nursing-home acquired pneumonia，NHAP）吸入性肺炎（aspiration pneumonia）终末期肺炎（End-of-life pneumonia，EOLP）几种特殊类型老年性肺炎概念是指在家庭、护理院等长期护理的老年人或残疾人所得肺炎，应属健

17、康护理相关性肺炎（health-care-associated pneumonia，HCAP）的概念范畴。病原学：不同于一般的社区获得性肺炎，病原菌常常是革兰氏阴性菌或厌氧菌。易感因素：长期卧床，缺乏活动，或是伴有多种慢性疾病，长期药物治疗及接触医院和医疗用品，易感染耐药菌。吸入性肺炎发生率较高，且易向重症发展。家庭护理相关性肺炎（Nursing-home acquired pneumonia，NHAP）Ewig S, Welte T, Chastre J et al. Rethinking the concepts of community-acquired and health-care-

18、associated pneumonia. Lancet Infect Dis 2010; 10: 279287.吸入类型：显性吸入：容易发现，可得到及时处理隐性吸入：不易发现，是导致吸入性肺炎的重要原因，其发生率高达71%，但常常被忽视，因此需要重视。易感因素：吞咽困难，尤其是口咽性吞咽困难吞咽反射减弱咳嗽反射减弱咳嗽无力口咽清洁功能减低吸入性肺炎（aspiration pneumonia）食物：进食时吸入或呛入气道在老年人时常发生。研究发现，吞咽困难是发生吸入性肺炎的独立危险因素。尤其是口咽性吞咽困难，导致食物吞咽后残留，成为吞咽后吸入的重要因素。吞咽反射的减弱导致食物易于进入气道咳嗽反射

19、减弱使进入气道的食物或分泌物不被咳出。口咽部分泌物：老年人口咽部清洁功能降低，口咽部可以存留较多分泌物，成为各种细菌定值的场所。胃内容物：胃内容物包括呕吐或返流物。胃酸分泌减少，应用制酸剂，使胃内酸性环境破坏，容易滋生细菌，甚至肠道菌群也可以上行到达口部，成为吸入性肺炎的重要致病菌。吸入物分类病原学标本很难获得合格的痰培养标本老年患者排痰困难或不会咳痰患者定植菌较多受口咽部污染侵入性方法获取标本受到限制对痰液培养结果的判断一定要慎重，需要结合血象、C反应蛋白、降钙素原、G试验和GM试验等检查综合判断老年性肺炎的病原学问题病原学肺炎链球菌、流感嗜血杆菌仍为主要致病菌革兰氏阴性杆菌比例增多铜绿假单

20、胞菌及其他非发酵菌肠杆菌其他革兰氏阳性球菌：金葡菌、卡他莫那菌 非典型病原体：肺炎支原体、肺炎衣原体、嗜肺军团菌病毒：腺病毒、呼吸道合包病毒、流感、副流感病毒厌氧菌肺孢子菌老年性肺炎的病原学问题The results of the present study demonstrate that the bacterial agents responsible for pneumonia, and their antimicrobial resistance patterns, are not significantly different in older adults and younger

21、adults.A comparison in the elderly andyounger adultsHashemi, SM. et al. TROPICAL DOCTOR 2010; 40: 8991治疗原则是尽快采取有效治疗，控制病情，降低病死率。在与病死率相关的诸多因素中，医生能够控制的就是尽快诊断（评估风险和严重程度）、尽快给予经验性的有效治疗。重视以下患者有合并症患者，此类患者可能因合并症而延误肺炎的诊断和治疗HCAP、HAP患者，此类患者应注意耐药菌感染有吸入风险的患者，此类患者要注意厌氧菌感染、胃内容或胃酸的吸入以临床为主，若临床无明显感染表现，即使痰培养阳性，也不作为抗感染治

22、疗或延长治疗的依据。老年性肺炎的治疗问题治疗选择要考虑诸多因素疾病严重程度有无危险因素和合并症CAP、HCAP、HAP肾功能情况，注意肾功亚临床损害等药物毒副作用药物相互作用老年性肺炎的治疗问题In one prospective study（RCT, 262 patients with CAP ) pathogen-directed treatment (PDT; n = 134; mean age, 62.0 years; 55.2% men) empiric, broad-spectrum antibiotic treatment (EAT; n = 128; mean age, 66.

23、7 years; 52.3% men).Conclusionno significant differences were observed between the PDT and EAT groups in the hospital LOS *(14.3 vs 13.2 days, respectively), 30-day mortality (7.9% vs 14.6%), or clinical failure (21.1% vs 23.2%).经验性（EAT）与靶向（PDT）H.B. Fung and M.O. Monteagudo-Chu . Community-Acquired

24、Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.*Length of StayEmpiric antibiotic treatment (EAT)H.B. Fung and M.O. Monteagudo-Chu . Community-Acquired Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.H.B. Fun

25、g and M.O. Monteagudo-Chu . Community-Acquired Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.broad-spectrum, multidrug regimens should be reserved only for healthcare-associated pneumonia patients who have at least two of the following: severe illness,

26、poor functional status prior antibiotic therapyBroad-spectrum, multidrug regimens Brito V and Niederman MS. How can we improve the management and outcome of pneumonia in the elderly?Eur Respir J 2008; 32: 1214Comparative evaluation of fluoroquinolones Anzueto A, Niederman MS, and Pearle J,et al. Com

27、munity-Acquired Pneumonia Recovery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Comparative evaluation of fluoroquinolones Anzueto A, Niederman MS, and Pearle J,et al. Community-Acquired Pneumonia Re

28、covery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Comparative evaluation of fluoroquinolones Comparative evaluation of 2 different fluoroquinolones in hospitalized elderly patients with CAP. There

29、no significant difference between two groups in clinical cure and Bacteriologic success.The finding that moxifloxacin therapy led to a significantly more rapid clinical improvement resolution of pneumonia than levofloxacin therapy in elderly patients (i.e., between days 3 and 5 after the start of th

30、erapy) may be clinically important.Anzueto A, Niederman MS, and Pearle J,et al. Community-Acquired Pneumonia Recovery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Treatment failure may manifest in tw

31、o clinical variants with different prognosis. One variant is progressive pneumonia defined as progressive clinical deterioration with respiratory failure and development of shock necessitating treatment in the ICU, vasopressor therapy and ventilator support.The second variant is non-response to the

32、initial therapy characterized by the persistence of initial symptoms without apparent clinical deterioration. with better prognosis overall,Half of these patients in fact have only a delayed response, which would not necessarily demand a change in the treatment. Careful re-evaluation of treatment an

33、d uncommon pathogens, include Legionella, mycobacteria, fungi, Nocardia and others.Treatment FailureThiem U, Heppner HJ and Pientka L. Elderly Patients with Community-Acquired Pneumoniaoptimal Treatment Strategies. Diugs Aging 2011; 26 (7); 519-537.First administration of antibacterials within 4 hou

34、rs of admission;Oxygen supply in the presence of hypoxaemia;Switch from parenteral to oral administration of antibacterials only when the antibacterials have comparable bioavailability and the patient is clinically stable; Discharge only when the patient is haemodynamically stable on the discharge d

35、ay as well as on the previous day. Lists four quality indicatorsfor hospital care in elderly patients with CAPThiem U, Heppner HJ and Pientka L. Elderly Patients with Community-Acquired Pneumoniaoptimal Treatment Strategies. Diugs Aging 2011; 26 (7); 519-537.The 148 cases were divided into two group

36、sSteroid groups :82patients ( Age 74.4 18.8 CAP: 72 cases, HAP: 10 cases) Nonsteroid groups: 66 patients(Age 75.6 17.9,CAP: 59 cases, HAP: 7 cases) 糖皮质激素应用问题 Kiyokawa K, Kawai S. Efficacy of steroid therapy on adult patients with severe pneumonia. J Infect Chemother (2010) 16:266271.糖皮质激素应用问题 Kiyokawa K, Kawai S. Efficacy of steroid therapy on adult patients with severe pneumonia. J Infect Chemother (201