郑湘榕肺炎课件上课用

同学们好！呼吸系统疾病

RespiratorySystemDisease湘雅医院儿科郑湘榕

婴幼儿上感、2种特殊类型上感的特点支气管肺炎临床表现、重症肺炎特点支气管肺炎的诊断、治疗支气管哮喘的临床表现、诊断和治疗重点IntroduceInpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.Whychildrenaresosusceptibletoacuterespiratoryinfections?breathedin(inspired)breathedout(expired)NasopharynxOrapharynxLarynxEpiglottisTracheaRightbronchiLeftbronchiAlveolianatomic

physiologicalfeatures

Thechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40-44/min<1year30/min2-3years24/min4-7years22/min8-14years20/minChildrenRespiratorySystemPhysiologicFeatureRespiratorytypeAbdominalrespirationThoracicabdominalrespiration

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanosisThreedepressionssign

ＡuscultationExamineMethod

Ａuscultation吸气喘鸣（inspiratorystrider）呼气喘息（expiratorywheeze）哮鸣音中、粗湿罗音细湿罗音ExamineMethod急性上呼吸道感染（AURI）

AcuteUpperRespiratoryInfectionEtiologyＶirus：Ｏccupy90%

Ｂacteria：Ｓecondary

Streptococuspyogens

PneumococcuＨaemophilusinfluenzaeCommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestationsSchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplicationsCommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽部充血，扁桃体肿大)Lymphadenectasisinsubmaxilla(有时下颌、淋巴结肿大)Rashwhenenterovirusinfection(肠道病毒感染时可出现皮疹)ClinicalManifestationsSpecialAURI柯萨奇病毒A组感染夏秋好发高热、咽痛、流涎咽腭弓、软腭处有疱疹疱疹破溃后可形成溃疡病程1周左右ClinicalManifestationsHerpangina疱疹性咽峡炎Pharyngo-conjunctivalfever咽结合膜热

腺病毒3，7型所致春夏发病，可小流行发热、咽炎、结合膜炎咽部充血、结合膜充血，颈部、耳后淋巴结肿大病程1~2周ClinicalManifestationsSpecialAURIAntivirusdrugs中药Ribovirin3-5daysAntibioticsPenicillinCephalosporin

Macrocycliclactone3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatmentDefervesceDrugs：对乙酰氨基酚，布洛芬PhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatment中国0-5岁儿童急性发热诊断处理指南2008婴幼儿上感、2种特殊类型上感的特点支气管肺炎临床表现、重症肺炎特点支气管肺炎的诊断、治疗支气管哮喘的临床表现、诊断和治疗重点Pneumonia肺炎

ChildrenfamiliardiseaseIntroductionPneumoniaaffects156millionchildrenundertheageof5yrsLeadingcauseofmortalityinunder5yrsMostofthesedeaths–preventableMosteffectiveintervention-EarlydiagnosisandappropriatemanagementThehospitalizationnumberofinfantandtoddleris39.5timesofschoolageWilliamsetal.LancetInfectDis,2002

World’sbiggestkillerIntroductionPneumonia(18%)anddiarrhea(15%)aretheleadingkillersinchildren.Theytooknearly3millionchildrenlivesin2008alone.(两种疾病在2008年一年就夺走三百万儿童的生命)•Inchildrenages0-59months:0-59月的儿童•Pneumoniacausednearly1.6mdeaths•Diarrheacausedmorethan1.3mdeathsBlacketal,Lancet2010PneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinitionOncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：1~3monthsClassification1OnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification3OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification4ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification5OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification6支气管肺炎

BronchopneumoniaEtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniae

PathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswallPathologicphysiology气道炎症循环系统神经系统水电解质消化系统肺A压增高中毒性心肌炎心衰代酸中毒性肠麻痹胃肠粘膜屏障功能脑水肿颅压呼酸K+↑水钠储留毒血症通气不足PaO2↓,PaCO2↑

换气障碍PaO2↓ClinicalmanifestationMild

symptomaticrespiratorysystemfeverrespiratory

distressnasalflaring,retractions,cyonosistachypnea

cough

rales<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分Rapidbreathing

Clinicalmanifestation<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailureClinicalmanifestSeveresymptomaticHeartfailure呼吸突然加快，>60次/分心率突然增快

婴儿>180次/分幼儿>160次/分突然烦躁不安、面色发灰心音明显低钝，奔马率，颈静脉怒张肝大肋下3cm以上尿少、下肢浮肿ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomaticClinicalmanifestDICBp四肢凉，脉速弱，出血SLADHNa+

≤130mmol/L渗透压<270mOsm/LEdemaSeveresymptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratorydataBloodbloodroutinebacteriainfect：WBC↑、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandcultureLaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis支气管肺炎正常胸片大叶性肺炎正常胸片fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosisDifferentiationacute

bronchitisrales、tachypneaforeignbodiesinbronchihistoryofforeignbodies、suddencough、respiratorydistress、lowerofbreathtoneorwheezingtuberculosishistoryofTBcontact、PPDtest、PPD-IgGIgM、X-ray、ralesTreatmentgeneraltreatmentBalanceofwaterandelectrolyte3%Nacl12ml/L→↑Na+10mmol/L

Temperature18-20℃

Humidity60%FoodnutritiveTreatmentControlinfectionvirus：noidealdruglikevirozolmycoplasma、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、fullperiodoftreatment,firstselectPeniccilinTreatment抗生素使用原则

根据药敏选药adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道浓度高的药物adoptdrugswhichcanfinallyinfiltratelungtissue足量足疗程重症静脉给药inseverecase,drugsshouldbeadministedbyvein

,fulldose,fullperiod

Bacteria,thecommonestpathogenDespitevariationinstudyresults,S.Pneumoniae,Staphaureus,Hinfluenzae

IdentifiedasmajorpathogensindevelopingcountriesPneumonia:Microorganisms

Pneumonia:microorganismsMixedinfection:8-40%(Viral/bacterialormorethan1bacteria)

MostcommoncombinationSpneumoniae+RSVorSpneumoniae+MycoplasmaKabirARML.AetiologyofALRTIininfancy’2003Organismisolationrate:11.69%Staphaureus (42%)

StrepPneumoniae (20%)

HInfluenzae (7%)

Paeroginosa (5.3%) comingup- previouslynot recognizedSeverepneumoniaEvaluationAntimicrobialResearch(SPEAR)’2007Allweresusceptibleto3rdgencephalosporinTreatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasma

pneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，fullperiodis6weekstreatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、

cyanosis、asthmasuppress、"toxicappearance,"methods:bynosecanal0.5~1L/min，40%；byveil2~4L/min,50%~60%mechanismventilate（

respirefailture）holdingrespiratory

tractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorbTreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥拉明0.5mg/kgivgtt

10%GS20mltreatagainstsymptomsTreatmenttreatofHeartfailure镇静给氧强心：西地兰减轻心脏负荷

treatagainstsymptomsTreatment中毒性脑病治疗脱水：甘露醇改善通气扩血管药物：酚妥拉明，654-2止痉：安定，鲁米那糖皮质激素：地塞米松神经营养

treatagainstsymptomsTreatment糖皮质激素应用适应症：①喘憋重,呼吸衰竭②全身中毒症状重③感染性休克

④脑水肿琥珀酸氢化可的松5~10mg/kg.d地塞米松0.1~0.3mg/kg.d

ivgtt2~3次/日×3~5天甲基强的松龙2~4mg/kg.次ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolveWhatifpatientsfailstorecover?Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen病毒性肺炎呼吸道合胞病毒肺炎腺病毒肺炎2岁，2~6月多见喘憋、呼吸困难，可合并呼衰、心衰哮鸣音，细湿罗音小点片状影，肺气肿肺不张间质性肺炎6月~2岁中毒症状重，稽留热，咳剧，喘憋，呼吸困难出现晚，湿罗音或肺实变

胸片改变出现早，肺气肿，片状影或融合年龄症状胸片体征细菌性肺炎葡萄球菌肺炎新生儿，婴幼儿急、重、快，弛张热或稽留热，咳嗽，呼吸困难，呻吟，易致迁徒化脓病灶，并发脓胸，脓气胸，肺大疱中细湿罗音，出现早，皮疹浸润影，持续时间较长，易变，可见多发性肺脓肿，脓胸，脓气胸等<4岁慢，重，发热，痉挛性咳嗽，呼吸困难，发绀。易致迁徒化脓病灶，易并发脓胸湿罗音或实变大叶性肺炎、支气管肺炎、肺实变年龄症状体征胸片革兰阴性杆菌肺炎肺炎支原体肺炎年长儿，婴幼儿发热、刺激性咳嗽，多系统病变不明显，婴幼儿可有呼吸困难，喘憋，哮鸣音，湿罗音肺门影增浓；支气管肺炎改变；间质性肺炎；均一实变影<6月起病慢，无发热，先URI症状后咳、喘、气促，部分伴结膜炎湿罗音，持续时间长间质性炎症，过度充气、片状影，持续时间长年龄症状体征胸片沙眼衣原体肺炎支衣原体肺炎

支原体肺炎

支气管哮喘

bronchialasthma

发展史asthma-喘息，2000年前就有对哮喘的详细描述过去认为是一种平滑肌功能异常性疾病80年代以来通过支气管黏膜活检，认识到哮喘是气道慢性炎症性疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,respiratorydistress,cough特征气道慢性炎症：此为哮喘主要特征可逆性的气流受限：指气流受限可被支气管扩张剂所逆转气道高反应性：对正常气道无反应或很小反（AHR）应的刺激产生收缩反应pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening病理生理急性支气管痉挛：速发型哮喘反应（IgE依赖）气道壁肿胀：迟发型哮喘反应（炎症诱导）粘液栓形成：难治疗的气流受限气道重塑：不可逆的气道狭窄核心气流受限atopy是指对普通环境中常见的变应原产生IgE介导反应的易感性，有明显的家族遗传倾向。特应性哮喘、过敏性鼻炎、湿疹、食物过敏等导致哮喘发生最确定的危险因素pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-

adrenalglandnerve

-

adrenalglandnerve

PneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistoryClinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticusauxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力呼气容积/用力肺活量，低于70-75％提示气流受限）PEFR（呼气风流速，其日间变异率>20%,使用支扩剂后增加20%可诊断哮喘）Diagnoseofchildrenasthmagasprecurrentattackslungwheezingralesreversibleairwayobstructionexcludeotherdiseasethatcancausegaspcough4weeks,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexc