呼吸系统疾病(英文)课件.ppt

1、Topicsv Respiratory disordersv Respiratory infectionsv PneumoniaRespiratory Disordersv50%of consultation with general practitioners or acute illness in young children and a third of consultations in older childrenv20-35%of acute pediatric admissions to hospital,some of which are life-threateningvAst

2、hma is the most common chronic illness of childhoodvCystic fibrosis is the most common inherited disorder in Caucasians causing chronic diseaseRespiratory Infectionsv The most frequent infections of childhood:6-8/yearv Pathogens:viruses,bacterial,other pathogensv Host and environmental factorsv Clas

3、sification of respiratory infectionsClassification of Respiratory InfectionsAccording to the level of the respiratory tree most involved:v Upper respiratory tract infectionv Lower respiratory tract infectionPneumoniaEnmei LiuChildrens Hospital,CMUCase-1C and a respiratory rate of 60 breaths/min.His

4、chest is hyperinflated with marked intercoatal recession.On auscultation there are generalized fine crackles and wheezes.QuestionDo you have 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 rapi

5、d,laboured breathing and poor feeding.He was born at 27 weeks gestation,birth weight 979g and was discharged home at three months of age.On examination he was a C and a respiratory rate of 60 breaths/min.His chest is hyperinflated with marked intercoatal recession.On auscultation there are generaliz

6、ed fine crackles and wheezes.QuestionWhat is pneumonia?Pneumonia is an inflammation of the parenchyma of the lungs.DefinitionQuestionHow about the prevalence of pneumonia?v Pneumonia accounts for approximately 15%of all respiratory tract infections.v Worldwide,about 3 million children die each year

7、from pneumonia,with the majority of these deaths occurring in developing countries.v Pneumonia remains the most common cause of morbidity in China.IncidenceQuestionHow to classify pneumonia in clinic?v Anatomyv Pathogensv Severityv Duration v Onset siteClassificationv Bronchopneumoniav Lobar or Lobu

8、lar Pneumoniav Interstitial PneumoniaBased on anatomy or X-ray manifestation Based on etiologyv Bacterial pneumoniav Viral Pneumoniav Mycoplasma Pneumoniav Chlamydia Pneumoniav Acute Pneumoniav Prolonged Pneumoniav Chronic PneumoniaBased on the process of pneumoniav Mild Pneumoniav Severe PneumoniaB

9、ased on the severity of pneumoniav Community Acquired Pneumonia(CAP)v Hospital Acquired Pneumonia(HAP)Based on the onset site of pneumoniaBronchopneumoniaQuestionWhy are children likely have bronchopneumonia?v Characters of childhood airway anatomic structure and their respiratory physiologyv Immune

10、 function of childhoodv High risk factors:premature baby,underlying disordersQuestionWhat cause bronchopneumonia?Bacteria:Streptococcus pneumoniae,Haemophilus influenzae Viruses MycoplasmaCauses of BronchopneumoniaPathology of PneumoniaInflammaory exudateInflammaory exudatePathology of PneumoniaQues

11、tionWhat are the pathophysiology of pneumonia?PathogensURTIBronchitisPneumoniaInflammatory exudateObstruction of airwayGas exchange abnormalVentilation abnormalhypoxemiahypercapniatoxinemiatachypneacyanosisralesfevercoughQuestionWhat are the signs and symptoms of pneumonia?The clinical signs and sym

12、ptoms of pneumonia depend primarily on the age of the patient,the causative organism,and the severity of the disease.FeverCoughCyanosisTachypeneaRales out breathing inWith inspiration,the side of the nostrils flares outwardsNasal FlaringWith inspiration,the lower chest wall moves inLower Chest Wall

13、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 lethargy,irritability,poor feedi

14、ng,vomiting.v If it appear respiratory failure or other abnormality of other system-severe pneumonia.Important PointsComplicationsv Empyemav Pyopneumothoraxv Pneumatocele v Lung abscesses v AtelectasisLaboratory Examination v White blood cell count and C-reaction proteinv Pathogens examination:1)Spu

15、tum cultures 2)Blood 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,pneu

16、matocele,atelectasisv CT Normal chest X-rayPatchy infiltratesLobar pneumonia of the right lower zone consolidation lung abscessespyopneumothoraxQuestionHow to diagnosis pneumonia clinically?v According to the typical clinical manifestation of bronchopneumonia.v According to X-ray manifestation v Pay

17、 attention to the atypical manifestation of infantsv Evaluate the severity of pneumoniav Find the etiology of pneumoniaDifferential Diagnosis v Bronchitisv Foreign Body Inspirationv TuberculosisQuestionHow is pneumonia treated?Managementv Supportive carev Antimicrobials therapyv Hospitalization in s

18、elected cases Supportive Care Adolescents.v Respiratory care may range from oxygenation,bronchodilators for wheezing,humidification or mist,suctioning,and postural drainage,intubation and mechanical ventilation.v Hydration(sometimes intravenous)v Control of feverv Management of complicationsAntimicr

19、obial Therapy Adolescents.OrganismAntimicrobialS.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 bet

20、a lactamase 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,tetracy

21、cline(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

22、simplexAmpicillin 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 SulfonamideInf

23、ants febrile 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 Parain

24、fluenza Adenovirus InfluenzaAzithromycinAmoxacillin-clavulanate:not active against atypical organisms(Mycoplasma,Chlamydia)Organisms Causing Pneumonia and Empiric Therapy in Pediatric QuestionHow about the clinical course of pneumonia?v With treatment,pneumonia caused by bacteria can usually be cure

25、d in 1 or 2 weeksv Pneumonia caused by a virus often lasts longerClinical Course Adolescents.Specific PneumoniasBrochiolitisv Brochiolitis is the most common serious respiratory infection of infancyv Two to three per cent of all infants are admitted to hospital with the disease each year during annu

26、al winter epidemics.v Ninety per cent are aged 1-9 months bronchiolitis is rare after one year old.v Respiratory syncytial virus(RSV)is the pathogen in 75-80%cases Clinical Features v Coryzal symptoms precede a dry cough and increasing breathlessness.v Wheezing is often but not always present.v Feed

27、ing difficulties associated with increasing dyspnoea are often the reason for admission to hospital.v Recurrent apnoea is a serious complication in infants in the first few months of life.v Infants born prematurely who develop bronchopulmonary dysplasia and infants with congenital heart disease are

28、more severely affected.v The finding on examination are characteristic:Sharp,dry cough Tachypnoea Subcostal and intercostals recession Hyperinflation of the chest Investigations v RSV can be identified rapidly using a fluorescent antibody test on nasopharyngeal secretions.v The chest X-ray shows hyp

29、erinflation of the lungs due to small airways obstruction and air trapping.v Blood gas analysis,which is required in only the most severe cases,shows lowered arterial oxygen and raised CO2 tension Hyperinflation of the lungs with flattening of diaphragmManagement v Is supportive.Humidified oxygen is

30、 delivered into a head-box v Mist,antibiotics and steroids are not helpful v Nebulised bronchodialators do not reduce the severity or duration of the illness vThe antiviral drug ribavirin only marginally shortens viral excretion and clinical symptoms,and should be considered only for infants with un

31、derlying cardiopulmonary disorders or immunodeficiency v Fluids may need to be given by nasogastric tube or intravenously v Mechanical ventilation is required in about 2%of infants admitted to hospital Etiology：Respiratory syncytial virus(RSV)is the pathogen in 75-80%cases Clinical features:1.Age:3-

32、6 month2.Season3.Wheezing4.X-ray5.Duration:7-10 daysManagement:BronchiolitisStaphylococcus aureus.v S.aureus is an uncommon but important cause of pneumonia that can occur in any age group.v S.aureus is a rapidly progressive fulminant illness v S.aureus pneumonia easily occurs complications.v Blood

33、cultures are positive in 20-30%of patients.v The pleural effusions should be drained by thoracentesis or,if large,by a chest tube.v Pneumatoceles are also common and are found in 45-60%of patients with S.aureus pneumonia.v Methicillin or vancomycin should be administered for 3-4weeks.Mycoplasma Pneu

34、monia v M pneumoniae is a common cause of symptomatic pneumonia in older children.v Endemic and epidemic infection can occur.v The incubation period is long(2-3weeks),and the onset of symptoms is slow.v Although the lung is the primary infection site,extrapulmonary complications sometimes occur.Clin

35、ical Features v Fever,cough,headache,and malaise are common symptoms as the illness evolves.v Rales are frequently present on chest examination,decreased breath sounds or dullness to percussion over the involved area may be present.Laboratory findings v The total and differential white blood cell co

36、unts are usually normal.v 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 diagnosis.Imaging Chest x-rays usually demonstrate intersititial or bronchopneumonic infiltrates,frequently in the middle or lo

37、wer lobes.Pleural 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

38、 multiforma and Stevens-Johnson syndromeTreatment v Antibiotic therapy with erythromycin for 7-10 days usually shortens the course of illness.v Supportive measures,including hydration,antipyretics,and bed rest,are helpful.Chlamydial Pneumonia v Pulmonary disease due to C trachomatis usually evolves

39、gradually as the infection descends the respiratory tract.v 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

40、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

41、penic.Scattered inspiraotrt rales are commonly heard,but wheezes rarelyv Significant fever suggests a different or additional diagnosis Laboratory findings v Although patients may frequently be hypoxemic,CO2 retention is not common.v Peripheral blood eosinphilia has been observed in about 75%of pati

42、ents.v Serum immunloglobulins are usually abnormal.IgM is virtually always elevated,IgG is high in many,and IgA is less frequently abnormal.v C trachomatis can usually be identified in nasopharyngeal washings using fluorescent antibody or culture techniques.Imaging Chest x-rays usually reveal diffus

43、e interstitial 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 days.v Oxygen

44、 therapy may be required for prolonged periods in some patients.Summary v Pneumonia in pediatric patients encompasses a wide spectrum of etiologies and illness from mild to severe and life threatening.v Therapy should include an antibiotic if a bacteria or atypical bacteria(chlamydia or mycoplasma)i

45、s suspected.No antibiotics are necessary for viral pneumonia.v Supportive therapy also includes fever control,maintenance of hydration and respiratory care.v Close follow-up is necessary in order to detect any secondary bacterial infection or the development of complications.Key Issues v Etiology of

46、 pneumoniav Pathophysiology of pneumoniav Clinical feature of pneumoniav Diagnosis and differential diagnosis of pneumoniav Management of pneumoniav Several special pneumoniasCase-2History:A 9-week old female infant come to see doctor with a 3 week history of rhinorrhea and a 2 week history of cough

47、.The cough is described as explosive and occurring in clusters and it persists as a major clinical symptom.On one occasion,the baby could not seem to catch her breath.She has not had any fever.No one else in this family is ill.At 6 weeks of age,the infant received on DPT.Physical examination:C.Pulse

48、 120beats/min,and respiratory rate is 65/min.There are intercostal and subcostal retractions.Ausculation reveals fine inspiratory rales throughout.Laboratory data:3/mm3 with 21%polymorphonuclear leukocytes,20%bands,50%lymphocytes,and 9%eosinophils.The chest radiograph is shown bilaterally patchy inf

49、iltrates,more confluent in the upper lobes without penumothorax or pleural effusions.Question 1.Please discuss this case.2.What is the most likely etiology diagnosis?References vNelson Textbook of PaediatricsvPneumonia(Sharon E.Mace,MD,FACEP,FAA)vCurrent Pediatric Diagnosis and TreatmentvMosby”s Crash CoursevPediatricsEmail address:Telephone:86-23-63624074Address:Childrens Hospital,CMU