1、Professor Enmei Liu M.D.,Ph.DDepartment of Respiratory Medicine,Childrens Hospital,CMURespiratory DisordersTopicsv Respiratory disordersv Respiratory infectionsv PneumoniaTopicsv Respiratory disordersv Respiratory infectionsv Pneumoniav 50%of consultation with general practitioners or acute illness
2、in young children and a third of consultations in older childrenv 25-30%of acute pediatric 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
3、 the most common inherited disorder in Caucasians causing chronic diseaseRespiratory DisordersTopicsv Respiratory disordersv Respiratory infectionsv PneumoniaRespiratory Infectionsv The most frequent infections of childhood:6-8/yearv Pathogens:viruses,bacterial,other pathogensv Host and environmenta
4、l factorsv Classification of respiratory infectionsClassification of Respiratory InfectionsAccording 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
5、 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 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 reces
6、sion凹.On auscultation there are generalized fine crackles劈啪声 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 cough,rapid,laboured breathing and poor feeding.He w
7、as born at 27 weeks 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 intercostal recession.On auscultation there are generalized fine crackles and wheezes.
8、PneumoniaQuestionWhat is pneumonia?Pneumonia is an inflammation of the parenchyma of the lungs.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 tra
9、ct infectionsv Worldwide,about 3 million children die each year from pneumonia,with the majority 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 Cha
10、ir,Department of International Health,Johns Hopkins Bloomberg School of Public Health,USA)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 classi
11、fy pneumonias clinically?v Anatomyv Pathogensv Severityv Duration v Onset siteClassificationv 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 Pneu
12、moniav Chlamydia Pneumoniav Acute Pneumoniav Prolonged Pneumoniav Chronic PneumoniaBased on 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 patho
13、gens in community and hospital infectionCommunity-acquired infectionViruses Streptococcus 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
14、pneumoniae（肺炎克雷伯菌）Escherichia coli（大肠杆菌）Streptococcus pneumoniaeStaphylococcus aureusAnaerobes（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 r
15、isk factors:premature baby,underlying disordersQuestionWhat cause bronchopneumonia?Bacteria: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,Haemophilu
16、s influenzae,Moraxellacatarrhalis（卡他莫拉菌），Staphyloccocus aureus Viruses:RSV MycoplasmaCauses of BronchopneumoniaPathology of PneumoniaNormalPneumoniaInflammaory exudateInflammaory exudatePathology of PneumoniaQuestionWhat are the pathophysiology of pneumonia?PathogensURTIBronchitisPneumoniaInflammato
17、ry exudateObstruction of airwayGas exchange abnormalVentilation abnormalhypoxemia(低氧血症）低氧血症）hypercapnia（高碳酸血症）（高碳酸血症）toxinemia（毒血症）（毒血症）tachypneacyanosisRales啰音啰音fevercoughSevere PneumoniaRespiratory failure PO2 6.67 kPa PCO2 6.67 kPaToxic carditis and DICToxic encephalopathy（中毒性脑病）Digestive system
18、symptom abdomen distension bloody diarrheaDisturbances of fluid and electrolyte metabolic acidosis 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
19、the severity of the diseaseFeverCoughCyanosisTachypeneaRalesAge rangeDefinition of“fast breathing”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,t
20、he side of the nostrils flares outwardsNasal Flaring（鼻扇）（鼻扇）With inspiration,the lower chest wall 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
21、 in infants and toddlers v Generally present with nonspecific signs and symptoms including lethargy,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 kP
22、aToxic carditis and DIC tachycardia pale ECG abnormalToxic encephalopathy irritability lethargy 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
23、 v White blood cell count and C-reaction proteinv Pathogens examination:1)Sputum 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 infi
24、ltrates bilaterallyv Complication:lung abscesses,empyema,pyopneumothorax,pneumatocele,atelectasisv 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 typ
25、ical clinical manifestation of bronchopneumoniav According to X-ray manifestation v Pay attention to the atypical manifestation of infantsv Evaluate the severity of pneumoniav Find the etiology of pneumoniaDifferential Diagnosis v Bronchitisv Foreign Body Aspirationv Tuberculosisv AsthmaQuestionHow
26、is pneumonia treated?Managementv Supportive carev Antimicrobials therapyv Hospitalization in selected cases Supportive Carev Respiratory care may range from oxygenation,bronchodilators for wheezing,humidification or mist,suctioning,and postural drainage,intubation and mechanical ventilationv Hydrati
27、on(sometimes intravenous)v Control of fever:brufen,acetaminophenv Management of complicationsAntimicrobial TherapyOrganismAntimicrobialS.pneumoniae Penicillin(if not resistant).third-generation cephalosporin e.g.cefotaximeceftriaxone(if resistant to penicillin)H.influenzae Azithromycin or Amoxicilli
28、n(if not resistant)B e t a lactamase Cefuroxime or third-generation cephalosporin(if beta 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 erythromyc
29、in);alternative,sulfa drugs MycoplasmaAzithromycin(other macrolides);alternative,tetracycline(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.col
30、i,Klebsiella,Listeria monocytogenes,S.aureus,other gram-positive)Cytomegalovirus Herpes 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 trachomat
31、is Ureaplasma urealyticum CytomegalovirusPneumocystis cariniiErythromycin SulfonamideInfants 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.,cefot
32、axime)Toddler or preschool ageS.pneumoniae,H.influenzae M.pneumoniae,ChlamydiaRSV Parainfluenza Adenovirus InfluenzaAzithromycinAmoxacillin-clavulanate:not active against atypical organisms(Mycoplasma,Chlamydia)Organisms Causing Pneumonia and Empiric Therapy in Pediatric BacteriaAntibioticsDurationG
33、+coccusPenicillin，1st and 2nd cephalosporin 710 daysG-bacillus2nd and 3rd cephalosporin12 weeks 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
34、 2 weeksv Pneumonia caused by a virus often lasts longerClinical CourseSeveral Pneumoniasp Bronchiolitis 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 s
35、yncytial virus(RSV)is the pathogen in 75-80%cases p Clinical features:1.Age:2-6 month2.Season3.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 secr
36、etionsv The chest X-ray shows hyperinflation 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 Management v Supportive.Humidified oxygen is delivered into a head-box
37、 v Mist雾,antibiotics and steroids are not helpful v Nebulised bronchodialators do not reduce the 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
38、 disorders or immunodeficiency v Fluids may need to be given by nasogastric tube or intravenouslyv 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 co
39、mmon early in life,it is especially common in less than 2 year-oldp Epidemic respiratory disease 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 in
40、filtratesp Adenoviral pneumonia can be necrotizing and cause permanent lung damage,especially bronchiectasisp 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 ra
41、pidly progressive fulminant illness v S.aureus pneumonia easily occurs complicationsv Blood cultures 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
42、 pneumoniav Methicillin or vancomycin should be administered for 3-4weeksMycoplasma Pneumonia v 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 th
43、e lung is the primary infection site,extrapulmonary complications sometimes occurClinical Features 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
44、 may be presentLaboratory findings v The total and differential white blood cell counts are usually 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 demonst
45、rate intersititial or bronchopneumonic infiltrates,frequently in the middle or lower 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
46、thrombocytopenia can also occurv A wide variety of skin rashes including erythema multiforma and 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 be
47、d rest,are helpfulChlamydial Pneumonia v Pulmonary disease due to C trachomatis usually evolves 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,eosino
48、philia,and elevated immunoglobulins can be seen Clinical Features v About 50%of patients with chlamydial 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
49、 can have a staccato character and resemble the cough of pertussisv The infant is usually tachypenic.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,CO
50、2 retention is not commonv Peripheral blood eosinphilia has been observed in about 75%of patientsv 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
