Keywords: bronchial pneumonia
Bronchial pneumonia in children during various types of pneumonia, the most common one, especially good occurs in infants and young children. Throughout the year can be the disease, more common in the north in winter and spring, in the south, mainly in the summer and autumn. Sporadic or epidemic. In children may be due to overcrowding, poor ventilation, the air is poor susceptible to this disease, malnutrition, vitamin deficiency, congenital heart disease also increased the incidence of pneumonia and her condition had deteriorated.
Pathogens as bacteria and viruses. The bacteria are the most common pneumococcal, Staphylococcus aureus, hemolytic streptococcus, Haemophilus influenzae type B, E. coli, and vice E. coli than common. Virus respiratory syncytial virus, adenovirus, influenza virus and parainfluenza virus is more common. The disease is often secondary bacterial infection, the infection based on the so-called “mixed infection".
Alveolar inflammation mainly mild bronchial wall and alveolar interstitial inflammatory lesions. Alveolar capillary dilatation and congestion, alveolar wall edema, alveolar neutrophils, red blood cells, exudate and bacterial cellulose. Inflammation through the channels and bronchioles alveolar spread to adjacent tissue, focal inflammation, small lesions were small pieces convergence expand. When small bronchi, capillary bronchial inflammation, the lumen is more narrow the lumen partially or completely blocked, causing emphysema or atelectasis. Viral pneumonia, bronchial, and the capillary bronchial wall and alveolar septa were edema, accumulation of mucus and damaged cells in the wall. Alveoli and alveolar ducts, interstitial visible mononuclear cell infiltration.
(A) respiratory insufficiency
Mainly hypoxemia, carbon dioxide retention can be serious. Pneumonia due to inflammation, on the one hand, the alveolar wall thickening, diffusion resistance increased, bronchial congestion, edema and secretions retention, so that the original has a relatively narrow lumen becomes narrower in children. As a result, lead to ventilation and ventilation with severe dysfunction, hypoxia and carbon dioxide retention. By increased respiratory rate and depth of breathing in children with early disease increased minute ventilation, carbon dioxide diffusing capacity than oxygen, often with only mild hypoxia and no significant carbon dioxide retention.
When the lesion progress seriously hamper effective gas exchange, arterial oxygen pressure (PaO2) and oxygen saturation (SaO2) decreased hypoxemia. If SaO2 decreased to 0.85, reduced hemoglobin 50g child can see the cyanosis. When pulmonary ventilation is severely reduced, the impact on carbon dioxide emissions, in Pa02 reduce arterial partial pressure of carbon dioxide (PaCOc) increased. Pa02 ~ 6.65kPa (50mmHg), PaC02 ≥ 6.65kPa (50mmHg), Sa02 ≤ 0.85, to respiratory failure.
Pathogens role, severe pneumonia is often accompanied by toxemia, causing varying degrees of infection symptoms, such as fever, lethargy, convulsions. Hypoxia and hypercapnia the stay and toxemia not only affect respiratory function, as well as the systemic metabolic important organ that barriers.
1. Acid-base balance
Aerobic metabolism in vivo hypoxia obstacles, the acidic metabolites accumulation, coupled with factors such as high fever, hunger, dehydration, vomiting and diarrhea, often accompanied by metabolic acidosis. In addition, carbon dioxide retention, PaCO2 increased, rising carbonic acid and hydrogen ion concentration, pH value decreased, resulting in respiratory acidosis. Hypoxia and carbon dioxide retention caused by renal artery spasm Shuinazhuliu hypoxia caused by increased ADH secretion caused dilutional hyponatremia. Acidosis H + into the intracellular K + to the extracellular transfer of blood K + increased or normal. Diarrhea, or malnourished blood Cl-low tendency compensatory respiratory acidosis; minority children early because of tachypnea, hyperventilation may appear respiratory alkalosis. Severe pneumonia, often mixed acidosis.
2. Circulatory system
Hypoxia and carbon dioxide retention can cause reflex spasm of the pulmonary vascular, pulmonary circulation pressure increased, leading to pulmonary hypertension. Widely lung disease pulmonary vascular resistance increase caused by right heart load increased. Myocardial damage by pathogens toxin prone to toxic myocarditis. The above factors can lead to heart failure. The small number of cases because of severe sepsis and hypoxemia microcirculation.
3. Central nervous system
Hypoxia can affect the function of the sodium pump in the brain cell membrane, the intracellular Na + increased absorption of moisture, combined with hypoxia telangiectasia, blood-brain barrier permeability increase caused the cerebral edema, in severe cases, can cause central respiratory failure . The the pathogen toxin can cause toxic encephalopathy.
4. Digestive system
Gastrointestinal tract in the role of hypoxia and toxins prone to dysfunction, severe cases can occur in paralytic ileus. Increased capillary permeability of the gastrointestinal tract can cause gastrointestinal bleeding.
(A) general symptoms
Abrupt onset or slow. Mild upper respiratory tract infection a few days before the onset can be sudden hair often fever, the early body temperature between 38 ~ 39 ℃, also up to 40 ° C, remittent fever or irregular heat. The frail babies mostly slow onset, fever is not obvious or below normal body temperature.
(B) respiratory symptoms
Cough more frequent early was irritating cough, cough anti-slightly alleviate the very period, the recovery period into wet cough. Severe coughing often cause vomiting. Shortness of breath, respiratory rate up to 40 to 80 times per minute. Children with severe perioral, nasolabial fold, the Zhizhi end cyanosis, nasal flap and three depressions sign.
Is not obvious, the early signs of lung breath sounds rough, or weakened, could later be heard in fine moist rales, to the lungs the end and paravertebral more and more obvious at the end of deep inspiration. Mostly scattered in small lesions, percussion normal, when lesions fusion expanding, fruit and some or the entire lobe, there may be a real variant disease. Percussion dullness and (or) decreased breath sounds in one lung, pleural effusion or empyema should be considered.
(C) The symptoms of circulatory system
The light slightly increased heart rate and severe, there may be varying degrees of heart failure or myocarditis. Complicated by heart failure may refer to the following diagnostic criteria:
Suddenly ① heart rate more than 180 beats / min;
The ② breathing suddenly accelerated, more than 60 beats / min;
③ sudden extreme irritability, cyanosis (toe) A microcirculation refill time, pale gray dark green;
The ④ liver increases rapidly;
⑤ low heart sound blunt, or gallop, jugular vein distention;
⑥ little or no urine, the five facial, eyelid or lower extremity edema can be diagnosed for heart failure.
Myocarditis, manifested as pale, tachycardia, low heart sound blunt, arrhythmia, electrocardiogram showed ST segment depression and T wave flat, two-way, and upside down.
Children with severe occurrence of disseminated intravascular coagulation, manifested as decreased blood pressure, cold limbs, skin, mucous membrane bleeding.
(D) The nervous system symptoms
Often drowsiness, irritability, or alternating between the two. Severe convulsion, a toxic encephalopathy performance coma or recurrent seizures.
(E) The digestive symptoms
There may be loss of appetite, vomiting, diarrhea, abdominal distension. Severe pneumonia often occurs in paralytic ileus apparent bloating, resulting in elevated diaphragm further aggravate breathing difficulties. Gastrointestinal bleeding may spit coffee-like material, blood in the stool or tarry stools.
【The different pathogens several common due to bronchopneumonia characteristics]
(A) Staphylococcus aureus pneumonia
Staphylococcus aureus pneumonia (staphylococciaureus pneumonia) referred to S. aureus pneumonia, common in newborns and infants, and often the primary S. aureus lung infection. The older children are mostly secondary to Staphylococcus aureus septicemia.
Pathological changes characterized by extensive hemorrhage and necrosis of lung tissue and multiple small abscess. Subpleural abscess, such as rupture, can form empyema, or pus. Sometimes erosion bronchial formation of bronchial fistula. In addition to lung abscess secondary sepsis, often to cause the other organs migratory purulent lesions.
Acute onset condition Benedict, rapid development. Generally the first several days of upper respiratory tract infection symptoms, and protruding high fever, often isolated and relaxation of hot type. Cough, sputum was mucopurulent difficult to expectorate.Poisoning symptoms significantly. There may be pale, gray hair, skin blur, the acral cold \ low heart sound blunt, fast heart rate, blood pressure drop shock performance. Pulmonary signs appear early, early stage decreased breath sounds and fine moist rales. Lesions progress rapidly and can easily develop into lung abscess, empyema, pus pneumothorax and lung bullae. The skin may appear red papules, scarlet fever or urticaria-like rash. Peripheral blood leukocytes and neutrophils increased, the phenomenon of a shift to the left. The small number of cases leukocytes was significantly lower, but still high percentage of neutrophils. X-ray examination of the early signs of visible markings thickening or small pieces infiltrates, lesions develop rapidly, within hours empyema, pus pneumothorax, bullae.
(B) adenovirus pneumonia
Adenovirus pneumonia (adenovirus pneumonia), caused by adenovirus, our infant pneumonia pathogenic adenovirus type 3,7, prevalent in the 6 months to 2 years of age in children, and high mortality.
The pathological changes in the lesions or confluent of necrotizing pulmonary infiltrates and bronchial and alveolar interstitial inflammation. Trachea, bronchus extensive necrosis, necrotic tissue and inflammatory infiltration was full of endobronchial blockage causing bronchial lumen.
Abrupt onset, often 1-2 days a sudden fever up to 39 ° C, mostly missed heat, even irregular fever. Longer duration of fever, without antibiotics affect, mild 7-10 days fever, severe sustainable 2 to 3 weeks, the symptoms of the nervous system. Regardless of severity, early lethargy, listlessness, irritability, severe drowsiness or coma, and even repeated convulsions, neck stiffness and other toxic encephalopathy or encephalitis performance can occur. The majority of the onset that the frequency of cough array, white sticky sputum difficult to expectorate. Incidence of 4 to 6 days later difficulty in breathing, pale or gray hair, and gradually increased, manifested as wheezing, bruising, nose, wing flapping and three depressions sign. The early signs of lung obvious, generally hear a little moist rales in fever only after 4 to 5 days, and gradually increased. There may be signs of pulmonary consolidation lesions fusion. Merger pleural reaction and a small amount of pleural effusion in the course of the disease often no secondary infection the exudate grass yellow, not cloudy, secondary infection, there is chaos, children prone to toxic myocarditis, heart failure. More than half of the cases of diarrhea, vomiting, abdominal distension. The small number of toxic hepatitis, liver and spleen enlargement.
Most of the white blood cell count early normal or reduced, a small number of cases in 10X109 / L (10 000/mm3) above, classification mainly lymphocytes.
Changes in X-ray lung than lung symptoms appear early, showing patchy shadows of varying sizes, a wide distribution, mutual confluent lesions common to the lungs to step down and the right lung, emphysema can also be found. Lesions are slowly absorbed, 2 to 4 weeks until completely absorbed, the small number of cases with pleural changes.
(C) the respiratory syncytial virus pneumonia
Respiratory syncytial virus pneumonia (respiratory syncytial virus pneumonia) system caused by respiratory syncytial virus, more common in infants and young children under 3 years old, especially in infants less than 6 months common.
Pathological changes off eyebrow necrotizing bronchitis, bronchiolitis, bronchopneumonia and interstitial pneumonia. Most of capillary bronchial mucosa off mixed clogged with mucus, inflammatory exudate lumen, secondary to emphysema or atelectasis. Peribronchial alveolar and pulmonary interstitial also exudate.
Abrupt onset, often in 2 to 3 days after upper respiratory tract infection, persistent dry cough, sudden wheezing, breathing significantly accelerated up to 60 to 80 times per minute, even more than 100 times. Breath longer associated with breath moaning. Difficulty breathing, nose flap, perioral cyanosis and three depressions significantly faster heart rate. The fever is not high, generally no more than 38 ° C, the short duration of fever, lasted only 1 to 4 days, and even from time to fever. Pulmonary percussion hyperresonance. Decreased breath sounds, when the capillary bronchial nearly complete obstruction, breath sounds weak even inaudible. Asthmatic attack often can not hear rales. Wheezing slightly ease the wheeze and fine moist rales could be heard. Not dominant negative hyperventilation caused increased water and inadequate fluid intake, dehydration symptoms can occur in children. Due to wheezing, difficulty in breathing, hypoxemia and hypercapnia, prone to cause respiratory acidosis.
X-ray showed pulmonary obstructive emphysema, lung markings, interstitial pneumonia, emphysema. The dot sheet may also have weak shadow.
(D) Mycoplasma pneumoniae pneumonia
Mycoplasma pneumoniae pneumonia (mycoplasma pneumoniae pneumonia) caused by Mycoplasma pneumoniae, more common in children aged 5 to 15, but increasing number of reports of recent years, the infant JL infection, can be distributed to the popular.
Pathological changes in the lower respiratory tract, the trachea, bronchus, bronchial capillary wall hyperemia, edema, thickening and infiltration of mononuclear cells and plasma cells, blocking the airway secretions and scaling of its features. Pulmonary interstitial mononuclear cell infiltration also.
Slow onset, early disease may have general malaise, fever, fatigue, headache, fever or moderate heat away 1 to 2 weeks. Prominent irritating cough, early dry cough, and changed intractable severe cough sometimes like pertussis-like cough, spit up mucus thick sputum, even with bloodshot eyes. Cough that lasts for a long time, up to 1-4 weeks, often accompanied by chest pain. Infant wheezing symptoms more prominent, and sometimes difficult distinction with respiratory syncytial virus pneumonia. The pulmonary signs lighter, about 1/3 of the cases without any positive signs throughout the course of the disease. Generally localized in the lungs to hear a little wet and dry rales, decreased breath sounds. In some cases may be complicated by pleurisy, pleural effusion, mostly serous, even bloody.
Normal or high white blood cell count, and increased number of neutrophils. ESR. Serum agglutination test positive diagnosis.
X-ray examination following four kinds of change: the increase in hilar concentrated more prominent; ② bronchopneumonia change, to step down more to the right lung; ③ interstitial pneumonia change was mesh or cords by hilar with radiation and foreign, surrounded by a small piece of thin film or miliary shadows; ④ in some cases there was a large shadow, uneven density, were segments like distribution. A small number of big-leaf shadows, more than the next leaf. Often an old foci, a further new lesions appeared.
(E) Chlamydia pneumoniae
Chlamydia pneumoniae (chlamydiaepneumonia) is caused by Chlamydia trachomatis. Multi-infected mothers in childbirth infections, about 20% of infected infants pneumonia, one of the main pathogens of pneumonia for infants less than 6 months.
Incubation period of 2 to 3 months, the onset and more in three weeks left to rust, about 50% of a history of suffering from conjunctivitis in the neonatal period. Occult onset, and more respiratory symptoms, such as runny nose, nasal congestion and cough, persistent and gradually increased, cough Duocheng paroxysmal, generally without fever, sometimes visible otitis media. The the lungs typical symptoms and signs visible breathing speed up, and occasionally see apnea, the lung-cho Wen Lo tone expiratory wheezing, prolonged course of up to several weeks to two months.
X-ray shows emphysema associated with diffuse symmetry interstitial lesions and scattered patchy infiltrates, pleural reaction can be seen a small number of cases.
In general, bacterial pneumonia wet rales clearer, viral pneumonia, especially early in the disease (1 week) rales often few. The white blood cell count, NBT positive cells and CRP were significantly higher, the vast majority of the case of bacterial pneumonia, and vice versa, mostly viral pneumonia. Bronchial pneumonia complicated migration purulent lesions, or merge empyema, pus pneumothorax, bullae often prompts for S. aureus pneumonia. Several common pneumonia clinical differential points are shown in Table 4. However, the final etiological diagnosis depends on a bacterial culture, virus isolation and virus rapid diagnostic techniques.
Fever, cough, shortness of breath or difficulty breathing, the lungs, the fine wet rales, the diagnosis can be made. X-ray examination of the signs of obvious cases are helpful in diagnosis. Cases has been diagnosed with pneumonia, should be read in conjunction with the clinical manifestations and laboratory test results, and strive to make the diagnosis of the cause, in order to guide treatment and prognosis.
The prognosis of pneumonia in children affected by various factors. Older children suffering from pneumonia fewer complications, the prognosis is good, and infant mortality is higher. Malnutrition, rickets, congenital heart disease, tuberculosis, measles, pertussis based on concurrent pneumonia, the prognosis is poor. Pathogens, Streptococcus pneumoniae to penicillin sensitive to this type of pneumonia prognosis is good; Staphylococcus aureus pneumonia complications, prolonged course and poor prognosis. Adenovirus pneumonia in serious condition, the case fatality rate is also higher. Mycoplasma pneumonia severity varies, the natural course of the disease, although longer, but many can be cured naturally. Severe pneumonia associated with worse prognosis.
Wards should maintain good ventilation, the room temperature is maintained at about 20 ℃, humidity of 60% is appropriate. Given a sufficient amount of vitamins and protein, often drinking and Small frequent meals. To keep the airway open, timely removal of the upper respiratory tract secretions, constantly changing position, reduce pulmonary congestion, in order to facilitate the absorption of inflammation and sputum discharge. In order to avoid cross-infection, mild pneumonia at home or out-patient treatment of hospitalized children should be possible to separate children with acute and convalescent separate bacterial infections and viral infections.
(B) oxygen therapy
Hypoxemia prevent respiratory failure and lung, brain edema, one of the main therapy. Therefore, there should be timely oxygen hypoxia performance. The most commonly used nasal vestibule catheter continuous oxygen until hypoxia disappeared before stop. The neonatal or nasal secretions and more, and who the hypoxia symptoms do not ease after nasal oxygen catheter, available masks, nasal congestion, hood or oxygen accounts oxygen. Oxygen concentration is too high, the amount of traffic, long duration, easy to cause adverse side effects, such as diffuse pulmonary fibrosis or crystal fiber hyperplasia psychosis. Severe hypoxic respiratory failure, with a respirator for intermittent positive pressure oxygen or continuous positive pressure oxygen to improve the ventilation function.
(C) antimicrobial treatment
Mainly antibiotics for bacterial pneumonia, Mycoplasma pneumoniae, Chlamydia pneumonia and secondary bacterial infections, viral pneumonia. Pharyngeal secretions or blood before treatment should be made, the thoracentesis fluid cultures and susceptibility testing, selection of effective drugs to facilitate targeted. The pathogen is unknown, unused antibiotic treatment of children, should be preferred to penicillin, every 20 to 40 million U twice daily intramuscular injections of 5 to 7 days after the date until the temperature is normal. Severe, can increase the dose of 2 to 3 times the intravenous administration. Younger or serious illness need to use broad-spectrum antibiotic combination therapy available ampicillin, 50 ~~ 100mg/kg daily 2 times intramuscular injection or intravenous injection, plus gentamicin or kanamycin. Penicillin poor efficacy switch to erythromycin or penicillin allergy in children 15 ~~ 30mg/kg daily, with 10% glucose solution was diluted to 0.5 ~ lmg / ml, 2 times intravenously. Suspected S. aureus infection available new penicillin Ⅱ, Ⅲ plus gentamicin or chloramphenicol, can also be applied Pioneer vancomycin, vancomycin, etc.. Suspected gram-negative bacilli infections available ampicillin plus gentamicin or kanamycin. The pathogen has been clearly identified, select effective antibiotic therapy based on susceptibility testing. Mycoplasma, chlamydia preferred erythromycin. Fungal infection should stop the use of antibiotics and hormones, choice nystatin atomization inhalation every 50,000 U once 4 to 6 hours, can also be used Clotrimazole, Diflucan or amphotericin B.
(IV) antiviral therapy
Domestic ribavirin treatment early adenovirus pneumonia have a certain effect, no significant effect of advanced cases. The drug trial is acceptable in influenza virus pneumonia. Respiratory syncytial virus is not obvious on the drug efficacy.
The immune preparations for treatment of viral pneumonia domestic use in recent years, such as specific horse serum in the treatment of adenovirus pneumonia early coinfection better effect. Interferon (interferons) can inhibit the replication of the virus within the cell, improving the phagocytic activity of macrophages, the treatment of viral pneumonia have a certain effect.
The whey liquid aerosols aerosol inhalation therapy syncytial virus pneumonia, have a role to shorten the course of treatment to alleviate the symptoms.
(E) symptomatic treatment
Cough, not to abuse the antitussive conducive to suppress cough without expectoration. To avoid sputum bronchial obstruction, the choice of expectorant such as BM, 10% ammonium chloride solution, syrup of ipecac, the enemy cough syrup, etc..
The sticky sputum can be used n-chymotrypsin 5mg plus saline 15 ~ 20ml ultrasonic atomizing inhalation, can also be used Houttuynia inhalation. Dry cough affect sleep and diet, taking 0.5% of codeine syrup each 0.1ml/kg, a day even with 1 to 3 times the drug can suppress the cough reflex, also inhibited breathing, it is not abused or used in too large. Dextromethorphan dextromethorphan) each 0.3mg/kg, 3 to 4 times a day, antitussive effect, but does not inhibit breathing.