【临床医学】肺炎.ppt
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1、Respiratory DiseasesPneumoniaDr.Bijie HU(胡必杰)Zhongshan Hospital of Fudan UniversityShanghai5/22/20241Dr.HU Bijie5/22/20242Dr.HU BijieSeminSemin RespirRespir Infect Infect 9(3):140-52 9(3):140-52,19941994mortality(per10 000)mortality(per10 000)Mortality Trends with Pneumonia from 1900 to 1990 in USAM
2、ortality Trends with Pneumonia from 1900 to 1990 in USA02040608010012014016018020019001910192019301940195019601970198019905/22/20243Dr.HU Bijie5/22/20244Dr.HU Bijie 1990 2020Cardiovascular diseaseCerebrovascular diseasesLower respiratory infectionsDiarrheaPerinatal diseaseCOPDTuberculosisMorbilliTra
3、ffic accidentsLung cancerGastric cancerHIVsuicideEditorial,Lancet,1997,349:1263.Mortality Forecast by WHO5/22/20245Dr.HU BijieEpidemiology6th leading cause of death in U.S.Number one Among the infectious diseases5.6 million patients annually in USIncidence 510/1,000/yearMortality in OPD patients 1-5
4、%,but Inpatients 25%,ICU 50-60%5/22/20246Dr.HU BijieDefinitionPneumonia is the inflammation of lower respiratory tracts including alveoli,interstitial tissues,and broncioles by the microorganisms,chemical irritations or by an immunological process 5/22/20247Dr.HU BijieClassifications&Terminology
5、Mild,moderate,severe Lobar vs interstitialInfections vs.noninfectionsBacterial,viral,fungal,parasiticPrimary vs.SecondaryCommunity Acquired Pneumonia Nosocomial Pneumonia Ventilator Associated PneumioniaTypical vs.AtypicalImmune compromised vs.Normal immunity5/22/20248Dr.HU BijieKey Bacterial Pathog
6、ens of CAP:A Global Meta-AnalysisFine MJ et al.JAMA 1996;275(2):134-41.Study cohorts:N=127Total patients:N=33,148Total patients reporting data:N=6866S.S.pneumoniaepneumoniae66%66%Other12%Legionella spp.4%M.pneumoniae7%H.influenzae12%5/22/20249Dr.HU BijieCausative pathogens in 5,961 adults admitted t
7、o hospital with CAP identified in 26 prospective studies from 10 European countriesS S pneumoniaepneumoniaeC C pneumoniaepneumoniaeViralViralMycoplasmaMycoplasma pneumoniaepneumoniaeLegionella spLegionella spH H influenzaeinfluenzaeG-G-negneg enterobacteriaenterobacteriaC C psittaciipsittaciiCoxiell
8、aCoxiella burnetiiburnetiiStaphStaph aureusaureusM M catarrhaliscatarrhalisOtherOtherWoodhead M.Chest 1998;183S-187S5/22/202410Dr.HU BijiePathogens of Hospital Acquired Pneumonia(HAP)Mild to moderate HAP or early severe HAPStreptococcus pneumoniaeHaemophilus influenza MSSAKlebsiella PneumoniaeEntero
9、bacter,E coli,Proteus,SerratiaSevere HAPPseudomonasAcinetobacterMRSA5/22/202411Dr.HU BijiePneumococcal Pneumonia5/22/202412Dr.HU BijieEtiology:S.pneumoniaGram-postive coccusmost common identifiable cause of bacterial pneumonia and accounts for 2/3 of bacteremic CAPPneumococcal pneumonia generally oc
10、curs sporadically but most frequently in winterIt occurs most commonly in persons at age extremes.5 to 25%of healthy persons are carriers of pneumococci,with the highest rates noted in winter for children and parents of young children.There are 80 serotypes(based on antigenically distinct capsular p
11、olysaccharides).5/22/202413Dr.HU BijiePathogenesisHost defenses impairedInoculum sufficient to cause infection enters lower respiratory tractVirulent organism5/22/202414Dr.HU BijiePathogenesisPneumococci usually reach the lungs by inhalation or aspiration.(Routes of entry for nosocomial pneumonia:Mi
12、croaspiration,Inhalation,Hematogenous spread,Direct extension,Via ET tube)They lodge in bronchioles,proliferate,and initiate an inflammatory process that begins in alveolar spaces with an outpouring of protein-rich fluid.The fluid acts as culture medium for the bacteria and helps spread them to neig
13、hboring alveoli,typically resulting in lobar pneumonia.5/22/202415Dr.HU BijiePathologyCongestion:earliest stage of lobar pneumonia,extensive serous exudation,vascular engorgement,and rapid bacterial proliferation.Red hepatization:consolidated lung,Airspaces are filled with polymorphonuclear cells,va
14、scular congestion occurs,and extravasation of RBCs causes a reddish discoloration on gross examination.Gray hepatization:accumulation of fibrin,associated with inflammatory WBCs and RBCs in various stages of disintegration,and alveolar spaces are packed with an inflammatory exudate.Resolution:charac
15、terized by resorption of the exudate5/22/202416Dr.HU BijieManifestationSystematicoften preceded by a URIsudden onset,shaking chill,Feverother:nausea,vomiting,malaise,and myalgiasLocal pain with breathing on the affected side(pleurisy)Cough:(dry initially but usually becomes productive,dyspnea,and sp
16、utum production)SignT:38 40.5;pulse is usually 100 to 140 beats/min;respirations accelerate to 20 to 45 breaths/min.lobar consolidation;crackles;pleural effusion5/22/202417Dr.HU BijieSevere PneumoniaRespiratory rate 30/minPaO2/FiO2 ratio 50%within 48 hoursB.P.90systolic or 60 mmHg diastolicNeed for
17、vasopressorsRenal failure5/22/202418Dr.HU BijieComplications:Serious and potentially lethal progressive pneumoniaARDSseptic shockSpecial infections:empyema or purulent pericarditis Pleural effusions are found in about 25%of patients by chest x-ray,but 1%have empyemaBacteremia,including septic arthri
18、tis,endocarditis,meningitis,and peritonitis(in patients with ascites).superinfections:temporary improvement during treatment followed by deterioration,with recurrence of fever and worsening pulmonary infiltrates5/22/202419Dr.HU BijieLab and X-ray ExaminationsGeneral LabBlood tests:leukocytosis with
19、a shift to the lefthypoxemia respiratory alkalosisMicrobiologic TestGram stain of sputum typically shows gram-positive lancet-shaped diplococci in short chainsPositive blood culturesCXRpulmonary infiltrate(bronchopneumonia are most common;dense consolidation confined to a single lobe with typical ai
20、r bronchograms is most specific for S.pneumoniae)5/22/202420Dr.HU BijieLobar pneumonia5/22/202421Dr.HU BijieDiffuse interstitial pneumonia5/22/202422Dr.HU BijieDiagnosisSuspectedacute febrile illness with chest pain,dyspnea,and coughPresumptivehistory,changes on CXR,culture and Gram stains of sputum
21、Definitivedemonstration of S.pneumoniae in pleural fluid,blood,lung tissue,or transtracheal aspirate(At least half of sputum cultures are falsely negative)5/22/202423Dr.HU BijiePrognosispoor prognosis factorsage extremes,especially 60 yr;positive blood cultures;involvement of 1 lobe;a peripheral WBC
22、 count=4 days to become afebrile(Therapy should not be modified if there is gradual clinical improvement and the etiology is confirmed)Factors associated with not improvement wrong etiologic diagnosisadverse drug reactionfar-advanced disease(most common)superinfectioninadequate host defenses due to
23、associated conditionsnoncompliance with the drug regimen by outpatientsantibiotic resistance of the involved strain of S.pneumoniaeComplicationsempyema requiring drainagemetastatic foci of infection requiring a higher dosage of penicillin(eg,meningitis,endocarditis,or septic arthritis)5/22/202425Dr.
24、HU BijieProphylaxisVaccinecontaining the 23 specific polysaccharide antigens of the pneumococcus types(account for 85 to 90%)recommended for children 2 yr and adults at increased risk for pneumococcal disease or its complications;older adultsduration of protection:5 yr(revaccinated in 85 yr40%Untrea
25、ted50%-90%5/22/202427Dr.HU BijieTreatmentpenicillin G 500,000 to 2 million U IV q 4 to 6 hcephalosporins,erythromycin,clindamycinAlternative drugs(25%of strains resistant to penicillin.Many penicillin-resistant strains are also resistant to other antibiotics)high doses of penicillin(not highly resis
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