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PNEUMONIA 1.ppt

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					pneumonia
                 overview
• Pneumonia is a inflammation of parenchyma
  of the lung.
• Most case of the pneumonia are caused by
  microrgnanisms viral bacterial atypial ,but
  there are several noninfections causes,which
  include aspiration of food or gastric
  acide,foreign bodies,and lipoid
  substances;drug or radiation-induced
  pneumonia.
• Classification
• 1 pathological Classification:by anatomy
  1) bronchopneumonia

  2) lobal



  3) interestitial
2 etiologial Classification
  1)viral pneumonia

  2) Bacterial pneumonia

   3)Mycoplasmal pneumonia

   4)Chlamydia pneumonia

   5)fungal pneumonia
   6) protozoan pneumonia
   7)Non-infective agent
• 3.Classification based on course
 1)acute pneumonia: the course of illness is less
  than 1month

2) persisting pneumonia: the course is 1-2
 months
3)Chronic pneumonia: the course is over 3
 months
• 4.Classification based on illness condition
• 1) mild case:
  mainly involve respiratory system, no
  generalized toxic symptoms.
• 2 )severe case:
    besides respiratory system, other system
  might severely involve, such as supervening
  of congestive heart failure, abdominal
  distention and intestinal paralysis ,body fluid
  derangement ,etc.
         bronchopneumonia
• bronchopneumonia is the most common form
  of pneumonia in young children. Typical
  bronchopneumonia is fever, cough, tachypnea
  and dyspnea, fixed moist rales over lung.
               Clinical findings
• Symptoms and signs
  Most cases have acute onset.
1.fever:        low-grade fever:37.4-38°C,
         Medium-grade fever:38.1-39°C
         High-grade fever:39.1-41°C
         Super high-grade fever:beyond41°C
   children younger than age 3 years have fever higher
   than 38,may have a seizure.febrile convulsion
 2.Cough:onset cough is dry but later becomes
   productive.
• 3.Tachypnea:
   breath rate is more than 40-80/min.
    Infant:40-45,      less than1 years:30-40
   1-3years:25-30,        4-7years:25-30
    8-14years:18-20
    nasal ala flap
  4.Dyspnea :three depressing sign: suprasternal,
  supra- clavircular, and inter-costal space
  retraction;
• 5.rales:auscultation of lungs reveal fixed
  moderate or fine moist rales.
  * Dry rale,ronchi:
    1)Sonorus
    2)Sibilant
   *Moist rales(bubble)
     1)Coares rale
     2)Medium rales
     3)Fine rales
6.cyanosis

  Blood being poorly oxygenated
• Physical examination
 1. inspection: tachypnea, 3 depression sign ,cyanosis
  2.tactile:abnormal tactile. vocal fremitus
  3.percussion:dullness to percussion
  4.auscultation: fixed moderate or fine moist rales.
  stridor or wheeze, decreased breath sounds.
  ronchus which you can heard when children
  expiratory.
          Congestive heart failure
•   1.tachycardia:heart rate is quicker than
    160-180 beats/min;
•   2.tachypnea:breath rate is more than
    60/min;
•   3.suddenly extreme restless, obvious
    cyanosis, pallor or grey complexion;
•   4.the heart sound decreased, gallop
    rhythm, high distention of cervical vein
    occured;
• 5.liver enlarged rapidly, liver can be palpable
  3cm at right subcostal region;
• 6.oliguria,facial edema and edema of lower
  extremity appeared.
• Extrapulmonary findings
   Severe cases caused by gram-negative bacillus even
  lead to microcirculation dysfunction that looks like
  shock.
 1.neverous system: mild hypoxia may cause agitated,
  drowsiness; cerebral edema may cause conscious
  disturbance, convulsion, and irregular respiratory
  rhythm.
2.digestive system: mild case may present
  nausea, vomiting, diarrhea, and abdominal
  distention; the severe case may present toxic
  paralysis of intestine, bowel sounds disappear.
3.myocarditis: pallor, tachypnea, arrhythmia,
  heart sound is low and dull.
• complication
   1.Empyema:may occur frequently with staphylococcal,
  gram-negative bacilii.have high
  feve.r,dyspnea,aggravated




 2.pyopneumothorax:
Tympany on the upper part
Of effusion,dullness on the
Lower part
3.Pneumatocele:maily caused by staphylococcus
             Laboratory findings
• White blood cell counts will
  elevated(﹥15,000/ul),neutrophil count will elevated.
• C reactive protein may increase;
• PaO2 and PaCO2 may change.
• Bacteria test involves blood culture and sputum
  culture.
• Virus test: rapid test, serum test
          Imaging/chest X-ray
• Patchy infiltrate are most
  common during infancy
• Hilar adenopathy/hilar
  lymph nodes may be
  enlarged
• Pleural effusion
• Lobar consolidation
Patchy infiltrate are most common
          during infancy


Here is
opacity,t
he right
heart
border
is not
clearly
• Chest radiographic findings: chest X-ray




                              edema
      abscess
Bilateral pneumonia and right sided pleural effusion
were observed.
Lobar consolidation is not a common finding in
infants and children
,it is occur in older children
Hilar adenopathy/hilar lymph nodes may
be enlarged
        Special examinations
• Invasive diagnostic:
   transtracheal aspiration,bronchial brushing or
  washing, lung puncture, or open or
  thoracoscopic lung biopsy.
• Culture of material from the respiratory tract
  section.
         Differential diagnosis
• 1.Acute bronchtis: cough is the main symptom,
  afebrile or low -grade fever ;previously
  audible ronchi or moist rales is not audible
  after cough or change of position, the unfixed
  rales is the characteristics.
 2.tuberculosis:low grade fever ,night sweat ,a positive
tuberculin test ,chronic cough, weight loss or failure to
             gain weight ,and chest X-ray.
PPD TEST
PPD(Protein
Purified
Derivative)
3.Foreign body aspiration:
 a history of foreign body, a
choking spell followed by
persistent cough, and
radiograph are diagnostic
tools of it. it leading to
atelectasis or emphysema.
nail
                  treatment
1.general therapy
   the room should be maintained good
  ventilation of air, proper temperature(18-
  20℃)and comfortable humidity(60%).
2.antimicrobial therapy
     WHO recommends 4 kinds of drug: compound
  sulfamethoxazole, penicillin, ampicillin, and
  amoxicillin.
if the etiologic agent is staphylococci, following drugs
   are commended : ampicillin, chloramphenicol,
   oxacillin,cloxacillin, and gentamycin. Gentamycin is
   effective for gram-negative bacillus.
antimicrobial duration of therapy:
    In general children with the usual bacterial
  pneumonia are treated till 5 to 7 days after
  fever declined and 3 days after clinical status
  improve.
    mycoplasma pneumonia is treated for 3 to 4
  weeks to avoid recurrence.
  Staphylococcal pneumonia total duration of
  therapy should be at least 6 weeks.
• Anti-virus
    Anti-virus: clinically used anti-virus include
  virazole (ribavirin) and interferon.
  Chinese herb: banlan gen, daqing ye and so on.
  Duration of therapy is 5 to 7 days.
• 3.symptomatic treatment
 1)maintain airway unblocked, (expectorants,
  bronchial antispasmodic,) clearing secretion of
  upper respiration tract in time.
 2)correct body fluid deficit: 50-60ml/kg/d.
 3)fever is controlled by antipyretics : aminopyrine,
  paracetamol, ibuprofen.
4).Humidified oxygen:
   if hypoxia occurs and is definitely indicated in
  the presence of cyanosis. giving oxygen by
  nasal catheter (flux 0.5-
  1L/min ,concentration<40%)or head box (flux
  2-4L/min ,concentration 50-60%)
4.Treatment of heart failure
• Medical palliation of congestive heart failure
  has two goats: to decrease oxygen
  consumption and improve oxygen deliver to
  the tissue.
• Sedation:Luminal, chloral hydrate,( clysis)
  diazepam(valium)
• Bed rest
Drug therapy attempts to improve the relationship
  between cardiac output and filling pressure.

• 1.Digitalis
   1) digoxin :It results when the heart can't pump
  blood well enough to supply the body's needs. If you
  have heart failure, digoxin can improve your heart's
  ability to pump blood.
   <2years:0.05-0.06mg/kg
   >2 years:0.03-0.05mg/kg
2).Lanatoside :
    loading dose is dose 20-40 ug/kg, which is
  usually given in three divided doses. Initially
  one half of the total is given and then one
  fourth of the total is given after 4-6 hours and
  the remaining one fourth is given after another
  4-6 hours.
   Maintenance is 5-10ug/kg/d , usually divided
  into two doses and given twice daily.
    <2years:0.03-0.04mg/kg
    >2 years:0.02-0.03mg/kg
3).Cardia output can also be improved by decreasing
  ventricular afterload. if the systemic vascular
  resistance is high, vasodilator particulary shows the
  effective treatment.
      phentolamine is one of the commonly used drugs
  of this type.
4).Diuretics:
    furosemide is one of the most
  patent.1mg/kg,iv.however,diuretics can cause
  numerous electrolyte and metabolic problems,
  including hypokalemia , hypochloremia,
  metabolic alkalosis and urinary calcium loss.
• 5.steroids
  inhaled steroids, prednisone,dexamethason
 1) toxic symptom is very severe,
 2)severe asthma,
 3)brain edema, toxic encephalopathy, infection
  shock, breath failure,
 4) Pleural effusion case
• Therapy of complication:
 1. if the pneumonia is complicated with
  emphysema or pyopneumothroax,
  thoracentesis for aspiration of purulent
  effusion and air should be performed without
  delay.
• 2.following conditions should be treated
  with continuous closed drainage using
  intercostal tube placement or thoracotomy:
  the younger age ,the presence of
  overwhelming toxic symptom, ropy pus,
  and repeated aspiration can not expel pus
  completely which results in tension
  pneumothorax.
6. Hydration and electrolyte supplementation
7.Fever is controlled by antipyretics,alcohol
             Thank you
  sponging is also used.
8.Early chest tube drainage of empyema
  fluid due to S aureus

				
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posted:11/2/2011
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