医学课件小儿肺炎专业医学知识宣讲.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,小儿肺炎,(pneumonia),肺炎是由不同病原体或其他因素,(,吸入或过敏反应等,),所致的肺部炎症,发热、咳嗽、气促、呼吸困难、肺部细湿罗音,重者累及其他系统,小儿肺炎为我国小儿第一位死亡原因,分类,病理分类,大叶性肺炎,支气管肺炎,间质性肺炎,毛细支气管肺炎,病因分类：,病毒性肺炎,支原体肺炎,衣原体肺炎,细菌性肺炎,真菌性肺炎,原虫 性肺炎,非感染性肺炎,病程分类：,急性肺炎,(,病程,3,个月,),病情分类：,轻症：,重症：,临床表现典型与否,典型性肺炎,非典型性肺炎,发生肺炎的地点,社区获得性肺炎,(community acquired pneumonia,，,VAP),院内获得性肺炎,(hospital acquired pneumonia,，,HAP),支气管肺炎,(bronchopneumonia),病因,病毒：,呼吸道合胞病毒、偏肺病毒、腺病毒、流感病毒和副流感病毒等,细菌：,肺炎链球菌最为多见，金黄色葡萄球菌、流感嗜血杆菌等,肺炎支原体、衣原体,A virus image from the International Committee on Taxonomy of Viruses,in,The Big Picture Book o,SARS,Transmission electron micrograph of adenovirus.Image courtesy of the US Centers for Disease Control,肺炎链球菌纯培养的镜下形态（革兰染色）,肺炎链球菌，俗称肺炎球菌，革兰阳性，呈矛头状，成双或链状排列，有荚膜；在痰标本中大多数成双排列,肺炎支原体,病理,肺泡炎症为主,肺泡毛细血管扩张充血,肺泡壁水肿,肺泡内有大量中性粒细胞、红细胞、纤 维素渗出液及细菌,支气管壁与肺泡间质炎性病变较轻,融合成片，肺气肿，肺不张,间质性肺炎,肺呼吸道合胞体病毒肺炎插图显示一个典型的巨细胞，形状为圆形,带有粉红色胞质包涵体,Sputum Gram stain from a patient with a pneumococcal pneumonia.Note the numerous polymorphonuclear,Pneumonia,community-acquired.Gram stain showing,Streptococcus pneumoniae.,Pneumonia,community-acquired.Gram stain showing,Haemophilus influenzae,Pneumonia,community-acquired.Gram stain showing,Moraxella catarrhalis,肺吸入性肺炎,高倍镜高倍镜下，可看到对吸入物质产生局部异物巨细胞反应,病理生理,(,一,),呼吸功能不全,肺炎肺泡壁增厚弥散阻力增加,支气管粘膜充血、水肿及分泌物潴留管腔狭窄,通气和换气,PaO2PaCO2,（二）循环系统,病原体和毒素侵袭心肌中毒性心肌炎心衰,缺氧肺小动脉收缩肺动脉高压右心负荷心衰,（三）中枢神经系统,PaCO2,脑脊液,PH,值脑脊液,H+,血管扩张 颅高压,病原体毒素脑细胞、血管透性颅高压,PaO2,无氧代谢乳酸,ATPNaK,泵功能脑细胞内钠水潴留脑水肿,（四）消化系统,低氧、毒素胃肠黏膜损伤黏膜糜烂、出血应急性溃疡,胃肠功能紊乱厌食、呕吐、腹胀、腹泻中毒性肠麻痹,（五）内环境紊乱,PaO2 PaCO2,肾小动脉痉挛水钠储留,ADH,分泌，细胞渗透性，,Na,泵功能,Na,进入细胞内稀释性低钠血症,吐、泻、摄入,Na,摄入，排出脱水、缺钠性低钠血症,（五）内环境紊乱,PaO2+,高热、进食吐泻无氧代谢产酸代酸,气道阻塞,PaCO2,呼酸,5.H+H+,到细胞内,K+,到细胞外血钾,吐、泻、摄入血钾,临床表现,(,一,),呼吸系统症状,发烧,咳嗽,气促、呼吸困难,肺部固定湿罗音,(,一,),呼吸系统症状：呼衰,诊断依据,临床表现：呼吸困难，紫绀，心血管和神经系改变,血气诊断标准：,型呼衰：,Po2 6.67Kpa(50mmHg),型呼衰：,Po2 6.67Kpa(50mmHg),，,6.67Kpa(50mmHg),氧合指数（,PaO2/FiO233.3Kpa(250mmHg,）,(,一,),呼吸系统症状：呼衰,(A-a)DO2=PAO2-PaO2=(PIO2-PaCO2/R)-PaO2,（,A-a)DO2.15mmHg:,肺内分流，弥散障碍、,V/Q,比列失调,PaCO2+PaO2,140mmHg,（不吸氧）：可能技术误差,(,二,),循环系统症状,婴幼儿肺炎合并心衰诊断标准,心率突然超过,180,次分或已超过,200,次,/,分,呼吸突然加快，超过,60,次分,突然极度烦躁不安，,明显发绀，面色苍灰，指,(,趾,),甲微循环再充盈时间延长、尿少或无尿,心音低钝，或有奔马律，颈静脉怒张,肝脏迅速增大、颜面、眼睑或下肢水肿,婴幼儿肺炎合并心衰诊断标准：,若出现前,14,项者可疑心衰,吸氧镇静,2030,分钟缓解可排除,不缓解或出现,6,项可诊断,5,项出现可确诊,(,三,),神经系统症状,1.,烦躁、嗜睡,8,小时以上，两眼上翻、凝视、斜视,2.,球结膜水肿,3.,昏迷、昏睡、反复惊厥（除低钙、高热惊厥）,4.,瞳孔改变、对光反射迟钝或消失,5.,中枢性呼吸节律不齐、紊乱或暂停,6.,脑脊液检查，压力增高外，余正常,1.2,项出现示脑水肿，伴其他,1,项以上者可确诊,（四）抗利尿激素分泌异常综合症（,SIADH),诊断标准,血钠,130mmol/L,，血渗透压,275mosm/Kg,肾脏排钠增加，尿钠,20mmol/L,临床上无血容量不足，皮肤弹性正常,尿渗透克分子浓度高于血,肾功能正常,肾上腺皮质功能正常,ADH,升高,（五）稀释性低钠血症,诊断标准,ADH,不升高，余同,SIADH,(,六）酸碱平衡紊乱,呼酸：改善通气,呼酸伴代酸：改善通气基础上用碱,乳酸酸中毒,血乳酸,4mmol/L,PH,低，不能用,PaCO2,增高解释,HCO3-,减少,除外其他代酸,70%vs20%,(,六）酸碱平衡紊乱,阴离子间隙（,aniongap,，,AG),高,AG,酸中毒：,15mmol/L,，高乳酸，改善通气循环,正常,AG,酸中毒：,615mmol/L,，胃肠道丢失,HCO3-,、肾小管酸中毒，补碱,(,七,),消化系统症状,食欲下降、呕吐、腹泻、腹胀,严重者呕吐物为咖啡色或便血，肠鸣音消失，中毒性肠麻痹，以及中毒性肝炎,（八）微循环障碍（休克或,DIC),精神萎靡或烦躁不安,面色苍白,四肢发凉,皮肤花纹,尿少或无尿,血压下降，脉速而弱,皮肤粘膜及胃肠道出血,毛细血管再充盈时间延长、眼底动脉痉挛,并发症,脓胸,脓气胸,肺大疱,Empyema caused by,Streptococcus pneumoniae.,Anteroposterior film.Courtesy of R.Duperval,脓胸,Bacterial pneumonia.Bilateral airspace infiltration secondary to community-acquired pneumonia,subs,气胸,This patient developed a left tension pneumothorax during treatment of a severe pneumonia.Note the,张力性气胸,Pneumonia with multiple pneumatoceles,肺大泡,实验室检查,（一）病原学检查,细菌培养,病毒分离,病原特异性抗原或抗体检测,（二）外周血检查,WBC,：细菌感染,WBC,总数及分数增高；病毒感染,WBC,正常或降低,CRP,：细菌感染,CRP,增高，非细菌感染,CRP,增高不明显,X,线检查,早期双肺纹理增粗,以后出现小点片状阴影，以双肺下野、中内带及心膈旁居多，可伴肺不张或肺气肿,Pneumonia,viral.Right-middle-lobe infiltrate in a 2-month-old boy with pneumonia due to respirator,支气管肺炎,Pneumococcal pneumonia complicated by lung necrosis and abscess formation,Lobar consolidation with pneumococcal pneumonia.Posteroanterior film.Courtesy of R.Duperval,MD,Chest radiograph of a child with severe adenoviral pneumonia as an infant.The child,诊断,临床表现结合,X,线胸片可诊断,鉴别诊断,支气管炎,肺结核,支气管异物,支气管 哮喘,治疗,采取合理的综合措施,积极控制感染,保持呼吸道通畅、纠正缺氧,防治并发症,增强机体抵抗力以促进康复。,(,一,),一般治疗,保持空气流通，室温维持在,20,左右，湿度以,60,为宜。,给予足量的维生素和蛋白质，经常饮水及少量多次进食。,保持呼吸道通畅,呼吸道隔离,（二）抗生素治疗,适应症：用于细菌性肺炎、支原体肺炎、衣原体肺炎及有继发细菌感染的病毒性肺炎。,用药原则：,敏感,早期,肺组织渗透性强,足量、足疗程，重症联合静脉给药,（二）抗生素治疗,疗程,体温正常后,5-7,天，,临床症状基本消失后,3,天；,支原体、衣原体感染至少,2-3,周；,金葡菌感染体温正常后继续用,23,周，总疗程,6,周,(,三,),抗病毒药物治疗,病毒唑、利巴伟林、干扰素等,(,四,),对症治疗：,1.,祛痰止咳,祛痰剂：复方甘草合剂、,10,氯化胺溶液、吐根糖浆等；超声雾化吸入,干咳影响睡眠和饮食者，可服用镇咳剂,2.,氧气疗法,鼻导管：,0.51L/min,，,FiO240%,面罩,:24L/min,，,FiO25060%,头罩或氧帐给氧,人工机械通气,3.,镇静：,烦躁不安小儿,镇静剂：氯丙嗪与异丙嗪合剂，每次,0.5-1mg/kg,肌注，或,5%,水合氯醛,1ml/kg.,次（灌肠或口服），二者可交替使用,注意镇静剂对呼吸中枢的抑制作用，及时吸痰防止气道阻塞,4.,利尿：,浮肿、尿少：速尿,0.5-1mg/kg.,次，防治水肿，减轻心脏前负荷,5.,抗心衰治疗：,原则：,镇静,吸氧,利尿,强心,改善微循环,5.,抗心衰治疗：洋地黄制剂,毒毛旋花子甙,K,：,饱和量,0.007,0.01mg,kg,，缓慢静脉注射，,12,小时后可重复一次,西地兰：,饱和量,2,岁以下,0.03,0.04 mg,kg,，,2,岁以上为,0.02,0.03mg,kg,，分次给予,首次给饱和量的,1,2,，余量分,2,次，每隔,4,6,小时给药,1,次，可肌内注射或缓慢静脉注射,5.,抗心衰治疗：洋地黄制剂,地高辛：,饱和量,0.04-0.06mg/kg,，,首次给饱和量的,1,2,，余量分,2,次，每隔,4,6,小时给药,1,次，可肌内注射或缓慢静脉注射,注意：,不宜同时静脉应用钙剂，,若合并低钙抽搐必需使用钙剂时，两药至少应相隔,4,6,小,6.,退热,物理降温,药物,冬眠,7.,腹胀,补钾,胃肠减压,Regitine:0.305mg/Kg.,次,（五）肾上腺皮质激素的应用,中毒症状明显,严重喘息或呼衰,中毒性休克、中毒性脑病（脑水肿）、中毒性心肌炎,胸膜有渗出,在应用足量抗生素的同时，可加用激素治疗,几种不同病原菌肺炎的特点,一、腺病毒肺炎,病原：,3,、,7,型腺病毒最常见。,好发季节：冬春季,好发年龄：,6,个月,-2,岁。,病变：支气管、肺泡间质炎，重者融合、坏死,一、腺病毒肺炎,临床特点：,起病急,体温：高热，呈稽留热,全身中毒症状重,咳嗽、呼吸困难、发绀明显。,肺部体征出现较晚，发烧,3-4,天后才出现肺部湿罗音，肺实变体征。,易发生呼吸衰竭、心力衰竭、中毒性脑病等。,一、腺病毒肺炎,X,线胸片,:,较体征出现早；,大小不等片影或大片影，伴肺气肿,病灶吸收慢,二、合胞病毒肺炎,病原：合胞病毒多见。,好发季节：冬春季。,好发年龄：,2,岁以内，尤其,6,个月以内多见,病变：毛细支气管炎性渗出、水肿,二、合胞病毒肺炎,临床特点：,（,1,）起病急。,（,2,）体温：不规则热，温度在,37-38,（,3,）全身中毒症状无或轻。,（,4,）以喘憋、呼气性呼吸困难为主。,（,5,）双肺可闻及密集喘鸣音及细湿罗音,二、合胞病毒肺炎,X,线胸片：,肺纹理增强，双肺透明度增强及小点状阴影,三、金黄色葡萄球菌肺炎,好发年龄：婴幼儿、新生儿及免疫功能低下者。,好发季节：冬春季。,病变：广泛出血、坏死、多发肺脓肿,三、金黄色葡萄球菌肺炎,临床特点：,（,1,）发病急，病情重，进展迅速。,（,2,）体温：稽留热或驰张高热,（,3,）全身中毒症状重。,（,4,）咳嗽、烦躁、呼吸困难明显,三、金黄色葡萄球菌肺炎,（,5,）肺部体征出现早，双肺可闻及密集湿罗音，或呼吸音减弱、肺实变体征。,（,6,）易并发多发肺脓肿，肺大疱、脓胸、脓气胸。及其它部位器官迁移化脓病灶，并导致系统功能障碍。,（,7,）皮肤出现各种皮疹，如红色斑丘疹、猩红热样皮,三、金黄色葡萄球菌肺炎,X,线胸片：可见大小不等斑片状阴影，可出现多发小脓肿，肺大疱、脓胸、脓气胸。,WBC,总数及中性粒细胞均增高，可有核左移，或有中毒颗粒,四、肺炎支原体肺炎,好发季节：秋、冬季。,好发年龄：年长儿，婴幼儿也见增多。,病变：肺间质及毛细支气管炎。,临床特点：,（,1,）起病急。,（,2,）体温：不规则热，或驰张高热，自然热程,1-4,周,四、肺炎支原体肺炎,（,3,）中毒症状不明显。,（,4,）刺激性干咳为其临床特点，以晨起及夜间为重。,（,5,）肺部体征不明显或出现较晚，仅为双肺呼吸音粗，或发热,3-5,天后出现湿罗音或肺实变体征。可伴有胸腔积液,四、肺炎支原体肺炎,（,6,）其它系统可受累，如消化系统、循环系统、神经系统，血液系统、泌尿系统及皮肤、肌肉、关节等系统。,（,7,）用,-,内酰胺类抗生素治疗无效,四、肺炎支原体肺炎,X,线胸片：有四种表现：,（,1,）肺纹理增强；（,2,）肺门影增浓；,（,3,）小叶性肺炎；（,4,）大叶性肺炎；,血清肺炎支原体,-IgM,抗体测定：,1,周开始升高，,2-4,周达高峰，以后开始下降，抗体可持续数月,五、沙眼衣原体肺炎,好发年龄：,6,个月以内小儿。,好发季节：不固定。,传播途径：母婴垂直传播，产时及产后均可传播,五、沙眼衣原体肺炎,临床表现：,（,1,）起病缓慢，初为感冒症状。,（,2,）无热或体温不超过,38,。,（,3,）持续阵发性咳嗽为其特点，可呈百日咳样咳嗽，但无回声，严重者可发生窒息,五、沙眼衣原体肺炎,（,4,）中毒症状不明显。,（,5,）双肺有湿罗音，无喘鸣音。,（,6,）约,1/2,患儿有眼结膜炎。,嗜酸细胞绝对计数大于,300G/L,。,X,线胸片：弥漫间质浸润及点状肺泡浸润影，伴肺过度通气,六、肺炎衣原体肺炎,好发年龄：,5,岁以上小儿；,临床特点：,（,1,）发病隐匿,（,2,）体温不高,（,3,）感冒症状,23,周后，咳嗽渐加重，持续,12,月,（,4,）双肺闻干湿罗音,（,5,）肺外表现：皮肤结节红斑、甲状腺炎、格林巴利综合征,X,线胸片：多单侧下叶浸润，少数双侧,七、流感嗜血杆菌肺炎,好发年龄：,4,岁小儿；,临床特点；,（,1,）亚急性起病；,（,2,）病情较重，中毒症状重；,（,3,）高烧；,（,4,）痉挛样咳嗽，吸气性呼吸困难，发绀；,（,5,）肺部湿罗音，肺实变；,（,6,）易并发脓胸、脑膜炎、败血症、心包炎、,化脓性关节炎、中耳炎等,七、流感嗜血杆菌肺炎,WBC,达,2070G/L,，,L%,。,X,线胸片：多样，呈小叶肺炎、大叶肺炎、肺段实变，伴胸腔积液,5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd3&VLCtja1!SJzqh7-ZPGxne5*WNDulbi9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGxne5*WNDukb2$TKAri8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*WMDtkb1$TJArh8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4*VMDtka1$SJAqh8-ZQGxoe5(WNEulc2%0#RIypg6)YOFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBri9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGxne5*WNDulb2%TKAri8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukb2$TJArh8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4*VMDb2$TKAri8+#QHyof6(XOEvmc3%ULBsj90!RIzpg7)YPFwnd4*VMDtkb1$TJArh8+ZQHxof5(XNEvlc2%UKBsi90#RIypg6)YOFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulb2%TKBri9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGxne5*WNDukb2$TKAripf6)XOFvmd3&VLCsja0!SIzqg7-YPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvmc3&ULCsj90!RIzpg7)YPFwnd4*VMDtkb1$TJArh8+ZQHxof5(XNEvlc3%ULBsi90#RIypg6)YOFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBri9+#RHypf6)XOnd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd3&VLCtja1!SJzqh7-ZPGxne5*WNDulb2%TKBri9+#RHypf6)XOFvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvlc3%ULBsj90!RIzpg7)Y*WMDukb1$TJArh8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4*VMDtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd4&VMCtja1!SJzqh7-ZPGxne5*WNDulb2%TKBri9+#RHypf6)XOFvi8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwnd4*VMDtkb1$TJArh8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFvmd3&1$SJAqh8-ZQGxoe5(WNEulb2%TKBri9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGxne5*WNDukb2$TKAri8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*Dulb2%TKBri9+#RHypf6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukb2$TKAri8+#QHyof5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4*VMDtkb1$TJArh8+ZQHxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd4&V$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd3&VLCtja1!SJzqh7-ZPGxne5*WNDulb2%TKBri9+#RHypf6)XOFvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvlc3%ULBsj90!RIzpg7)YPne4*W!RIzpg6)YOFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGxne5*WNDulb2%TKBri9+#RHypf6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukbi8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwnd4*VMDtkb1$TJArh8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwmd4&VMCtka1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFvmd3&VLCtja1!SJh8+ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd4&VMCtka1$SJAqh8-ZPGxne5*WNDulb2%TKBri9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-YPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvmch8-ZQGxoe5(WNEulc2%UKBsi90#RYOFwmd4&VMCtka1$SJAqh8-ZQGxne5*WNDulb2%TKBri9+#RHypf6)XOFvmd3&VLCtja1!SJzqh7-ZPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwnd4*VMDtkb1$TJArh#QHyof6(XOEvmc3&ULCsja0!SIzqg7-YPGwne4*WMDukb2$TKAri8+ZQHxof5(XNEvlc3%ULBsj90!RIzpg7)YPFwnd4*VMDtkb1$TJArh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)YOFwmd4a1$SJAqh8-ZQGxoe5(WNEulc2%UKBsi90#RIypg6)XOFvmd3&VLCtja1!SJzq(XOEvmc3a0!SIzqg7-YPGwne4*WMDukb2$TKAri8+#QHyof6(XOEvmc3&ULCsja0!RIzpg7)YPFwnd4*VMDtkb1$TJArh8+ZQHxof5(XNEvlc3%ULBsj90#RIypg6)YOFwm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