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Respiratory Diseases. Lin Guangyu Department of Pediatrics, The Second Affiliated Hospital to Medical College, Shantou University. General Introduction.

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Respiratory Diseases

Lin Guangyu

Department of Pediatrics, The Second Affiliated Hospital to Medical College, Shantou University


General Introduction

  • Respiratory diseases that include inflammation of upper and lower respiratory tract, allergic diseases, pleura diseases, foreign body, pulmonary tumors and congenital disorders is a significant cause of death and chronic illness in children.

  • Pediatric pulmonary diseases account for almost 50% of deaths in children under age 1 year and about 20% of all hospitalization of children under age 15 years.


General Introduction

  • Respiratory infections are the most frequently occurring illness in childhood.

  • Pneumonia accounts for almost 28% of deaths in children under age 5 years.

  • Approximately 7% of children have some sort of chronic disorder of the lower respiratory system


Pneumonia


Classification

  • Classified by anatomy

    • Lobar Pneumonia

    • Bronchopneumonia

    • Interstitial Pneumonia

    • Bronchiolitis


Classification

  • Classified by etiology

    • Viral Pneumonia

      • Respiratory Syncytial Virus (RSV )

      • Adenovirus

      • Rhinoviruses

      • Parainfluenza or influenza viruses

      • Enteroviruses

      • Cytomegalovirus (CMV)

      • Measles virus


  • Human metapneumovirus

  • Human bocavirus

  • SARS coronavirus


About Human Metapneumovirus

  • It is classified by paramyxovirus.

  • It is about over 10% of all children with

    respiratory infection in winter.

  • It is nearly not covert infection at all.

  • It is one of the most important pathogens that cause the wheeze.

  • It is mainly cause bronchopneumonia and bronchiolitis.


About Human Bocavirus

  • It is classified by parvoviridae.

  • It is about 1.5~11.3% of all children with

    respiratory infection.

  • It is one of the most important pathogens that cause the wheeze.

  • It is mainly cause bronchopneumonia and bronchiolitis.

  • Is it a pathogen?


Aboutcoronavirus

Type 1 —— Mammal

Type 2 —— Mammal

Type 3 —— Aves

Type 4 —— SARS Coronaviruses


Classification

  • Bacterial Pneumonia

    • Gram-positive coccus

      • Streptococcus Pneumoniae

      • Staphylococcus aureus ,CNS!

    • Gram-negative bacillus

      • Pneumobacillus

      • Escherichia coli

      • Pseudomonas

      • Haemophilus influenzae

      • Klebsiella

      • Legionella pneumophila

    • Anaerobe


Classification

  • Mycoplasmal pneumonia

    • Mycoplasma pneumoniae

  • Chlamydial pneumonia

    • Chlamydia

  • Fungal Pneumonia

    • Cryptococcus

    • Candida

    • Coccidioides

    • Histoplasma


Classification

  • Protozoal pneumonia

    • Pneumocystis Carinii

  • Noninfectious pneumonia

    • Inhalation Pneumonia

    • Eosinophilic pneumonia


Classification

  • Classified by course

    • Acute Pneumonia: <1 month

    • Deferred Pneumonia: 1~3 months

    • Chronic Pneumonia: >3 months


Classification

  • Classified by patient’s condition

    • Mild pneumonia

    • Severe pneumonia


Classification

  • Others

    • Typical pneumonia

    • Atypical pneumonia

      Pneumonia caused by SARS coronavirus

    • Community acquired pneumonia (CAP)

    • Hospital acquired pneumonia (HAP)


Bronchopneumonia


Introduction

  • Bronchopneumonia, accounting for 24.5%~56.2% of all hospitalizatons of children, is the most frequently occurring illness in childhood.

  • The incidence is higher in early childhood than in any other period of life.

  • There are significant difference in the incidence of bronchopneumonia by season and geographic region.


Etiology

  • Most pneumonia in children are caused by viruses and bacteria.

    • Viruses

      • RSV

      • Parainfluenza viruses (1, 2 and 3)

      • Influenza viruses (A and B)

      • Adenovirus

    • RSV, parainfluenza and influenza are responsible for more than 75% of cases.


Etiology

  • Bacteritic

    • Streptococcus Pneumoniae (the most common cause of bacterial infection)

    • Staphylococcus aureus ,CNS

    • Haemophilus influenzae

    • Klebsiella

    • Pneumobacillus

    • Escherichia coli

    • Pseudomonas

  • Mycoplasma pneumoniae


Different organisms affect different age groups Age Bacterium Virus others 1d-20d Group B H Streptococcus Cytomegalovirus Gram-negative bacilli(E.coli) 3w-3m Streptococcus pneumoniae RSV Chlamydia trachomatis Bordetella pertusssis Parainfluenza virus Staphylococcay aureus 4m-4y Streptococcus pneumoniae RSV Mycoplasma pneumoniae Haemophilus influenzae Parainfluenza virus Mycobacterium tuberculosis Influenze virus Adenovirus Rhinoviruses 5y-15y Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydial pneumonice


Etiology

  • Other causes

    • Age

    • Season of the year

    • Immune status of the host

    • Environmental factors


Pathology

  • Inflammatory cell infiltration, exudate, edema and localized hemorrhage of bronchiolar submucosa, Interstitium, alveoli, Interalveolar septa and lymphatic vessels

  • Necrosis of bronchiolar and alveolar epithelium

  • Hyperinflation or collapse of the distal lung tissue


Pathology

  • Lesions of viral or bacterial infection result in tracheitis, bronchitis, interstitial pneumonia and lobuli pneumonia.

  • Interstitial involvement is relatively common in viral pneumonia.

  • Bacterial pneumonia is characterized by the presence of damages of lung tissue.


Pathophysiology

  • Respiratory disorder (acute respiratory failure)

    • Ventilation and /or perfusion disorder (V/Q mismatch)

    • Diffusion defects

    • Intrapulmonary shunt


Pathophysiology

  • Circulatory disorders

    • Viral and/or toxipathic myocarditis

    • Pulmonary hypertension

    • Heart failure

    • Circulatory failure ( shock)

    • Disseminated intravascular coagulation (DIC)


Pathophysiology

  • Anomalies of central nervous system

    • Cerebral edema (toxic encephalopathy)

      • Hypoxemia

      • Hypercapnia

      • Metabolic Acidemia

      • Energy metabolism disorder

      • Toxin


Pathophysiology

  • Anomalies of Alimentary system

    • Toxic enteroparalysis

    • Gastrointestinal bleeding

      • Hypoxemia and hypercapnia

      • Abnormalities of electrolyte balance

      • Toxaemia

      • shock

      • Acute stress ulcer

    • Hepatic injury


Pathophysiology

  • Acute renal failure

  • Adrenal crisis (insufficiency)

  • Abnormalities of water, electrolyte and pH balance

    SIRS→MODS→MOF


Bronchia mucosa edema

Alveolus edema

air exchange

air entry

Respiratory failure

Metabolic acidosis

Respiratory acidosis

toxic encephalopathy

Gastrointestinal

breeding

Heart failure

Toxic

enteroparalysis

Toxaemia


Clinical Manifestations

  • Symptoms and sings

    • General symptoms and sings

      • Fever

        • Body temperature is higher in bacterial infection than viral infection

      • Hypothermia (infant)

      • symptoms and sings of generalized toxicity

        • Myalgia, Malaise and headache


Clinical Manifestations

  • Symptoms of respiratory system

    • Cough

      • Dry cough

      • Productive cough

    • Tachypnea

      • Dyspnea

      • Rapid, shallow respirations( 40~80/ min)

      • Nasal flaring

      • Intercostal, subcostal, and suprasternal retraction

      • Cyanosis

      • Respiratory fatigue


Clinical Manifestations

  • Signs of respiratory system

    • Widespread moist rales and wheezing

    • Signs of substantial variations

      • Decreased breath sounds

      • Dullness to percussion

      • diminished tactile or vocal fremitus

      • Bronchial breath sounds


Clinical Manifestations

  • Severe Pneumonia

    • Circulatory system

      • Rival or toxic myocarditis

      • Heart failure


Heart failure

  • Rapid, shallow respirations≥60/min

  • Rapid heart rates ≥180/min

  • Dyspnea with intercostal and subcostal retractions, cyanosis, pale and gray of face , irritability, and peripheral pallor

  • Muffled and distant heart sounds, and a gallop rhythm

  • Liver enlargement

  • Edema of the face and extremities,oliguria or anuria


Clinical Manifestations

  • Nervous system

    • Toxic encephalopathy

  • Alimentary system

    • Toxic enteroparalysis

    • Gastrointestinal bleeding

  • DIC

  • SLADH

  • MODS


Complications

  • Empyema

  • Pneumothorax

    • tension pneumothorax

  • Pyopneumothorax

  • Pneumatocele


Laboratory Test

  • Tests for etiologic agent

    • Bacterial culture

      • Blood culture

      • Culture of material from the respiratory tract secretion

      • Culture of Pleural effusion

      • Other culture


Laboratory Test

  • Laboratory diagnosis of viral infections

    • Antigen or nucleic acid detection

    • Isolation of viruses by culture of the respiratory tract secretions

    • Use of special antibodies


Laboratory Test

  • Isolation and culture of other etiologic agent

    • Mycoplasma pneumoniae

    • Chlamydia

    • Fungi

  • Specific antibody detection on the pathogens

  • Tests of molecular biology

    • DNA probs

    • Polymerase chain reaction (PCR)


Laboratory Test

  • Blood test

    • White blood cell counts

      • Bacterial pneumonia ↑↓

      • Rival pneumonia↓

    • NBT test

      • NBT-positive cells>10%

    • C-reactive protein (CRP)

      • CRP ≥15μg/ml

  • Blood gas analysis


Chest X-ray Findings

  • Perihilar streaking

  • Increased interstitial markings

  • Peribronchial cuffing

  • Patchy infiltrates in the lung

  • Development of pneumatoceles

  • Hyperinflation of the lung

  • Atelectasis

  • Lobar consolidation (as in bacterial pnuemonia)

  • Radiographic findings of pleural effusion


Diagnosis and Differential Diagnosis

  • Diagnosis

    • According to symptoms, signs, and Radiographic findings, bronchopneumonia are easily diagnosed.

    • A key decision in evaluating children with bronchopneumonia is to determine whether the illness is mild or severe, or whether a secondary infection or complication is present


Diagnosis and Differential Diagnosis

  • Differential Diagnosis

    • Acute bronchitis

    • Pulmonary tuberculosis

      Acute miliary tuberculosis of the lungs

    • Foreign body in bronchus


Acute bronchitis


  • Acute miliary tuberculosis of the lungs


  • Acute miliary tuberculosis of the lungs


Foreign body in bronchus


Treatment

  • General treatment

    • Humidification of inspired gases

    • Hydration and electrolyte supplementation

    • Oral hygiene

    • Nutrition


Treatment

  • Etiological treatment

    • Antibiotic therapy

      • It is not possible to differential reliably between bacterial or viral pneumonia on clinical or radiological grounds ,so all children diagnosed having pneumonia should be giving antibiotics as the pathogen is rarely known when treatment is started.


Treatment

  • Before the pathogen is identified, therapy of patients is determined by the pattern of disease and the organisms that are common for age of the children .

    • Community-acquired bacterial infection

    • Nosocomial infection acquired in the hospital


The choice of antibiotic is determined by agesAge Out-patientsIn-patients(Intravenous) (oral) Less severe Severe 1-20d Ampicillin Ampicillin+Cefotaxime Ampicillin+Cefotaxime 3w-3m Erythromycin Erythromycin Cefotaxime Azithromycin Erythromycin +Cefotaxime 4m-4y Amoxicillin Ampicillin CefotaximeCeforoxime5y-15y Erythromycin Erythromycin Cefotaxime Clarithromycin Azithromycin Cefuroxime Azithromycin Erythromycin+Ampicillin Cefotaxime+Azithromycin Azithromycin +Ampicillin Cefuroxime+Azithromycin


Treatment

  • Oral antibiotics (e.g. co-amoxiclav or a second-generation cephalosporin such as cefaclor) can given for less severe pneumonia.


Treatment

If intravenous therapy is requried,activity against pneumococci, H.influenzae and Staph aureus can be achieved with a cephalosporin(e.g.cefotaxime, ceftriaxone, cefuroxime, cefazidime )


Treatment

  • Therapy for most patients should be continued for a total of 5~7 days after body temperature is normal, or at least 3 days after clinical symptoms has disappeared.

  • The course of treatment for staphylococcus aureus is usually for 6 weeks

  • Treatment for Mycoplasmal pneumonia is usually for 2~3 weeks.


Treatment

Once the pathogen has been identified and the antibiotic sensitivities determined, the most appropriate drugs should selected.


The choice of antibiotic is determined by organisms(1)Organisms First choice Second choiceStrept pneumoniae Pnicillin G Ceftriaxone Cephlosporins Cefotaxime (1st or 2nd generation) Vancomycin H. influenzae Amoxicillin+Clav Acid Cephlosporins Amoxicillin +Sulbactam (1st or 2nd generation) Macrolides (New generation)Staphylococeus MSSA MSSE Oxacillin Cephlosporins Claxacillin (1st or 2nd generation) MRSA MRSE Vancomycin RifampineM.catarrhalis Amoxicillin+Clav Acid Macrolides (New generation) Cephlosporins (1st or 2nd generation)


The choice of antibiotics is determined by organisms(2)Organisms First choice Second choiceEnteric bacilli Ceftriaxone Ticarcillin+Clavulanic Acid (+Amikacin) Azfreonam Cefotaxime Imipenem 4th generatim Cephlosporins P.aeruginose Ticarcillin+Clav.Acid AMK+Azfreonam Piperacillin+TAZ Imipenem Mezlocillin Ceflazidime Cefoperazone+Sulperazon Cefepime+AMKGBS Penicillin G(LD) Amoxicillin Ampicillin


Treatment

If staphytococcal aureas or CNS pneumonia is suspected, Penicillin, Clindamycin, Vacomycin (one of them ) is given.


Treatment

If M.pneumoniae or

Ch.trachomatis pneumonia is suspected, erythromycin is given.


Treatment

  • Anti-viral therapy

    • Ribavirin

    • Interferons

    • Poly I:C


Treatment

  • Heteropathy

    • Oxygen therapy

    • Maintaining free airway

    • Treatments for heart failure

    • Treatments for toxic enteroparalysis

    • Treatments for respiratory failure

    • Treatments for shock

    • Treatments for toxic encephalopathy


Treatment

  • Treatments for heart failure

    • Oxygen inhale

    • Sedation

    • Cardiotonic

    • Diureses

    • Drugs of dilating blood vessel


Treatment

  • Treatments of toxic encephalopathy

    • Oxygen inhale

    • sedation

    • Pyretolysis

    • Subhibernation

    • Anhydration

      • 20%Mannitol 1.5~5ml/kg /does q6h


Treatment

  • Application of cortical hormone

    • Indication

      • Severe pneumonia

      • Superhigh fever

      • Severe toxic symptoms

      • Wheezing

      • Shock, toxic encephalopathy, Cerebral edema, and respiratory failuer

      • pleural effusion


Treatment

  • Treatments for complications

    • Repeat pleural taps for remove of pleural fluid


Clinical Teafures of Pneumonia due to Some Pathogen

  • Rspiratory syncytial virus pneumonia

  • Adenovirus pneumonia

  • Staphylococal aureus pneumonia

  • Gram-negative bacillary pneumonia

  • Mycoplasma pneumonia

  • Chlamydial pneumonia


Respiratory snycytial virus pneumonia

  • Diffuse wheezing and tachypnea following upper respiratory symptoms in an infant (age <one year).

  • Epidemics in late fall to early spring .

  • Hyperinflation on chest X-ray.

  • RSV antigen detected in nasal secretions.

  • 30%-40% of patients hospitalized with this infection will wheeze later in childhood.


Adenovirus pneumonia

  • Severe pneumonia may occur at all ages. It is especially common in young chillren (age<6months~2years).

  • Chest X-rays show bilateral peribronchial and interstitial infiltrates.

  • Symptoms include high fever, respiratory symptoms, diarrhea, encephalitis, hepatitis and myocarditis may persist for 2-3weeks.

  • Can be necrotizing and cause permanent lung damage, especially bronchiectasis.


Staphytococcal aureus pneumonia

  • This pneumonia is characterized by abdominal distention, high fever, respiratory distress, and toxemia.

  • It often occurs without predispossing for factors or after minor skin infections.

  • Pneumotoceles, pyopneumothora, and empyema are frequently encountered.

  • Rapid progression of disease is characteristic.

  • Frequent chest X-rays to monitor the progress of disease are indicated.

  • WBC↑↑


Myeoplasma pneumoniae pneumoia

  • Essentials of diagnosis typical festures:

    • Fever

    • Cough

    • Appropriate age:over5year

  • Endemic and epidemic infection can occur.

  • The incubation period is long(2-3weeks).and the onset of symptoms is slow.

  • Extrapnlmonary complications sometimes occur.

  • Chest X-rays usually demonstrate interstitial or bronchopneumonia infiltrates, frequently in the middle or lower lobes.


Chlamydial pneumonia

  • Cough, tachypneu, rales, few, wheezes, and no fever.

  • Appropriate age:2~12weeks.

  • Inclusion conjunctivitis, eosinophilia, and elevated immunoglobulins can be seen.

  • Chest X-rays may reveal diffuse interstitial thickening, or focal consolidation.


Avian influenza in human beings

  • Due to the infection of HPAI virus ( highly pathogenic avian influenza ,type H5N1).

  • Characteristic syndrome of sudden onset of high fever,severe myalgia, headache and chills.

  • Diarrhea, vomiting, and MOF, DIC are common.

  • High case fatality rate (over 30%~67%)


Questions


How to diagnose pneumonia in children?


What is severe pneumonia in children?


How to consider the etiology of pneumonia in children?


What is your opinion about pneumonia complicate with heart failure in children?


Heart failure

  • Rapid, shallow respirations≥60/min

  • Rapid heart rates ≥180/min

  • Dyspnea with intercostal and subcostal retractions, cyanosis, pale and gray of face , irritability, and peripheral pallor

  • Muffled and distant heart sounds, and a gallop rhythm

  • Liver enlargement

  • Edema of the face and extremities,oliguria or anuria


REFERENCES

1.薛辛东主编. 儿科学.第一版.2005

2.Tom L. Paediatrics.2nd.2002

3.周伯平,等.人禽流感.第一版.2007


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