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1、Pneumonia Case Discussion,Xu ChangqingAddress: Hangzhou City, Wenzhou Road No. 16Email：,2022/12/11,1,The condition of the patient,1,Yu Jinyu, male, 64 years old, 2, 5 months ago, the patient started coughing without a cause, coughing white sputum. More severely: fever with a temperature of 38 . In t
2、he local community hospital he was treated for 2 days without any improvement. So he came to our hospital to be admitted with pulmonary infection.,2022/12/11,2,The condition of the patient,3, Examination of pulmonary CT: Double pneumonia lesions, for anti infection, stop cough and phlegm and other t
3、reatments. The temperature dropped gradually and the condition improved.4, The patient was careless as to inhale food one month beforehand, then the patient began to cough, sputum, and have fever. After being hospitalized, feeding through a nasogastric tube , anti infection, and phlegm treatment. Th
4、e condition improved. Multiple hospitalizations.,2022/12/11,3,The condition of the patient,4, 1 day ago, the patients condition worsened. He was admitted to the hospital for further treatment, quasi “Pneumonia, Parkinsons disease, admitted to our department. Has Parkinsons disease history for 5 year
5、s.,2022/12/11,4,The condition of the patient,Physical examination: P 90 / R 19 / BP 119/72mHg T 36.6. Clear consciousness, bed rest, nasal feeding. Skin and sclera without yellow dye, no lips cyanosis, a soft and not swollen superficial lymph node of neck, no jugular vein enlargement, tracheae, no c
6、hest deformity, the intercostal space without broadening, double lung breathing symmetry, no change, fremitus without change, bilateral percussion sound, two pulmonary respiration crude and obviously, no rales or rhonchi; heart has no enlargement, heart rate 90, the law is neat; the abdomen is soft,
7、 complete abdomen tenderness, no rebound tenderness, below liver lienal costal region without palpable mass, renal area without percussion pain; lower extremities edema, neurological examination: limbs adverse events, activities joint degree is limited, muscle tension increased, strength can not che
8、ck.,2022/12/11,5,The condition of the patient,2013-11-27 chest CT scan: comparison of the front sheet (2013-10-28) two pulmonary infections with bilateral pleural effusion was improved; hint at the thoracic inlet endotracheal nodular protrusion.,2022/12/11,6,Normal Chest CT Scan,2022/12/11,7,Lung: t
9、he right lung left lung two leaf clover.The pulmonary fissures (oblique fissure, horizontal fissure) boundary, appeared as low density pancivascular area or linear high densityPulmonary segments: the right lung left lung is divided into ten segments, eight segments. Segmental bronchusTube in the lun
10、g, pulmonary artery segment center.Alveolar: filled with gas, so the lung showed low density shadow.Bronchus: filling gas, the tubular low-density gas as the characteristics of.Pulmonary vascular: pulmonary intravascular filling blood, showed high density.,Chest CT scan of the patient2013-11-262014-
11、01-02,2022/12/11,8,Recurrent cough, feverThrough a variety of antimicrobial treatment,The first, second, three line antibioticsPenicillin, Cephalosporinsseflosp:rnz, Fluoroquinolonesflrokwanlonz , Carbapenemsk:bpenemz etc.,There are 4 possibilities,1, The diagnosis is not clear2, The older3, Abnorma
12、l immune functions4, Combined with various underlying diseases,2022/12/11,9,Thought,We can see, the patients condition has improved, but there is no obvious improvement in imaging,This is characteristic of aspiration pneumonia, pulmonary lesions difficult to absorb,Patients with low immunity, easy r
13、ecurrence of pneumoniaSo, the patients with recurrent pneumonia, so he has to stay in the hospital,2022/12/11,10,Thought,Symptoms of bacterial pneumonia is larger, can be light weight, determined by the pathogen and host state. The common symptoms were cough, expectoration, or the original respirato
14、ry symptoms increased, and the emergence of purulent sputum or sputum with blood, with or without chest pain.,2022/12/11,11,Pneumonia disease range can have difficulty breathing, respiratory distress. Most of the patients have fever. Early signs have no obvious abnormity, serious person can have hig
15、h respiratory rate, flaring of nares, cyanosis.,2022/12/11,12,Thought,Clinical manifestation,Pulmonary consolidation with typical signs, such as enhanced, fremitus percussion dullness and bronchial breath sounds, can also be heard and rales. Pleural effusion, ipsilateral chest percussion dullness, d
16、iminished breath sounds.,2022/12/11,13,Differential diagnosis,1, Pulmonary tuberculosis Many symptoms of systemic poisoning, afternoon fever, night sweats, fatigue, weakness, weight loss, insomnia, heart palpitations and other symptoms. X-ray visible lesions in the apical or supraclavicular, uneven
17、density, dissipated slowly, and can form a cavity or intrapulmonary spread. Mycobacterium tuberculosis can be found in the sputum. The conventional antibiotic therapy.,2022/12/11,14,Differential diagnosis,2, Lung cancer Often has a history of smoking. Has a cough, sputum, bloody sputum symptoms. Whi
18、te blood cell count is not high, if found that the cancer cells in sputum can be confirmed. Be accompanied with obstructive pneumonia, after antibiotic treatment inflammation is not easy to dissipate, or visible hilar lymph node enlargement, sometimes appears atelectasis. It is necessary to do the C
19、T, MRI, fiberoptic bronchoscopy and sputum cytologic examination.,2022/12/11,15,Differential diagnosis,3, Acute pulmonary abscess The early clinical manifestation is similar. As the disease progresses, expectoration of purulent foul sputum for lung abscess. The X-ray films showed the abscess cavity
20、and fluid level.,2022/12/11,16,Differential diagnosis,4, Pulmonary thromboembolism Many risk factors for venous thromboembolism, can occur hemoptysis, syncope, respiratory difficulties are obvious, jugular venous engorgement. X-ray showed partial reduction of lung markings, wedge-shaped shadow visib
21、le tip pointing to the hilar, common hypoxemia and hypocapnia. The two D- dimer, CT pulmonary angiography, radionuclide lung ventilation / perfusion scan and MRI examination can help identify.,2022/12/11,17,Differential diagnosis,5, Non infectious pulmonary infiltration To exclude non infectious pul
22、monary diseases, such as pulmonary fibrosis, pulmonary edema, atelectasis, pulmonary eosinophilia and pulmonary vasculitis.,2022/12/11,18,Treatment,A stable condition after from intravenous to oral therapy.Pneumonia antibiotic treatment for at least 5 days, most of the patients need 7-10 days or a l
23、onger course of treatment,If the temperature is normal for 48-72 hours, without any a pneumonia clinical instability signs, can disable antibiotics,2022/12/11,19,Therapy,In view of the patientAnti infection treatment of penicillin injection and Ciprofloxacin Injection for 7 days.,2022/12/11,20,Thera
24、py,Patients in addition to bed rest, drinking lots of water, oxygen, positive sputum, the main aspects of the treatment of pneumonia is an infection. According to patient age, underlying diseases, whether have aspiration level factors, serious illness, selection of antimicrobial agents and route of
25、administration.,2022/12/11,21,Therapy,Treatment of bacterial pneumonia pathogens (including the treatment of choice in vitro according to sputum culture and drug sensitivity test results, sensitive antibiotics). Empirical treatment (antibiotics selection may cover the pathogen).,2022/12/11,22,Therap
26、y,Suspected pneumonia immediately give first dose of antibiotics.A stable condition after the intravenous to oral therapy. Pneumonia antibiotic treatment for at least 5 days, the majority of patients to 7 10 days or longer course of treatment, the normal body temperature of 48 72 hours, without any
27、a pneumonia clinical instability signs, can disable antibiotics.,2022/12/11,23,Therapy,1, Young adults with and without underlying diseases of community acquired pneumonia Selection of penicillin, first generation cephalosporins antibiotics, the drug resistance of Streptococcus pneumoniae can use sp
28、ecial effects on respiratory tract infection (fluoroquinolone moxifloxacin, levofloxacin).,肺炎链球菌,46%,流感嗜血杆菌,10%,肺炎支原体,25%,肺炎衣原体,14%,金黄色葡萄球菌,5%,2022/12/11,24,Therapy,2, Elderly people have basic diseases, or need to be hospitalized with community-acquired pneumonia The fluorinated quinolones, second
29、/ three generation cephalosporins, beta lactam / beta lactamase inhibitor, can be combined with large ring vinegar.,流感嗜血杆菌需氧 G 杆菌,60%,肺炎衣原体,5%,金黄色葡萄球菌,卡他莫拉氏菌,5%,15%,肺炎链球菌,15%,2022/12/11,25,Therapy,3, Hospital acquired pneumonia The second / three generation cephalosporins, beta lactam / beta lactama
30、se inhibitor, quinolones or carbapenems.,2022/12/11,26,Therapy,4, Severe pneumonia The preferred broad-spectrum strong antibacterial drugs, drug combination is sufficient. Severe community acquired pneumonia with beta lactam combined with large ring vinegar or fluoroquinolones; Hospital acquired pne
31、umonia available fluoroquinolones or aminoglycoside combined antipseudomonal beta lactam, ampicillin / beta in any kind of amide enzyme inhibitors, carbapenems, when necessary, can be combined with vancomycin, teicoplanin and linezolid.,2022/12/11,27,Pneumonia clinical stability criteria:,The T 37.8
32、 ;The heart rate 100 / min.; Respiratory frequency 24 / min.;The blood pressure: SBP 90mmHg;Indoor air conditions and breathe the oxygen saturation of arterial blood 90% and PaO2 60mmHg; To oral intake;The normal mental state.,2022/12/11,28,The condition evaluation,Anti bacterial drug 48-72 hours af
33、ter treatment with the condition evaluation, effective performance:The drop in body temperature, improve symptoms, clinical stability, leucocyte decreases or return to normal.Chest X-ray focus absorption later.,2022/12/11,29,72 hours after the symptoms non improvement, the possible causes:,The drug
34、failed to cover the pathogenic bacteria, and bacterial drug resistance;Such as mycobacteria, fungi, viruses and other special pathogen infection;The complications or affect the existence of host factors effect (such as immunosuppression);The non infectious diseases misdiagnosed as pneumonia;The drug fever.,2022/12/11,30,Thank you,2022/12/11,31,
