肺炎的診斷治療

Pneumonia肺炎問(wèn)鼎不治之癥1919流感大流行1950s青霉素發(fā)現(xiàn)之前1976嗜肺軍團(tuán)菌1990s年P(guān)RSP1999禽流感2003年SARS冠狀病毒肺炎當(dāng)前：超級(jí)細(xì)菌DefinitionPneumoniaisaninflammationofthelungs(pulmonaryparenchyma)causedbyaninfectionMechanismofinfectionAspirationMicroaspirationoforopharyngealcontentsduringsleepGrossaspirationnormallyoccursonlyinthosewithalteredsensorium,depressedconsciousnessInhalationofaerosolizeddropletBloodstreamspread三種解剖分型

6interstitialpneumonia百草枯中毒04.11.04百草枯中毒04.11.10百草枯中毒04.11.17EtiologicalClassificationBacterialpneumoniaAtypicalpneumoniaViralpneumoniaFungalpneumoniaOthersClassificationbytheSiteofInfectionCommunity-acquiredpneumonia(CAP)Hospital-acquiredpneumonia(HAP)orNosocomialpneumonia(NP)Healthcareassociatedpneumonia(HCAP)Pneumoniainimmunocompromisedhosts9CommonpathogensofCAP其他卡他10%流感25%肺鏈40%1.RussellW.Steel.InfectionsinMedicine.Vol.14(suppl.)PP9-11199710Spneumoniaethemostcommoncauseofbacterialpneumonia11HinfluenzaePneumoniafromHinfluenzaeoftenisassociatedwithdebilitatingconditionssuchasasthma,COPD,smoking,andacompromisedimmunesystem.12MycoplasmapneumoniaeMpneumoniaeisacommoncauseofmildpneumoniaandusuallyaffectspeopleyoungerthan40.Variousstudiessuggestthatitcauses15-50%ofallpneumoniainadultsandanevenhigherpercentageofpneumoniainschool-agedchildren.Peopleathighestriskformycoplasmapneumoniaincludethoselivingorworkingincrowdedareassuchasschoolsandhomelessshelters,althoughmanypeoplewhocontractmycoplasmapneumoniahavenoidentifiableriskfactor.

13Legionella

Legionnaire'sdiseasewasfirstdescribedin1976afteranoutbreakoffatalpneumoniaataLegionnairesconvention.ThenewlydescribedorganismwhichcausedthediseasewasnamedLegionellapneumophila,showninthispicture.(ImagecourtesyoftheCentersforDiseaseControlandPrevention.)ClinicalManifestationsPrecursorysymptomCoughSputumDyspneaFeverAtypicalinelderlyorinImmunocompromisedhost

15Additionalsymptomspleuriticchestpain，abdominalpain，

consciousnessdisorders

-------pneumococcalinfectionheadaches,malaise,nausea,vomiting,anddiarrhea-------Legionella,Chlamydia,orMycoplasmaspecies.

16重要表現(xiàn)及并發(fā)癥重要表現(xiàn)氣急紫紺病變廣泛、ARDS

出血點(diǎn)DIC、敗血癥鞏膜黃染敗血癥低血壓休克并發(fā)癥休克、胸膜炎、膿胸心包炎、腦膜炎和關(guān)節(jié)炎

ClinicalManifestationsinspectionpalpationpercussionAusculation

18實(shí)驗(yàn)室和其它檢查血液檢查(血常規(guī)、炎性指標(biāo)、血清學(xué)、血培養(yǎng))痰涂片及痰培養(yǎng)(痰、纖支鏡)尿抗原實(shí)驗(yàn)經(jīng)皮細(xì)針穿刺細(xì)胞學(xué)或肺活檢影像學(xué)1920LobarPneumoniaStaphylococcusPneumoniaViralPneumoniaAconed-downviewofthechestdemonstratesfinetomediumheterogeneousreticularopacitiesinbothlowerlobes.ThispatternisthemosttypicalseenwithcytomegalovirusPneumocystisCariniiPneumoniaWithPneumothorax香港SARS病例26細(xì)菌性肺炎診斷標(biāo)準(zhǔn)主要標(biāo)準(zhǔn)次要標(biāo)準(zhǔn)胸片：新出現(xiàn)或進(jìn)展性浸潤(rùn)影發(fā)熱或體溫不升呼吸道癥狀體征：叩診濁音、管狀呼吸音、羅音白細(xì)胞，N%27病情評(píng)估年齡、基礎(chǔ)病、意識(shí)障礙高熱或低溫、R>30,P>125,BP<90/60mmHgWBC、PLT、PH<7.3,PO2<60mmHg,BUN及Cr升高，X線多葉病變或胸水，菌血癥或肺外病灶中國(guó)CAP指南重癥肺炎判斷出現(xiàn)下列征象中1項(xiàng)或以上者意識(shí)障礙呼吸頻率≥30次/minPaO2＜60mmHg,PaO2/FiO2＜300,需行機(jī)械通氣動(dòng)脈收縮壓＜90mmHg并發(fā)膿毒性休克胸片雙側(cè)或多肺葉受累，或入院48h內(nèi)病變擴(kuò)大≥50％尿＜20ml/h,或＜80ml/4h，或并發(fā)急性腎功衰需要透析29aSARSpatient4daysafteronsetofsymptomstwodayslater

30鑒別診斷

31結(jié)核中毒癥狀肺實(shí)變歷久不消散，多位于肺尖伴空洞，肺內(nèi)播散肺結(jié)核(干酪性肺炎)32TUBERCULOSIS33LUNGCANCER34pulmonaryembolism35ForeignBodyAspiration36Bronchiectasis37LungAbscess38其他鑒別疾病間質(zhì)性肺炎肺水腫肺血管炎社區(qū)獲得性肺炎的治療CAPguidelinesAustralia2000InformationtobeupdatedCanada2000CanadianInfectiousDiseasesSociety/CanadianThoracicSocietyChina1999/2006中華醫(yī)學(xué)會(huì)呼吸病學(xué)分會(huì)France2001FrenchSocietyofInfectiousDiseasesGermany2000GermanRespirAssociation/PaulEhrlichSocietyforChemotherHongKong2001HongKongUniversityandHongKongHospitalAuthorityJapan2001/2005JapanRespirSocietyCAPTreat.GuidelineCreationCommitteeLatinAmerica2002AsociaciónLatinoamericanadelTóraxThePhilippines1998PhilippineSocietyforMicrobiologyandInfectiousDiseasesPortugal2000PortugueseRespiratorySocietySingapore2000PhysiciansAcademyofMedicineofSingaporeSouthAfrica1996SouthAfricanPulmonarySociety/AntibioticStudyGroupSouthAmerica2001ConsenSurSouthAmericanWorkingGroupSpain2001SpanishRespiratorySociety/SpanishSocietyofChemotherapyUK2001BritishThoracicSocietyUSA98/03/05/07ATS/CDC/IDSAEtiologyofCAP國(guó)家/年度,樣本量S.Pneumoniae(%)Hflu(%)M.Pneumoniae(%)C.Pneumoniae(%)瑞典/2003,n=17732.028.018.05.0芬蘭/2001,n=30441.13.99.99.9西班牙/1999,n=22823.92.31.313.5西班牙/1999,n=22729.011.05.07.0阿根廷/2000,n=34624.012.013.08.0加拿大/2005*,n=5075.94.915.012.0中國(guó)臺(tái)灣/2005，n=16823.84.814.37.1中國(guó)大陸/2006，n=61010.39.220.76.6*Ambulatorypatients中華醫(yī)學(xué)會(huì)呼吸分會(huì)06年CAP指南

推薦初始經(jīng)驗(yàn)性應(yīng)用抗生素－門診治療青壯年&無(wú)基礎(chǔ)疾病老年人/有基礎(chǔ)疾病青霉素/阿莫西林多西環(huán)素大環(huán)酯第I/II代頭孢呼吸喹諾酮第II代頭孢±大環(huán)酯b內(nèi)酰胺/酶抑制劑±大環(huán)酯呼吸喹諾酮43有基礎(chǔ)疾病或有危險(xiǎn)因素的社區(qū)獲得性肺炎β-內(nèi)酰胺類加大環(huán)內(nèi)酯、或加呼吸氟喹諾酮藥物當(dāng)有銅綠假單胞菌感染危險(xiǎn)因素時(shí)（如結(jié)構(gòu)性支氣管異常），可選用抗銅綠假單胞菌β-內(nèi)酰胺類聯(lián)合環(huán)丙沙星或聯(lián)合氨基糖甙及呼吸氟喹諾酮/大環(huán)內(nèi)酯。CAP的簡(jiǎn)化治療方案肺炎鏈球菌不典型致病菌肺結(jié)構(gòu)異常肺結(jié)構(gòu)正常銅綠假單胞菌PRSPPSSP/PISP阿莫西林+/-BLI2ndGCs或曲松呼吸喹諾酮高級(jí)大環(huán)酯呼吸喹諾酮抗銅綠假單胞b-內(nèi)酰胺呼吸奎諾酮，氨基糖苷吸入性肺炎克林霉素或阿莫西林+/-BLI45重癥肺炎

強(qiáng)效、足量、聯(lián)合重癥CAP:

-內(nèi)酰胺＋新大環(huán)/呼吸喹諾酮

-內(nèi)酰胺過(guò)敏：呼吸喹諾酮±克林霉素

抗生素療程和靜脈-口服轉(zhuǎn)換歐美指南關(guān)注抗生素療程和靜脈-口服轉(zhuǎn)換抗生素療程至少5天，通常為7～14天，軍團(tuán)菌肺炎至少14天靜脈-口服轉(zhuǎn)換時(shí)機(jī)(LevelII證據(jù))血液動(dòng)力學(xué)穩(wěn)定臨床狀況改善胃腸道功能正常47短期治療不佳時(shí)應(yīng)考慮幾點(diǎn)細(xì)菌耐藥，未能覆蓋致病菌其它特異性感染，如TB、真菌、病毒等并發(fā)癥、或基礎(chǔ)病未控制誤診、誤治藥物熱等48治療（2）支持治療休息，能量補(bǔ)充監(jiān)測(cè)體溫、血壓、尿量等對(duì)癥治療并發(fā)癥治療49院內(nèi)肺炎(HAP)入院時(shí)不存在、也不處于潛伏期于入院48小時(shí)后發(fā)生VAP：機(jī)械通氣后48h50院內(nèi)肺炎的病原譜克雷伯桿菌綠膿桿菌不動(dòng)桿菌腸桿菌大腸桿菌葡萄球菌MRSA/MRSE其它：真菌肺炎球菌卡氏肺囊蟲軍團(tuán)病…51HAP的抗生素選擇抗銅綠假單胞的b內(nèi)酰胺/酶抑制or碳?xì)涿赶?呼吸奎諾酮or氨基糖苷類MDR的球菌--萬(wàn)古霉素/替考拉寧/利賴唑胺53Staphylococcuspneum