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上海交通大学医学院附属上海交通大学医学院附属新华医院儿科新华医院儿科
鲍一笑鲍一笑
Infection Diseases of Infection Diseases of Respiratory System in ChildrenRespiratory System in Children
IntroductionIntroduction
High Morbidity RateHigh Morbidity Rate
High Mortality RateHigh Mortality Rate
Each year, respiratory infection diseases cause about 15 million deaths among children younger than age 5 year through the world. This is a significant cause of mortality in childhood. Pediatric pulmonary infection accounts for about 63.89% of all hospitalizations of children, in which 44.6 percent are pneumonia.
Acute and Chronic Infection
Rheumatic Disease
Pleural Disease
Foreign Body of Airway
Neoplasm
Congenital Anomalies
Cricoid cartilage
Venting, , Warming, , Humidification
and conditioning
ventilation
Upper respiratory tractUpper respiratory tract : nose, paranasal sinuses pharynx, eustachian tube, epiglottis, larynx
Lower respiratory tractLower respiratory tract:: trachea, , bronchi, , bronchioles, , alveolus
Anatomy and Anatomy and PhysiologyPhysiology
Anatomy and Anatomy and PhysiologyPhysiology
Upper Upper respiratory respiratory tracttract
Short Short Nasal passages, nasolacrimal duct and eustachian tubeNasal passages, nasolacrimal duct and eustachian tube
Significance :These characters make nasal cavity easy to become hyperemia, edema, and congestion which will induce infection. Local infection can spread to nearby organs and tissues easily and cause dyspnea, hoarseness and apnea.
Nasal mucosaNasal mucosaIs softIs soft
More vascularMore vascular Nasal cavity Nasal cavity is short and is short and
narrow narrow
Anatomy and Anatomy and PhysiologyPhysiology
Narrowed airwayNarrowed airwaySoft mucous menbraneSoft mucous menbraneMore vascularMore vascularSofter and more compliantSofter and more compliant pulmonary alveolisIgA on sIgA on Respiratory Mucosaalveolar surfactant
Clinical significance:
Easy to become hyperemia, edema, and congestion Easy to become hyperemia, edema, and congestion
which will induce infectionwhich will induce infection
Complication: Pulmonary emphysema and atelectasisComplication: Pulmonary emphysema and atelectasis
Lower Lower respiratory respiratory tracttract
Small Small amountsamounts
Anatomy and Anatomy and PhysiologyPhysiology
The younger the child The younger the child The quicker the frequencyThe quicker the frequencyThe less regular the rhythmThe less regular the rhythm
Vital capacity (VC)Vital capacity (VC)
Tidal volumeTidal volume
Total lung capacity (TLC)Total lung capacity (TLC)
Respiratory frequency and rhythm :The respiratory frequency is inversely related to ageThe respiratory frequency is inversely related to age ..
⑴ neonate : 40 ~ 50 bpm ; 6 ~ 12mo: 30-35 bpm ; 1-3 yr : 25 ~ 30 bpm ; 4 ~ 9 yr : 20-25 bpm ; 8-14 yr :18 ~ 20 bpm 。(2) Some young infants present with irregular rhythm or apnea due to immature respiratory center.
Small
Anatomy and Anatomy and PhysiologyPhysiology
Thoracic cageThoracic cage The thorax is barrel shaped. The ribs are in horrizontal he ribs are in horrizontal
position which are almost position which are almost perpendicular to the spinal perpendicular to the spinal column. The location of diaphragm is oppositely column. The location of diaphragm is oppositely superior, which make the size of thoracic cavity superior, which make the size of thoracic cavity decrease, and the size of lung increase.decrease, and the size of lung increase.
Respiratory immune functionRespiratory immune function The specific and nonspecificnonspecific immune function are poor.
Acute Upper Respiratory Tract Infection Acute Upper Respiratory Tract Infection AURIAURI
commonly called ““ common cold”common cold”
Acute Upper Respiratory Acute Upper Respiratory InfectionInfection
IntroductionIntroduction
The common cold is the most common pediatric disease and
accounts for 80-90% proportion of visit to clinic.
Local infection may spread to nearby organs and tissues which
will likely to cause otitis media, conjunctivitis, lymphadenitis,
lymphadenitis and pneumonia.
Bronchial asthma, nephritis, myocarditis, measles and pertussi
s may also follow AURI
90% of AURI are
caused by viral
infection
Etiology
Rhinovirus
Echo virus
Coxsackievirus
Parainfluenza
Influenza
Adenovirus
RSV(Respiratory Syncytial Virus)
PneumococcusMoraxelle catarrhalis
Haemophilus influenzae
Staphylococcus aureus
BacteriaBacteria
Mycoplasma
Chlamydia
Other Microorganisms
OthersOthers
Mild symptomMild symptom
Nasal congestion, rhinorrhea,
sneezing, sore throat
Severe symptomSevere symptom
High fever, convulsion, anorexia,frequency cough
Mild symptomMild symptom
Nasal congestion, rhinorrhea,
sneezing, sore throat
Severe symptomSevere symptom
High fever, convulsion, anorexia,frequency cough
Clinical ManifestationClinical Manifestation
Symptoms of URI in children Symptoms of URI in children of different agesof different ages
< 3 mo Infants AdolescentsSystemicsymptom
Usually mildLow grade fever
Usually severeHigh feverConvulsionIrritability
Usually mildLow grade fever
Respiratory Symptoms
Nasal congestion Dyspnea
Absent or mildor severe
Nasal congestionRhinorrheaSneezingSore throat
Gastrointestinal Symptoms
DiarrheaVomiting
DiarrheaVomitingAnorexia
Abdominal Pain
The pharynx is red Retropharyngeal folliculosis Erythematous enlarged tonsils Enlarged lymph nodes Enterovirus illnesses may be associated with a wide
variety of skin rashes
Physical SignPhysical Sign
HerpanginaCoxsackievirus AMost often occurs in summer and autumnMore often in infants ( 0-3 yr of age )Characterized by sudden onset of fever, sore throat and
dysphagia Characteristic lesions, present on the posterior pharynx,
are discrete vesicles and ulcersDuration of illness is usually 7 days
Two Special TypeTwo Special Type
Occurs typically with type 3,7 adenovirus
Most often occurs in spring and summer
Children ( >3 yr ) more often affected
Features include:
A high temperature that lasts 4–5 days, pharyngitis,
conjunctivitis, cervical lymphadenopathy, and rhinitis.
Duration of illness is usually 1-2 weeks
Pharyngoconjunctival FeverPharyngoconjunctival Fever
Otitis mediaCervical lymphadenitisBronchitisPneumoniaSepticemia
Complication Complication
Viral Infection
→ → Viral Myocarditis Viral Encephalitis
Bacterial Infections ( streptococcus))
→ → Acute Nephritis Rheumatic Fever
DiagnosisDiagnosis
Clinical manifestations
Symptoms and sighs
The differential diagnosis of the URl includes other acute infectious disease.
In patient with In patient with febrile convulsion, central nervous system Infections should also considered.
Patients with abdominal pain may have acute abdomen.
Differential diagnosisDifferential diagnosis
Difference Between Mesenteric Lymphadenitis Difference Between Mesenteric Lymphadenitis and and Acute appendicitisAcute appendicitis
Clinical Manifestation
Mesenteric lymphadenitis Acute appendicitis
Symptom of URI exist absent
Fever andAbdominal Pain
1st present with: feverFollow : pain (mild)
1st present with : pain (severe)Follow : Low grade fever
Abdomen signs Diffuse tendernessNo rebound tenderness and guarding
Progressive localized abdominal tendernessWith rebound tenderness and guarding
Blood routine WBC is usually normal or elevated
WBC is elevatedhigher level of neutrophils
ProphylaxisProphylaxis
Increase outdoor activities. Improve physical fitness. Enhance immunity function. Patients in collective institutions should be isolated.
General treatment Etiological treatment Anti-virus : Ribavirin Avoid the abuse of antibiotics
Symptomatic treatment Severe nasal obstruction Irritability-restlessness High fever Pharyngeal portion ulcer Conjunctivitis
TreatmentTreatment
Upper respiratory infection is the most common disease in childhood
most of which are caused by viral infections.
The severity of clinical manifestations is related to age of the patients.
Infants present mild local symptoms and severe systemic symptoms, while older children
present on the contrary.
A stuffy, congested nose may exist in infants younger than 3 months of age.
Treatment for the common cold should be mainly symptomatic. Antibiotics should not be
used unless in those young, infant patients which are suspected to complicate bacterial
infections.
SummarySummary
Acute bronchitis is inflammation of the tracheobronchial
epithelium .
Trachea is usually involved , so acute bronchitis is also called
‘acute tracheobronchitis’.
Acute bronchitis is commonly secondary to an acute viral
infection, or just one manifestation of acute infectious disease.
Acute BronchitisAcute Bronchitis
Infectious factors : viral, bacterial or other pathogen infections
Characters of respiratory tract of infants: The mucous become edema and hyperemia which make the bronchus narrower when inflammation.
Other factors : immunodeficiency, nutritional diseases, specific body constitution.
EtiologyEtiology
Clinical ManifestationClinical Manifestation
Begins as an URI
Cough is a significant signs nonproductive cough→ productive
The systemic symptoms is usually serve in infants including fever, vomiting and diarrhea
Medical examination : Respiratory rudeness
Diffuse or scattered rales
No dyspnea
CXR : may be normal
or thickening lung markings
Acute bronchitis is an inflammation of the major conducting airways within the
lung which caused by viral or bacteria, and is most often in infants. Cough is the
most significant clinical manifestation. Fever, vomiting and diarrhea are
frequent in infants. Respiratory sounds are rough and scattered rales are heard
on auscultation. Radiographic examination of the chest may show a mild
increase in bronchovascular markings. Antibiotics are indicated if a bacterial
infection of the airway is suspected or proven. Corticosteroids are
recommended in severe cases.
SummarySummary
Pneumonia is an inflammation of the parenchyma of the
lungs.
Most cases of pneumonia are caused by microorgnanisms,
but there are several noninfectious causes, which include
aspiration of food or gastric acid, foreign bodies and so on.
Acute PneumoniaAcute Pneumonia
Season of onsetSeason of onset
Age of onsetAge of onset
Morbidity rateMorbidity rate
Mortality rateMortality rate
EpidemiologyEpidemiology
Classified according to the infecting organism:Classified according to the infecting organism: Viral pneumonia, bacterial Pneumonia, mycoplasma
Pneumonia.Classified according to Pathology:Classified according to Pathology: Bronchopneumonia, lobar pneumonia,interstitial
pneumonia.Classified according to duration of disease:Classified according to duration of disease: Acute pneumonia(<1 mo), persistent pneumonia(1-3 mo)
and chronic pneumonia(> 3mo).Classified according to severity of disease:Classified according to severity of disease:
Mild pneumonia and severe pneumonia.
CategoryCategory
BacteriaBacteriaStreptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus, Escherichia coli, Pseudomonas pyocyanea
Viruses Respiratory Syncytial Viruses,
adenovirus, influenza, parainfluenza
othersIncidence rate of Chlamydia pneumoniae
and Mycoplasma pneumoniae are
increasing recent years.
EtiologyEtiology
AgeAge More often in infants
Disease
Environment
Malnutrition, Congenital heart disease,
Immunodeficiency disease
The recidence is wetness, stuffiness and crowding.
InducementInducement
Patients with the following problems are particularly predisposed to this disease:
Hyperemia, edema and
inflammatory infiltration of lung
tissues
Alveolar exudate
Patchy Inflammation focus,
and consolidation
Atelectasis and emphysema
of lung
PathologyPathology
FeveFeverr
coughcough
tachypnetachypneaa
RalesRales
fourfour
symptomssymptoms
ClinicalClinical ManifestionManifestion
pneumoniapneumonia
Apart from the general features of bronchopneumonia, Apart from the general features of bronchopneumonia,
severe pneumonia also present with systemic toxic severe pneumonia also present with systemic toxic
symptoms in respiratory system, circulatory system, symptoms in respiratory system, circulatory system,
nervous system and digestive system.nervous system and digestive system.
Severe PneumoniaSevere Pneumonia
Circulatory system Myocarditis, heart failureMicrocirculation disturbance
Digestive system Gastrointestinal dysfunction, enteroplegiaAlimentary tract hemorrhage
Nervous system Intracranial hypertensionEncephaledema
Water-Electrolyte Balance
Mixed acidosis, dehydrationHyponatremia
Extrapulmoanry Extrapulmoanry presentationspresentations
Suddenly onset of tachypnea, R>60 bpm, increased pulmonary rales.
Tachycardia that can not be explained by high fever or tachypnea, HR>180 bpm
Irritability and cyanosis
Gallop rhythm or dull heart sound , distension of jugular vein and enlarged cardiac
Increased liver with tenderness, > 1.5cm.
Oliguria or anuria that present with edema of eyelid or lower extremities.
Myocardial failureMyocardial failure
Empyema of pleura Purulent pneumothorax Bullae of lung
Others : Septicemia Purulent pericarditis
ComplicationComplication
Peripheral blood examination White cell count CRP (C-reactive protein) Nitroblue tetrazolium testEtiological examination
Bacteriological examination : Bacterial culture Virological examination : Viral isolation Examination of mycoplasma : Specific immunity examination
Laboratory Laboratory ExaminationExamination
Lobular pneumonia (Bronchopneumonia)
Pathogen
Streptococcus pneumoniae
Haemophilus influenzae
Pathology
Pathological changes such as hyperemia and edema of
bronchiolar wall, exudation of pulmonary lobule, and
bronchiolar obstruction are scattered surround bronchus.
Clinical manifestation
Hyperpyrexia, cough, tachypnea and dyspnea
More common in infants, aged people and weak people
Increase lung markingsIncrease lung markings
Diffuse bilateral Patchy infiltrates and Diffuse bilateral Patchy infiltrates and consolidation scattered throughout both consolidation scattered throughout both lungslungs
Atelectasis, hyperinflation, bullae of lung and pyothorax
Chest radiographic findings in bronchopneumonia
Chest radiographic findings in bronchopneumonia
Frontal views :
Patchy infiltrates and consolidation at the inner zone and middle zone of bilateral lower lobes, with or without hyperinflation
Segmental atelectasis
Frontal views :
It is a segmental atelectasis at the right superior lobe. The transversa fissure is displaced toward the airless lobe. There is a sector high density shadow with the apex toward the hilum of lung. The diaphragm is elevated and the mediastinum is shifted to the side of involvement.
Lobar pneumonia
Pathogen: maily streptococcus pneumoniae
Pathology : inflammtion infiltrates throughout a whole lobe or infiltrates throughout a whole lobe or
segment of the lung.segment of the lung.
Main clinical manifestation:
More common in adolescence, rare in young children.
Hyperpyrexia, cough, and rusty sputum
X-ray findings Change after changes of clinical symptoms.
Lobar pneumonia at Lobar pneumonia at middle lobe of right lungmiddle lobe of right lung
Frontal views :A consolidation within the transverse fissure and oblique fissure can be seen at the middle lobe of right lung,
viral disease, RSV (85%).
aged 2-6 months.
airway obstruction is due to pathological changes include
swelling and distension of bronchioles, secretions block
age.
BronchiolitisBronchiolitis
expiratory wheezing
tachypnea, nasal flaring
Cyanosis
fine rales
emphysema
The duration of illness is 4 ~ 7 days
expiratory wheezing
tachypnea, nasal flaring
Cyanosis
fine rales
emphysema
The duration of illness is 4 ~ 7 days
Clinical ManifestationClinical Manifestation
Hyperexpansion is commonly present
Peribronchial cuffing
Increased interstitial markings
Patchy infiltrates
Hyperexpansion is commonly present
Peribronchial cuffing
Increased interstitial markings
Patchy infiltrates
Chest radiographic findingsChest radiographic findingsChest radiographic findingsChest radiographic findings
Frontal views of CXR:
Ground-glass opacity Decreased lung markingsPatchy infiltrates in innner and middle zoneAcquired hyperinflation
RSV PneumoniaRSV Pneumonia
Escherichia coli is the most common pathogen in neonate. In young
infants > 1 week, mainly pathogen are staphylococcus aureus and
hemolytic streptococcus. Some patients may present only with signs of Some patients may present only with signs of
generalized toxicity.generalized toxicity. Patient uauslly present no cough or
fever. Rales are seldom heard on ausculation. Clinical manifestation
may be milk-resistant, drowsiness, low response, and tachypnea.
Cyanosis, foaming at mouth, nodding respiration or apnea may
present in severe cases.
Respiratory signs is rare.
Pneumonia of newbornPneumonia of newborn
Chest X-rayChest X-ray
Frontal views :
There is patchy shadows and infiltrates at right lung field.
Adenovirus pneumoniaAdenovirus pneumonia Type 3,7 adenovirusYoung children ( 6 mo-2 yr ) are more often
affectedAcute onset of high fever, toxic symptoms and pale
face. Sometimes present with cardiac dysfunction and symptom of nervous system
Severe cough, dyspnea and wheezing Respiratory signs such as fine rales occur after 3-4
daysPatchy infiltrates and consolidation with
hyperinflation.
Adenovirus pneumoniaAdenovirus pneumonia
Frontal views :
Chest radiographs reveals
diffuse interstitial and patchy
alveolar infiltrates,
peribronchial thickening, and
focal consolidation
throughout both lung field.
Staphylococcal pneumoniaStaphylococcal pneumonia
More common in neonate and infantsMore common in neonate and infants Present a sudden onset and progress quicklyPresent a sudden onset and progress quickly Signs include: Signs include: rashes, severe toxic symptoms,
digestive symptoms, convulsion and shockSigns vary with stage of diseaseConsolidation of lung is obviousChest X-ray reveals infiltrates, abscess and bullae
of lung
Abscess of lung
Frontal views :
Multiple round high density shadow in both sides
PyopneumothoraxPyopneumothorax
Encapsulated pleural effusion
Pulmonary Bulla
Female , 7 day , hyperpyrexia and no crying
CXR: multiple giant
air-containing cavity
Common cause of symptomatic pneumonia in older children
Fever, dry cough are common symptoms Extrapulmonary complications sometimes
occurChest radiographs are untypical, usually
demonstrate interstitial or bronchopneumonic infiltrates
Mycoplasma pneumoniaMycoplasma pneumonia
Interstitial infiltrates in Interstitial infiltrates in Mycoplasma Mycoplasma
pneumoniapneumonia
A 5-year-old boy
complain of fever and cough.
MP antibody (+)
Frontal views of CXR:
Increased lung markings
Diffuse patchy infiltrates
Volume loss of lower lobes of bilateral lung
Enlarged hilar shadow
Peak age of onset
Clinical manifestation
Laboratory examination
X-ray examination
Others
DiagnosisDiagnosis
Acute bronchitisAcute bronchitis
Pulmonary tuberculosisPulmonary tuberculosis
Foreign body in bronchusForeign body in bronchus
Differential DiagnosisDifferential Diagnosis
Nursing and Nursing and supporting therapySymptomatic treatment :: Oxygen supply Conscious sedation Pyretolysis Cough suppressants Eliminate sputum Antimicrobial therapy Treatment of complicationEnhance immunity functionphysical treatment
TreatmentTreatment
Principle of antibiotic treatment:Principle of antibiotic treatment:
Sensitive
Early treatment
Sufficiency
Drug combination
Antimicrobial treatment
Antibiotic treatment
Streptococcus pneumoniae penicilin Amoxicillin
Bacillus influenzae Amoxicillin plus clavulanate2nd or 3rd-generation cephalosporins
Staphylococcus aureus Oxacillin sodium Vancocin
Moraxelle catarrhalis Amoxicillin plus clavulanate
Mycoplasma Pneumonia Erythromycin Macrolide
Antiviral treatmentAntiviral treatment
There is no ideal drug in antiviral therapy.There is no ideal drug in antiviral therapy.
Ribovirin
interferon (IFN)
Human Immunoglobulin
Traditional chinese drug therapy
Yuxingcao, Double coptis
Severe Severe toxic symptom that include shock, ultrahyperpyrexia and toxic encephacopathy
Increased Increased secretions and and bronchial spasm
Complicated with Complicated with pleural effusion in early periodin early period
Indication of Indication of Systemic corticosteroidsSystemic corticosteroids
Heart failure :: cardiotonic, sedative diuresis and oxygen supplyRespiratory Failure :: suctioning, oxygen supply intubation and artificial respiratorToxic encephacopathy :: anti-infection, oxygen supplY, correct acidosis
Treatment of severe Treatment of severe pneumoniapneumonia
Fever, cough, tachypnea and fine rales are four major symptoms of pneumonia.
Besides, severe pneumonia present circulatory, neurological and digestive symptoms
Diagnosis mainly depends on clinical manifestations and X-ray examination.
According to the characteristics of clinical symptoms, signs and auxiliary examination, we classify different type and severity.
Treatment should emphasize comprehensive treatment. Choose different antibiotics according to different pathogens. Pay attention to the importance of nursing, supporting therapy, and
symptomatic therapy.
SummarySummary
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