Transcript 上海交通大学医学院附属 新华医院儿科 鲍一笑 Infection Diseases of Respiratory

Infection Diseases of Respiratory
System in Children
上海交通大学医学院附属
新华医院儿科
鲍一笑
Introduction
 High Morbidity Rate
 High 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
Anatomy and Physiology
Venting, Warming,
Humidification
and conditioning
Upper respiratory tract ： nose, paranasal sinuses
pharynx, eustachian tube, epiglottis, larynx
Cricoid cartilage
Lower respiratory tract:
alveolus
ventilation
trachea, bronchi, bronchioles,
Anatomy and Physiology
Upper
respiratory
tract
Nasal mucosa
Is soft
Nasal cavity
is short and
narrow
More vascular
Short Nasal 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.
Anatomy and Physiology
Lower
respiratory
tract
Small
amounts
Narrowed airway
Soft mucous menbrane
More vascular
Softer and more compliant
pulmonary alveoli
sIgA on Respiratory Mucosa
alveolar surfactant
Clinical significance:
Easy to become hyperemia, edema, and congestion
which will induce infection
Complication:
Pulmonary emphysema and atelectasis
Anatomy and Physiology
The younger the child
The quicker the frequency
The less regular the rhythm
Vital capacity (VC)
Small
Tidal volume
Total lung capacity (TLC)
Respiratory frequency and rhythm ：
The 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.
Anatomy and Physiology
 Thoracic cage
The thorax is barrel shaped. The ribs are in horrizontal
position which are almost perpendicular to the spinal
column. The location of diaphragm is oppositely
superior, which make the size of thoracic cavity
decrease, and the size of lung increase.
 Respiratory immune function
The specific and nonspecific immune function are poor.
Acute Upper Respiratory
Infection
Acute Upper Respiratory Tract Infection
AURI
commonly called “common cold”
Introduction
 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, m e a s l e s
pertussis may also follow AURI
and
Etiology
Rhinovirus
Echo virus
Coxsackievirus
90% of AURI are
Parainfluenza
caused by viral
Influenza
infection
Adenovirus
RSV(Respiratory
Syncytial Virus)
Bacteria
Pneumococcus
Moraxelle catarrhalis
Haemophilus influenzae
Staphylococcus aureus
Others
Mycoplasma
Chlamydia
Other Microorganisms
Clinical Manifestation
Mild symptom
Nasal congestion, rhinorrhea,
sneezing, sore throat
Severe symptom
High fever, convulsion,
anorexia,frequency cough
Symptoms of URI in children
of different ages
< 3 mo
Infants
Systemic
symptom
Usually mild
Low grade fever
Usually severe
High fever
Convulsion
Irritability
Usually mild
Low grade fever
Respiratory
Symptoms
Nasal congestion
Dyspnea
Absent
or mild
or severe
Nasal congestion
Rhinorrhea
Sneezing
Sore throat
Gastrointestinal
Symptoms
Diarrhea
Vomiting
Diarrhea
Vomiting
Anorexia
Abdominal Pain
Adolescents
Physical Sign





The pharynx is red
Retropharyngeal folliculosis
Erythematous enlarged tonsils
Enlarged lymph nodes
Enterovirus illnesses may be associated with a wide
variety of skin rashes
Two Special Type
Herpangina




Coxsackievirus A
Most often occurs in summer and autumn
More 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 ulcers
 Duration of illness is usually 7 days
Pharyngoconjunctival Fever
 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
Complication
Otitis media
Cervical lymphadenitis
Bronchitis
Pneumonia
Septicemia
Viral Infection
→
Viral Myocarditis
Viral Encephalitis
Bacterial Infections（streptococcus))
→
Acute Nephritis
Rheumatic Fever
Diagnosis
Clinical manifestations
Symptoms and sighs
Differential diagnosis
 The differential diagnosis of the URl includes
other acute infectious disease.
 In patient with febrile convulsion, central nervous
system Infections should also considered.
 Patients with abdominal pain may have acute
abdomen.
Difference Between Mesenteric Lymphadenitis
and Acute appendicitis
Clinical
Manifestation
Mesenteric lymphadenitis
Acute appendicitis
Symptom of URI
exist
absent
Fever and
Abdominal Pain
1st present with: fever
Follow : pain (mild)
1st present with : pain (severe)
Follow : Low grade fever
Abdomen signs
Diffuse tenderness
No rebound tenderness and
guarding
Progressive localized abdominal
tenderness
With rebound tenderness and
guarding
Blood routine
WBC is usually normal or
elevated
WBC is elevated
higher level of neutrophils
Prophylaxis




Increase outdoor activities.
Improve physical fitness.
Enhance immunity function.
Patients in collective institutions
should be isolated.
Treatment
 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
Summary

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.
Acute Bronchitis
 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.
Etiology
 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.
Clinical 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
Summary
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.
Acute Pneumonia
 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.
Epidemiology
 Season of onset
 Age of onset
 Morbidity rate
 Mortality rate
Category
Classified according to the infecting organism:
Viral pneumonia, bacterial Pneumonia, mycoplasma
Pneumonia.
Classified according to Pathology:
Bronchopneumonia, lobar pneumonia,interstitial
pneumonia.
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:
Mild pneumonia and severe pneumonia.
Etiology
Bacteria
Viruses
others
Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus,
Escherichia coli, Pseudomonas pyocyanea
Respiratory Syncytial Viruses,
adenovirus, influenza, parainfluenza
Incidence rate of Chlamydia pneumoniae
and Mycoplasma pneumoniae are
increasing recent years.
Inducement
Patients with the following problems are
particularly predisposed to this disease:
Age
Disease
Environment
More often in infants
Malnutrition, Congenital heart disease,
Immunodeficiency disease
The recidence is wetness, stuffiness and crowding.
Pathology
 Hyperemia, edema and
inflammatory infiltration of lung
tissues
 Alveolar exudate
 Patchy Inflammation focus,
and consolidation
 Atelectasis and emphysema
of lung
Clinical Manifestion
Fever
pneumonia
four
cough
symptoms
tachypnea
Rales
Severe Pneumonia
Apart from the general features of bronchopneumonia,
severe pneumonia also present with systemic toxic
symptoms in respiratory system, circulatory system,
nervous system and digestive system.
Extrapulmoanry
presentations
Nervous system
Intracranial hypertension
Encephaledema
Circulatory system
Myocarditis, heart failure
Microcirculation disturbance
Digestive system
Gastrointestinal dysfunction, enteroplegia
Alimentary tract hemorrhage
Water-Electrolyte
Balance
Mixed acidosis, dehydration
Hyponatremia
Myocardial failure
 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.
Complication
 Empyema of pleura
Purulent pneumothorax
Bullae of lung
 Others：Septicemia
Purulent pericarditis
Laboratory Examination
Peripheral blood examination
White cell count
CRP (C-reactive protein)
Nitroblue tetrazolium test
Etiological examination
Bacteriological examination ：
Bacterial culture
Virological examination：
Viral isolation
Examination of mycoplasma：
Specific immunity examination
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
Chest radiographic findings in
bronchopneumonia
Increase lung markings
Diffuse bilateral Patchy infiltrates and
consolidation scattered throughout both
lungs
Atelectasis, hyperinflation,
bullae of lung and pyothorax
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
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 middle
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,
Bronchiolitis
 viral disease, RSV (85%).
 aged 2-6 months.
 airway obstruction is due to pathological changes include
swelling and distension of bronchioles, secretions
blockage.
Clinical Manifestation
expiratory wheezing
 tachypnea, nasal flaring
Cyanosis
 fine rales
 emphysema
The duration of illness is 4 ~ 7 days
Chest radiographic findings
Hyperexpansion is commonly present
Peribronchial cuffing
Increased interstitial markings
Patchy infiltrates
RSV Pneumonia
Frontal views of CXR:
Ground-glass opacity
Decreased lung markings
Patchy infiltrates in innner and
middle zone
Acquired hyperinflation
Pneumonia of newborn
 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 generalized
toxicity. Patient uauslly present no cough or fever. Rales are
seldom heard on ausculation. Clinical manifestation may be milkresistant, drowsiness, low response, and tachypnea.
 Cyanosis, foaming at mouth, nodding respiration or apnea may
present in severe cases.
 Respiratory signs is rare.
Chest X-ray
Frontal views :
There is patchy shadows
and infiltrates at right lung
field.
Adenovirus pneumonia
 Type 3,7 adenovirus
 Young children（6 mo-2 yr ）are more often
affected
 Acute 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
days
 Patchy infiltrates and consolidation with
hyperinflation.
Adenovirus pneumonia
Frontal views :
Chest radiographs reveals
diffuse interstitial and patchy
alveolar
infiltrates,
peribronchial thickening, and
focal
consolidation
throughout both lung field.
Staphylococcal pneumonia
 More common in neonate and infants
 Present a sudden onset and progress quickly
 Signs include: rashes, severe toxic symptoms,
digestive symptoms, convulsion and shock
 Signs vary with stage of disease
 Consolidation of lung is obvious
 Chest X-ray reveals infiltrates, abscess and bullae
of lung
Abscess of lung
Frontal views :
Multiple round high density
shadow in both sides
Pyopneumothorax
Encapsulated pleural effusion
Pulmonary Bulla
Female，7 day，
hyperpyrexia and no crying
CXR: multiple giant
air-containing cavity
Mycoplasma pneumonia
 Common cause of symptomatic pneumonia in
older children
 Fever, dry cough are common symptoms
 Extrapulmonary complications sometimes
occur
 Chest radiographs are untypical, usually
demonstrate interstitial or bronchopneumonic
infiltrates
Interstitial infiltrates in Mycoplasma
pneumonia
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
Diagnosis
 Peak age of onset
 Clinical manifestation
 Laboratory examination
 X-ray examination
 Others
Differential Diagnosis
Acute bronchitis
Pulmonary tuberculosis
Foreign body in bronchus
Treatment
 Nursing and supporting therapy
 Symptomatic treatment：
Oxygen supply
Conscious sedation
Pyretolysis
Cough suppressants
Eliminate sputum
 Antimicrobial therapy
 Treatment of complication
 Enhance immunity function
 physical treatment
Antimicrobial treatment
Principle of antibiotic treatment:
 Sensitive

Early treatment

Sufficiency
 Drug combination
Antibiotic treatment
Streptococcus pneumoniae
penicilin Amoxicillin
Bacillus influenzae
Amoxicillin plus clavulanate
2nd or 3rd-generation
cephalosporins
Staphylococcus aureus
Oxacillin sodium
Vancocin
Moraxelle catarrhalis
Amoxicillin plus clavulanate
Mycoplasma Pneumonia
Erythromycin Macrolide
Antiviral treatment
There is no ideal drug in antiviral therapy.
 Ribovirin
 interferon (IFN)
 Human Immunoglobulin
 Traditional chinese drug therapy
Yuxingcao, Double coptis
Indication of
Systemic corticosteroids
 Severe toxic symptom that include shock,
ultrahyperpyrexia and toxic encephacopathy
 Increased secretions and bronchial spasm
 Complicated with pleural effusion in early period
Treatment of severe
pneumonia
 Heart failure：
cardiotonic, sedative
diuresis and oxygen supply
 Respiratory Failure：
suctioning, oxygen supply
intubation and artificial respirator
 Toxic encephacopathy：
anti-infection, oxygen supplY,
correct acidosis
Summary
 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.
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