Pneumonia

Junying Qiao
the department of pediatrics
the third affiliatted hospital of zhengzhou university
 Definition
§is an inflammation or infection of the br
onchioles and alveolar spaces of t
he lungs, and be caused by differ
microorganisms or other factor.
§main clinical manifestation are fever, cough
, tachypnea, dyspnea, local moist rales (bu
bble,craches).
 Classification
• Morphologic classification

Bronchopneumonia
Lobar pneumonia
Interstitial pneumonia
 Classification
• Etiological factor classification

§infectious pneumonia

§noninfectious pneumonia
Infectious pneumonia
Viral pneumonia
Bacterial pneumonia
Mycoplasmal pneumonia
Chlamydia pneumonia
Fungi and pneumocystis
Parasite pneumonia
 Noninfectious pneumonia
• Foreign body aspiration
Lipoid substances aspiration
Hypersensiticity reaction
Drug or radiation-induced pneumonia
 Classification
• Course agent classification
acute <1m
progressive 1~3m
chronic >3m
 Classification
• State of illness classification
Mild pneumonia
(only invoved pulmonary system)
Severe pneumonia
(other organ may be involved)
• Clinical manifestation classification

Typical pneumonia
Atypical pneumonia
• Region that happened pneumonia
classification

community acquired pneumonia

hospital acquired pneumonia

ⅠBronchopneumonia
 Etiology
▲susceptible factor
＜２ y ， winter and spring ， bad ventilation
， malnutrition ， congenital heart disease
,low birthweight ， immunologic deficit 。
▲pathogen
bacterium ， virus ， mycoplasma ， chlamy
dia 。
 Pathogens cousing pneumonia in infants and children

Age Pathogens

Group B streptococci
Neonates(<1month) E.coli
Chlamydia trachomatis

Respiratory viruses, e.g.RSV

,adenovirus
infants Streptococcus pneumoniae
Haemophilus influenzae
Bordetella pertussis
Streptococcus pneumoniae
Hoemophilus influenzae group
children
A streptococci
Mycoplasma pneumonia
 Pathology
• Lung tissue congestion,edema 、
§Inflammatory infiltration,the lumen of tr
acheal tubule is obstructed partly or c
ompletely.
§Differ etiology ,differ pathological chang
es
Virus---interstitium
Bacterium—lung parenchyma
 bronchus
bronchus Mucousme
mbranes c
Mucousm
ongestive,
embranes edema Ventilation
congestive Changes of
p ,edema disturbance
a Respiratory
hypoxia
emphysema Circulation
t Alveolar wall
congestive and
edema, Pulmonary Nervous
h closure CO2
Inflammatory retention Digestive
effusion in gas exchange
o alveolar
function system
g disturbance Acid-base
e imbalance

n
toxin toxicemia

pathophysiogical changes of bronch

opneumonia
Pathophysiogical changes
１ hypopnoea;respiratory insufficiency 　
　　 cyanose 　 Increased heart and respiration
rate 　 flaring of alaenasi(nasal wing) three de
pressin sign (intercostal ,subcostal and supr
asternal retraction) 　 respiratory failure
２ circulation system 　
　 myocarditis ， pulmonary artery, hypertension
， congestive heart failure ， circulatory disorde
， circulatory collapse;shock ， DIC(diffuse intra
vascular clotting).
 Pathophysiogical changes
３ central nervous system 　
vascular cerebral edema ， cellulous cerebral e
dema 。
４ digestive system
functional disorder ， mucous membrane anabro
sis and hemorrhage ， toxic enteroparalysis.
５ fluid,electrolyte acid-base imbalance 　　　　
　 acidosis ， respiratory alkalosis ， water a
nd sodium retention ， dilutional hyponatremia.
 Clinical features

★ Starting with upper respiratory

tract infection.
★ be acute with high fever, dyspnea and
grunting respiration.
★ Respiratory rate is always increased
apprently.
 Clinical manifestation
• Cardinal symptom
　　 fever 、 cough 、 short breath(breathlessn
ess) , general or constitutional symptom

• sign
　　　 tachypnea 、 flaring of nasal alae,
cyanosis 、 rales 、 lung consolidation sign
• Other manifestation for severe pneumonia
1circulation system 　
　 myocarditis: Pale, cardiac sound low and blunt, cantering rhythm.
congestive heart failure:
shock
2nervous system
Somnolence, restlessness, conscious disturbance, convulsion, anterior fonta
nele minence, Chemosis, pupillary light reflex slow or dispear,,
Respiratory rhythm have no regularity or respiration ceases.
3digestive system
4DIC(diffuse intravascular clotting).
5 Syndrome of inappropriate secretion of antidiuretic hormone;SIADA
 Complication
• empyema
• pyopneumothorax
• bullae;pneumatocele
 Laboratory test
• Etiology examination
• 1. bacterial culture and film preparation
2. viral isolation
3. pathogen specific antigen detection 　
4. specific antibody detection 　
5 PCR
 Laboratory test
• peripheral blood examination
1. leukocyte
2. C-reactive protein (CRP)
　
 X-wayexamination
pulmonary markings thickening 、
Patching or punctiform infiltration film 、
pulmonary closure,emphysema.
 Ⅱ Bacterial Pneumonia

• Pneumococcal pneumonia.
• Staphylococcal pneumonia.
• Hemophilus influenzae pneumonia.
• Streptococcal pneumonia.
 Hallmarks of bacterial
pneumonia
• Polymorph leucocytosis.
• Lobar consolidation.
• Pleural effusion.
(I) Pneumococcal pneumonia
 1.Introduction :
• ★ transmitted by droplets
• ★ more common in the winter months.
• ★ Overcrowding and diminished host r
esistance predispose the children to
infection with pneumococci.
 2. Pathology:

★Bacteria multiply in the alveoli and an inflam

matory exudate is formed.
★Scattered areas of consolidation occur, which c
oalesce around the bronchi and later become lob
ular or lobar in distribution.
★There is no tissue necrosis.
★Pathological process passes from the stage of c
ongestion to red and gray hepatization before t
he final stage of resolution.
 3. Clinical features:
• 1) Pneumococcal pneumonia is less c
ommon in the infants under 1 year o
f age.
• 2) Incubation period is 1 to 3 days
.
• 3)The onset is abrupt with headache
, chills, cough and high fever.
 3. Clinical features:
• 4).Pleural pain is complained of and this m
ay be referred to the shoulder or abdomen..
• 5)Cyanosis is minimal.
• 6)crepitations are heard and bronchophony a
nd whispering pectoriloquy may be observed.
• 7)Meningismus may be present in apical pneu
monia
 4. Diagnosis:
• 1)history(Rarely begin with URTI)
• 2)physical examination (cyanosis, crepitations a
nd so on)
• 3) x-ray findings of lobar consolidation 4)leuco
cytosis.
• 5)Bacteriololgical confirmation is difficult but
sputum may be examined by Gram staining and cult
ure.
(Ⅱ). Staphylococcal
pneumonia
 1. Introduction:
★occurs in infancy. Three-fourth of the patients ar
e below the age of one year.
★The pulmonary lesion may be primary infection of
the parenchyma; or may be secondary to generalized
staphylococcal septicemia.
★It may be a complication of measles, influenza and
cystic fibrosis of the lungs or may follow minor
staphylococcal pyoderma.
★Debilitating conditions including malnutrition pre
dispose the infants to infection with staphylococc
i.
 2.Pathology
★In infants, the pneumonic process is diffuse initially, but soon the
lesions suppurate, resulting in bronchoalveolar destruction. Multiple
microabscesses are formed, which erode the bronchial wall and dischar
ge their contents in the bronchi.
★During inspiration, the air enters the abscess cavity because the bro
nchi are dilated in this phase. The bronchioles collapse during expir
ation and therefore the air cannot easily move out. Thus the abscess
is progressively inflated, resulting in pneumatoceles, which are cons
idered pathognomonic of staphylococcal pneumonia. Several pneumatocel
es may form and they may form and they may fluctuate in size over the
time, ultimately resolving and disappearing within a period of few we
eks to months. Epithelialization of the walls of the air cysts may oc
cur.
 2.Pathology
★ Staphylococcal abscessed in the lun
gs may erode into the pericardium cau
sing purulent pericarditis.
★Empyema in a child below two years o
f age is nearly always staphylococcal
in etiology.
3. Clinical manifestations
• 1) The illness usually follows upper respir
atory tract infection, pyoderma or other as
sociated purulent disease.
• 2) Besides the usual features of pneumonia,
i.e, grunting respiration, the child has fe
ver and anorexia, is listless and irritable
. Abdomen is usually distended due to septi
cemia and ileus.
• 3) Cyanosis may be present.
 3. Clinical manifestations
• 4) Progression of the symptoms and signs is
rapid. Rarely, the onset may be less abrupt
.
• 5) Sometimes pulmonary infection may be com
plicated by disseminated disease i.e, invol
vement of more than 2 anatomically differen
t sites. This may manifest as metastatic ab
scesses in to joints, bone, muscles, perica
rdium, liver, mastoid or brain.
 4. Diagnosis
• 1) is suspected in a newborn or an infant with res
piratory infection who has evidence of staphylococ
cal infection elsewhere in the body or in the envi
ronment.
• 2) The characteristic complications of pyo-pneumot
horax and pericarditis in an infant are highly sug
gestive of the diagnosis.
• 3) Pneumatoceles are present in x-ray films of the
lung.
• 4) Often staphylococci can be grown from the blood
.
 5. Prognosis
Prognosis is poor in the younger
infants in whom mortality is high.
(III) Hemophilus influenzae
Pneumonia
 1.Introduaction

• Hemophilus influenzae infections oc

cur usually between the age of thre
e months and three years and are ne
arly always associated with septice
mia.
 2 Pathology
• Pathology is similar to that of
infections with pneumococci. Ther
e is extensive destruction of bro
nchial epithelium and hemorrhagic
edema extending into interstitial
area.
 3.Clinical features
• 1)The onset of the illness is gradual with
nasopharyngeal infection.
• 2) The child has moderate fever, dyspnea, g
runting respiration and retraction of the l
ower intercostal spaces. Presentation may
mimic acute bronchiolitis.
• 3)The course is subacute and prolonged. 4)P
atients do not respond to therapy with peni
cillin.
 4. Complications

• bacteremia
• pericarditis
• empyema
• meningitis
• polyarthritis.
 5.Treatment
• Hemophilus influenzae pneumonia is be
st treated with ampicillin in a dose
of 100 to 150 mg/kg/day and chloramph
enicol 50mg/kg/day in four divided do
ses. Cefotaxime (100mg/kg/day) or cef
triaxone(50-75mg/kg/day) are other al
ternatives in seriously ill patients.
(Ⅳ) Streptococcal
pneumonia
 1. Introduation
• streptococcal infection of the lungs by Gro
up A betahemolytic streptococci is usually
secondary to measles, chickenpox, influenza
or whooping cough. Group B streptococcal pn
eumonia is an important cause of respirator
y distress in newborns. Pathologically it i
s interstitial Pneumonia, which may at time
s be hemorrhagic. Tracheobronchial mucosa m
ay be ulcerated. Lymph nodes are enlarged.
Serosanguineous or thinly purulent pleural
effusion is frequently associated.
 2.Clinical features

• 1)The onset is abrupt. Fever, chills,

dyspnea, rapid respiration, blood streaked
sputum, cough and extreme prostration
characterize the illness. 2)Signs of
bronchopneumonia are generally less
pronounced( as the pathology is usually
interstitial).
 3.Complications

• 1) Thin serosanguineous or purulent e

mpyema is a usual complication.
• 2) Pulmonary suppuration is less freq
uent.
• 3) Ten percent of the patients have b
acteremia.
 4.Diagnosis
• 1) X-ray film shows interstitial pneumonia, s
egmental involvement, diffuse peribronchial d
ensities or an effusion. (This should be dist
inguished from primary atypical pneumonia due
to mycopoasma). The radiological findings are
disproportionately more than the physical fin
dings in mycoplasma pneumonia.
• 2) Blood counts show increased neutrophils, a
nd the patient looks more ill in streptococca
l pneumonia.
 5. Treatment
• Penicillin G should be given in doses of 50
,000 to 100,000 units/kg of body weight, da
ily in 2-3 divided doses for a fortnight. T
he response is gradual but recovery is gene
rally complete.
• Empyema is treated by repeated aspirations
since the pus is thin. Closed drainage with
indwelling intercostal tube may be required
in some cases.
 Diagnosis
• History+symptom+sigh+test
• Younger------symptom!!
• Sever case
 Differential diagnosis
• bronchitis
• pulmonary tuberculosis (TB)
• bronchial foreign body
• bronchial asthma
 Treatment

principle
control infection positively ， improve
pulmonary ventilation and gas -exchange
function ,prevent complication
 General treatment
　 air current ， nutrition ， body posture
， separation.

etiological agent therapy

1. antibiotics
Apply principle
（ 1 ）根据病原菌选用敏感药物
（ 2 ） 早期治疗
（ 3 ）足量足疗程，重症 联合
用药，静脉给药。
（ 4 ）选用渗入下呼吸道浓度高
的药
 选择抗生素
• 肺炎链球菌　　青霉素
• 金葡菌　新青Ⅱ
• 流感噬血杆菌　阿莫西林＋克拉维酸
• 大肠杆菌肺炎杆菌　头孢曲松
• 绿脓杆菌　替卡西林＋克拉维酸
• 支原体衣原体　大环内酯类　　
• 用药时间

体温正常后 5—7 天，临床症状基本

消失后 3 天。支原体感染 2—3 周，葡萄
球菌感染体温正常后２－３周可停药，
总疗程≧ 6 周。
2. 抗病毒
• 三氮唑核苷
• 干扰素
对症治疗
• 氧疗
• 气道管理　清理分泌物，吸痰，气道
湿化，雾化吸入，拍背，变换体位。
• 腹胀的治疗　补钾，禁食，胃肠减压
，新斯的明，酚妥拉明。
• 退热　镇静
 心衰的治疗
• 吸氧
• 镇静
• 利尿
• 强心药物应用
• 血管活性药物应用
糖皮质激素的应用

（ 1 ）中毒症状明显
（ 2 ） 严重喘憋或呼吸衰竭
（ 3 ）伴有脑水肿 ` 中毒性脑病 `
感染性休克
（ 4 ）胸膜有渗出
 并存症和并发症的治疗
１休克，脑水肿，心肌炎
２脓胸，脓气胸
３营养不良，先心等。
　生物制剂
几种不同病原体
　　　　所致肺炎的特点
　　　　　
　　　病　毒　性　肺　炎
呼吸道合胞病毒肺炎
（ 1 ） A 亚型为主。多见于 2 岁以内，尤
为 2—6 个月婴儿。
（ 2 ）病毒对肺的直接侵害，非变态反应。
病理特点为间质炎症 , 肺气肿。
（ 3 ）发热，发绀，喘憋严重，呼吸困难。
（ 4 ）两肺听诊有中细湿罗音。
（ 5 ） X 线点片，斑片状阴影 , 肺气肿。
（６）白细胞数多正常。
 呼吸道合胞病毒肺炎
• 特点
１病情重，中毒症状重，呼吸困难明显。
２体征出现早，满肺喘鸣，肺底湿罗音，憋
喘性肺炎。
３ X 线多有肺气肿。
腺病毒肺炎
（ 1 ）病理改变为支气管和肺泡间质炎，渗
出性坏死性。
（ 2 ）多见于 6 个月 ~2 岁小儿，冬春季节。
（ 3 ）病情严重，发病急，稽留高热，持续
时间长。中毒症状重。萎靡嗜睡。
（ 4 ）咳嗽剧烈，喘憋，呼吸困难。
（５）肺部体征出现较晚。
 腺病毒肺炎
（６）消化道症状。
（７）肝脾肿大
（８）麻疹样皮疹。
（９）心肌炎
（１ 0 ）易合并中毒性脑病。
（１１）可继发支扩和慢阻肺。
 腺病毒肺炎
特点 :
1 X 线表现较肺部体征出现早。
２大小不等的片状阴影融合成大病灶。
３大灶小灶并存，大叶阴影。
４肺气肿多见。
５病灶吸收较慢。
四多：肺纹理多，肺气肿多，大病灶多，融
合灶多。两一致：临床与 X 线表现一致。
　　　细　菌　性　肺　炎
金黄色葡萄球菌肺炎

（ 1 ）多见于新生儿及婴幼儿。
（ 2 ）呼吸道入侵或血行播散。
（ 3 ）病理改变特点为肺部广泛出血 , 坏
死和多发性小脓肿。
 金黄色葡萄球菌肺炎
（ 4 ）急性起病，进展快，中毒症状明显。
（ 5 ）发热弛张热。肺部体征出现较早，中
细湿罗音。
（ 6 ）皮疹　蕁麻疹，猩红热样疹。
（７）其它脏器损害。
（８）易并发脓胸，脓气胸 , 胸腔积液．败血
症及其它部位化脓灶。
 金黄色葡萄球菌肺炎
X 线特征
１临床症状与胸片不一致， X 线征象出现和
消散均慢；
２病变发展迅速；
３多合并脓肿，脓气胸，肥大泡；
４病变吸收缓慢。
 金黄色葡萄球菌肺炎
• 实验室检查
１白细胞
２ C 反应蛋白
３痰液细菌培养
革兰氏阴性杆菌肺炎
（ 1 ）病原为流感嗜血杆菌和肺炎杆菌
（ 2 ）病情重，治疗困难，预后差。
（ 3 ）肺内侵润，实变，出血坏死。
（４）起病较缓慢、中毒症状重、呼吸困
难、发绀、三凹征。肺部湿罗音
 革兰氏阴性杆菌肺炎
（ 4 ）易出现并发症
（ 5 ）外周血白细胞增高
（ 6 ） x 线多种多样，多为支气管肺炎，也
有大叶性肺炎。
其他微生物所致肺炎
支原体肺炎

（ 1 ）常年发病，有一定流行性。
（２）可发生于各个年龄组。
（３）起病缓，热程长，刺激性干咳为突
出表现。
（４）肺部体征不明显。
 支原体肺炎
（５）婴幼儿起病急，病程长，病情较重，
呼吸困难，喘鸣；罗音较年长儿多。
（６）可有多个系统疾病表现。
（７） X 线改变：支气管肺炎，间质性肺炎
，肺门阴影增浓为主；均一实变影。
特征：游走性浸润
　　　咳嗽重而肺部体征轻，体征轻而胸片
阴影显著。
衣原体肺炎
　　沙眼衣原体肺炎　
　　（１）多＜３月
　　（２）间质性肺炎。
　　（３）起病缓慢，一般状况良好，不发
热．
　　（３）呼吸增快，阵发性咳嗽，肺部偶
闻及干湿啰音
　　（４） X 线：双侧间质性或小片状浸润
　　★６月以下无热肺炎应考虑本病
 衣原体肺炎
肺炎衣原体肺炎　
　　（１）多﹥５岁
　　（２）起病缓慢，轻型。一般状况良好，不发
热．
　　（３）先上感，２－３周后上感渐消退，咳嗽
加剧，可持续１－２月。肺部可闻及干湿啰音。
　　（４）肺外表现
　　（４） X 线：单侧肺下叶浸润