推动评分体系在儿童重症肺炎中的应用

肺炎是全球5岁以下儿童死亡的首要原因,早期诊断儿童重症肺炎以及精准评估肺炎严重程度对治疗及预后至关重要。目前关于儿童重症肺炎的诊断标准不完全一致,因此需要应用评分系统或量表对重症肺炎的病情进行评估,以指导临床治疗及评估预后。目前改良的PIRO评分量表是应用最多的、可能适合儿童重症肺炎的评分量表。     

小儿重症肺炎并发症的诊治进展

由于众所周知的原因 ,小儿重症肺炎仍是我国5岁以下儿童死亡的主要原因 ,其中绝大多数患儿是死于各种肺炎并发症[1] 。关于小儿重症肺炎并发症国外极少报道 ,可能与国外肺炎及重症肺炎发病率较低 ,以及对重症肺炎及并发症的界定不同有关。因此可以说 ,我国儿科工作者在小儿肺炎并发症的诊治方面具有许多独到的见解 ,对降低我国小儿重症肺炎的病死率也起到了非常积极的作用。1　关于小儿重症肺炎的评估、诊断绝大多数肺炎并发症都发生在重症肺炎的基础之上。因此 ,评价儿童肺炎病情轻重 ,不仅是决定在门诊治疗、住院治疗或在PICU治疗的依据…     

儿科重症监护病房十五年死亡疾病分析

目的　 为进一步减少重症监护病房患儿的病死率 ,分析和总结引起死亡的主要疾病 ,有助于提高儿内科医生特别是PICU专业人员对儿科常见病、危重病的认识。 方法 　对近 15年来引起儿童死亡的主要疾病、各年龄段的主要死亡疾病以及不同时期的主要死亡疾病进行回顾性分析总结。 结果 　比较 80～ 90年代 ,PCIU病死率有明显下降 ;重症肺炎 (包括先天性心脏病合并肺炎 )是儿童死亡的主要疾病 ,近年来死亡数有明显下降 ;婴儿期重症肺炎 (先心 肺炎 )、败血症为主要死亡疾病 ,幼儿期以重症肺炎、重症病毒性脑炎为主 ,学龄前期以重症病毒性脑炎、败血症为主 ,而学龄期则以恶性肿瘤、重症病毒性脑炎为主 ;入PICU后 2 4小时内死亡者占 41 0 1%。 结论 　儿童主要死亡疾病是重症肺炎 (先心 肺炎 ) ,不同时期比较 ,虽然肺炎的病死率明显下降 ,但死亡数仍占首位。不同的年龄段 ,主要的死亡疾病不同 ,降低病死率的关键是对危重病有足够的认识、及早诊断、及时治疗。     

小儿重症肺炎并发症的诊治进展

由于众所周知的原因，小儿重症肺炎仍是我国5岁以下儿童死亡的主要原因，其中绝大多数患儿是死于各种肺炎并发症。关于小儿重症肺炎并发症国外极少报道，可能与国外肺炎及重症肺炎发病率较低，以及对重症肺炎及并发症的界定不同有关。因此可以说，我国儿科工作者在小儿肺炎并发     

婴幼儿重症肺炎抗生素的合理应用

婴幼儿重症肺炎抗生素的合理应用上海市儿童医院（２０００４０）陆际晨婴幼儿肺炎是小儿感染性疾病最常见的死亡原因。尤其在发展中国家，婴儿及５岁以下儿童因肺炎致死的人数，占死亡儿童的２０～４０％根据临床表现对于肺炎一般不难作出诊断，但可靠的病原学诊断尚存在...     

儿童肺炎、重症肺炎及肺炎高危儿的临床分析

目的 分析儿童肺炎、重症肺炎及肺炎高危儿的临床特点.方法 对儿科10年来收治的5 346例肺炎患儿的临床资料进行总结分析.结果 肺炎高危因素的患儿为3 584例,重症肺炎448例,死亡2例,占0.37%,高危因素中经常感冒或患过肺炎的为3 106例,3个月以内小婴儿75例,4个月～3岁婴幼儿266例,先天性心脏病等畸形17例,营养不良、佝偻病、贫血32例,早产儿和低体重儿39例,出生时窒息和羊水吸入49例.结论 重症肺炎常威胁患儿生命,重视儿童肺炎、重症肺炎及肺炎高危儿之间的关系,并分别做出及时的诊断和恰当的治疗在降低肺炎病死率方面起着至关重要的作用.     

不同病原感染所致的重症社区获得性肺炎的临床表现

肺炎是5岁以下儿童死亡的首要原因,绝大部分儿童肺炎为社区获得性肺炎(community acquired pneumonia,CAP),其中的重症肺炎是造成儿童死亡和影响生命质量的重要原因。国内指南和规范都提出根据儿童年龄、临床及影像学资料等评估儿童社区获得性肺炎的严重程度;及早明确病原,尽快使经验治疗转为目标治疗,改善预后。该文将从病原学角度,阐述不同病原感染所致的重症社区获得性肺炎的临床表现,加深对儿童重症肺炎认识,达到早发现、早治疗,降低儿童CAP的发病率和死亡率的目标。     

婴幼儿重症肺炎的概念

婴幼儿重症肺炎的概念中国医科大学第二临床学院ＰＩＣＵ（１１０００３）袁壮当前，婴幼儿肺炎病死率仍在４～５％，因肺炎而死亡的多为重症肺炎。因此，如何降低婴幼儿重症肺炎的病死率是降低５岁以下儿童病死率的关键。什么是重症肺炎？不同年代对其有不同理解和诊断标...     

小儿重症肺炎及其合并症的诊断和治疗

小儿重症肺炎及其合并症的诊断和治疗中华儿科杂志编辑委员会编者按小儿肺炎是造成发展中国家５岁以下儿童死亡的主要原因，全世界儿童死因调查表明，前五位死亡疾病中肺炎居首位。世界卫生组织提出，到本世纪末的战略目标是：将儿童肺炎死亡率降低三分之一。而我国现阶段...     

儿童肺炎链球菌感染与疫苗

肺炎链球菌是儿童呼吸道感染中最常见的病原之一,也是导致儿童重症肺炎、肺炎并发症和死亡的主要致病菌.近年来,由于世界各地肺炎链球菌对抗生素的耐药不断增加和广泛传播,造成疾病的负担日益增加,也使临床诊治面临严峻挑战.疫苗的出现和推广在肺炎链球菌病的防治方面有着光明的前景.     

儿童重症肺炎合并心力衰竭——争议与实践

儿童重症肺炎无器质性心脏病者是否并发心力衰竭,目前存在争议.随着肺炎诊治策略的变迁,临床更重视肺炎合并呼吸衰竭、休克、心肌损伤等引起心力衰竭的病理生理过程,重视肺炎时心肺相互作用机制和全身炎症反应,根据不同病理生理机制,通过监测血流动力学状态来指导治疗.     

Radiologic Predictors of Hyponatremia in Children Hospitalized With Community-Acquired Pneumonia

BACKGROUND: Hyponatremia (HNa) is the most common electrolyte imbalance seen in clinical practice and a common laboratory finding in children with community-acquired pneumonia (CAP). This study investigated whether there is a link between the radiological pattern seen in patients with CAP and the occurrence of HNa, hypothesizing that children with moderate and severe HNa would have a lobar-segmental pattern on chest radiograph. METHODS: The medical files and chest radiographs of 54 children with moderate to severe HNa (sodium <130 mmol/L) admitted with CAP over a 2-year period at our institution were retrospectively studied. Community-acquired pneumonia was defined as either lobar-segmental or interstitial by a radiologist blinded to laboratory results. RESULTS: Hyponatremia was seen more frequently in children with lobar-segmental pneumonia: 40 (74%) compared with 14 (26%) with interstitial pneumonia (P = 0.004). There was no relationship between the pattern of pneumonia seen on chest radiograph and severity of HNa; however, all 6 cases of severe HNa had lobar-segmental CAP, and all patients with complicated CAP were from the lobar-segmental group. CONCLUSIONS: We found an association between lobar-segmental CAP and moderate or severe HNa. In addition, all cases of severe HNa occurred in patients with lobar-segmental CAP. The presence of a lobar-segmental pattern on chest radiography in CAP suggests the need for assessment of electrolyte status even in patients with adequate respiratory status.     

Children with cough: who needs antibiotic therapy,and who needs admission to hospital?

Pneumonia is one of the commonest causes of death in children in the world. However, lung aspiration studies have shown that most cases of severe pneumonia in children in developing countries are caused by bacteria, so mortality could be substantially reduced by antibiotic therapy. Although most children with penumonia present with cough, most children with cough do not have pneumonia, so it is important to develop clear guidelines about how to manage children who have a cough. Prospective studies suggest that, although most children with a cough do not need antibiotics, children less than 5 years old with cough and a respiratory rate over 50 breaths per minute should be treated as outpatients with either procaine penicillin intramuscularly, or ampicillin, amoxycillin or cotrimoxazole orally. Children with intercostal recession (chest indrawing) should be admitted to hospital for more intensive therapy with benzyl penicillin. Children who are cyanosed or too sick to feed have a very high mortality, and should be treated with chloramphenicol. Use of these guidelines would decrease the unnecessary use of antibiotics in children with mild respiratory infections, while reducing the very high mortality from pneumonia in young children.     

Prevalence and prediction of hypoxemia in children with respiratory infections in the Peruvian Andes

To determine the effect of respiratory infections on oxyhemoglobin saturation in a high-altitude population, we recorded clinical signs, oxyhemoglobin saturation determined by pulse oximetry, and findings on radiographs of the chest of 423 children with acute respiratory infections; the children were living at an altitude of 3750 m in the Peruvian Andes. We defined hypoxemia as an oxyhemoglobin saturation value greater than 2 SD below the mean value for 153 well children in this population. Eighty-three percent of children with clinical bronchopneumonia, but only 10% of children with upper respiratory tract infection, had hypoxemia (p less than 0.001). Compared with previous studies of children living at lower altitudes, the presence of tachypnea was relatively nonspecific as a predictor of radiographically determined pneumonia or of hypoxemia, especially in infants. A history of rapid breathing was 74% sensitive and 64% specific in the prediction of hypoxemia, and performed as well as a standard World Health Organization case management algorithm in the prediction of radiographic pneumonia or hypoxemia. Radiographic pneumonia was not a sensitive predictor of hypoxemia or clinically severe illness. In contrast, the presence of hypoxemia was a useful predictor of radiographic pneumonia, with both sensitivity and specificity of 75% in infants. We conclude that acute lower respiratory tract infection in children living at high altitude is frequently associated with hypoxemia, and that oxygen should be administered to children with a diagnosis of pneumonia in these regions. Case management algorithms developed in low-altitude regions may have to be modified for high-altitude settings. In this setting, pulse oximetry is a good predictor of pneumonia. Because pulse oximetry is more objective and cheaper than radiography, its role as a clinical and investigative tool merits further exploration.     

重症肺炎患儿血清可溶性细胞间黏附分子-1水平的变化及临床意义

目的探讨重症肺炎患儿血清可溶性细胞间黏附分子-1(sICAM-1)水平的变化,以及不同病原体所致重症肺炎血清sICAM-1的水平及其临床意义。方法采用双抗体夹心酶联免疫吸附法测定40例重症肺炎患儿和43例普通肺炎患儿急性期、恢复期、以及48例健康对照组小儿血清sICAM-1水平。结果重症肺炎急性期血清sICAM-1水平明显高于重症肺炎恢复期,差异有非常显著性(P<0.01);与普通肺炎急性期与健康对照组比较,差异有非常显著性(P<0.01);重症肺炎恢复期血清sICAM-1水平与普通肺炎恢复期及健康对照组比较,则差异均无显著性(P>0.05);重症细菌性肺炎、病毒性肺炎、支原体肺炎、病毒与细菌混合感染性肺炎急性期血清sICAM-1水平比较,差异均无显著性(P>0.05)。结论重症肺炎患儿急性期血清sICAM-1水平较普通肺炎急性期明显增高,但不同病原体所致重症肺炎血清sICAM-1水平变化无统计学意义;sICAM-1参与了重症肺炎的炎症过程,其水平的高低可以作为肺炎病情轻重的判断指标之一。     

Acute Community Acquired Pneumonia in Emergency Room

Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO’s classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3–5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.     

重症肺炎患儿肺泡灌洗液病原学分析及临床特点

目的了解苏州大学附属儿童医院重症肺炎患儿肺泡灌洗液病原学分布及主要病原菌耐药性。方法选取2014年1月至2018年12月在苏州大学附属儿童医院行纤维支气管镜镜检的重症肺炎患儿177例作为研究对象,收集患儿肺泡灌洗液行病原体鉴定及病原菌培养、药敏分析,并采用直接免疫荧光定量PCR技术对其病原进行检测。结果 177例重症肺炎患儿中,有100例检出至少1种病原体,总检出阳性率为58.13%;其中肺炎支原体(MP)检出率最高(41/100例);前3位检出的细菌分别为肺炎链球菌9例(10.59%)、金黄色葡萄球菌8例(9.41%)、铜绿假单胞菌6例(7.06%);前3位检出的病毒分别为巨细胞病毒(CMV)14例(33.33%)、人博卡病毒(HBoV)10例(23.81%)、呼吸道合胞病毒(RSV)8例(19.05%);药物敏感试验结果提示,主要的革兰阳性菌对万古霉素、利奈唑胺耐药率较低,主要的革兰阴性菌对喹诺酮类、氨基糖苷类、碳青霉烯类、加酶的β内酰胺类耐药率较低。<5岁重症肺炎患儿病毒检出率约为30.00%,MP检出率约为20.00%,>5岁重症肺炎患儿MP检出率>30.00%;<2岁重症肺炎患儿细菌检出率>20.00%,>2岁重症肺炎患儿细菌检出率约为15.00%。重症肺炎患儿中,气道畸形比例较高,以气道软化、气道狭窄为主。结论苏州地区<5岁的重症肺炎患儿肺泡灌洗液病原学检查以病毒最常见,<2岁者细菌检出率亦较高;常见革兰阳性菌对万古霉素、利奈唑胺敏感性高;铜绿假单胞菌对喹诺酮类、氨基糖苷类、碳青霉烯类、加酶的β内酰胺类抗生素敏感性高。重症肺炎患儿,尤其是小年龄组婴儿需要重视气道畸形的可能。     

Risk factors for mortality among children hospitalized because of acute respiratory infections in Bangui, Central African Republic

BACKGROUND: Acute respiratory infections are the most common cause of death in children in developing countries. Little information is available on risk factors for mortality among African children presenting with symptoms compatible with acute respiratory infections. OBJECTIVE: To identify risk factors for death among children hospitalized for respiratory complaints who satisfy the WHO clinical definition for pneumonia or severe pneumonia. METHODS: Children <5 years of age who presented with cough and/or difficult breathing and were hospitalized in Bangui during a 1-year period were investigated for risk factors for mortality. The study population consisted of 395 children who satisfied the WHO clinical definition for pneumonia/severe pneumonia. The associations between death and demographic, nutritional, socioeconomic, laboratory and clinical variables were examined. RESULTS: Of the 49 (12.4%) children who died, all but one had had indrawing of the chest which, in univariate analysis, was the risk factor most strongly associated with death [odds ratio, 22.99; 95% confidence interval (CI), 3.81 to 935.2]. In a multivariate model the independent risk factors for death were indrawing of the chest [adjusted odds ratio (AOR) 8.35, CI 1.04 to 66.82], hepatomegaly (AOR 6.72, CI 2.35 to 19.21), age between 2 and 11 months (AOR 6.37, CI 2.18 to 18.59), grunting (AOR 4.53, CI 1.96 to 10.45), a moderate/severe alteration of general status (AOR 3.23, CI 1.17 to 8.94) and acute malnutrition (AOR 2.74, CI 0.96 to 7.78). CONCLUSIONS: These findings could be used in flow charts for the management of children with respiratory complaints to identify children at increased risk of death who need to receive aggressive therapy.     

不同类型戈谢病患儿感染风险差异分析

背景 戈谢病是一种罕见的免疫功能异常的疾病,患儿易受到不同病原体感染,不同类型戈谢病感染特点值得关注.目的 探讨不同类型的戈谢病与感染相关的临床特征,为预防相关感染提供帮助.设计病例系列报告.方法 采集不同类型的戈谢病患儿反复呼吸道感染、重症肺炎发生情况,减毒活疫苗接种及其发生感染情况,外周血细胞计数,行电话随访预后(...     

Tracheal bronchus: association with respiratory morbidity in childhood

An aberrant right upper lobe (RUL) bronchus arising from the trachea (tracheal bronchus) can be responsible for recurrent pneumonia. In this hospital, 2% of children requiring bronchoscopy for respiratory symptoms are found to have a tracheal bronchus, which is frequently thought to be an incidental finding. We reviewed findings in 18 patients to determine when a tracheal bronchus is of clinical significance. The age at presentation ranged from 1 day to 54 months (mean 17 months). The children had recurrent pneumonia (nine), stridor (six), respiratory distress (two) and a thoracic mass (one). Other congenital abnormalities were present in 14, including Down syndrome (two), tracheoesophageal fistula (two), and fused or hypoplastic first and second ribs (four). Recurrent RUL pneumonia was present in five. Bronchiectasis or bronchial stenosis was shown by bronchography in four of five; in all five the right upper lobe was surgically resected, with resolution of the recurrent pneumonias. The presence of a clinically significant tracheal bronchus should be considered in every child with recurrent RUL pneumonia, especially in children with Down syndrome or rib abnormalities; if bronchiectasis or bronchial stenosis is found, surgical resection should be performed.