Download 7. pneumonia

MINISTRY OF PUBLIC HEALTH REPUBLIC OF UZBEKISTAN
THE TASHKENT MEDICAL ACADEMY
"CONFIRM"
The pro-rector on study
professor Teshaev O.R.
___________________
____ ___________ 2012
Department: INFECTIOUS DISEASE AND PEDIATRICS
Subject: CHILDREN'S DISEASE
TECHNOLOGY TRAINING
On practical training on the topic:
PNEUMONIA IN CHILDREN
Tashkent
Compiled by:
Khalmatova B.T. – Head of Department, Doctor of Medical Sciences
Mirrakhimova M. Kh. – docent, Ph.D.
Education technology approved:
At the faculty meeting report №
from «___ » ____________ 2012
Flow chart classes
№
1
2
Stage of learning
Form of learning
Lead-in teacher (Ad practice
session topics, goals, learning
outcomes, the characteristics of
the studies, indicators and
evaluation criteria)
Discussion of the topic of practical The
survey,
an
lessons, baseline assessment of explanation
students' knowledge with the use
of new educational technologies
3
Summing up the discussion
4
Supervision
on
patients,
performing skills
Hear and discuss students'
individual work
Determination of the degree of
achievement based on the lessons
mastered
the
theoretical
knowledge and the results of the
development of practical skills
The conclusion of the teacher in
this lesson. Assessing the students
on a 100 point system and its
announcement. Dacha job to the
next class
5
6
7
Duration
5
30
5
100
30
Oral
survey,
case
studies, discussion
45
Information. Questions
for self-training
5
Topic: The course of pneumonia in children. Etiology, pathogenesis,
clinical manifestations, diagnosis, treatment and prevention. Tactics GPs.
1. Location of classes
- Department of Infectious Diseases and Pediatrics, Hospital.
2. Duration of study subjects
Number of hours – 6,0
3. Purpose of classes
To consolidate and deepen the students' knowledge of pneumonia develop the skill of
early diagnosis, differential diagnosis and tactics GPs on remediation and clinical examination.
4. Pedagogical Task:
- To teach students the criteria for diagnosis of pneumonia in children.
- Discuss the right choice of antibacterial drugs and drug correction of violations, the main vital
functions of organs and systems.
- Demonstrate the principles of differential diagnosis.
- Consider the criteria of possible complications of pneumonia.
- The organization of specialized advice to help the ill child with pneumonia.
- To teach students draw up a plan recreational activities.
- To introduce students to the prevention of disease.
5. Learning Outcome
Student should know:
 Anatomical and physiological features of broncho pulmonary apparatus in different age
periods;
 Know the etiology and pathogenesis of acute pneumonia;
 Criteria for the diagnosis of bronchitis, pneumonia;
 Classification of acute pneumonia in children;
 The main clinical manifestations, principles of diagnosis and treatment of acute
pneumonia.
 Clinical options for the various forms of acute pneumonia, the principles of differential
diagnosis;
 The main complications of acute pneumonia;
 Principles of treatment and prevention;
 Indications for pulmonary consultation.
Students should be able to:
- The right to collect medical history and complaints of the patient, to interpret them.
- Inspect the child with pneumonia.
- Conduct palpation, percussion, auscultation in children.
- Interpret the results of clinical and biochemical studies on the disease.
- To calculate the dose of antibiotics, depending on the age of the child.
6. Learning methods and techniques
Brainstorming, case studies, technology: graphic organizer - a conceptual table
7. Learning tools
Manuals, training materials, ECG patients, slides, video, audio, medical history
8. Learning form
Individual work, group work, team
9. Learning conditions
Auditorium, the Chamber
10. Monitoring and marking
Oral control: control issues, the implementation of learning tasks in groups, performing skills,
IWS
11. Motivation
Knowing the characteristics of a pneumonia in children will allow general practitioners to
diagnose and choose the tactics. Pay attention to the nature of the lung disease, the nature of the
flow and the state of breathing (with a mandatory assessment of premorbid background, presence
of chronic foci of infection), pay attention to the most characteristic symptoms of the disease, in
the different character of the disease, with or without complications.
12. Intra and interdisciplinary communication
Teaching of the subject is based on the knowledge of students the basics of anatomy, physiology,
pathophysiology, pathology, microbiology, biochemistry, internal medicine, propaedeutics
childhood diseases, clinical pharmacology. Acquired during the course knowledge will be used
during the passage of the GP - pediatrics and other clinical disciplines.
13. Contents of classes
13.1. Theoretical part
Pneumonia (Greek rneumon - "light", the syn: inflammation of the lungs) - inflammation
of the lungs in the respiratory, emerging as a distinct disease or complication of an illness. The
incidence of pneumonia was about 10-15 per 1000 infants, 15-20 per 1000 children 1-3 years old
and about 5-6 per 1,000 children under 5 years old in the year.
Classification. In November 1995, the problem commission on pediatric pulmonology
and hereditary deterministic Lung Ministry of Health adopted the following working
classification of pneumonia in children.
According to this classification, community-acquired pneumonia is divided into, hospital,
perinatal and immunodeficiency. The morphology distinguish focal, segmental, focal-drain, and
lobar interstitial pneumonia.
Adrift: acute and protracted.
Also by the presence of complications divided into uncomplicated and complicated
pneumonia.
Complications include pneumonia, toxemia, toxic shock, sinpnevmonichesky pleurisy
metapnevmonichesky pleurisy, adult-type distress syndrome, pulmonary edema, pulmonary
destruction, pneumothorax, DIC, etc.
Under nosocomial pneumonia understand, developing after 48 hours of hospitalization or
within 48 hours after discharge from hospital. Of hospital (nosocomial) pneumonia early release
(the first 4 days of mechanical ventilation) and late (more than 4 days on mechanical ventilation)
Ventilation pneumonia.
Prolonged duration of pneumonia diagnosed without permission pneumonic process from
6 weeks to 8 months of onset.
Pneumonia severity (mild, moderate, severe) is given by toxicosis. Respiratory failure
and cardiovascular changes, which depends not only on the type of pathogen, the massiveness of
infection and the status of microorganism (reactivity child), but also on the timeliness and
efficiency of care.
Etiology. The most common cause of pneumonia in children aged 6 months to 5 years old
who are sick at home, are the pneumococcus (Streptococcus pneumonia) and Haemophilus
influenzae - Haemophylus influenzae b. In the 60-70's on the first cause of pneumonia in
children out Staphylococcus aureus.
In the epidemic season (August-November) increases the value of Mycoplasma
pneumoniae (Mycoplasma) as a causative agent of pneumonia in young children of preschool
and school age. Adolescents should consider the role Chlamidia pneumoniae (Chlamydia
pneumonia) as a causative factor of the disease. Viruses are important in the development of
viral pneumonia predominantly in infants.
In debilitated children with regurgitation and aspiration of gastric contents, with cystic
fibrosis often cause pneumonia is Escherichia coli, Staphylococcus aureus, rarely - Moraxella
(Branchamella) catharalis. Pneumonia caused by Legionella bacterium L. Rneumophila (the
cause of Legionnaires' disease) in children are rare. In utero infection is most often diagnosed
chlamydial pneumonia. In rare cases, children born prematurely, similar flows pneumocystis
(pathogen - Pneumocystis) in very preterm infants are described as pneumonia caused by
ureaplasma and Mycoplasma hominis.
When forms of humoral immunodeficiency (usually primary and associated with lack of
immunoglobulins), pneumonia caused by the same pulmonary flora that in healthy children,
however, are more severe and have a tendency to recur. In patients with cellular immune
deficiencies are common forms of pneumonia (particularly frequent in HIV infection), rarely pneumonia caused by cytomegalovirus. It should be borne in mind and form, caused by fungi or
mycobacteria (BCG, Micobacteria avium).
Separately isolated large group of nosocomial pneumonia that develops in children
hospitalized for other illnesses. These are caused by pneumonia or a "hospital" strains, usually
highly resistant to antibiotics (Staphylococcus, Klebsiella, Pseudomonas - Pseudomonas
aeruginosa, Proteus) or autoflora the patient. Are fueled by antibiotic therapy, conducted by the
patient, because it suppresses the normal microflora of the lung, to which the child has some
degree of immunity. As a result of this "open road" to move the lower respiratory tract bacteria
foreign to him. Nosocomial pneumonia is called hospital.
Pathogenesis. Pathogens most likely to be inhaled into the lungs through the air aerogenic by. Predispose to subsidence of microbes on the bronchial mucosa prior acute
respiratory viral infections and diseases that lead to the weakening of the immune mechanisms of
the child.
In sepsis possible drift of microbial cells in blood in the lung tissue - that is, by
hematogenous. Already directly from lung tissue by lymphatic infection can spread to the
surrounding areas and the pleura - lymphogenous route of infection.
When infected develops an inflammatory edema of small airway bronchus. This leads to
disruption of ventilation and control the supply of air to the alveoli, where the exchange of
oxygen and carbon dioxide. There atelectasis (spadenie alveoli) and inflammation of the lung
tissue. Because of the breakdown of the processes of gas exchange develops anoxia all organs.
Complete regression of changes in uncomplicated inflammation occurs in 3 weeks.
Atelectasis or purulent process in the inflamed lung require 4-6 weeks for resorption. Recovery
in the presence of pleural lesions may take up to 2-3 months. When limiting the spread of the
inflammatory response in the immediate vicinity around the respiratory bronchioles develop
alopecia and chamber-confluent pneumonia. In the case of the spread of bacteria and edema
fluid through the pores of the alveoli within a single segment and plugging an infected mucus
segmental bronchus arises segmental pneumonia, and with more rapid dissemination of the
infected edema fluid within the lung lobe - Equity (lobar) pneumonia.
A characteristic feature of pneumonia in children is the early involvement of the
pathological process of the regional lymph nodes (bronchopulmonary, bifurcation, paratracheal),
so one of the earliest symptoms nevmonii which can be detected in an objective study is to
expand the roots of the lungs. The children of the first year of pneumonia is usually localized in
segment II of the right lung or the IV-VI, IX-X to both sides. In older children often amazed II,
VI, X, and the right segments VI, VIII, IX, X left.
Oxygen deficiency, naturally developing pneumonia, primarily affects the central nervous
system activity. The child in the midst of pneumonia occurs autonomic dysfunction of the
nervous system with a predominance of sympathetic. During exit toxicity is dominated by
cholinergic response. Changes in the cardiovascular system in patients with pneumonia due to
both CNS disorders and NAM plethora pulmonary toxicity.
With pneumonia in children observed changes in other functional systems: digestive
(reduced enzyme activity of digestive juices, impaired motility of the gastrointestinal tract and
the frequent development of young children flatulence, dysbiosis, parenteral dyspepsia),
endocrine (increased secretion of glucocorticoids, catecholamines), excretory ( Phase changes of
filtration, reabsorption of the secretory function of the kidneys, reducing
mochevinoobrazovatelnoy and deamination of the liver), immune reactivity.
Bronchoalveolitis
Focal pneumonia - the most common type of pneumonia, flowing with some differences
in toddlers and preschoolers, schoolchildren.
The clinical picture. The children of preschool and school-age clinic bronchoalveolitis up
of "lung" (respiratory) complaints, symptoms of intoxication, signs of local physical changes.
Onset of the disease can be as gradual, with slow development of characteristic
symptoms after 1 to 2 weeks of illness, and sudden that it is now in the first 3 days of the clinical
picture to diagnose pneumonia.
In the first version of the sick child of SARS, even with short-term improvement of the
emerging or growing signs of intoxication: fever, headache, deterioration of health and appetite,
lethargy, and decreased interest in surroundings or anxiety, insomnia, coated tongue,
tachycardia, inadequate degree fever.
"Pulmonary" appeal is enhanced by the dying respiratory catarrh with an increase or
appearance of wet cough, shortness of breath, and sometimes pain in the side. Noisy expiratory
dyspnea for pneumonia is not typical. Typical of a pale skin with normal color of the mucous
membranes sometimes perioral cyanosis, part of the auxiliary muscles in breathing: swelling of
the nose and supraclavicular indrawing pits intercostal space.
On light note local Physical changes: shortening of percussion tone of the lesions, but
here the weakened or hard breathing, and sonorous krepitiruyuschie permanent finely wheezing.
Characteristic of pneumonia is the local resistance symptoms.
In the clinical analysis of the blood of patients are leukocytosis, leukocyte left shift,
increased erythrocyte sedimentation rate. X-ray examination revealed patchy shadows in one
lung.
The clinical picture of focal pneumonia in young children is somewhat different. On the
foreground signs NAM, intoxication, and the local Physical changes in the lungs were more
prevalent later, the process is sometimes bilateral. In the initial period of pneumonia in young
children celebrate catarrhal changes: runny nose, sneezing, dry cough, low-grade or febrile body
temperature, impaired general condition.
On examination, attention is drawn to lethargy, often weakness, hypotonia, dyspnea with
accessory muscles in breathing, pale skin, perioral cyanosis or generalized.
In addition to shortness of breath, respiratory arrhythmia can be observed with short
periods of apnea.
An objective examination of, above all, show signs of swelling of the lungs: a box shade
of percussion tones, narrowing the boundaries of relative cardiac dullness.
Auscultation in early pneumonia listen respiratory depression. Local sonorous finely
krepitiruyuschie and wheezing in the first days of pneumonia listen to half of patients, and later
they can be detected in most children. Diffuse rales, listens evenly over most of the lungs - a sign
of bronchitis, bronchiolitis. However, bronchiolitis, which lasts no significant dynamics more
than 1 week is often complicated by pneumonia.
Radiographically focal pneumonia in infants is characterized by swelling of the lungs, the
expansion of the roots of the lungs and increased lung markings. Irregular patchy shadows with
blurred contours, often ranging in the back and less in the anterior. Shadows often merge.
Chamber-drain shadow on chest radiograph is considered as risk factors for abscess formation.
Within. Usually benign, antibiotikozavisimoe. Recovery both clinically and radiologically
occurs in 3-4 weeks.
Segmental Pneumonia
Focal pneumonia, which occupy a segment or several segments, called segmental.
Describes three vartanta flow segmental pneumonia. The clinical course of the first warrants
benign. Often they are not even diagnosed, because the focal changes are kept for a few days,
and respiratory failure, intoxication, or even cough in patients not. Diagnosis can be made during
the X-ray.
The second option flow segmental pneumonia is almost similar to the clinic lobar
pneumonia with sudden onset, fever and cyclic course of the disease. Sign segmental pneumonia
can be a pain in the abdomen, pain in the chest.
In the third option segmental shadow formed immediately, but only at the end of the 1 - st
on the second week of illness.
The clinical picture in these cases is fully consistent with the above-described with focal
pneumonia in preschool and school children, but, as a rule, auscultation mark only weakened and
hard breathing, increased bronhofonii in the absence of wheeze. Percussion data for sealing of
lung tissue are not clear. Frequent pleural lesions and atelectasis. The tendency to abscess
formation, destruction, prolonged duration.
Lobar Pneumonia
Typical course of lobar pneumonia seen in children of preschool and school age, rarely in the age of 1-3 years, and as an exception - in the first year of life. In the pathogenesis of lobar
pneumonia, an important role belongs allergic reactivity, which develops in sensitized
pneumococci body prone to hyperergic reactions. The rarity of lobar pneumonia in the first year
of life due to lack of sensitization in children of this age pneumococci.
In children with lobar pneumonia is not always affected all share, inflammatory focus can
be determined only in a few segments. Most often lobar pneumonia in children is localized in the
upper or lower lobe of the right lung.
The clinical picture. The disease begins with no prior SARS with a sudden rise in
temperature to 39-40 ° C, headache, severe disruption of the general condition, coughing with a
"rusty" sputum, chest pain. Prodrome if ever, it takes several hours. Many patients early in the
disease complain of pain in the right iliac fossa or around the navel. This is typical of pneumonia
during its localization in the lower lobe of the right lung and caused viscero-visceral reflex.
However, unusual shortness of breath, rapid pulse line fever, a slight delay in breathing of one
half of the chest, abdomen, and free trips no clear rigidity of its wall send a doctor to the correct
path.
Some pre-school children at the beginning of the disease to a high body temperature,
headache, vomiting, delirium join, neck stiffness, clonic convulsions, which resembles the
clinical symptoms of meningitis. For pneumonia is often the case with its localization in the
upper lobe of the right lung.
On examination, patients early in the disease attention is drawn to some confusion, pale
skin with rosy cheeks and bright eyes, dry lips, herpes blisters on the lips and nose, shortness of
breath, with the participation of the subsidiary in breathing muscles. At the beginning of the
supraclavicular fossa pneumonia seems deeper, and the shoulder is shifted forward and medially.
On examination also show a lag of the chest in breathing and limited mobility of the lower edge
of the lung, voice jitter attenuation, enhanced Bronhofoniya, swelling of the skin and a shorter
tympanic sound orazheniya over the fire. In the first hours there ohayuschee breathing short and
painful cough with a small amount of viscous, glassy mucus. With a deep breath in a child there
is a pain in my side.
In the future, the body temperature is kept at a high level, kshel increases, but it becomes
less painful and torturous, wet growing dyspnea, cyanosis and edema occurs lips and face. With
the 2-3rd day of the disease in the physical examination can already detect bronchial breathing,
shortening of percussion tones, irregular, tender krepitiruyuschie wheezing. Wheezing often join
later.
Lobar pneumonia at the peak and is characterized by lesions vnelogechnymi:
cardiovascular (heart sounds muted, small expansion of the boundaries of the relative cardiac
dullness, mild systolic murmur, a fall of vascular tone - hypotension), nervous system (insomnia,
headache, changes in skin and tendon reflexes) , liver (unsharp increase and pain, and for
laboratory research - a violation of the detoxifying function) buds (small albuminuria, and
sometimes red blood cell and tsilinduriya).
Clinical analysis of blood in patients with lobar pneumonia characterized by significant
leukocytosis, neutrophilia with a marked shift to the left, increased erythrocyte sedimentation
rate.
When X-ray in patients with lobar pneumonia allocated seat shade, covering all or part of
the share.
Within. Duration of the disease in children depends on the nature of therapy and
reactivity. The patient's condition gradually improved, cough becomes more humid, but
harakerny adult cough with a "rusty" sputum in children is rare. Krepitiruyuschie wheezing,
which were heard at the beginning of the disease (crepitatio indux), disappear, and then reappear
at the time of resolution of pneumonia (crepitatio redux).
Lobar pneumonia may occur with atypical clearly marked main clinical symptoms or
bilateral localization process.
In recent years, due to the early treatment with antibiotics classic picture of lobar
pneumonia is rare in both children and adults. Most often in patients with lobar pneumonia has
one or more of the classic symptoms of a disease affecting a few or even a single segment.
Forecast. With early treatment the prognosis of lobar pneumonia favorable.
Interstitial Pneumonia
In 1946 the group R.Lenk acute pneumonia identified pneumonia, characterized
radiographically by the following features:
1. Changing the type of lung pattern emanating from the extended fusiform root,
consisting of rough or gentle-cut strips, which are based on peribronchial infiltration and
possibly filling bronchial exudate.
2. Mesh pulmonary drawing in the affected area with varying largest aerated. Against the
background of these two types of changes in the development of foci of atelectasis appears fine
spotting.
3. Common tyazhistye clearly defined shadows signs bronchoconstriction
These interstitial pneumonia author named after K.Rokitanskim pathologist, who
described them in 1842 in children, according to V.K.Tatochenko, interstitial pneumonia are
rare, is 1% of the total number of patients with acute pneumonia.
Etiology. They are caused by viruses, pnvmotsistami, chlamydia, mycoplasma,
pathogenic fungi.
Pathogenesis. In patients with interstitial pneumonitis occurs next staging of lung injury:
1) generalizovany arteriolar spasm - I stage;
2) local trombogemorragichesky syndrome - II stage;
3) lack of surfactant and spadenie alveoli, leading to the development of lung
mikroatelektazov - III stage.
The clinical picture. Clinical manifestations of interstitial pneumonia can distinguish two
types of flow.
Symptomatic, acute type. It occurs in infants and preschool children with symptoms of an
allergic diathesis. The disease begins hard, with symptoms of neurotoxicity and respiratory
failure (severe breathlessness with respiratory rate 80-100 in 1 minute, cyanosis nasolabial
triangle, cyanosis, nails, and with anxiety - generalized cyanosis, voltage of the nose, indrawing
of the intercostal spaces), fever in the future with addition of frequent and painful cough.
Catarrhal symptoms in the lungs indistinct: Listening for single unstable high dry rales,
krepetiruyuschie rarely and only with additional bacterial infections - moist rales. For percussion
note tympanitis, low standing edges of the lungs, narrowing the boundaries of relative cardiac
dullness, expanding roots of the lungs. Shortening of percussion tones not typical.
The most severe the flu hemorrhagic pneumonia with fever were severe neurotoxicity and
respiratory failure, bloody, sometimes frothy sputum, collapse. In the study of light often find
plenty of wet and dry rales, crackles. Suggest that the hemorrhagic syndrome caused by
intravascular coagulation. Characteristically developed acute and subacute right heart failure,
moderate enlargement of the liver, microhematuria.
Oligosymptomatic, subacute type. Were more common among children of school age.
After suffering acute respiratory disease in children are lethargy, fatigue, poor appetite, lowgrade fever body, complaining of headaches, fatigue, and cough. Physical findings in patients
takh scarce: moderate signs of intoxication, dyspnea at low load, several discharged pulmonary
tone, sometimes expanding root of the lung, single dry rales. However, the chest X-ray, there is
convincing evidence of interstitial pneumonia.
For interstitial pneumonia in children with weakened immune systems characteristic
tetrad of symptoms: shortness of breath, hypoxemia, diffuse interstitial infiltrates, and cough.
Within. During acute interstitial pneumonia type heavy. Sometimes, at the height of
intoxication children die of specific viral encephalitis virus infection and internal organs. Even
with a favorable course of the disease radiographic changes in the lungs are kept for a long time 6-8 weeks or more. Outcome of interstitial pneumonia can be a full back development or
formation pneumosclerosis.
ATYPICAL PNEUMONIA
The clinical picture of atypical pneumonia syndrome prevalent manifestations of
systemic toxicity, at the time, the symptoms of broncho-pleural pulmonary syndrome are
secondary. For atypical pneumonia characterized epidemiological outbreak (meaning outbreaks
in children, school, student and soldier groups), as well as the family hearth respiratory diseases.
Mycoplasma pneumonia.
Exciter. Mycoplasma pneumonia is a separate genus of microorganisms having a small
size (150-200 nm) containing RNA and DNA. The causative agent is able to reproduce in a cellfree environment, and produce toxins (b-hemolysin). Mycoplasmas are intermediate between
viruses, bacteria and protozoa. May persist for years in the lipophilic dried state at - 70 ° C.
Epidemiology. The source of infection is the patient respiratory mycoplasmosis and
media. Modes of transmission: airborne, transplacental.
Pathogenesis. When vozdushnokapelnom transmission Mycoplasma causes mucous back
of the throat, trachea, bronchi. But major changes occur in the alveolar epithelium, where the
parasite multiplies, causing hyperplasia and cell changes. Alveolar macrophages and neutrophils
perform phagocytosis, and this process is accompanied by a sharp change in desquamation of
alveolar cells, intracellular fluid exudation.
Features of the clinic. The clinical picture depends on the virulence of the pathogen, the
intensity of its propagation, patient age, reactivity, the presence or absence of other viral or
bacterial infection. The incubation period of 1 to 3 weeks (usually 12-14 days).
The initial manifestations are characterized by moderate general intoxication
(Headache, fatigue, mild fever). Joins a sore throat and abdomen. Characterized by a dry
painful cough (often begins before obscheintoksikatsionnyh manifestations), the phenomenon of
pharyngitis grit back of the throat, chest pain.
On the skin in 50% of cases there is a red blotchy rash or purple, rarely rash - vesicular,
papular, maybe Herpes labialis. Such elements can be detected in the mucous, the eardrum.
Symptoms of intoxication increase toward the end of the first week, beginning of the
second, but then there are typical symptoms of pneumonia, expressed unsharp (in children under
one year are often asymptomatic). Dyspnea is rare.
Mosaic-like percussion. Physical findings scarce: against hard and weakened respiratory
rales are heard, rarely - obstructive syndrome (in infants may be clinical bronchiolitis).
Extrapulmonary manifestations: 50% - vomiting, severe abdominal pain, appendicular
syndrome, in 30% - moderate hepatomegaly, and in 20% - haemorrhagic syndrome (skin
hemorrhages, nosebleeds), hematuria, and very rarely meningeal syndrome, even more rarely
meningoencephalitis.
The disease monotonous. Ostatochnқe phenomena are stored in a dry compulsive cough
subfebrile from 2.5 weeks to 2-2.5 months. In older children mycoplasma pneumonia contributes
to chronic bronchopulmonary processes.
Features of clinic for children under 1 year: effects of bronchiolitis often without fever,
anemia, mild jaundice, hepatosplenomegaly, hemorrhagic syndrome (due to an increased
sensitivity to b-hemolysin).
On R-gram: heterogeneous inhomogeneous lung infiltration, without clear boundaries in
small spotty (or drain) opacities. Often infiltration in the form of the "fog", "cloud." Typical is
marked enhancement and thickening of lung pattern (usually the process is one-sided and is
localized in the lower part). Reinforced bronhososudisty pattern remains for a long time, and
after recovery.
Paraclinical data often without any changes can be mild anemia: a few accelerated ESR,
monocytosis.
Mycoplasma infection newborn is generalized, affected lung parenchyma. Bronchial
tissue and upper respiratory tract remains intact, as the pathogen penetrates hematogenous route
and the trail to the lung tissue. Mother of these infants have a family history of midwifery
(urogenital mycoplasmosis). Children are born with low birth weight, pale and icteric staining of
the skin. Pneumonia developed in the first hours of life. By the end of the first week meningoencephalitis. According to statistics, these children are 10 - 30% of the dead babies.
Pathological anatomy. Manifestations of pharyngitis with hypertrophy of the follicle, the
peribronchial and perivascular edema - early on.
Next - a thickening of interalveolar septa, their limfogistiotsitarnaya infiltration. In the
alveoli present serous exudate containing exfoliated cells of the alveolar epithelium. Pathological
changes occur in the liver and kidneys.
Diagnosis is based on the detection of the pathogen in the prints of the nasal mucosa by
means of fluorescent sera, serological tests (RAC - increasing the titer of complement binding
antibodies). Isolation of Mycoplasma from sputum culture by plating on tissue cultures or special
environments (complex method).
Principles of treatment. Causal treatment is the use of macrolide antibiotics:
erythromycin at a dose of 30-50 mg / kg per day, lincomycin 10-20 mg / kg per day,
oleandomycin - up to 3 years - 0.02 g / kg, 3-6 years - 0.25 - 0.5 g / kg, 6-14 years - 0.5-1 g / kg
over 14 years - 1-1.5 g daily dose divided into 4-5 receptions. Course of 5-7 days.
Applied and derivatives oxytetracycline (children older than 8 years), such as
Vibramycin, Doxycycline. From 8-12 years - 4 mg / kg per day for the first day of treatment with
2 mg / kg - the daily dose in the following days. Over 12 years -0.2 g on the first day, and 0.1 g
per day on. Course of 7-10 days.
Chlamydia pneumonia.
Pathogen. Chlamydia - a group of obligate intracellular parasites that are very close to the
gram-negative bacteria. In the structure, they contain DNA and RNA, and ribosomes, the cell
wall, they multiply by binary fission, are sensitive to antibiotics. They are divided into two types:
Chlamydia psitacci and Chlamydia trachomatis.
Epidemiology. Clear seasonality in the course of the disease is observed. Ornitoznoy for
pneumonia caused by Chlamydia psitacci, the source of infection, birds (pigeons, parrots, ducks,
chickens). Chlamydia - mainly pathology newborns who are infected intrapartum, during the
passage through an infected birth canal of the mother. In adults, a pathology related to infections,
sexually transmitted diseases.
Pathogen - is Chlamydia trachomatis. The main routes of transmission in infants vozdushnokapelny, aspiration. Usually affects the middle and lower parts of the lungs. The
causative agent, breaking through the protective barriers, reaches the alveoli, where it causes
serous edema spreads to adjacent areas of the lung.
Clinic. Incubation period - 10 days. Home accompanied obscheinfektsionnym syndrome
in the form of weakness, fever (over 39 (C), severe headache, bradycardia, muffled heart sounds,
muscle pain, and sore throat. After 1-3 days showing signs of respiratory lesions: a dry cough
and a pain in side, the chest. According physical data indicated a local shortening of percussion,
fine crackles, which is not accompanied by increased toxicity and tendency to abscess formation.
Clinics like the flu. During the long-term. The fever lasts for 2 - weeks, may be repeated
waves, asthenia persists up to 2 or 3 months. Weather favorable.
Infants with chlamydial infection, after 1-2 weeks of life there is a unilateral
conjunctivitis. During the slow and only after 1-2 weeks - muco-purulent discharge from the
eyes. During this period, can join pneumonia (up 4-12 weeks) occurs with shortness of breath
and cough pertussislike, in the absence of fever and intoxication.
R-gram. Characterized by two-way small focal shadows. For ornithosis - strengthening
and deformation of lung markings, seal roots.
Paraclinical data. In UAC - ESR acceleration, more leukopenia, lymphocytosis,
eosinophilia may be. Of immunological parameters - high level of immunoglobulin M and G.
Diagnosis is based on sputum microscopy and discharge from the eyes, as well as
increasing the titer of specific antibodies in the RAC for 2-3 weeks.
Pathological anatomy. Changes in the lungs are inflammatory: ischemia vascular stromal edema
serous, fibrinous exudation. The latter is distributed within the entire share. The modified part of
the lung is increased, pleura dull, rough. On the cut - liver density.
Treatment. The basic principle - this antibiotic.
Biseptol - 8-10 mg / kg per day. To 2 hours. Course of 10-20 days.
Erythromycin - 30-50 mg / kg per day. Newborn 2 times a day, over 2 - months - 4-6 times a
day. Course of 15-20 days.
Claforan - 50-100 mg / kg per day. Newborn 2 times a day, 3-4 times a day - with up to 50 kg,
parenterally. Course of 10-15 days.
Fortum - up to 2 months at 25-60 mg / kg per day, 2 times a day, 2 months.
- 1 year of 30-100 mg / kg per day 3 times a day. Course of 7-10 days.
Ceftriaxone (longatsef) 20-80 mg / kg per day parenterally for 10-15 days.
Roxithromycin (rumid) for adults to 0.15 g 2 times a day for 10-15 days.
Tarivid - for adults 0.2-0.8 grams per day in 2 divided doses. Course of 7-14 days.
Legionella pneumonia.
Legionellosis - an acute infectious disease caused by various species of Legionella.
Pathogen. The genus Legionell include 9 species: L. pneumophilla, L. bozemanii, L.
miedadei, L. dumoffii, L. longbeache, L. gonmanii etc. This is a Gram-negative bacillus, with
pointed ends, a width of 0.3-0.4 mm and a length of 4.2 m, has flagella. Long-term remains in
the environment (in water up to 1 year), grows well on artificial media. Germ contains a set of
antigenic and toxic components.
Epidemiology. The natural reservoir of the pathogen is soil.
Legionellosis is widespread and is registered in the form of epidemic outbreaks in autumn
and summer and sporadic cases, regardless of the season. Contributing factors are living near the
sites of construction works, taking immunosuppressive drugs.
Infection occurs through aerogenic. Described the outbreak by inhalation of tiny droplets
of infected water, resulting in air conditioners, fans. Transmission from person to person is not
marked, but this possibility is not excluded.
Pathogenesis. Pathogen through the upper respiratory tract is inside and affects the
bronchioles and alveoli, and infiltrate the lung parenchyma. To see him rush macrophages,
neutrophils, which destroy bacteria and helps release of endotoxin. As a result of parenchymal
necrosis, alveolar fibrosis, atelectasis, emphysema. Dissemination of bacteria and their
endotoxin, BAS cause changes in the cardiovascular system, gastrointestinal tract, central
nervous system, kidneys, causes the development of DIC.
Clinics. Distinguish 3 types of legionellosis: acute pneumonia, acute alveolitis, acute
bronchitis. Acute pneumonia is characterized by acute onset, fever up to 39-40 (C, may be
vomiting, diarrhea, chills, myalgia, severe headache - obscheinfektsionny syndrome. Pulmonary
disease manifests as painful cough, pain in the chest. Cough later becomes wet, with the office of
the mucous "rice" sputum. also develop symptoms of CNS (delirium, delusion, dizziness).
Acute alveolitis begins as acute pneumonia, flu-like. But subsequently rises above the
lung shortness of breath and listened krepitiruyuschie heavy wheezing. In protracted cases have
fibrosing alveolitis by type Hamm-Rich. Acute bronchitis is rare.
R-gram. Massive infiltrative shadow far greater intensity than detected during the
inspection.
Para-clinics. UAC - neutrophilic leukocytosis (10-15 * 109 / l), lymphopenia, accelerated
ESR to 60 mm / h or more. In OAM - proteinuria, red blood cell, tsillindruriya. LHC sets
hyponatremia (less than 130 mmol / L). Marked impairment of the function of the liver in the
absence of apparent hepatitis (bilirubin and transaminase activity above normal in 2 times,
hypoalbuminemia).
Diagnosis is based on the detection of specific antibodies in the serum of patients, the
detection of bacteria in the bronchial lavage, sputum, pleural fluid, as well as material from the
bodies of the dead.
Diagnostic is a 4-fold increase in antibody titer.
Treatment. The most effective dose of erythromycin in age, and a group of tetracycline
and chloramphenicol. Showing detoxification, symptomatic therapy, the use of
immunocorrection.
Pneumocystis pneumonia (PCP).
Pathogen. Pneumocystis carinii, taxonomic affiliation not yet been precisely determined:
by tradition often denotes a prime, although there is evidence that the body is a fungus.
P. carinii - almost exclusively pulmonotropny parasite plant grows in the alveoli of the
human lung, and various animals. The life cycle of the parasite involves the following stages:
cysts - round or oval formation between 5-8 microns with a three-layer shell, which is 8
sporozoidov; cysts rupture - and the release sporozoidov, maturing in sporozoidov trofozoidy
and pretsisty, turning them into mature cysts. The life cycle takes place within the alveoli, and
trofozoidy numerous processes, have an affinity with the surface membrane of alveolar cells.
Epidemiology. The vast majority of people infected with P. carinii in early childhood, as
evidenced by the presence of antibodies against antigens of P. carinii almost anyone. For
immunocompetent organism, this meeting has pathological consequences. At the same time as
the immunodeprecsii (medication, chemotherapy, after transplantation, stress) infection of P.
carinii is often implemented in the form of severe interstitial pneumonia.
Clinics. The most frequent symptoms of PCP are: dry cough (80%), dyspnea (70%), fever
(over 38%). Rales on auscultation of the rare, occur but are not common, chest pain, and phlegm.
Characteristic discrepancy severity of clinical observations and physical data.
R-gram. The first sign - this increased bronchial pattern. Then there are patchy, flushing
shadow on both lung fields.
Para clinical data. UAC noted neutrophilic leukocytosis, eosinophilia, anemia,
accelerated ESR. Diagnostic importance is the discovery P. carinii in frothy sputum, in the
biopsy material.
Treatment. Currently, there are two well-tested and about ravnoeffektnye PEP regimen:
trimethoprim - sulfamethoxazole (TMP-SMZ) and pentamidine, and several alternative schemes
(dapsone, difluoromethylornithine, trimeksat / leucovorin). Combined therapy pentamidine and
TMP-SMZ has advantages. Both of the main drug used to treat the panel are numerous and not
completely identical side effects. Given the high antibacterial activity of TMP-SMZ, the more
justified its use in concurrent bacterial infection. Pentamidine is the drug of choice if the patient
has a history of allergy to sulfosoderzhaschim drugs.
Mortality in patients treated adequately control panel on average about 20%. The sooner
treatment begins, the better chance of success - if the therapy is started when the X-ray is normal
or arterioalveolyarny oxygen gradient less than 30 mm Hg, the mortality rate is reduced from 4555% to 10-15%.
Cytomegalovirus (CMV)
Pathogen - Cytomegalovirus hominis of the family Herpesviridae, 180 nm diameter
virion contains DNA. For a virus of low virulence, the capacity for lifelong persistence,
expressed immunosuppressive effect, transforming effect on the cell at a slow replication. The
virus may develop in cultures of human fibroblasts, resulting in the normal cells become
cytomegalic (25-40 microns). The appearance in the transformed cells of large intranuclear
inclusion separated from karyotheca bright rim, giving them the appearance of "owl's eye."
Epidemiology. Reservoir and source of infection - people. The virus is found in blood,
cervical and vaginal secretions, semen, breast milk, saliva, urine, feces, tears. Infection occurs
through transplacental (acute exacerbation of chronic CMV infection or pregnant, impaired
barrier function of the placenta), a contact fekalnooralnym, inhalatory, through breast milk,
iatrogenic (transfusion of blood and blood components, organ transplants).
Pathogenesis. Initially penetrated into the blood, CMV reproduced in leukocytes
(lymphocytes, monocytes), or persist in the lymphoid organs. With the development of immune
deficiency virus spreads through the blood to organs and filtered in a liquid medium and
excretions. In amazed organ specific changes, which causes the clinic.
Clinics. Acquired CMV infection often occurs in the form of low-grade pneumonia.
Congenital CMV infection is always generalized. Ekstralegochnyh of lesions observed
encephalitis, hepatitis, sialoadenity, eye disease (chorioretinitis, cataracts, optic atrophy) of the
kidneys.
According to clinical - radiological data for CMV pneumonia is little different from
Chlamydia, Pneumocystis pneumonia. The main symptoms - tachypnea, dyspnea, paroxysmal
cough, signs of hypoxia.
Roentgenological giperaeratsiya, diffuse bilateral changes. In the initial phase change
creates turbidity background. Next infiltrate becomes denser in its presence visible illumination
(air bronhogramma).
Para-clinical data. Progressive anemia with reticulocytosis, hemorrhagic syndrome,
thrombocytopenia, jaundice.
Morbid anatomy. Morphological pattern of CMV infection is composed of two
components: the metamorphosis of cytomegalic cells and stromal infiltration
limfogistiotsitarnaya bodies. The more pronounced immune deficiency, the more cytomegalic
cells and less pronounced limfogistiotsitarnaya infiltration. The lungs are primarily cytomegalic
transformation of cells of the alveolar macrophages and alveolar epithelium, especially those that
line the bronhososudistye cases, interlobular septa, pleural sheets. Favourite localization SSC
(cytomegalic cells) are the sections of adenomatous restructuring lung atelectasis in around
granulating ulcers, cysts, lesions pneumosclerosis. In the bronchial tree CMK more often
localized in the epithelium of the respiratory bronchioles, at least - in the epithelium of the large
bronchi in the capillary endothelium of interalveolar septa and lamina propria of the trachea and
major bronchi. Pathognomonic for CMV interstitial pulmonary infiltrates. Limfogistiotsitarnye
diffuse pulmonary infiltrates with signs pneumosclerosis interstitial and alveolar epithelial
cytomegalic metamorphosis and bronchioles were observed in cases of chronic active course of
CMV infection. Similar changes (ICC, limfogistiotsitarnaya with sclerosing stromal infiltration)
are observed in the salivary glands, kidneys, and liver.
Diagnosis. The simplest method - identification of SSC precipitation saliva and urine.
Other methods: cultivation of the virus in cultures of fibroblasts by ELISA and
radioimmunoassay, immune blot less reliable and expensive. It should be remembered that the
antibodies to CMV can be transmitted transplacentally.
Specific treatment is the use of the following drugs:
1. Nucleoside analogues (integrated into the genome of the virus, and blocking the
assembly of viral DNA). This - tsitorabin (daily dose - 100 mg / m 2 doses). Course of 4-10
days.
2. Zovirax (acyclovir). This drug blocks the viral DNA, but does not block their own
DNA. The dose for children up to 2 years - 2.5 mg per kg, with severe infection is introduced
into / drip or 0.2 g of 5 times a day.
3. As immunozamestitelnoy therapy can be applied vysokotitrovanny gamma globulin
from donors convalescents, placental gamma globulin in high doses, and immunoglobulins pentaglobin, Sandoglobulin.
USING "WEB" METHODOLOGY
This method will allow the teacher in the beginning of class to determine the level of
preparedness of the student to the subject by theoretical questions asked students to each - other.
methodology:
1. Previously students are given time to prepare questions on the passed occupation.
2. Participants sit in a circle.
3. One of the participants is given hank yarn, and he asks his prepared question (which itself
needs to know the full answer), hold the thread end and transferring skein any student.
4. Students who received a skein, answers the question (the party who asked him, says the
answer), and passes the baton to the issue further. Participants continue to ask questions and to
answer them, until everything will be in the web.
5. Once all the students have finished asking questions, the student holding the coil, returns to a
participant, from whom he received the question, while asking the question, and so on, until the
"unwinding"
12. Analytical part (on the subject developed a case study).
13.3. Practical Part
1. Conduct palpation, percussion, auscultation in children.
2. Interpret the results of clinical and biochemical studies on the disease.
3. To calculate the dose of antibiotics, depending on the age of the child.
14. Control forms of knowledge, skills and abilities
- Oral
- Decision of situational problems
- Demonstration of practical skills
- IWS
15. The evaluation criteria of the current control
№
1
Progress in (%) and points
96-100
Mark
Excellent
«5»
2
91-95
3
86-90
The level of knowledge of the student
Depending on the situation, to make the
right decision and concludes.
In preparation for practical training uses
additional literature (both native and
English)
Independently analyze the essence of
the problem.
Themselves can examine the patient and
correct diagnoses (pneumonia), assigns
a plan of treatment and improvement of
the disease.
Shows high activity, creativity during
interactive games.
Correctly solve situational problems
with full justification of the answer.
During the discussion of the IWS is
actively asking questions, making
additions
Practical skill performs confidently,
understand the essence.
Depending on the situation, to make the
right decision and concludes.
In preparation for practical training uses
additional literature (both native and
English)
Independently analyze the essence of
the problem.
Themselves can examine the patient and
correct diagnoses (pneumonia), assigns
a plan of treatment and improvement of
the disease.
Shows high activity, creativity during
interactive games.
Correctly solve situational problems
with full justification of the answer.
During the discussion of the CDS is
actively asking questions, making
additions
Practical skill performs confidently,
understand the essence.
Independently analyze the nature of the
disease.
Shows high activity, creativity during
interactive games.
Correctly solve situational problems,
justifies treatment is prevention plan.
AFI knows broncho pulmonary system,
says confidently. There is an exact
representation
of
the
etiology,
4
76-80
Good
«4»
6
71-75
7
66-70
Satisfactorily
pathogenesis, clinical picture, can carry
differential
diagnosis,
prescribe
treatment, can be prevented pneumonia.
Practical skill performs confidently,
understand the
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. Can interpret research data.
Actively involved in the discussion
IWS.
Shows high activity during interactive
games.
Correctly solve situational problems, but
cannot assign a specific treatment,
confuses dosages. AFI knows broncho
pulmonary is covered in confidence.
There is an exact representation of the
etiology, pathogenesis, clinical picture,
can carry differential diagnosis,
prescribe treatment, but cannot carry out
prevention and rehabilitation of
pneumonia.
Practical skills to step through
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. These laboratories can
interpretation of the study. Actively
involved in the discussion IWS.
Correctly solve situational problems,
knows how to put on the classification
of the clinical diagnosis, but cannot
assign a plan of treatment and
prevention.
AFI knows broncho pulmonary system,
says confidently.
There is an exact representation of the
etiology, pathogenesis, clinical picture
and differential diagnosis, but cannot
prescribe medication
Practical skill to perform, but confusing
steps.
Properly collect history, examines the
patient, and makes a preliminary
diagnosis. Can interpret laboratory
findings. Actively involved in the
discussion IWS.
Correctly solve situational problems, but
cannot justify the clinical diagnosis
AFI knows broncho pulmonary system,
says confidently
There is an exact representation of the
etiology, pathogenesis and clinical, but
«3»
8
61-65
9
55-60
10
54 -30
11
20-30
cannot carry out differential diagnosis
and prescribe treatment.
Properly collect history, examines the
patient, but cannot assess the severity.
Partly to interpret laboratory findings.
Actively involved in the discussion
IWS.
Making mistakes in solving situational
problems (cannot put a diagnosis on
classification)
Knows pneumonia clinic, says no
confidence
There is an exact representation of the
etiology of the disease, but cannot relate
to the pathogenesis of clinic
History was not focused, not on the
inspection scheme. Cannot interpret the
data of laboratory research. Passive
when discussing IWS.
Has a general idea of the disease, says
no confidence
Confuses AFI’s broncho pulmonary
Alone cannot interrogate and examine a
sick child. Cannot interpret the research
data. Does not participate in the
discussion of the IWS.
Does not have an accurate picture of
Unsatisfactorily
pneumonia.
«2»
AFI does not know broncho pulmonary.
For the presence of the student in class,
Unsatisfactorily
in due form, have a notebook,
«2»
stethoscope.
16. Flow chart classes
№
1
2
3
4
5
6
Learning stages
Learning form
Lead-in teacher (Ad practice session
topics, goals, learning outcomes, the
characteristics of the studies, indicators
and evaluation criteria)
Discussion of the topic practically The survey, an explanation
anyone classes, baseline assessment of
students' knowledge with the use of new
teaching technologies transformations
Summing up the discussion
Supervision on patients, performing
skills
Hear and discuss students' individual
work
Determination of the degree of Oral survey, case studies,
Duration in min
5
30
5
100
30
45
7
achievement based on the lessons discussion discussion
mastered the theoretical knowledge and
the results of the development of
practical skills
The conclusion of the teacher in this Information. Questions for
lesson. Assessing the students on a 100 self-training
point system and its announcement.
Distribution of jobs to the next class
5
17. Test question
1. Give the definition of pneumonia in children;
2. Classification of pneumonia in children;
3. The etiology and pathogenesis of the disease in young children;
4. What are the symptoms of clinical and radiological features of pneumonia?
5. Diagnostic criteria for pneumonia
6 Diagnosis and differential diagnosis of the disease in children;
7. Algorithm antibiotic pneumonia in children;
8. Tactics GPs in pneumonia in children.
18. Recommended Reading
Main:
1. Childhood diseases, ed. L.A. Isayeva. 1994.
2. Propaedeutics childhood diseases A. V. Mazurin, I. M. Vorontsov, 1995
3. Childhood diseases, ed. H. P. Shabalova, 2002
4. Childhood diseases, ed. H. P. Shabalova, 2010
5. Childhood diseases, ed. A. A. Baranova, 2010
6. Childhood diseases T. O.Daminov, B. T. Khalmatova, U. R. Babaeva, 2012
Extra:
1. "Diseases of young children" - a guide for physicians, edited A.A.Baranova - MoscowIvanov, 1998, p.241-257.
2.
Korovin, N.A., Zaplatnikov A.L., Zakharov I. Cough in children. Manual for physicians. New York: 2000.
3.
Nazirov F.G., I. Denisov, Ulumbekova E. G. Reference practitioner. 2000
4.
Acute pneumonia in children, edited V. K. Tatochenko, 1994
5.
Pathology older children - edited A. A. Baranova, M, -1998
6.
Directory GP. Edited by Acad. RAMS. N. R. Paleeva. EKSMO 2002
7.
Directory GP. EKSMO, Edited acad. RAMS N.R. Paleeva. 2002
8.
Reference pediatrician. St. Petersburg, Moscow, 2004
9. "Directory of the family doctor" (Pediatrics) - Minsk, 2000 - s.390-398, 417-420.
10. The five Minute child Health Advisor/ - M. William Schwartz, MD., - 1998, USA
11. A therapist’s guide to pediatric assessment, - Linda King-Thomas, Bonnie J. Hacker, 1987,
USA
12. Pediatrics, - Margaret C. Heagarty., William J. Moss, -1997, USA
13.
14.
15.
16.
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