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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. www.tma.uz www.medlincs.ru www.medbook.ru www.medafarm.ru