What Is Bronchopneumonia?

Bronchopneumonia is a common infectious disease in children, especially infants and young children. It is the most common cause of hospitalization for children. It is common in children under 2 years of age. Bronchial pneumonia is also known as lobular pneumonia. Pneumonia mostly occurs during the cold winter and spring seasons and when the climate changes suddenly, but it is no exception in summer, and even in some southern China, it is more common in summer. Bronchopneumonia is most often caused by bacteria, viruses, or fungi, and pathogens such as Mycoplasma pneumoniae, and can also be a "mixed infection" by viruses and bacteria. Viral pneumonia is mainly caused by interstitial involvement, and bacterial pneumonia is mainly caused by lung parenchymal damage. Inflammation of the lung tissue causes thickening of the respiratory membrane and obstruction of the lower respiratory tract, resulting in dysfunction of ventilation and ventilation, mainly manifested by fever, cough and shortness of breath. The main signs are rapid breathing, cyanosis around the mouth and fingers, toes, and middle and fine wet rales in the lungs.

Basic Information

nickname: Lobular pneumonia
English name: bronchopneumonia
Visiting department: Pediatrics

Multiple groups: Children under 2 years
Common causes: Often caused by bacteria, viruses or molds and pathogens such as Mycoplasma pneumoniae
Common symptoms: Fever, cough, shortness of breath, etc.

Causes of bronchial pneumonia in children

Predisposing factor

The prone to pneumonia in infants and young children is due to the physiological and anatomical characteristics of the respiratory system, such as narrowing of the trachea and bronchial lumen, low secretion of mucus, poor cilia movement, poor development of lung elastic tissues, rich blood vessels and easy hyperemia, strong interstitial development, and alveoli Less, the lungs have less air content, and are easily blocked by mucus. Infants and young children at this age have not yet fully developed the defense function of the immune system and are prone to diseases such as infectious diseases, malnutrition, and rickets. These inherent factors not only make infants and young children prone to pneumonia, but also have a more serious disease. Infants under the age of one year have very poor immunity, so pneumonia easily spreads, fuses, and extends to both lungs. Older children with stronger physiques gradually mature their responsiveness, limit their ability to infect, and often have larger lesions in pneumonia. If confined to one leaf, it is lobar pneumonia.

2. Pathogenic bacteria

All pathogens that can cause upper respiratory tract infections can induce bronchopneumonia, but mainly bacteria and viruses. Among them, Streptococcus pneumoniae, Haemophilus influenzae, and respiratory syncytial virus (RSV) are the most common. Generally, bronchopneumonia is mostly caused by Streptococcus pneumoniae. Other bacteria such as Staphylococcus, Streptococcus, Influenzae, Escherichia coli, Pneumococcus, and Pseudomonas aeruginosa are rare. In recent years, mycoplasma pneumoniae, chlamydia, and Haemophilus influenzae have increased. Pathogens often invade from the respiratory tract, and a small amount of blood enters the lungs.

Clinical manifestations of bronchial pneumonia in children

General pneumonia

Generally, the main clinical manifestations of pneumonia are fever, cough, shortness of breath, and fixed middle and fine wet rales in the lungs. Typical clinical manifestations include:

(1) Systemic symptoms Sudden or delayed onset of symptoms , including fever, vomiting, irritability, and wheezing. There may be symptoms of mild upper respiratory tract infection for several days before the onset of the disease, and the heat type is uncertain, mostly irregular fever, and also may be relaxation fever or residual fever. Early body temperature is mostly between 38 ° C and 39 ° C, and can reach as high as about 40 ° C. Most of them have a relaxation or irregular fever. The newborns may not have fever or their temperature does not rise. Most of the weak babies have slow onset, low fever, cough and lungs. The physical signs are not obvious. Breastfeeding, vomiting, or dyspnea are common. Breastfeeding is sometimes significant. It can overflow from the nostrils at each feeding. Axillary temperature> 38.5 ° C, accompanied by tri-concavity signs, especially inhalation of the chest wall and rapid breathing (except those caused by crying, fever, etc.) should be considered serious.

(2) Cough Cough and phlegm in the throat are usually obvious early. The early stage is dry cough, which can be reduced in the extreme stage, and the cough increases in the recovery stage, with sputum. Newborn and premature infants may have no cough, and only show foaming in the mouth.

(3) Shortness of breath often occurs after fever and cough, with shallow breathing and increased breathing frequency (60 times / minute in 2 months of age, 50 times / minute in 2-12 months, and 40 times in 1 to 5 years old) / Min, more than 5 years old 30 times / min), groaning when breathing in severe cases, cyanosis may occur, and the ratio of breathing and pulse increased from 1: 4 to about 1: 2.

(4) Dyspnea Common dyspnea, cyanosis of the mouth or nails, and wing flaps of the nose, severe cases of nodular breathing, trident sign, prolonged expiration, etc. Some children tilt their heads back to breathe more smoothly. If the children passively bend their neck forward, the resistance is obvious. This phenomenon should be distinguished from cervical stiffness. Dyspnea is more important for pneumonia than faster breathing.

(5) The chest signs of fine wet rales fixed in the lungs may not be obvious in the early stage or the breathing sounds may be rough or slightly reduced. Later, fixed medium, fine wet rales or twisted sounds can be heard and often heard when crying and deep breathing. . It is more obvious on the lower sides of the back and on both sides of the spine at the end of deep inhalation. The percussion is normal or there is a slight percussion dullness or reduced breathing sounds. However, when the lesion fusion enlarges and involves part or the entire lung lobe, corresponding signs of pulmonary consolidation may appear. If there is significant percussion dullness and / or reduced breathing in one lung, consideration should be given to the presence of pleural effusion or empyema.

2. Severe pneumonia

In addition to severe involvement of the respiratory system, severe pneumonia can also affect the circulatory, nervous, and digestive systems, and the corresponding clinical manifestations appear:

(1) Respiratory failure Due to severe hypoxia and toxemia, one month-old to 5-year-old child who has one of the manifestations of chest wall inhalation depression or wing flap or moaning, suggesting hypoxemia, which is severe pneumonia Blood gas analysis is required in a timely manner. Irritability in children with pneumonia indicates that hypoxia is likely, and those who are hypoxic may have no cyanosis.

(2) Common heart failure in children with severe pneumonia of the circulatory system is manifested as: the breathing rate suddenly increases at a quiet state, exceeding 60 beats per minute; the heart rate suddenly increases, greater than 160 to 180 beats per minute; sudden extreme irritability Uneasy, obvious cyanosis, gray complexion, prolonged filling time of toenails microvessels; the above three items cannot be explained by fever, pneumonia itself and other complications. The heart sounds are dull, the horse runs rhythm, the jugular vein is swollen; The liver is significantly enlarged or rapidly enlarged in a short time; oliguria or anuria, facial eyelids or edema of both lower limbs. Some scholars believe that the above symptoms are only manifestations of pneumonia, and those who cannot be explained by other reasons should consider heart failure, finger vein filling, or facial and limb edema, which are signs of congestive heart failure. Sometimes limbs are cold, gray around the mouth, and weak pulses are signs of peripheral circulatory failure.

(3) The following symptoms and signs of the nervous system after confirming pneumonia may be considered as hypoxic toxic encephalopathy: irritability, drowsiness, eyeball channeling, staring; bulbar conjunctival edema, anterior condylar bulge; lethargy, coma, Convulsions; pupil changes: dull or disappeared response to light; respiratory rhythm irregularity, respiratory heartbeat dissociation (with heartbeat, no breathing); meningeal irritation, cerebrospinal fluid examination is normal except for increased pressure. On the basis of pneumonia, febrile seizures, hypoglycemia, hypocalcemia, and central nervous system infections (encephalitis, meningitis) are excluded. If items and indicate cerebral edema, a diagnosis can be made with more than one.

(4) Digestive system When severe hypoxic toxic intestinal paralysis occurs, frequent vomiting, severe abdominal distension, increased dyspnea, and auscultatory bowel sounds disappear. Severe children can also vomit coffee-like substances, positive fecal occult blood or tar-like stools.

(5) Antidiuretic hormone abnormal secretion syndrome blood sodium 130mmol / L, blood osmotic pressure <275mmol / L; increased renal sodium excretion, urinary sodium 20mmol / L; clinically no hypovolemia, normal skin elasticity Molar osmolarity is higher than blood osmolarity; Renal function is normal; Adrenal cortex function is normal; ADH is increased. If ADH does not rise, it may be diluted hyponatremia. SIAHD and toxic encephalopathy sometimes behave similarly, but the treatment is completely different.

(6) Disseminated intravascular coagulation (DIC) can manifest as decreased blood pressure, cold limbs, weak pulse rates, and bleeding from the skin, mucous membranes, and gastrointestinal tract.

Pediatric bronchial pneumonia examination

(A) peripheral blood test

1. Peripheral white blood cell count and differential count

It is valuable for judging bacteria or viruses. Bacterial pneumonia has an increased white blood cell count, increased neutrophils, and a nuclear shift to the left. Poisonous granules may be present in the cytoplasm. Most of the white blood cell counts of viral pneumonia are normal or low, and there are also a few people who have elevated lymphocytes, sometimes with increased lymphocytes or variant lymphocytes. Most patients with Mycoplasma infection have normal or high peripheral white blood cell counts, and are classified mainly by neutrophils. However, in severe Staphylococcus aureus or Gram-negative pneumonia, the white blood cell count can increase or decrease.

2.C-reactive protein (CRP)

The serum CRP value increased mostly during bacterial infection, but it was not significantly increased during non-bacterial infection.

3. Procalcitonin (PCT)

It can rise when bacterial infections occur, and can decrease rapidly when antibacterial treatment is effective. However, for children with pneumonia, these indicators cannot be used alone or in combination to predict bacterial or viral infections, and comprehensive judgments must be made in combination with clinical history and other laboratory tests.

(Two) specific pathogen examination

Bacteriological examination

(1) Bacterial culture and smears Take tracheal aspirate, alveolar lavage fluid, pleural fluid, pus, and blood samples for bacterial culture and identification, and conduct drug sensitivity tests at the same time to guide the identification of bacterial pathogens and treatment. Can also be used for smear staining microscopy and preliminary screening test.

(2) Other tests, such as serological detection of streptococcus pneumoniae capsular polysaccharide antibody level, bacterial antigen detection such as streptococcus pneumoniae capsular polysaccharide antigen, hemolysin antigen, HI antigen, etc.

2. Virological examination

(1) Virus isolation Virus isolation from infected lung tissues, bronchoalveolar lavage fluid, and nasopharyngeal secretions is a reliable method for viral pathogen diagnosis.

(2) Serological test In the acute phase and the recovery phase (after 14 days), double serum was used to determine the specific immunoglobulin G (IgG) antibody level. If the antibody was raised 4 times, it was positive. But because it takes too long, it can only be used as a comparison between retrospective diagnosis and other methods, which limits its practical application. Elevated specific immunoglobulin M (IgM) in serum can be diagnosed early. Specificity can be found with throat swabs, nasopharyngeal secretions, tracheal aspirates, or alveolar lavage fluid smears, or after rapid culture using virus-specific antibodies (including monoclonal antibodies) immunofluorescence, immunoenzyme or radioimmuno Sex virus antigen.

3. Other pathogenic examinations

(1) Mycoplasma pneumoniae Condensation set test 1: 32 is of great reference value. This test is non-specific and can be used as a screening test; but the traditional cold agglutinin test has certain diagnosis of Mycoplasma pneumoniae (MP) infection. Value, but its sensitivity and specificity are insufficient, specific diagnosis: including MP isolation and culture or specific IgM and IgG antibody determination. Detection of complement-binding antibodies is a common method for the diagnosis of MP; gene probes and polymerase chain reaction (PCR) technology have strong specificity and sensitivity for MP detection, but contamination should be avoided.

(2) Chlamydia Chlamydia that can cause pneumonia are Chlamydia trachomatis (CT), Chlamydia pneumonia (CP), and Chlamydia psittaci. Cell culture is used to diagnose CT and CP. CT can be checked by direct immunofluorescence or Giemsa staining. Other methods include enzyme-linked immunosorbent assay, radioimmunoelectrophoresis to detect duplicate serum-specific antibodies or antigens, nucleic acid probes, and PCR technology. Detection of antigen.

(Three) X-ray inspection

The etiology of bronchial pneumonia is different, so the changes shown on the X-ray have both common points and their own characteristics. In the early stage, the texture of the lungs was enlarged, and small patchy shadows later appeared. Most of the lungs were in the lower field, mid-inner zone, and palpitations, and may be accompanied by atelectasis or emphysema. Patchy shadows can also be merged into large patches. And even the entire segment.

Lesion shape

Bronchial pneumonia is mainly an inflammatory exudation in the alveoli, which often spreads along the bronchi and invades the leaflets, lung segments or lobules. X-ray signs can be non-specific small patchy infiltrates of lung parenchyma, which are more common in the two lungs, palpitations, and mid-inner bands. This change is common in infants under 2 years of age, and small patch lesions can partially Blended together into a large sheet of infiltrates, which can even resemble the segment or lobar pneumonia. If there are many small round lesions in the lesion, it should be considered that there may be multiple mixed purulent infections.

2. Atelectasis and emphysema signs

Because bronchial secretions and exudates of pneumonia are blocked, partial atelectasis or emphysema can occur. Emphysema is one of the early common signs in children with pneumonia. The more severe the symptoms of poisoning, the more obvious emphysema. The chance of vesicular emphysema and mediastinal emphysema during the course of the disease is more common than adults.

3. Pulmonary interstitial X-ray sign

The infant's lung interstitial tissue develops well. When suffering from bronchial pneumonia, some X-ray signs of the lung interstitial can appear, and the inner lungs often have increased texture and blur. These X-ray signs can be seen in the interstitial inflammation of the lung caused by influenza virus pneumonia, measles virus pneumonia, and pertussis pneumonia.

4. Hilar X-ray sign

Most of the local lymph nodes around the hilum are not enlarged or show only darkened hilar shadows, or even moist around the hilar.

5. X-ray sign of pleura

Pleural changes are rare, and one-sided or bilateral pleurisy or pleural effusion can sometimes occur. Although the X-ray manifestations of bronchial pneumonia of various etiologies have similarities, they are not the same. Therefore, we must grasp the X-ray manifestations of various pneumonias and closely combine clinical symptoms to make a correct diagnosis.

Diagnosis of bronchial pneumonia in children

According to typical clinical symptoms, combined with X-ray chest radiography, diagnosis is not difficult. Bronchial pneumonia can be diagnosed on the basis of acute onset, fever, cough, shortness of breath, fixed middle and fine wet rales in the lungs, and changes in chest imaging with pneumonia.

Pediatric bronchial pneumonia treatment

Comprehensive treatment is adopted. The principles are to control inflammation, improve ventilation, symptomatic treatment, and prevent and treat complications.

Nursing

The ward should maintain air circulation, and the room temperature should be maintained at about 20 ° C, and the humidity should be 60%. Give adequate amounts of vitamins and protein, drink plenty of water, and eat several times in small quantities. Keep the airway unobstructed, clear the upper airway secretions in time, change positions frequently, reduce pulmonary congestion, and facilitate the absorption of inflammation and the discharge of sputum. To avoid cross-infection, mild pneumonia can be treated at home or out-patients. Hospitalized children should be separated as far as possible from acute and recovery, and bacterial and viral infections should be separated.

2. Oxygen therapy

There are hypoxia manifestations, such as irritability and irritation when the mouth is cyanotic. Use nasal vestibular catheters to give oxygen. The flow of humidified oxygen is 0.5 to 1 liter / minute, and the oxygen concentration does not exceed 40%. Newborns or infants can use a mask, oxygen tent, and nasal congestion to supply oxygen. The oxygen flow rate of the mask is 2 to 4 liters per minute, and the oxygen concentration is 50% to 60%. Children on oxygen therapy should monitor body temperature, pulse, number of breaths, and pulse oxygen saturation at least every 4 hours.

3. Anti-infective treatment

(1) Principles of antibacterial drug treatment : Select sensitive drugs according to pathogenic bacteria: Before using antibacterial drugs, appropriate respiratory secretions should be collected for bacterial culture and drug sensitivity tests to guide the treatment; before culture results are obtained, they can be selected based on experience Sensitive drugs; The selected drug should have a higher concentration in the lung tissue; Early medication; Combined medication; Full amount and foot treatment. Severe children should be combined with intravenous medication.

Community-acquired pneumonia (CAP) antibacterial treatment should be limited to bacterial pneumonia, mycoplasma pneumonia, chlamydia pneumonia, fungal pneumonia, etc. There is no indication of antibacterial drugs for simple viral pneumonia, but it is necessary to pay attention to the mixture of bacteria, viruses, mycoplasma, chlamydia, etc. Likelihood of infection. Children under 3 months have the possibility of Chlamydia trachomatis pneumonia, and mycoplasma pneumoniae and Chlamydia pneumoniae pneumonia are higher in those over 5 years old, so macrolides are preferred, especially the new generation of macrolides, which have a broad antibacterial spectrum. Can cover most children's CAP pathogens. For the treatment of CAP antibacterial drugs at the age of 4 months to 5 years, especially in severe cases, the pathogenic bacteria should be considered to be macrolide-resistant Streptococcus pneumoniae, and large doses of amoxicillin or cephalosporin can be preferred.

For fungal infections, antibiotics and hormones should be stopped. Nystatin may be used for nebulization and inhalation. Clotrimazole, dafukang, or amphotericin B may also be used.

(2) Antiviral therapy Influenza virus: Ostavir, zanamivir, and panamivir are inhibitors of neuraminidase, which are effective against influenza virus types A and B. Amantadine and rimantadine are M2 membrane protein ion channel blockers and are only effective against influenza A viruses. Ribavirin (ribavirin) can be administered by nasal, aerosol inhalation, intramuscular injection and intravenous drip, and can inhibit a variety of RNA and DNA viruses; -interferon (IFN-), 5 to 7 days as a course of treatment, Can also be aerosolized. Ganciclovir is guanosine, which is the first-line medication for cytomegalovirus infection in children.

4. Symptomatic treatment

(1) Airway management Remove nasal diarrhea, nasal secretions, and sputum in time to keep the airway open and improve ventilation. Humidification of the airways is very important, which is conducive to the discharge of sputum, and aerosolized inhalation helps to relieve bronchospasm and edema. Secretion accumulates in the lower respiratory tract and cannot be ruled out by humidification and atomization. When exacerbating respiratory failure, intubation should be performed to facilitate removal of sputum. In severe cases, mechanical ventilation (respirator) should be used for a short period of time. Those receiving mechanical ventilation should pay particular attention to humidification of the airway, changing position and patting the back to maintain airway humidity and patency.

(2) Treatment of abdominal distension Children with hypokalemia should be supplemented with potassium salts. In case of toxic intestinal palsy, fasting and gastrointestinal decompression should be used, and phentolamine plus 5% glucose and 20ml intravenous infusion can be used.

(3) Other children with high fever can use physical cooling; apply cold packs on the armpits, groin, and head; orally take acetaminophen or ibuprofen. If accompanied by irritability, intramuscular injection of chlorpromazine, promethazine, or intramuscular injection of phenobarbital can be given.

5. Glucocorticoids

Glucocorticoids can reduce inflammation and exudation, relieve bronchospasm, improve vascular permeability and microcirculation, and reduce intracranial pressure. The indications for use are: severe wheezing or respiratory failure; the symptoms of systemic poisoning are obvious; combined toxic shock with infection; cerebral edema occurs. The above conditions can be short-term application of hormones, hydrocortisone succinate or dexamethasone can be added to the bottle for intravenous drip, the course of treatment is 3 to 5 days.