Pneumonia in the elderlyDefinition: inflammation of lung parenchyma the elderly. Caused by a variety of pathogens such as bacteria, viruses, fungi, parasites. Others such as radiation, chemical, allergic factors can also cause pneumonia.
* Due to the lung parenchyma, and interstitial lung function in the distinction between anatomy and other organs as well, it also includes interstitial pneumonia, inflammation of the former is commonly used in English pneumonia, the latter with pneumonitis
Pathogens causing pneumonia in the elderly often refers to inflammation of the lung parenchyma Medical Education Network. Of which the most common bacterial infection.
For a long time, pneumonia has been considered the major health problems affecting the elderly, Hourmann and Dechambre in 1835 published a series entitled "The elderly pneumonia," the article, about 20 years after the classic description of the disease Laennec. Olser he edited the first edition of the textbook that pneumonia is the "special old enemy", in its third edition is called "old friend."
Category collected Medical Education Network
Cause categories: bacterial pneumonia viral pneumonia, mycoplasma pneumonia of fungal pneumonia caused by other pathogens
Anatomy Category: lobar (alveolar) lobular pneumonia (bronchial) pneumonia interstitial pneumonia
Pneumonia took place at the time were divided into: Social-acquired pneumonia (community-acquired pneumonia, CAP) and nosocomial pneumonia
(nosocomial pneumonia, NP), also known as nosocomial pneumonia (hospital-aquired pneumonia, HAP)
Epidemiology and risk factors collected Medical Education Network
1921-1930 Massachusetts state analysis shows that 44,684 cases of pneumonia, pneumonia calculated by the population age of 70 years age group is 10-year-old age group 5 times, the mortality rate of up to 100 times. The incidence of pneumonia in the age of 20 after 10 years of age for each increase, the incidence rate increased by 10%. These studies before the era of antibiotics, their susceptibility to treatment with modern science has nothing to do with age.
The application of antibiotics, has completely changed the statistics, the recent population survey of a Houston, 3 years, pneumonia hospitalization rates over 65 years old to 30 ~ 60 / million, while the other age group 5 to 15 / million. Refound that 25 to 60% of the elderly suffering from lower respiratory tract infection.
Many factors have led to increased incidence of pneumonia in the elderly. Clearly the most important factor is the flu. Lower respiratory tract infection caused by concurrent high-risk because of: long-term smoking, COPD, congestive heart failure, cerebrovascular disease, cancer, diabetes, malnutrition.
Etiology and Pathogenesis
The main pathogens causing pneumonia in the elderly is a bacteria. Community-acquired pneumonia (CAP) is a common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, aerobic gram-negative bacilli, Staphylococcus aureus, the card he Mora monocytogenes. Influenza A, B virus, respiratory syncytial virus (RSV), Chlamydia can cause infection, Legionella is often found. Pathogens of nosocomial pneumonia in the elderly is mainly Gram-negative bacilli (GNB), about 80%, Pseudomonas aeruginosa (P. aeruginosa) the most, followed by Enterobacter, Klebsiella pneumoniae and Proteus, etc.: About 20% of Gram-positive cocci to S. aureus is more common, and mostly methicillin-resistant Staphylococcus aureus (MRSA) strains. Other pathogens include fungi and viruses.
Predisposing factors of pneumonia in the elderly are:
Changes in the elderly respiratory anatomy and physiology, and organ dysfunction with age, osteoporosis, kyphosis, and rib cartilage calcification, intercostal and accessory muscle atrophy, thoracic activity limitation, by the flat chest into a barrel chest that lung function decline; tracheobronchial mucociliary dysfunction; swallowing and aspiration hazard to increase glottal often uncoordinated; poor cough reflex, decreased elasticity of lung tissue as a result of reduced expectoration function.Defense and immune dysfunction, the elderly in the aging process, decrease the barrier function of skin and mucous membranes; immune senescence in the elderly pneumonia important reason for increased mortality may be related to T cells in the immune response weakens; the same time the level of humoral immunity reduction related.
Increase in the normal bacterial colonization of oropharyngeal oropharyngeal a large number of normal flora, including aerobic and anaerobic bacteria colonization, generally in many cases can stop dwelling pathogens, such as the G-bacteria appeared only temporary, and occurs rate of less than 2% over the age of 65 G-bacilli isolation rate of 20%, and other pathogenic bacteria detection rate has also increased. Parasite of the upper respiratory tract infection in the lungs caused by inhalation is the main pass.Increased weakness of oropharyngeal bacteria, based on the respiratory system diseases, paralysis, cancer, those with broad-spectrum antibioticsClinical features of pneumonia in the elderly:
* Occurred on the underlying disease; * atypical clinical symptoms;
* Non-respiratory symptoms are sometimes more prominent;Sudden onset, cough, expectoration, fever, chest pain and signs of pulmonary consolidation of these young people the primary clinical manifestations of pneumonia in the elderly rare. The performance of any of the above may appear, but usually not obvious, and insidious onset, the performance deterioration of the health status of non-specific. Often "elderly patients" formula appears: the state of consciousness decreased, activity decreased physical and psychological discomfort and social failure, there are lethargy, loss of appetite, nausea, vomiting, diarrhea, decreased thirst, pain reduction and low heat, and the concomitant other diseases. Pneumonia and other diseases easily overshadowed by the clinical manifestations.
Clinical diagnosis: Chinese Medicine in 1999 made life would be community-acquired pneumonia (CAP) and hospital acquired pneumonia (HAP) diagnosis and treatment guidelines (draft) CAP, HAP, and the diagnostic criteria for severe pneumonia.
The clinical diagnosis of CAP based on
Emerging cough, sputum, or the original respiratory symptoms increased, and the emergence of purulent sputum; with or without chest pain.
Signs of pulmonary consolidation and (or) moist rales. 10 109 / L or <10 109 / L with or without a left shift.
Chest X-ray examination showed sheets, patchy interstitial infiltration shadow or change with or without pleural effusion.
The clinical diagnosis of CAP based on
Under the above item 1 to 4 plus any fifth, and except for tuberculosis, lung cancer, non-infectious interstitial lung disease, pulmonary edema, atelectasis, pulmonary embolism, pulmonary eosinophil infiltration, pulmonary Vascular go far, clinical diagnosis can be established.
Clinical diagnosis is based on HAP
There is no admission of patients, nor in latency of infection, and 48 hours after the occurrence of pneumonia in the hospital. With the clinical diagnosis of CAP.
The clinical diagnosis based on severe pneumonia
When the patients diagnosed pneumonia, the following symptoms may be considered a diagnosis of severe pneumonia:PaO2 <60mmHg, PO2/FiO2 <300, the need for mechanical ventilation;The clinical diagnosis based on severe pneumonia
Chest radiograph showed bilateral or multi-lobe involvement, or lesions within 48 hours of hospitalization by 50%;
Oliguria: urine output <20ml / h or 80mml/4h, or acute renal failure requiring dialysis;
There pulmonary infection focus, such as septicemia, meningitis.
The onset of these late-onset pneumonia (hosp 5 days of mechanical ventila 4 days) and the presence of risk factors, even if not fully meet the required standards of severe pneumonia, is also regarded as severe.
Sputum smear specimen collection to facilitate analysis of etiological diagnosis of significant value. Qualified sputum specimens: polymorphonuclear c 25 / low magnification, squamous epithelial cells <10 / low magnification. Diagnosis of sputum Gram stain and sputum culture specimens were the result of a lot of consistency, on the pneumococcal, influenza, staphylococcus, and smear immunofluorescence method in the diagnosis of Legionella value. Diagnosis of pneumonia, sputum culture, the credibility is very small, because the elderly is difficult to be satisfied with the results of false-positive sputum specimens and, therefore, should be repeated Sputum smear and improve credibility.Chest X ray diagnosis of pneumonia is extremely important
The emergence of new invasive lung lesions can be diagnosed
Yue performance to lobular inflammation or bronchial pneumonia majority, accounting for about 80%, followed by lobar pneumonia and interstitial pneumonia; the following lung field is more common.
Chest X-ray examination can provide the basis for the diagnosis and differential diagnosis of chest plain film pulmonary infiltrates and pneumonia is an important method.
Lung CT can often provide more detailed information on pulmonary infiltrates.About 10% of elderly patients with pneumonia to the specificity of blood culture pathogens, detachable, and few treatment misleading.Bronchoscopy (fibreoptic bronchoscopy) Check
Transthoracic needle aspiration (transthoracic needle aspiration, TNA) samples
Attracted by the trachea (transtracheal aspiration, TTA) samplingBlood biochemistryWith congestive heart failure, pulmonary shadow identification
Around the lung fields and pulmonary embolism caused by the infiltration of segmental uniform, looks like pneumonia
Identification and pulmonary hemorrhage
And atelectasis caused by alveolar infiltrates identificationNow that early diagnosis and supportive care and effective antibiotic treatment, is the best measure.
I. General measures
Diet and nutrition, appropriate activity or bed rest
Correcting water, electrolyte imbalance
Second, anti-infection treatment
Antibiotic use principles: early enough, drug selection for pathogens, severe combined treatment
The characteristics of older drugs: antibiotics, must take into account changes in age and physiological functions.
Such as renal function decreased with age and body mass decreased, the choice of the role of the kidney toxic drugs such as aminoglycosides, vancomycin and other antibiotics, and from the renal excretion of drugs such as most of the cephalosporins, penicillin, etc., should consider dosage regimen to prevent drug nephrotoxicity; use of antibiotics in the liver metabolism, such as erythromycin, chloramphenicol, penicillin and other cefoperazone and ethoxy naphthalene removal from the liver, the liver should be considered in the clearance of drugs capacity;
Commonly used antibiotics and the treatment of the elderly, such as warfarin, digitalis exists between the role of various latent phase, should be aware of;
Should pay attention to age-related antibiotic-associated colitis;
Third, the choice of antibiotics
Antibiotic treatment is the cause of bacterial pneumonia treatment. As long as the diagnosis established, treatment should begin.
The initial experience of drug treatment the treatment should consider the following aspects: a common etiology of various cases; general and efficacy of antibacterial drugs; drug toxicity; drug prices.
By pathogen-specific information, the promise to improve disease-free, you need to replace antibiotics.
Several new antibiotics
Third-generation cephalosporin - lactamase inhibitor (such as clavulanic acid, sulbactam)Carbapenems such as imipenem (imipenem), meropenem
Cephamycin, aztreonam (bacteria g single)These drugs reduce mortality in patients with severe pneumonia in the elderly is very promising and will continue to research.