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Pneumonia |
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肺 炎 |
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BRONCHOPNEUMONIA |
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支氣管肺炎 |
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It may occur in previously normal lungs or be superimposed on underlying bronchitis or other respiratory disease, e. g. bronchiectasis or carcinoma. It is preceded by bronchial infection and is commonest in children (measles and whooping cough) and the elderly (chronic bronchitis and hypostatic pneumonia in debilitated patients in bed). In normal adults it may follow respiratory viral infections. |
可以發(fā)生在原來正常的肺，亦可在原有支氣管 炎或其他呼吸道疾病(例如支氣管擴(kuò)張癥或肺癌)的 基礎(chǔ)上再發(fā)生本病。發(fā)病之前有支氣管感染，這在兒童(麻疹及百日咳)及老年人(慢性支氣管炎及臥 床不起者的體位性肺炎)最常見。在正常成年人可 在呼吸道病毒感染之后發(fā)生。 | |
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Clinical presentation |
臨床表現(xiàn) | |
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The history is initially often of acute bronchitis. Fever and malaise develop with a cough producing infected (yellow or green) sputum. On examination, coarse crepitations may be areas of consolidation with dullness to percussion, increased vocal resonance and bronchial breathing. |
病史上常以急性支氣管炎發(fā)病，出現(xiàn)發(fā)熱，不 適，并咳膿痰(黃或綠色)。體檢有粗的水泡音，部分肺野可能有實(shí)變，叩診實(shí)音，語音共振增強(qiáng)，并有支氣管性呼吸音。 | |
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Investigation |
檢查 | |
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Diagnosis is confirmed on chest X-ray. Blood cultures should be sent. Sputum should be sent for culture and Gram stain before starting antibiotics. These should not be withheld until sensitivities are available. |
胸部X線檢查可確診。應(yīng)送血培養(yǎng)，在開始抗 生素治療之前應(yīng)送痰培養(yǎng)及革蘭染色檢查，但不必 等敏感試驗(yàn)的結(jié)果出來后再行治療 | |
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Management Haemophilus influenzae and Streptococcus pneumoniae are the most common organisms but other bacteria (e.g. klebsiella and staphylococcus) may be responsible. Initial therapy involves the use of: (1) Oxygen--28% in the presence of respiratory chronic failure. (2) Antibiotics - erythromycin, amoxicillin or trimethoprim in the first instance. (3) Physiotherapy. |
處理 最常見的致病菌是流感嗜血桿菌及肺炎鏈球菌，但亦可由其他細(xì)菌(例如克雷白桿菌及葡 萄球菌)引起。開始時(shí)可用以下方法治療：(1)氧氣，有慢性呼吸衰竭出現(xiàn)時(shí)可給氧(28％)。(2)抗生素， 最先可用紅霉素，羥氨芐青霉素或甲氧芐氨嘧啶。 (3)理療。 | |
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Important predisposing causes should be considered including diabetes mellitus and carcinoma of the bronchus. Complications include lung abscess, pleural effusion and empyema. |
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LOBAR PNEUMONIA |
大葉性肺炎 | |
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This has become less common since the advent of penicillin. |
自從青霉素問世以后，大葉肺炎已不常見。 | |
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Clinical presentation |
臨床表現(xiàn) | |
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The onset is sudden with cough, rusty sputum, marked fever and rigors. There are signs of consolidation if a large area of lung is involved. Vesicles of herpes simplex occur around the lips. Chest X-ray shows consolidation in lobar distribution. Cerebral abscess is a rare complication. The pneumococcus is particularly dangerous to the splenectomised patient.醫(yī)學(xué)全.在.線www.zxtf.net.cn |
突然發(fā)病，咳嗽、咳鐵銹痰，高熱及寒顫。如果一大片肺被侵犯則有實(shí)變征。唇部可發(fā)生單純皰疹。胸部X線檢查見有呈大葉性分布的實(shí)變陰影。腦膿腫是較少見的合并癥。對脾切除患者，肺炎雙球菌(感染)是特別危險(xiǎn)的。 | |
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Management |
處理 | |
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The organism most frequently cultured from sputum and blood is S. pneumoniae (pneumococcus) and this responds to i. m. crystalline penicillin (1-2 million units 6-hourly) which is the drug of first choice. |
從血及痰中培養(yǎng)出的細(xì)菌最常見的是肺炎雙球 菌，肌內(nèi)注射青霉素有效(100～200萬uq6h)，故作為首選藥物。 | |
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NB Lobar consolidation, particularly with loss of volume on chest X-ray, may indicate an underlying bronchial obstruction, e. g. neoplasm, foreign body. |
注意 大葉實(shí)變，特別是X線檢查有肺不張，可能提示有潛在支氣管阻塞性疾患(例如新生物，異物)。 | |
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OTHER BACTERIAL PNEUMONIAS |
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Klebsiella pneumoniac (Fried!~nder's). This is rare and often opportunistic in patients with leukaemia, lymphomas or on steroids. The history is of sudden prostration, fever, rigors and cough with blood-stained viscous sputum. The chest X-ray 'shows patchy areas of consolidation, often involving the upper lobe. The mortality is high (40%) and subsequent respiratory disability common. |
克雷白桿菌肺炎 罕見，偶可發(fā)生于白血病，淋巴瘤或激素治療的患者�；颊卟∏橥蝗粣夯l(fā)熱，寒顫，咳嗽并有帶血的粘痰。胸部X線可見片塊狀實(shí)變區(qū)常累及上葉。死亡率高(占40％)�；颊咴谝院蟪Ｓ泻粑δ墚惓�。 | |
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The bacillus is not penicillin or ampicillin sensitive. It responds to streptomycin, chloramphenicol and with some strains, tetracyclines. Lung abscess and bronchiectasis are common complications. |
本菌對青霉素及氨芐青霉素不敏感，用鏈霉素、氯霉素有效。有些菌株用四環(huán)素有效。常合并肺膿腫及支氣管擴(kuò)張癥。 | |
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Staphylococcal pneumonia This produces widespread infection with abscess formation. It occurs in patients with underlying disease which prevents normal response to infection, e.g. chronic leukaemia. Hodgkln's disease, cystic fibrosis, and patients on steroid therapy. It may complicate influenzal pneumonia and this makes it relatively common during epidemics of influenza. The organism may not be penicillin sensitive, so flucloxacillin is the drug of choice. Lung abscess, empyema and subsequent bronchlectasis are relatively common complications. |
葡萄球菌肺炎 它引起廣泛的感染和形成膿腫。常發(fā)生在有潛在疾患的病人，因?yàn)檫@些病妨礙了他們對感染的正常反應(yīng)，例如慢性白血病、何杰金病、囊性纖維化，以及激素治療的病人都常發(fā)生。可以并發(fā)流感肺炎，因而在流感流行時(shí)較常見。本菌可能對青霉素不敏感，因而可選用氟氯苯唑青霉素治療。較常見的合并癥有肺膿腫、膿胸及隨后發(fā)生的支氣管擴(kuò)張癥。 | |
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LEGIONNAIRE'S DISEASE |
軍 團(tuán) 病 | |
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This was first described ill a group of American army veterans (legionnaires). It begins as an influenza-like illness with fever, malaise and myalgia and proceeds with cough (little sputum). dyspnoea and sometimes severe anoxia, marked confusion and coma. Diarrhoea and vomiting are common and renal failure may develop. Examination shows consolidation which usually affects one or both lung bases. Radiological changes may persist for more than 2 months after the acute illness. The bacterium is the Gramnegative bacillus Legionella pneumophila and the diagnosis confirmed by a rising antibody titre. |
本病首先報(bào)道是在一組美國陸軍退伍軍人中發(fā)生。發(fā)病時(shí)好似流感，有發(fā)熱、乏力及肌痛，以后發(fā)生咳嗽(痰少)、氣急。有時(shí)嚴(yán)重缺氧，顯著的精神錯(cuò)亂及昏迷。常有腹瀉及嘔吐，且可發(fā)展為腎功 能衰竭。檢查可見實(shí)變，常波及一側(cè)或雙側(cè)肺底部。X線改變在急性病變后可持續(xù)2個(gè)月以上。本病由革蘭陰性的需氣軍團(tuán)桿菌所引起，抗體滴定度升高可確定診斷。醫(yī)學(xué)全.在線提供 | |
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Erythromycin or tetracycline are the antibiotics of choice but the mortality remains high (20%). |
可選用紅霉素或四環(huán)素治療，但死亡率仍高 (占20％)。 | |
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NB Legionnaire's disease (and Mycoplasma pneumoniae or psittacosis) should be suspected in all patients who develop atypical pneumonia which does not respond to standard antibiotics especially after travel away from home—often to the Mediterranean. |
注意 凡患有非典型肺炎而對標(biāo)準(zhǔn)的抗生素治療無效，特別是離家出外旅行的患者——通常是到地中海地區(qū)，應(yīng)疑患軍團(tuán)病(及肺炎支原體肺炎或鸚鵡病)。 | |
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RECURRENT BACTERIAL PNEUMONIA |
復(fù)發(fā)性細(xì)菌性肺炎 | |
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In the absence of chronic bronchitis, recurrent pneumonia arouses the suspicion of: (1) Bronchial carcinoma preventing drainage of infected areas of the lung. (2) Bronchiectasis (including fibrocystic disease). (3) Achalasia of the cardia, 25% of which present as chest disease; pharyngeal pouch and neuromuscular disease of the oesophagus, e. g. bulbar palsy, (4) Hypogammaglobulinaemia and myeloma. |
如果患者沒有慢性支氣管炎而再發(fā)生肺炎，應(yīng)考慮：(1)支氣管癌妨礙了肺感染部位的引流。(2)支氣管擴(kuò)張癥(包括纖維囊性疾病)。(3)胃賁門松弛不良患者，25％表現(xiàn)為胸部疾患，咽袋及食管的神經(jīng)肌肉病(例如延髓麻痹)。(4)低γ-球蛋白血癥及骨髓瘤。 | |
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VIRAL PNEUMONIA |
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The most common virus producing pneumonia in children in this country and the USA is the respiratory syncytial virus (so called as it is a respiratory virus which produces syncytium formation when grown in tissue culture). The agent is not responsive to antibiotics and it may be indistinguishable from acute bacterial bronchitis or bronchiolitis in children and infants. The presence of an associated skin rash supports the likelihood of RSV infection. |
在英美的兒童中，最常見的肺炎病毒為呼吸道合胞病毒(之所以用這個(gè)名稱是因?yàn)樵摬《驹诮M織培養(yǎng)時(shí)可以形成合胞體)。本病用抗生素?zé)o效。在嬰兒及兒童患者，與急性細(xì)菌性支氣管炎或細(xì)支氣管炎不易區(qū)別。如果患者同時(shí)出現(xiàn)皮疹，則支持呼吸道合胞病毒感染。 | |
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Acute virus pneumonia in adults is very rare and occurs during epidemics of influenza A (Asian' flu). The picture is of rapid and progressive dyspnoea. Death may occur within hours from acute haemorrhagic disease of the lungs. The most common cause of pneumonia during epidemics of influenza results from secondary bacterial infection, the most serious being staphylococcal pneumonia. The viruses of measles, chickenpox, and herpes zoster may directly affect the lung. The diagnosis is confirmed by a rise in specific antibody titre. |
成人的病毒性肺炎極罕見，有時(shí)在A型流行性感冒(亞洲型流感)流行時(shí)發(fā)生。臨床表現(xiàn)為迅速發(fā)生氣急，并進(jìn)行性加重�？赡芤蚣毙苑纬鲅约膊《跀�(shù)小時(shí)內(nèi)死亡。在流感流行時(shí)發(fā)生的肺炎，最常見的病因是繼發(fā)性細(xì)菌感染，最嚴(yán)重的是葡萄球菌性肺炎。麻疹、水痘及皰疹病毒可直接侵犯肺。特異性抗體滴定度升高可確定診斷。 | |
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MYCOPLASMA PNEUMONIA |
肺炎支原體肺炎 | |
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This is caused by Mycoplasma pneumoniae, the only mycoplasma definitely pathcgenic to man. The clinical picture resembles bacterial pneumonia although cough and sputum are absent in one-third of cases. |
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病因?yàn)榉窝字гw，是能使人致病的唯一支原體。臨床表現(xiàn)類似細(xì)菌性肺炎，但l／3患者可不咳、無痰。 |
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Respiratory symptoms and signs and. X-ray changes (patchy consolidation with small effusions) are usually preceded by several days of flu-like symptoms. Polyarthritis occurs and may persist for months. Malaise and fatigue may persist long after the acute illness is over. The diagnosis is confirmed by a rise of specific antibody titre, the presence of cold agglutinins and antibodies to Mycoplasma in the serum and/or isolation of the organism. Tetracycline (0.5--1.0gqds) is the antibiotic choice. Psittacosis and ornithosis (Bedsoniae) may cause a similar picture and also respond to tetracycline, though diarrhea is commoner. |
在出現(xiàn)呼吸道癥狀及X線征狀的前幾天常有流感樣癥狀。X線表現(xiàn)為片塊狀實(shí)變及小量積液。可有多發(fā)性關(guān)節(jié)炎，并持續(xù)數(shù)月。不適及疲乏在急性期后可持續(xù)甚久。如特異性抗體滴定度升高，血清中存在冷凝集素，支原體抗體或分離出支原體(或同時(shí)出現(xiàn)后兩者)，可確診為本病�？蛇x用四環(huán)素治療(每次0．6一1．0g，每日4次)。鸚鵡熱及鳥病毒病(衣原體屬)的臨床表現(xiàn)與之相同。用四環(huán)素亦有效，但腹瀉較常見。 | |
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OPPORTUNISTIC INFECTION OF THE LUNGS |
機(jī)遇性肺部感染 | |
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This is seen in immunosuppressed patients usually on steroids, azathioprine, or cytotoxic agents following transplantation or for leukaemia or lymphoma. The range of organisms found is very wide and includes bacteria (Pseudomonas M. tuberculosis, E. coli), fungi (Aspergillus, Monilia, Cryptococcus). Viruses (Cytomegalo-Virus. Herpes zoster) and Pneumocystis carinii. It is important to attempt to isolate the organism from the sputum and to carry out blood culture, endobronchial brush biopsy, and/or percutaneous lung biopsy. Treatment should not be delayed, because the prognosis is very poor. |
在免疫受到抑制的病人可發(fā)生此病，患者因移植、白血病或淋巴瘤而常應(yīng)用激素、硫唑嘌呤或細(xì)胞毒類藥物治療者。致病微生物的范圍很廣泛，包括細(xì)菌(假單胞菌屬、結(jié)核桿菌，大腸桿菌)，真菌(曲霉屬、念珠菌屬、隱球菌屬)，病毒(巨細(xì)胞病毒、皰疹病毒)及卡氏肺囊蟲。努力從痰中分離出致病的微生物極為重要，送血培養(yǎng)，支氣管刷洗活檢，及(或)經(jīng)皮穿刺作肺活檢。治療必須及時(shí)，因?yàn)楸静☆A(yù)后差。 | |
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ASPIRATION PNEUMONIA |
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There are two main varieties differentiated from each other by the type of fluid aspirated and the circumstances in which it occurs. |
根據(jù)吸入的液體及得病的情況主要可分成兩大類。 | |
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Aspiration of gastric contents may produce a severe chemical pneumonitis with considerable pulmonary oedema and bronchospasm (Mendelson's syndrome). The acute respiratory distress and shock can be rapidly fatal and very difficult to treat. It tends to occur in states of reduced consciousness such as general anaesthesia, drunks, and when gastric lavage (for drug overdose) has been performed inexpertly. |
吸入胃內(nèi)容可以產(chǎn)生嚴(yán)重的化學(xué)性肺炎，有相當(dāng)程度的肺水腫及支氣管痙攣(Mendelson’s綜合征)。急性呼吸困難及休克可迅速致死，很難治療。意識模糊時(shí)易于發(fā)生，例如全麻、醉酒，以及由不熟練者洗胃(因藥物過量)時(shí)均易發(fā)生。 | |
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Aspiration of bacteria from the oropharynx may follow dental anaesthesia and can occur in bulbar palsies. The bacteria, apart from bacteroides, are nearly all penicillin sensitive and crystalline penicillin with metronidazole are the antibiotics of choice initially until sensitivities are known. Recurrent episodes occur in some oesophageal diseases includinghiatus hernia, stricture, achalasia of the cardia, and in patients with diverticula or pharyngeal pouch. |
自口咽中吸入細(xì)菌可在牙科麻醉時(shí)發(fā)生，亦可在延髓麻痹時(shí)發(fā)生。除類桿菌感染以外，吸入的細(xì)菌差不多都對青霉素敏感，在獲悉細(xì)菌藥敏試驗(yàn)報(bào)告之前，可先選用青霉素及滅滴靈治療。某些食管病患者可以并發(fā)此病，例如膈疝，狹窄、賁門松弛不良以及食管憩室或咽袋患者. |
