end-stage pneumonia in the elderly
Introduction
Introduction to end-stage pneumonia in the elderly End-stage pneumonia in the elderly refers to pneumonia caused by depression of advanced or long-term bedridden diseases, extreme immune failure and decreased respiratory function. Common diseases that cause end-stage pneumonia include: recovery period of various cerebrovascular diseases, advanced malignant tumors, severe diabetes patients, liver and kidney failure, brain trauma, radiotherapy and chemotherapy patients, acquired immunodeficiency (AIDS), after major surgery, Organ transplant patients, as well as patients with indwelling catheterization and endotracheal intubation. These patients are often referred to as immunocompromised hosts, and the incidence of co-infection is quite high, with pulmonary infection being the most common and the leading cause of death. basic knowledge Sickness ratio: 1-2% Susceptible people: the elderly Mode of infection: respiratory transmission Complications: respiratory failure, arrhythmia, renal failure
Cause
The cause of end-stage pneumonia in the elderly
(1) Causes of the disease
The number of end-stage pneumonia patients is more than that of the elderly. With the increase of age, the respiratory system structure, function and respiratory mechanics are degenerative, the upper respiratory tract is weakened, and the sputum dysfunction is reduced, especially cerebrovascular disease, disturbance of consciousness. Patients, swallowing reflexes and cough reflexes have a significantly higher stimulation threshold, throat dysfunction, aspiration caused by aspiration in sleep, aspiration, pneumonia caused by gastric tube stimulation in nasal feeding patients can also cause aspiration pneumonia, so in the end stage In pneumonia, aspiration pneumonia accounts for a considerable proportion, and part of it is due to low immunity. Bacteria enter the lungs from other parts of the body through the bloodstream, causing lung infections, including fungi.
Elderly end-stage pneumonia often suffers from decreased sputum sputum ability, or due to disturbance of consciousness, and there is no satisfactory sputum specimen. Therefore, the cases with unclear pathogens are much more than those of general pneumonia. Generally, the related factors of immune damage and the existence of susceptible pathogens are certain. Relationship, end-stage patients with immune damage caused by T cell abnormalities are susceptible to Listeria, Mycobacterium, Nocardia, Salmonella (in addition to typhoid), Legionella, fungi including Cryptococcus neoformans, tissue cells Pasteurellosis, mucormycosis, coccidioidomycetes, viruses including cytomegalovirus, herpes zoster virus, herpes simplex virus, parasites including Pneumocystis carinii, roundworm, and end-stage patients with immune damage caused by B cell abnormalities The main infectious bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and patients with granulocytosis are mainly infected with Escherichia coli, Pseudomonas aeruginosa, Klebsiella, Serratia and other Gram-positive bacilli, fungi, splenectomy End-stage patients are susceptible to end-stage pneumococcal, Staphylococcus aureus, Haemophilus influenzae, Escherichia coli, hormone or cytotoxic drugs The patient's infectious bacteria are Staphylococcus aureus, Listeria, Pseudomonas aeruginosa and other Gram-negative bacilli, fungi, cytomegalovirus, herpes zoster virus, Pneumocystis carinii, toxoplasma, fecal round Nematodes, barrier destruction, and end-stage patients with various intubations are mainly infected with staphylococci, Pseudomonas aeruginosa, and the like.
(two) pathogenesis
People inhale more than 10,000 liters of air per day, which may contain a large number of microorganisms. In general, the defense mechanisms of the lungs and respiratory tract can discharge, inactivate and eliminate these virulence factors, but if the inhaled pathogenic microorganisms are too much or too strong Or the lung's defense function may lead to respiratory inflammation, the lungs of the elderly are similar to emphysema, the thoracic stiffness increases, the respiratory muscles weaken, so the cough effect is reduced, and the bronchial cilia activity decreases and the ineffective cavity increases. It is prone to respiratory infections. Most of the end-stage pneumonia is lobular bronchial pneumonia. That is, infection can be distributed along the bronchus. Due to the decline of phagocytic function in such patients, foreign bodies in the alveoli (dead bacteria, etc.) cannot be swallowed in time, which may lead to absorption. Delayed pneumonia, that is, after the application of sensitive antibiotics, symptoms and signs disappear, but chest X-ray examination of inflammation shadows for a long time does not absorb, inhalation pneumonia can stimulate the trachea caused by bronchospasm, and then cause acute inflammation of the bronchial epithelium and inflammation around the bronchi. The gastric juice entering the alveoli rapidly spreads to the surrounding tissues, the lungs The epithelial cells are destroyed, degenerated, and involve the capillary wall. The vascular permeability increases, and interstitial pulmonary edema is formed. If the oral colonization bacteria are brought into the lungs when inhaling food or foreign matter, lung abscess is formed, and pulmonary edema is caused by lung tissue. Decreased elasticity, decreased compliance, decreased lung capacity, and decreased alveolar surfactants, resulting in small airway closure, alveolar collapse caused by micro-lung atelectasis, can cause hypoventilation, ventilated blood flow imbalance and arteriovenous shunt increase, Cause hypoxemia or acidosis.
Prevention
Elderly end stage pneumonia prevention
With the aging of the population, a series of changes in the structure and function of the respiratory system, including changes in cough reflexes, post-bend bending, etc., make older people prone to pneumonia and death, and the physical defense function of the elderly Including increased mucus secretion in the lung tissue, decreased ciliary movement, decreased phagocytic activity of polymorphonuclear leukocytes, and a significant lack of T cell function associated with aging, which creates an opportunity for microbial invasion, suffering from various chronic From the perspective of prevention, the elderly patients with diseases are prone to pneumonia. From the perspective of prevention, the community of patients with end-stage diseases should be registered and registered, and regular health education for themselves and their families can be carried out according to seasonal changes and pathogens. Sexual vaccination, try to avoid contact with respiratory infection patients, often open the window ventilation, regular boiling vinegar for room air disinfection, for long-term bedridden patients, regular turn over, shoot back, in order to facilitate the drainage of respiratory secretions, reduce infection opportunities, Do oral cleansing every day to prevent pathogenicity in the mouth Inhalation of substances, to ensure sleep time, diet should be given nutritious food, can do some functional exercise in the bed to enhance the body's immunity, such as patients with fever, listlessness, refusal to eat, change of consciousness, etc., should be immediately sent to the hospital for treatment .
Complication
Elderly end-stage pneumonia complications Complications, respiratory failure, arrhythmia, renal failure
Complications include respiratory failure, arrhythmia, heart and kidney failure, and electrolyte imbalance.
Symptom
End-stage pneumonia symptoms in the elderly Common symptoms Drowsiness, dizziness, respiratory failure, drowsiness, dehydration, repeated infection, renal failure, blister, systemic failure, cyanosis
Symptom
1 Most of the symptoms of typical pneumonia such as fever, cough, cough, etc., the onset of the disease is generally mentally wilting, fatigue, bed rest, incontinence, changes in consciousness, fall more common, easy to misdiagnosis and missed diagnosis.
2 The condition changes frequently, and complications are common, such as respiratory failure, heart and kidney failure, arrhythmia, electrolyte imbalance, dehydration, etc., and the prognosis is poor.
3 often have multiple organ function or malnutrition, systemic failure.
4 poor efficacy, high mortality.
5 has the characteristics of repeated infections.
6 often have double or multiple infections.
7 insidious onset, the course of disease is prone to delay.
2. Signs
Blurred consciousness, lethargy and lethargy, shortness of breath, deep breathing when combined with acidosis, cyanosis with hypoxemia, dehydration and poor skin elasticity when dehydrated, typical lung signs more than back smell and wet Voice, the formation of obstructive pneumonia may have respiratory sounds disappear, but end-stage pneumonia often lacks signs.
Examine
Examination of end-stage pneumonia in the elderly
Electrocardiogram
In this disease, 60% to 70% of cases of ECG can be abnormal, including T wave inversion, ST segment down, pre-systolic, atrial fibrillation, pulmonary P wave.
2. Imaging
End-stage pneumonia due to symptoms, signs are not obvious, so the diagnosis is mainly based on X-ray, more showing small shadows, along the bronchial, right lower lung, but clinically can also hear the lungs can be heard and obvious blisters However, if the sign of chest inflammation is not obvious, it may be related to prolonged bed rest, inflammatory secretions accumulating to the spine and causing unclear inflammation shadows. In addition, if the heart failure is combined, the heart shadow is enlarged, and the signs of pleural effusion are visible. The reason for this is due to the pleural inflammatory response, hypoproteinemia and heart failure combined factors.
3. Blood test:
Leukocytosis is more common than general pneumonia. In 40% to 50% of cases, white blood cells are in the normal range, 90% of cases may have nuclear left shift, 50% of cases have different degrees of anemia, and 80% of patients have increased erythrocyte sedimentation rate. Hypoproteinemia, plasma protein and total protein are lower than normal, low potassium and low sodium, hypochloremia is common, 50% of cases of blood gas analysis have hypoxemia, carbon dioxide partial pressure is often at normal level, when combined with chronic obstruction In patients with pulmonary disease, hypercapnia may occur, and sputum bacteriological examination: patients with end-stage pneumonia have difficulty in sputum sputum, or because they do not have satisfactory sputum specimens due to disturbance of consciousness, the pathogen diagnosis is difficult, but for severe cases or Patients with ineffective empiric therapy urgently require reliable pathogenic diagnosis. The most useful technique at present is to prevent contamination by fiberoptic bronchoscopy, but there is a certain risk, generally speaking, the partial pressure of oxygen is >8 kPa (60 mmHg). No serious cardiovascular disease, no abnormal blood coagulation mechanism, this technology is available after sufficient preparation. The common pathogens of end-stage pneumonia are Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli Bacteria, Pseudomonas aeruginosa, Klebsiella, Staphylococcus aureus, Listeria and other Gram-negative bacilli, other pathogens including fungi, viruses (cytomegalovirus, herpes zoster virus, etc.), parasites ( Pneumocystis carinii, A. faecalis).
Diagnosis
Diagnosis and diagnosis of end-stage pneumonia in the elderly
diagnosis
Most of the end-stage pneumonia in the elderly lacks typical symptoms and signs. The diagnosis is mainly based on the X-ray of the lungs. There are small shadows combined with the sound of the lungs and the blisters.
Differential diagnosis
Heart failure
In the early stage of left heart failure, there is cough, cough foaming, difficulty in breathing, and it is not easy to lie down. The wet sounds of both lungs are more extensive and can change with body position.
2. Lung cancer with obstructive pneumonia
If the effect of adequate antibiotic treatment is not satisfactory or the nature of the intrapulmonary shadow is unknown, it should be used for the diagnosis of exfoliated cells, carcinoembryonic antigen, X-ray film, CT and fiberoptic bronchoscopy.
3. Tuberculosis
Older pulmonary tuberculosis often lacks typical symptoms, signs and X-ray findings. The cause of fever is unknown. X-rays have obvious shadows. Generally, those with poor anti-infection effects should consider the possibility of tuberculosis. Carefully trace the history, X-ray film on the old tuberculosis The presence and examination of acid-fast bacilli are helpful for diagnosis.
4. Pulmonary embolism
There are surgery, trauma, heart disease (especially with atrial fibrillation) and history of phlebitis, manifested as sudden dyspnea, cough, hemoptysis and chest pain, typical changes in ECG help to identify.
5. Other
Patients with gastrointestinal symptoms should be differentiated from acute gastroenteritis and acute abdomen; shock pneumonia should be differentiated from cerebrovascular accident and shock caused by it.
