elderly pneumonia
Introduction
Introduction to elderly pneumonia Older pneumonia often lacks obvious respiratory symptoms, and the symptoms are atypical. The disease progresses rapidly and is prone to missed diagnosis and misdiagnosis. According to reports in the literature, the missing rate of pathologically confirmed pneumonia but clinically undiagnosed was 3.3%-61.4%; and the misdiagnosis rate of clinical diagnosis of pneumonia but no corresponding pathology was 10.8%-39.3%. basic knowledge Sickness ratio: 0.5% Susceptible people: good for the elderly Mode of infection: non-infectious Complications: heart failure, respiratory failure, stress ulcer, diabetes, hypertension
Cause
The cause of pneumonia in the elderly
1, Gram-negative bacilli are more common
In the 1950s, pneumococci were the main pathogens of pneumonia (90%), but with the advent of penicillin and some synthetic penicillins, the prevalence and harm of pneumonia were reduced. Gram-negative bacilli infection has increased significantly (82%) mostly Escherichia coli, Klebsiella, Pseudomonas aeruginosa, influenza bacillus, etc. Although new antibiotics continue to emerge, it has not changed this trend.
2, respiratory conditions, pathogenic bacteria infection gradually increased
Due to the lowering of the body's resistance, the common bacteria (fungi, anaerobic bacteria, etc.) in the oropharynx can cause pneumonia. The anaerobic bacteria in the normal flora of the oropharynx are 10-20 times more than the aerobic bacteria. 1/3-1/2 of the anaerobic infection is difficult to be neglected due to conventional culture. Therefore, routine anaerobic culture should be carried out when the specimen is sent, and Gram-negative bacilli in the oropharynx live or not, and the body Related to health status, the normal population of pharyngeal Gram-negative bacilli only accounted for 2%, outpatients bound 20%, hospitalized patients increased to 30% -40%, critically ill patients up to 75%, which may be caused by Gram-negative bacilli in the elderly The main cause of pneumonia.
3, mixed infection is more common
Due to the low immune function, the elderly often show mixed infections caused by various pathogens, such as bacteria plus virus, bacteria plus fungi, aerobic bacteria plus anaerobic bacteria.
4. Increased number of resistant bacteria
Gram-negative bacilli are most prominent due to the large number and extensive use of antibiotics, resulting in changes in the genes of pathogenic microorganisms.
Prevention
Elderly pneumonia prevention
The main reason for senile pneumonia is early prevention. In daily life, it is necessary to carry out appropriate physical exercise to enhance cold tolerance and disease resistance. The body's resistance is closely related to nutrition. Therefore, nutrition should be strengthened and high protein should be selected in diet. High-carbohydrate low-fat foods and fruits and vegetables rich in vitamin A and vitamin C. If you eat more fresh fish, lean meat, beef and mutton, chicken and eggs, cauliflower, carrots, tomatoes, apples, bananas, pears, etc. Active treatment of chronic bronchitis, rhinitis, sinusitis, pharyngitis, periodontitis and other diseases to clear the hidden dangers of respiratory infections; pay attention to clean and ventilated rooms, do a good job in the sanitation of the living room, keep the air fresh, according to temperature changes, especially In the morning and evening, you should increase or decrease the clothes properly, and remember to keep your feet warm. These measures have positive significance in preventing respiratory infections.
First of all, we must actively participate in physical exercise to improve physical fitness and improve cold and disease resistance.
Secondly, it is necessary to eat more foods such as pears, lilies, fungus, radishes and sesame seeds.
The third is to pay attention to the hygiene of the living room. The living room should be kept clean, the air is fresh and the sun is sufficient. Keep warm to prevent cold and infestation and induce colds.
The fourth can sit on the chair before going to sleep every day, the body is upright, the two knees are naturally separated, the hands are lightly placed on the thighs, the head is closed, the whole body is relaxed, the dantian is intent, the inhalation is in the chest, and the exhalation is from the top. Pat down, about 10 minutes, then gently rub your back with the back of your lungs, this method has the effect of clearing the lungs.
The fifth is to enhance the respiratory function, gradually changing from thoracic breathing to abdominal breathing, that is, when inhaling, the stomach is swollen to lower the diaphragm, and the gas is Shen Dan, and the movement is slow and gentle to enhance the breathing depth.
Complication
Elderly pneumonia complications Complications heart failure respiratory failure stress ulcer diabetes hypertension
Concurrent heart failure, respiratory failure, stress ulcers, electrolyte imbalance, diabetes, high blood pressure and other diseases.
Symptom
Symptoms of pneumonia in the elderly Common symptoms Loss of appetite, diarrhea, abdominal pain, fever, abdominal pain, ... Old people, severe cough, cough, phlegm, high fever, difficulty breathing, rust
(1) There are no typical symptoms such as fever, chest pain, rust and rust, and only about 35% of the symptoms.
(2) The first symptom is highlighted by non-respiratory symptoms: elderly pneumonia patients may first manifest as abdominal pain, diarrhea, nausea, vomiting and loss of appetite, or gastrointestinal symptoms such as palpitations, shortness of breath, or apathy, lethargy, sputum Neuropsychiatric symptoms such as incitement and disturbance of consciousness are often manifested in one or more of the typical five-year syndromes of senile diseases (urinary incontinence, mental paralysis, unwanted activity, falls, loss of ability to live, etc.).
(3) Lack of typical signs: rarely appearing typical pneumonia, increased vocal fibrillation, bronchial breath sounds and other signs of the lungs, pulse rate, rapid breathing, weakened breath sounds, the bottom of the lungs can smell wet rales, but easy to Coexisting chronic bronchitis, heart failure and other confusion.
(4) The results of laboratory tests are not typical:
1 The basic diseases are many, and it is prone to multiple organ dysfunction.
2 complications are more and more serious: elderly pneumonia is prone to water and electrolytes and acid-base balance disorders, respiratory failure, hypoproteinemia, arrhythmia and shock and other serious complications, high mortality.
Common type
(1) Aspiration pneumonia, due to atrophy and thinning of the larynx mucosa in the elderly, the sensation of the larynx is reduced, the action of the pharyngeal muscles is weakened, and phagocytic disorders are caused, causing food and parasitic bacteria to enter the lower respiratory tract, causing inhalation. Pneumonia, clinical symptoms are not typical, high fever only accounts for 34%, 14% of patients without respiratory symptoms, more than 35% of patients with gastrointestinal symptoms, high rate of misdiagnosis, 20% of patients with neuropsychiatric symptoms, hypotension, septic shock , cyanosis, fatigue, etc., chest pain and rust are rare, white blood cells are not high, water is prone to occur, electrolytes are disordered, chest radiographs show spots or small shadows, and sputum bacteria are mainly Gram-negative bacilli, point 1/2- 1/3, Gram-positive cocci account for only 10%, mixed infection 1/3.
(2) Gram-negative bacilli pneumonia, 20% of pneumonia infected by out-of-hospital infection, 15%-80% of nosocomial infections, and the mortality rate can reach more than 50%. The pathogens mainly include Escherichia coli, Proteus, and Pseudomonas aeruginosa. , Klebsiella pneumoniae, etc., can be divided into:
1 socially acquired pneumonia, mostly primary pneumonia;
2 Hospital-acquired pneumonia, mostly caused by inhalation of pharyngeal secretions (endogenous infection), from airborne droplets (exogenous infections) are rare.
(3) Mycoplasmal pneumonia, mycoplasma pneumonia accounted for 20% of the elderly lung infection, the onset of concealment, the main clinical expression is irritating dry cough, irregular fever, headache, chest tightness, nausea; chest X-ray film inflammation, patch Or point-like shadow, polymorphism, right lung more than left lung, and a small amount of pleural effusion, clinically difficult to distinguish from viral or mild bacterial infection, misdiagnosis rate as high as 55%, so the following:
1 has a clinical manifestation similar to viral infection, the treatment of antibiotics (except erythromycin, tetracycline) is not effective;
2 The disease is not commensurate with the chest radiograph (ie, the chest inflammatory lesion is obvious, and the symptoms are not heavy);
3 inflammation of the lower part of the lungs and a small amount of pleural effusion, difficult to explain tuberculosis, should be further tested for serum mycoplasma antibodies, serum specific complement binding test (+) 1:40-1:80, condensation test (+), to help diagnose.
(4) End-stage pneumonia refers to the pneumonia that occurs before the patient's death. It is often secondary to the advanced stage of other diseases. It is not the same as general pneumonia. The pathological data is as high as 30% to 60%. It has not been included in independent diseases. Clinical features In the early stage, there are often no obvious signs. As the condition worsens, the following characteristics can be obtained:
1 can not use the primary disease to explain the fever or shiver;
2 dyspnea or purpura is not commensurate with the primary disease;
3 can not be explained by primary disease or other reasons for hypotension, shock or coma;
4 sepsis;
More than 5 rashes or pustules occur;
6 The lungs breathe sounds weakened or disappeared, and the wet rales did not change with the receptor position.
(5) Hospital acquired pneumonia refers to lung inflammation caused by bacteria, fungi, mycoplasma, virus or protozoa during hospitalization. The incidence rate in the elderly is significantly higher than that of young people, and the incidence rate is 0.5%-15. %, accounting for 1-3 times of various infections in hospitals, the most common pathogens are Gram-negative bacilli, accounting for 68%-80%, of which Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter, Krebs Common bacilli, Gram-positive cocci account for 24%, mold accounts for about 5%.
Examine
Examination of pneumonia in the elderly
First, chest X-ray examination
Chest X-rays provide a basis for diagnosis and differential diagnosis, and chest CT often provides important additional information about the etiology of X-ray infiltration.
Second, sputum check
Sputum examination is the first step to determine the cause of pneumonia. Because the elderly can not properly cough or cooperate, the qualified rate of sputum specimens is only 1/3, and the qualified sputum specimens are polymorphonuclear leukocytes >25/low magnification. Vision, squamous epithelial cells <10/low power field, Gram staining of high quality sputum specimens provides sufficient sensitive and specific information for clinical decision making.
The credibility of sputum culture for the diagnosis of pneumonia is very small. Because it is difficult for the elderly to obtain satisfactory sputum specimens, the quality of sputum specimens should be checked before culture, and unsatisfactory sputum specimens should be avoided as a basis for bacteriology diagnosis. Streptococcus pneumoniae cultivation is difficult. It is easy to lead to false positive results, the positive rate of culture of S. pneumoniae or influenza bacillus pneumonia is <50%. The discovery of multiple potential pathogens often makes the diagnosis confusing, and the G-bacteria colonized by the upper respiratory tract often contaminate the sputum specimens. Therefore, unless tuberculosis fungi are suspected, sputum culture is not recommended as the primary test for geriatric pneumonia. For qualified lower respiratory tract cultures, it is diagnostic value to repeatedly find the same Gram-negative bacteria (GNB).
Third, blood culture
About 10% of elderly patients with pneumonia can be isolated from specific pathogens in blood culture, and rarely cause errors in treatment. It is currently considered that for non-critical elderly CAP patients, blood culture should not be classified as routine, but not for early treatment. The blood culture of patients is valuable.
Fourth, pleural fluid culture
The pleural effusion of pneumococcal patients after pleural effusion is bacteriologically examined, and pathogens are often detected in patients infected with pneumococcal infection.
V. Invasive inspection
For elderly patients with pneumonia, these tests are only occasionally applied to provide a pathogenic diagnosis. Fibrobronchoscopy is safe and acceptable for the general elderly, but its risk increases as clinical performance and chronic underlying diseases increase. Due to the contamination of upper respiratory tract secretions, conventional fiberoptic bronchoscopy has been developed by double-cannula protective brush and protected bronchoalveolar lavage, bronchoalceolar lavage, BAL, a new development based on fiberoptic bronchoscopy Technology, BAL is a method of bronchoalveolar lavage using fiberoptic bronchoscopy, taking alveolar surface lotion for inflammation and immune cells and soluble substances. It is different from bronchial flushing of small amounts of liquid into the bronchus and perfusion of large amounts of fluid for bronchoalveolar lavage. The use of bronchoalveolar lavage fluid for cytology, microbiology, parasitology and immunology has opened up a new way for some lower respiratory diseases and diagnosis, disease observation and prognosis, " href= "http ://www.cmechina.net/cme/html/cme_K1000009/1303/index .html#1">Bronchoalveolar lavage technique is replaced by antibody-coated bacteria from bronchoalveolar lavage fluid (BALF), which facilitates the identification of lower respiratory tract infections and oropharyngeal pathogen reproduction, despite these techniques. Has good specificity and sensitivity, but is not recommended as a routine diagnostic method for pneumonia in the elderly, however, for
(1) Severe pneumonia requiring ICU accommodation;
(2) progressively worsening pneumonia, especially in patients with mechanically ventilated pneumonia;
(3) suspected to be a rare pathogen infection, such as Mycobacterium tuberculosis, Aspergillus infection;
(4) Any delayed absorption of pneumonia and progressive pneumonia;
(5) Most patients with low immune function.
Fiberoptic bronchoscopy should be performed.
Transthoracic needle aspiration (TNA) sampling can provide specific pathogenic diagnosis in 80% of patients with pneumonia, but the incidence of complications such as pneumothorax and hemoptysis is high, so it is usually only used for diagnosis and immune function. Elderly patient.
Transtracheal aspiration (TTA) is a relatively reliable method for the diagnosis of experienced physicians, but the rate of false positives is high. Patients with underlying diseases are prone to complications or are not easily accepted by patients. Therefore, in recent years, The application of this method is on a downward trend.
Diagnosis
Diagnosis and diagnosis of pneumonia
Diagnosis can be based on medical history, clinical symptoms, and laboratory findings.
A few non-infectious conditions may have similar manifestations of pneumonia, such as acute respiratory distress syndrome (ARDS), congestive heart failure, pulmonary embolism, chemical gas inhalation, allergic alveolitis, drug pneumonia, radiation pneumonitis, connective tissue disease involving the lungs Department, tuberculosis, leukemia or other malignant tumors in the lung infiltration or metastasis, etc., should be identified, if necessary, diagnostic treatment can be used to confirm the diagnosis.
