提高對(duì)老年性肺炎的認(rèn)識(shí)課件

1、提高對(duì)老年性肺炎的認(rèn)識(shí)濟(jì)南軍區(qū)總醫(yī)院呼吸內(nèi)科劉書盈A 1960s article in Time magazine speculated that “bacterial and viral diseases will have been virtually wiped out” by the year 2000.Into the new millennium, pneumonia is still a significant public health problem in the world. Not only has the incidence of pneumonia increased

2、, but new threats have emerged with highly virulent pathogens with epidemic potential, such as the Coronavirus (SARS) and avian influenza.About PneumoniaMuthiah MP. Pneumonia in the Elderly: Whose Friend Is It Anyway? Southern Medical Journal, 2008 ,101(11):1084-1085.In old age pneumonia may be late

3、nt, . . . coming on without a chill, the cough and expectoration are slight, . . . The physical findings ill-defined and changeable . . . And the constitutional symptoms out of proportion to the extent of the local lesion. pneumonia was the friend of the aged that often allowed patients with advance

4、d illness to die peacefully-William Osler,In 1892About geriatric pneumoniaMalin. A. Pneumonia in old age. Chronic Respiratory Disease. 2011, 8(3): 207210.老年性肺炎（geriatric pneumonia，pneumonia in the elderly）不是一個(gè)標(biāo)準(zhǔn)的診斷術(shù)語(yǔ)，但將之單純看作是發(fā)生在老年人的“肺炎”是不合適的。老年性肺炎在病因、發(fā)病及臨床表現(xiàn)各個(gè)方面有其特殊性，與一般成人肺炎相差較大。對(duì)其缺乏認(rèn)識(shí)或錯(cuò)誤認(rèn)識(shí)，或重視不夠，將導(dǎo)

5、致誤診、誤治或延誤治療。概念和認(rèn)識(shí)研究發(fā)現(xiàn)，人類生命的兩端是肺炎的高發(fā)年齡段，呈V字形或倒鐘形，在60歲后發(fā)病率明顯升高，且老年人肺炎較為嚴(yán)重。老年性肺炎發(fā)病情況Malin. A. Pneumonia in old age. Chronic Respiratory Disease. 2011, 8(3): 207210.易感因素是老年性肺炎的一個(gè)重要特點(diǎn)。各種生理機(jī)能的進(jìn)行性衰退，年齡本身即是一個(gè)重要的易感因素，其機(jī)理涉及諸多方面：各系統(tǒng)功能降低，尤其是免疫功能的下降，粒細(xì)胞、淋巴細(xì)胞、NK細(xì)胞及抗原呈遞細(xì)胞功能降低，使其更容易罹患肺炎。近年研究發(fā)現(xiàn)，脾臟的邊緣區(qū)與肺炎球菌的清除和T細(xì)胞依賴的

6、抗體產(chǎn)生有關(guān)，65歲及以上老年人脾臟功能降低，致使其易患肺炎球菌肺炎。易感因素 1、Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(11):1141-1145.2、Birjandi S, Witte P. Why are the elderly so susceptible to pneumonia? Expert R

7、ev. Respir. Med. 2011, 5(5), 593595.呼吸系統(tǒng)退行性變患者肺臟彈性回縮力減弱肺泡腔擴(kuò)大（老年性肺氣腫）呼吸肌乏力支氣管纖毛功能降低呼吸道分泌性IgA減少咳嗽反射減弱、咳嗽無(wú)力諸多因素都使之易于受到感染，且容易發(fā)生呼吸衰竭。易感因素 1、Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(1

8、1):1141-1145.2、Birjandi S, Witte P. Why are the elderly so susceptible to pneumonia? Expert Rev. Respir. Med. 2011, 5(5), 593595.老年性肺炎并不是“老年人的肺炎”，常常缺乏肺炎的表現(xiàn)。沒(méi)有呼吸道癥狀咳嗽反射減弱、對(duì)缺氧和高二氧化碳刺激不敏感、排痰功能降低極易被家屬，乃至醫(yī)生忽視，造成漏診、誤診，從而延誤治療。表現(xiàn)為“肺外”癥狀或以“肺外”表現(xiàn)發(fā)病精神萎靡、神智淡漠，甚至意識(shí)模糊，乃至昏迷等神經(jīng)系統(tǒng)癥狀，達(dá)21%-73%；心功能不全、心律失常、血壓下降等心血管系統(tǒng)癥狀，

9、高達(dá)70%；惡心、嘔吐、腹瀉、食欲減退等消化系統(tǒng)癥狀；不明原因的電解質(zhì)紊亂，虛弱乏力、甚至莫名跌倒。臨床上因跌倒就診發(fā)現(xiàn)肺炎的病例并不少見。因此，臨床醫(yī)生對(duì)老年患者的以上表現(xiàn)一定要注意。老年性肺炎的特點(diǎn)一“隱匿性”Falcone M, Blasi F and Menichetti F,et al. Pneumonia in frail older patients: an up to date. Intern Emerg Med. 2012, 7:415424.“低體溫”：患者體溫反應(yīng)不同于其他人群，常常表現(xiàn)不明顯，體溫不高，甚至低體溫。個(gè)別患者可以向另一個(gè)極端發(fā)展，即持續(xù)性高熱，高熱不退預(yù)示

10、預(yù)后不良；“低血象”：即患者血白細(xì)胞常常不升高，甚至降低，但中性粒細(xì)胞可增高，此時(shí)C反應(yīng)蛋白可能較之更敏感；“低治療反應(yīng)”：即對(duì)治療反應(yīng)慢，即使敏感抗生素，用藥后起效也慢或根本無(wú)效，因此，抗菌藥物不宜頻繁更換，一般至少3天以上。“低耐受性”：患者各種器官功能降低，處于臨界狀態(tài)，對(duì)各種藥物毒副作用耐受性低，極易出現(xiàn)治療作用尚未達(dá)到，毒副作用已經(jīng)出現(xiàn)的現(xiàn)象，因此，藥物選擇及劑量要慎重。老年性肺炎的特點(diǎn)二“低反應(yīng)性”由于患者抵抗力降低，老年性肺炎極易向重癥進(jìn)展，尤其是漏診、誤診病例，因延誤治療，易發(fā)展至重癥狀態(tài)，病死率高。國(guó)外報(bào)道，在家庭護(hù)理和醫(yī)院相關(guān)性感染患者，病死率高達(dá)44%-57%，社區(qū)獲得性

11、肺炎病死率高達(dá)30%。老年性肺炎是老年人最常見的死亡原因之一。老年性肺炎的特點(diǎn)三“高致死性”Chong CP, Street,PR. Pneumonia in the Elderly: A Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. Southern Medical Journal. 2008, 101(11):1141-1145.CURB65評(píng)分：精神異常;尿素氮升高大于7mmol/L；呼吸頻率30次/分；血壓下降收縮壓低于90mmHg或/和舒張壓60mmHg；年齡超過(guò)65歲。每

12、項(xiàng)1分，0-1分為低嚴(yán)重度，死亡風(fēng)險(xiǎn)3%，2分為中度嚴(yán)重度，死亡風(fēng)險(xiǎn)為9%，而3分以上為高嚴(yán)重度，死亡風(fēng)險(xiǎn)達(dá)15%-40%。老年性肺炎嚴(yán)重性評(píng)估 Chong CP, Street,PR. Pneumonia in the Elderly: A Review of Severity Assessment, Prognosis, Mortality, Prevention, and Treatment. Southern Medical Journal. 2008, 101(11):1134-1140.Myint等研究發(fā)現(xiàn)，精神異常和尿素氮升高在老年患者非常普遍，對(duì)肺炎嚴(yán)重程度的預(yù)計(jì)作用較小，氧合

13、狀況是最好的預(yù)計(jì)指標(biāo)。提出了SOAR標(biāo)準(zhǔn)：收縮壓90mmHg；氧合指數(shù)（PaO2/FiO2 ）250；年齡65歲呼吸30次/分每項(xiàng)1分，并建議將其作為老年患者的評(píng)估工具。老年性肺炎嚴(yán)重性評(píng)估最新研究發(fā)現(xiàn)，老年性肺炎病死率與宿主因素如年齡和體能狀況等密切相關(guān)，而與肺炎的嚴(yán)重程度和對(duì)耐藥菌治療失敗無(wú)關(guān)。我們臨床上也發(fā)現(xiàn)，老年性肺炎即使病原菌對(duì)藥物敏感，抗菌藥物完全覆蓋也照樣無(wú)效，此時(shí)其抵抗力降低可能是主要因素。老年性肺炎的死亡問(wèn)題Komiya K, Ishii H and Okabe E, et al. Risk factors for unexpected death from suffocat

14、ion in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int. 2013, 13: 388392.近年發(fā)現(xiàn)，感染所導(dǎo)致的全身炎性反應(yīng)綜合征可能為促進(jìn)患者死亡的重要原因，即使抗感染有效，細(xì)菌死亡所導(dǎo)致的內(nèi)毒素釋放可能成為促進(jìn)病情加重的“最后一根稻草”。因此，抗炎、抗毒素治療應(yīng)該受到重視。研究發(fā)現(xiàn)，延誤診斷和治療可能與其高死亡率有關(guān)。老年性肺炎的死亡問(wèn)題老年性肺炎患者的非預(yù)期性死亡是臨床上一個(gè)重要問(wèn)題，且可能是引起糾紛的重要因素，但常常被忽視或不被重視。國(guó)際衛(wèi)生組織將老年性肺炎非預(yù)期性死亡定義為：臨床治療成功或進(jìn)入

15、恢復(fù)期（如癥狀、體征、化驗(yàn)檢查和影像學(xué)改善）；死亡前1周生命體征穩(wěn)定（血壓波動(dòng)在20mmHg以內(nèi)，心率波動(dòng)在10次/分，血氧飽和度波動(dòng)在5%以內(nèi)，體溫低于37.5）；窒息后24小時(shí)內(nèi)死亡；氣管內(nèi)吸出吸入物。吸入物主要為嘔吐物和口咽部分泌物。老年性肺炎的非預(yù)期死亡問(wèn)題Komiya K, Ishii H and Okabe E, et al. Risk factors for unexpected death from suffocation in elderly patients hospitalized for pneumonia. Geriatr Gerontol Int. 2013, 13

16、: 388392.最新研究發(fā)現(xiàn)，胃管鼻飼可能增加窒息所致非預(yù)期性死亡的危險(xiǎn)可能與胃-食道反流及胃-唾液反射所致口咽部分泌物增多有關(guān)。加強(qiáng)口咽部護(hù)理對(duì)防止老年患者非預(yù)期性死亡具有重要意義。心腦血管意外導(dǎo)致患者意外死亡也是老年性肺炎住院期間非預(yù)期性死亡的重要原因，應(yīng)該予以重視。老年性肺炎的非預(yù)期死亡問(wèn)題家庭護(hù)理相關(guān)性肺炎（Nursing-home acquired pneumonia，NHAP）吸入性肺炎（aspiration pneumonia）終末期肺炎（End-of-life pneumonia，EOLP）幾種特殊類型老年性肺炎概念是指在家庭、護(hù)理院等長(zhǎng)期護(hù)理的老年人或殘疾人所得肺炎，應(yīng)屬健

17、康護(hù)理相關(guān)性肺炎（health-care-associated pneumonia，HCAP）的概念范疇。病原學(xué)：不同于一般的社區(qū)獲得性肺炎，病原菌常常是革蘭氏陰性菌或厭氧菌。易感因素：長(zhǎng)期臥床，缺乏活動(dòng)，或是伴有多種慢性疾病，長(zhǎng)期藥物治療及接觸醫(yī)院和醫(yī)療用品，易感染耐藥菌。吸入性肺炎發(fā)生率較高，且易向重癥發(fā)展。家庭護(hù)理相關(guān)性肺炎（Nursing-home acquired pneumonia，NHAP）Ewig S, Welte T, Chastre J et al. Rethinking the concepts of community-acquired and health-care-

18、associated pneumonia. Lancet Infect Dis 2010; 10: 279287.吸入類型：顯性吸入：容易發(fā)現(xiàn)，可得到及時(shí)處理隱性吸入：不易發(fā)現(xiàn)，是導(dǎo)致吸入性肺炎的重要原因，其發(fā)生率高達(dá)71%，但常常被忽視，因此需要重視。易感因素：吞咽困難，尤其是口咽性吞咽困難吞咽反射減弱咳嗽反射減弱咳嗽無(wú)力口咽清潔功能減低吸入性肺炎（aspiration pneumonia）食物：進(jìn)食時(shí)吸入或嗆入氣道在老年人時(shí)常發(fā)生。研究發(fā)現(xiàn)，吞咽困難是發(fā)生吸入性肺炎的獨(dú)立危險(xiǎn)因素。尤其是口咽性吞咽困難，導(dǎo)致食物吞咽后殘留，成為吞咽后吸入的重要因素。吞咽反射的減弱導(dǎo)致食物易于進(jìn)入氣道咳嗽反射

19、減弱使進(jìn)入氣道的食物或分泌物不被咳出?？谘什糠置谖铮豪夏耆丝谘什壳鍧嵐δ芙档?，口咽部可以存留較多分泌物，成為各種細(xì)菌定值的場(chǎng)所。胃內(nèi)容物：胃內(nèi)容物包括嘔吐或返流物。胃酸分泌減少，應(yīng)用制酸劑，使胃內(nèi)酸性環(huán)境破壞，容易滋生細(xì)菌，甚至腸道菌群也可以上行到達(dá)口部，成為吸入性肺炎的重要致病菌。吸入物分類病原學(xué)標(biāo)本很難獲得合格的痰培養(yǎng)標(biāo)本老年患者排痰困難或不會(huì)咳痰患者定植菌較多受口咽部污染侵入性方法獲取標(biāo)本受到限制對(duì)痰液培養(yǎng)結(jié)果的判斷一定要慎重，需要結(jié)合血象、C反應(yīng)蛋白、降鈣素原、G試驗(yàn)和GM試驗(yàn)等檢查綜合判斷老年性肺炎的病原學(xué)問(wèn)題病原學(xué)肺炎鏈球菌、流感嗜血桿菌仍為主要致病菌革蘭氏陰性桿菌比例增多銅綠假單

20、胞菌及其他非發(fā)酵菌腸桿菌其他革蘭氏陽(yáng)性球菌：金葡菌、卡他莫那菌 非典型病原體：肺炎支原體、肺炎衣原體、嗜肺軍團(tuán)菌病毒：腺病毒、呼吸道合包病毒、流感、副流感病毒厭氧菌肺孢子菌老年性肺炎的病原學(xué)問(wèn)題The results of the present study demonstrate that the bacterial agents responsible for pneumonia, and their antimicrobial resistance patterns, are not significantly different in older adults and younger

21、adults.A comparison in the elderly andyounger adultsHashemi, SM. et al. TROPICAL DOCTOR 2010; 40: 8991治療原則是盡快采取有效治療，控制病情，降低病死率。在與病死率相關(guān)的諸多因素中，醫(yī)生能夠控制的就是盡快診斷（評(píng)估風(fēng)險(xiǎn)和嚴(yán)重程度）、盡快給予經(jīng)驗(yàn)性的有效治療。重視以下患者有合并癥患者，此類患者可能因合并癥而延誤肺炎的診斷和治療HCAP、HAP患者，此類患者應(yīng)注意耐藥菌感染有吸入風(fēng)險(xiǎn)的患者，此類患者要注意厭氧菌感染、胃內(nèi)容或胃酸的吸入以臨床為主，若臨床無(wú)明顯感染表現(xiàn)，即使痰培養(yǎng)陽(yáng)性，也不作為抗感染治

22、療或延長(zhǎng)治療的依據(jù)。老年性肺炎的治療問(wèn)題治療選擇要考慮諸多因素疾病嚴(yán)重程度有無(wú)危險(xiǎn)因素和合并癥CAP、HCAP、HAP腎功能情況，注意腎功亞臨床損害等藥物毒副作用藥物相互作用老年性肺炎的治療問(wèn)題In one prospective study（RCT, 262 patients with CAP ) pathogen-directed treatment (PDT; n = 134; mean age, 62.0 years; 55.2% men) empiric, broad-spectrum antibiotic treatment (EAT; n = 128; mean age, 66.

23、7 years; 52.3% men).Conclusionno significant differences were observed between the PDT and EAT groups in the hospital LOS *(14.3 vs 13.2 days, respectively), 30-day mortality (7.9% vs 14.6%), or clinical failure (21.1% vs 23.2%).經(jīng)驗(yàn)性（EAT）與靶向（PDT）H.B. Fung and M.O. Monteagudo-Chu . Community-Acquired

24、Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.*Length of StayEmpiric antibiotic treatment (EAT)H.B. Fung and M.O. Monteagudo-Chu . Community-Acquired Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.H.B. Fun

25、g and M.O. Monteagudo-Chu . Community-Acquired Pneumonia in the Elderly. The American Journal of Geriatric Pharmacotherapy. 2010, 8(1):47-62.broad-spectrum, multidrug regimens should be reserved only for healthcare-associated pneumonia patients who have at least two of the following: severe illness,

26、poor functional status prior antibiotic therapyBroad-spectrum, multidrug regimens Brito V and Niederman MS. How can we improve the management and outcome of pneumonia in the elderly?Eur Respir J 2008; 32: 1214Comparative evaluation of fluoroquinolones Anzueto A, Niederman MS, and Pearle J,et al. Com

27、munity-Acquired Pneumonia Recovery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Comparative evaluation of fluoroquinolones Anzueto A, Niederman MS, and Pearle J,et al. Community-Acquired Pneumonia Re

28、covery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Comparative evaluation of fluoroquinolones Comparative evaluation of 2 different fluoroquinolones in hospitalized elderly patients with CAP. There

29、no significant difference between two groups in clinical cure and Bacteriologic success.The finding that moxifloxacin therapy led to a significantly more rapid clinical improvement resolution of pneumonia than levofloxacin therapy in elderly patients (i.e., between days 3 and 5 after the start of th

30、erapy) may be clinically important.Anzueto A, Niederman MS, and Pearle J,et al. Community-Acquired Pneumonia Recovery in the Elderly (CAPRIE): Efficacy and Safety of Moxifloxacin Therapy versus That of Levofloxacin TherapyClinical Infectious Diseases 2006; 42:7381Treatment failure may manifest in tw

31、o clinical variants with different prognosis. One variant is progressive pneumonia defined as progressive clinical deterioration with respiratory failure and development of shock necessitating treatment in the ICU, vasopressor therapy and ventilator support.The second variant is non-response to the

32、initial therapy characterized by the persistence of initial symptoms without apparent clinical deterioration. with better prognosis overall,Half of these patients in fact have only a delayed response, which would not necessarily demand a change in the treatment. Careful re-evaluation of treatment an

33、d uncommon pathogens, include Legionella, mycobacteria, fungi, Nocardia and others.Treatment FailureThiem U, Heppner HJ and Pientka L. Elderly Patients with Community-Acquired Pneumoniaoptimal Treatment Strategies. Diugs Aging 2011; 26 (7); 519-537.First administration of antibacterials within 4 hou

34、rs of admission;Oxygen supply in the presence of hypoxaemia;Switch from parenteral to oral administration of antibacterials only when the antibacterials have comparable bioavailability and the patient is clinically stable; Discharge only when the patient is haemodynamically stable on the discharge d

35、ay as well as on the previous day. Lists four quality indicatorsfor hospital care in elderly patients with CAPThiem U, Heppner HJ and Pientka L. Elderly Patients with Community-Acquired Pneumoniaoptimal Treatment Strategies. Diugs Aging 2011; 26 (7); 519-537.The 148 cases were divided into two group

36、sSteroid groups :82patients ( Age 74.4 18.8 CAP: 72 cases, HAP: 10 cases) Nonsteroid groups: 66 patients(Age 75.6 17.9,CAP: 59 cases, HAP: 7 cases) 糖皮質(zhì)激素應(yīng)用問(wèn)題 Kiyokawa K, Kawai S. Efficacy of steroid therapy on adult patients with severe pneumonia. J Infect Chemother (2010) 16:266271.糖皮質(zhì)激素應(yīng)用問(wèn)題 Kiyokawa K, Kawai S. Efficacy of steroid therapy on adult patients with severe pneumonia. J Infect Chemother (201