Symptoms of hospital (nosocomial) pneumonia in children

Staphylococcal pneumonia - a rapid increase in intoxication, high fever (39-40 ° C), grayish skin color, lethargy, poor appetite. In the lungs percussion there is a significant area of shortening of tone (often massive dulling), auscultatory-weakened breathing with bronchial shade, crepitic wheezing. On the part of the blood - a significant leukocytosis, neutrophilia with a pronounced shift to the left and a sharply increased ESR, often appears the toxic granularity of neutrophils.

On the roentgenogram - an infiltrate, occupying a share with the involvement of the pleura. A special threat to the life of the child is the complication of staphylococcal pneumonia - pyopneumothorax - a breakthrough of the abscess that communicates with the lumen of the bronchus into the pleural cavity. The picture is so characteristic that it is possible to name exactly the time of the catastrophe in the state of the child. The moment of abscess breakthrough into the pleural cavity occurs suddenly. The already serious condition of the patient deteriorates sharply, motor excitation, frequent respiration (up to 70-80 or more per 1 minute), marked pallor, rapidly changing cyanosis, cold sticky sweat, tachycardia (up to 200 beats / min, weak pulse). On the sore side of the lung, a boxed sound is detected with percussion (previously defined dullness disappears), respiratory noises are strongly attenuated or not audible. The heart is shifted in the opposite direction, its tones are deaf. In the next few hours, the degree of displacement of the mediastinum basically determines the severity of the patient's condition.

In young children with pyopneumotorax, bloating is noted, often vomiting. With pyopneumotorax, urgent puncture of the pleural cavity and aspiration of the contents are shown. In the presence of a functioning bronchial fistula - thoracotomy and underwater drainage, which ensures the passage of air and pus from the pleural cavity. An active aspiration of air from the pleural cavity is necessary in order to achieve complete expansion of the lung.

Klebsielleznaya pneumonia begins acutely. The phenomena of intoxication are expressed. In the lungs, infiltration often has a draining character, but not segmental (focal-drain pneumonia). The shortening of the percussion sound is clearly expressed, uninvited, humid finely bubbling rales are heard. On the roentgenogram, an intense shadow of darkness, localized more often in the upper parts of the lungs (posterior parts of the upper lobes, upper parts of the lower lobes). The tendency to abscessing is extremely pronounced. A very high ESR is characteristic.

Complications - abscess of the lung, pleural empyema, pyelonephritis, sepsis.

Pneumonia caused by Pseudomonas aeruginosa (Pseudomonas aeruginosa). A typical hospital infection, especially in patients with immunity defects. The current is sharp. The condition is severe, intoxication and fever are expressed, cyanosis and tachycardia. Characteristic is the rapid spread of the source of infiltration and the appearance of new foci in the lungs. In the bronchi and lungs, necrotic changes are observed, in connection with which there are early complications - abscess of the lung, pleurisy. On the part of the blood - leukocytosis with neutrophileosis, a significant increase in ESR.

Pneumonia caused by Haemophilus influenzae. With ARVI expressed nasopharyngitis, cough without phlegm. The temperature reaction is pronounced. The defeat of the lungs is of a focal character, often pneumonia develops in the atelectasis segment, caused by the obstruction of the small bronchi. There may be drainage infiltrates - a focal-drainage form of pneumonia. Characteristic of the predominance of purulent bronchitis. Variability, "mosaic" of percussion and auscultative data is noted. On the part of the blood, leukocytosis with neutrophilia, an increase in ESR.

Legionellosis pneumonia (Legionella pneumophila). Pathogen - Gram-negative rod, transmitted aerosol (nest in aerosol devices, air conditioners). The disease begins acutely with chills, malaise. The temperature rises to 38.5-40 C for 2-3 days. There is a headache, myalgia. Often, a fever is preceded by diarrhea. Infectious-toxic shock can develop. In the early days, the cough is dry, then the phlegm becomes purulent. Shortness of breath and cyanosis. With an objective examination in the lungs, the uneven shortening of the percussion sound, with auscultation, the breathing is weakened, and small- and medium-bubbling rales are heard. On the roentgenogram - focal and drainage infiltrates, sometimes capturing the proportion of the lung. From the cardiovascular system - tachycardia, muffled heart sounds.

In the blood - leukocytosis, ESR 60-80 mm / h and relative or absolute lymphopenia. Often, damage to the kidneys; when studying urine proteinuria, leukocyturia, erythrocytes and cylinders.

Pneumocystis pneumonia refers to parasitic diseases. Pneumocystae carinii - fungi, close to yeast fungi. They can occur in the form of epidemics and are observed in the departments for infants and preterm infants. In the emergence of pneumocystosis, general weakening of the body as a result of prematurity, hypotrophy, dyspepsia and other diseases is of great importance, and in severe cases of pneumonia, in patients of any age receiving glucocorticosteroids and cytostatics, immunodeficiency develops.

Typical symptoms are: sudden dyspnea (up to 100 or more breaths per minute); cyanosis around the mouth and acrocyanosis; the allocation of foamy contents and dyspnea with a pronounced cough. There is no toxicosis.

On the roentgenogram of the lungs, focal discharge shadows on both lung fields are "wadded lungs", interstitial changes. In the blood - leukocytosis, neutrophilia, increased ESR.

In diagnostics, the detection of pneumocysts in the mucus from the upper respiratory tract, which is taken from the trachea by a catheter, is of particular importance.

Classification of pneumonia in children (1995)

Morphological form	Conditions of infection	Flow	Complications
			Pulmonary	Extrapulmonary
Focal	Community-acquired	Sharp	Syncope-pleurisy	Infectious-toxic shock
Segmented	Inside-hospital	The protracted	Metampneumonia pleurisy	DIC-Syndrome
Ochagovo-draining	With perinatal infection		Pulmonary destruction	Cardiovascular failure
Croupous	In patients with immune deficiency		Abscess of the lung	Respiratory distress syndrome
Interstitial			Pneumothorax Piopnevo-thorax

According to the classification of clinical forms of bronchitis: gonorrhea in children in addition to the form of pneumonia, are allocated to community-acquired and nosocomial pneumonia.

Nosocomial (hospital, nosocomial) pneumonia is considered to be those that manifested in 48-72 hours after hospitalization with the exclusion of infections that could be in the incubation period at the time of admission to the hospital.

Current - acute and protracted; Complications are pulmonary and extrapulmonary.

Prolonged flow of pneumonia is diagnosed in the absence of resolution of the pneumonic process in the period from 6 weeks to 8 months from the onset of the disease; it should be an occasion to search for possible causes of such a course.

In case of recurrence of pneumonia (with the exception of re-and superinfection), it is necessary to examine the child for the presence of cystic fibrosis, immunodeficiency state, chronic aspiration of food, etc.

To establish the etiology of pneumonia, medical personnel of the inpatient department of hospitals, polyclinic offices, a nursing nurse in the pediatric area (when treating a child at home), it is necessary to take the patient's phlegm and send a smear to the Gram stained smear. Then, sputum culture on the flora, the use of quantitative methods for estimating the bacterial content in 1 ml of sputum, concentrations of 10 ⁶ -10 ^{8 are of} diagnostic significance . The indices of 10 ³ or less are characteristic of the accompanying microflora.

The most promising methods for rapid detection of the etiological agent, methods that allow to identify the antigens of bacterial pathogens in sputum, blood and other pathological materials are counterimmune electrophoresis, coagglutination. It is important that with these methods of research, the result is not affected by prehospital antibiotics.

The definition of serum C-reactive protein (CRP) at the level of 40 μg / ml for a viral infection, for bacterial infection - 8.0 μg / ml and higher can be considered a differentiation of bacterial and viral infection. The upper limit of the norm of CRP is 20 μg / ml.

In cases of effective therapy, there is a rapid decrease in the level of CRP to 20 μg / ml, which is accompanied by a decrease in body temperature, the disappearance of intoxication and radiological reduction of pneumonic infiltration. Long-term preservation of high figures of CRP indicates ineffective treatment of pneumonia. The detection of a second wave of elevated CRP in pneumonia indicates the development of complications, in particular, metapneumonic pleurisy.

For the etiological interpretation of chlamydial, mycoplasmal, legionella pneumonia, so-called non-cultural methods are used. Specific antibodies to these pathogens are determined by the indirect immunofluorescence reaction, complement fixation reaction, or by more modern ELISA test methods (detection of specific antibodies of classes IgM, IgG, IgA to mycoplasma and chlamydia).

One of the extrapulmonary complications of pneumonia in young children is the development of adult respiratory distress syndrome (RD SV).

Respiratory distress syndrome in adults is a complication of pneumonia. It is characterized by refractory hypoxemia, which is not eliminated in the hyperoxic trial, with X-ray signs of interstitial and alveolar edema of the lungs (widening of the vascular pattern of the lungs with edema of the interlobar pleura, reduction of pneumatization and focal shadows - "fluffy lungs", segmental and lobar edema, "air bronchogram").

The essence of ARDS is that there is a defeat of the respiratory apparatus, which makes it impossible to carry out physiological gas exchange, that is, the lung loses the ability to transform the venous blood arterial. The dominant syndrome in pneumonia complicated by ARDS is the respiratory-hemodynamic insufficiency syndrome.

Clinically, it is characterized by the pallor of the skin with a marble pattern, gray or earthy tinge, widespread cyanosis, severe shortness of breath with superficial groaning, groaning breathing, participation of ancillary muscles in the act of breathing, tachycardia, enlargement of the liver, neurological disorders (precoma, coma, convulsive syndrome ), peripheral circulatory insufficiency, hemorrhagic syndrome (cutaneous hemorrhages, gastrointestinal bleeding), polyorganic insufficiency with oliguria, or anuria. Arterial pressure in a part of children is increased, in the part - reduced.

Approximately with equal frequency, fever and hypothermia are noted, DN III, rarely DN II. Confirmation of the presence of ARDS in pneumonia is the appearance of X-ray signs of interstitial alveolar edema.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]