重症甲型流行性感冒15例诊治分析
중증갑형류행성감모15례진치분석
Analysis on diagnosis and treatment of 15 cases with severe influenza A
  • 万方数据
    中华儿科杂志 중화인과잡지
    Chinese Journal of Pediatrics
    2014年 2期 142-145 ,共4页

    左云龙%杨镒宇%洪婕%武志远%余莉%陶建平%龚四堂

    좌운룡%양일우%홍첩%무지원%여리%도건평%공사당

    流感病毒A型,H1N1亚型%流感,人 流感病毒A型,H1N1亞型%流感,人
    류감병독A형,H1N1아형%류감,인
    Influenza A virus,H1N1 subtype%Influenza,human
    目的 探讨重症甲型流行性感冒(甲流)的诊治特点.方法 采用原卫生部(2011年版)重症甲流诊断标准为入选标准,对2013年1月至5月广州市妇女儿童医疗中心儿童院区重症监护室(PICU)收治的15例重症甲流患儿的临床表现、胸X线片、电子纤维支气管镜检查及其取出物的病理结果、救治经过和转归等进行回顾性分析.结果 15例重症甲流患儿中,男11例,年龄2岁3个月～11岁;女4例,年龄1个月～5岁;占同期因流行性感冒住院的4.2％ (15/360);3例有基础疾病(2例为肾病综合征,1例为先天性心脏病);所有患儿均有发热、咳嗽和气促,均诊断为重症甲流并发支气管肺炎、呼吸衰竭;均采用H1N1和H7N9试剂盒分型,10例为H1N1亚型,5例排除H1N1亚型;15例均排除H7N9亚型.并发症:肺不张8例,气胸4例,纵隔气肿3例,胸腔积液4例,肺出血1例;7例痰培养发现合并细菌或真菌等感染;4例涂片发现:2例革兰阳性球菌,2例革兰阴性杆菌.治疗方法:12例接受气管插管和机械通气治疗,1例接受无创通气治疗,2例患儿仅面罩吸氧.10例行电子纤维支气管镜检查发现,5例树枝样或冻胶样支气管塑形,病理检查1例为纤维素性渗出物,伴有大量中性粒细胞、嗜酸粒细胞浸润,4例为纤维素性渗出物伴坏死物改变,伴有中性粒细胞浸润;4例经过吸除支气管管型后,病情得到明显改善.所有病例均强化左右侧身体位引流,电动振荡按摩拍背,加强吸痰,协助改善患儿肺部通气功能.预后:12例顺利转出PICU,死亡3例,其中1例为入院时出现肺出血、肾功能衰竭和多器官功能障碍综合征后放弃治疗,1例合并肾病综合征患儿,1例为合并先天性心脏病并入院后行矫治手术患儿.结论 重症甲流有基础疾病者死亡率高.临床上出现进行性呼吸困难,喘憋症状明显伴有肺不张、非对称性实变或肺气肿时,应考虑是否并发塑形性支气管炎,尽早进行电子纤维支气管镜检查.肺部物理治疗是改善患儿双肺通气功能重要辅助措施.
    목적 탐토중증갑형류행성감모(갑류)적진치특점.방법 채용원위생부(2011년판)중증갑류진단표준위입선표준,대2013년1월지5월엄주시부녀인동의료중심인동원구중증감호실(PICU)수치적15례중증갑류환인적림상표현、흉X선편、전자섬유지기관경검사급기취출물적병리결과、구치경과화전귀등진행회고성분석.결과 15례중증갑류환인중,남11례,년령2세3개월～11세;녀4례,년령1개월～5세;점동기인류행성감모주원적4.2％ (15/360);3례유기출질병(2례위신병종합정,1례위선천성심장병);소유환인균유발열、해수화기촉,균진단위중증갑류병발지기관폐염、호흡쇠갈;균채용H1N1화H7N9시제합분형,10례위H1N1아형,5례배제H1N1아형;15례균배제H7N9아형.병발증:폐불장8례,기흉4례,종격기종3례,흉강적액4례,폐출혈1례;7례담배양발현합병세균혹진균등감염;4례도편발현:2례혁란양성구균,2례혁란음성간균.치료방법:12례접수기관삽관화궤계통기치료,1례접수무창통기치료,2례환인부면조흡양.10례행전자섬유지기관경검사발현,5례수지양혹동효양지기관소형,병리검사1례위섬유소성삼출물,반유대량중성립세포、기산립세포침윤,4례위섬유소성삼출물반배사물개변,반유중성립세포침윤;4례경과흡제지기관관형후,병정득도명현개선.소유병례균강화좌우측신체위인류,전동진탕안마박배,가강흡담,협조개선환인폐부통기공능.예후:12례순리전출PICU,사망3례,기중1례위입원시출현폐출혈、신공능쇠갈화다기관공능장애종합정후방기치료,1례합병신병종합정환인,1례위합병선천성심장병병입원후행교치수술환인.결론 중증갑류유기출질병자사망솔고.림상상출현진행성호흡곤난,천별증상명현반유폐불장、비대칭성실변혹폐기종시,응고필시부병발소형성지기관염,진조진행전자섬유지기관경검사.폐부물리치료시개선환인쌍폐통기공능중요보조조시.
    Objective To analyze the diagnosis and treatment characteristics of patients with severe Influenza A.Method A retrospective investigation on the clinical manifestation,chest radiography,electronic fiber bronchoscopy and the histology of the cast,rescue course and outcome was conducted in 15 children with severe influenza A during January to May of 2013.Result Eleven cases were male,the range of age was 2 to 6 years ; 5 cases were female,the range of age was 1 month to 6 years,accouting for 4.2％ of hospitalized children with influenza.Three patients had an underlying chronic disease,two had nephrotic syndrome,and one had congenital heart disease.All the 15 cases were diagnosed as severe influenza A virus infection complicated with pneumonia and respiratory failure,of whom 10 cases were infected with H1 N1 virus,the other 5 cases could not be identified as H1N1 virus by using H1N1 kit,but none of the 15 cases were infected with H7N9 virus.Of 15 cases,8 had atelectasis,4 had pneumothorax,3 had pneumomediastinum,4 had pleural effusion,1 had pneumorrhagia; 12 patients required mechanical ventilation.1 only required noninvasive mask CPAP,2 did not require assisted ventilation,they were just given mask oxygen.Seven cases' sputum culture showed combined infection with bacteria and fungi,sputum smear examination detected:G + cocci in 2 cases,and G-bacilli in the other 2.By using electronic fiber bronchoscopy,bronchial cast was detected in 5 patiens.Histological examination of the bronchial cast revealed a fibrinous exudation containing large quantity of eosinophils,neutrophils in 1 patients,fibrinous exudation and necrotic material containing large quantity of neutrophils in 4 patients.After the bronchial casts were removed,4 patients were improved greatly.All patients were treated with postural drainage of left and right side position,massage of electric oscillation,strengthening the sputum suction aiming to improve pulmonary ventilation function.Three patients died:1 case was compliicated with nephrotic syndrome,another case had congenital heart disease,and 1 case hads pneumorrhagia,renal failure and multiple organ dysfunction syndrome (MODS).Conclusion The mortality of severe Influenza A is higher if it is complicated with underlying chronic diseases.In children undergoing rapid and progressive respiratory distress with lung atelectasis,consolidation or emphysema on chest X-ray,plastic bronchitis should be considered.Electronic fiber bronchoscopy should be performed early Lung physicotherapeutics still are important assistant measures for improving the pulmonary ventilation function.
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