An article to understand the diagnosis and treatment of suppurative pleurisy in children

The patient, male, 8 months, Cantonese, was admitted to hospital on January 2 because of fever and cough for 7 days.
7 days ago, there was no obvious cause of fever, body temperature fluctuations between 37 degrees C to 39.5 degrees C, accompanied by cough, for monotony cough.
has been diagnosed in the hospital as an "upper respiratory tract infection", has used the virus pyridoxine, oxycodone, penicillin and other drugs treatment, the effect is not obvious, still continued fever and cough, 2 days ago appeared shortness of breath, today's increased shortness of breath and irritability and emergency hospitalization.
illness, appetite has decreased and stools have been normal.
no convulsions, vomiting, no urine less, edema.
has no history of hepatitis, tuberculosis, leprosy, no history of trauma, surgery and drug allergies.
vaccinations, including card-in-the-child seedlings, are carried out on time after birth.
have no hepatitis, tuberculosis patients in their homes, no similar medical history.
: T39.4 degrees C, P150 times/min, R54 times/min, Wt8kg, 4cm head circumference.
normal development, nutrition in general, acute symptoms, pale.
skin without rashes, bruises, bruises, and shallow lymph nodes throughout the body.
sclere without yellow dyeing, two-sided pupils and other large contocation, diameter of 3mm, the presence of light reflection.
the nose wing flaps, slightly tingling the mouth, pharynx full of blood.
neck is soft, the thyroid gland is small, and the trachea shifts to the left.
three concave signs.
chest is fuller, the tactile vibrato is weakened, the diagnosis is cloudy, and the hearing breathing tone is weakened.
small blisters can be heard in the left pulmonary field.
heart rate 150 times / minute, heart rhythm is neat, the heart boundary is not large, the valve stethoscope area is not heard and pathological noise.
abdominal flat soft, liver ribs under 2cm can be touched, soft, side pure, spleen under the ribs not touched, liver and neck signs (-), abdominal signs (-).
spine, limbs without deformities, no edema, joints without redness, swelling, heat, normal muscle dysticks, normal knee reflexes, did not lead to pathological neuroreflexes.
laboratory examination: hemoglobin 120g/L, red blood cell 4.00x1012/L, white blood cell 16.4x109/L.
: neutral 0.78, lymph 0.22, plateplate 158 x 109/L.
urine routine: normal.
stool routine: normal.
: 32mm/h.
blood sodium, potassium, chlorine, sugar, urea nitrogen, creatinine, carbon dioxide binding force is normal.
liver function is normal.
(-) electrostatic chart: sinus titration.
: A large amount of fluid build-up in the right chest cavity.
speckled shadow on the left lung, and a 2x2cm2 pulmonary blister in the upper left lung.
the heart shadow size is normal.
is offset to the left.
Discuss the characteristics of intern A: the symptoms of this case: (1) male, 8 months;
The trachea is biased to the left, the right chest is full, the speech vibrato weakens, the sclerosis turbid tone, the stethoscopic breathing tone weakens, the left lung smells small blisters;
Intern B: According to the characteristics of the child's condition, first fever, cough, and then appear shortness of breath, the right chest full, speech tremor weakened, the breathing tone weakened, the trachea to the left offset, combined with chest examination can be clear right chest fluid diagnosis.
teacher: chest fluid can be caused by a variety of reasons, how to judge the nature of chest fluid? Intern C: In order to judge the nature of chest fluid build-up, a chest puncture must be carried out and chest water taken for examination.
first to judge whether water is oozing or leaking.
seepage liquid is characterized by appearance yellow-green or pink, slightly cloudy, more viscous, easy to solidify, the proportion is more than 1.016, protein quantification is often higher than 2.5-3g/L, chest water protein and serum protein ratio is more than 0.5, sugar quantification is often lower than blood sugar, chest water mucous protein qualitative test positive.
and leakage fluid is characterized by the appearance of pale yellow, clear, thin, non-condensation, the proportion is more than 1.016, chest water protein and serum protein ratio is often less than 0.5, sugar quantification and blood sugar equal, chest water mucous protein qualitative test negative.
Intern D: Leakage is commonly seen in heart disease, cardiac inflammation, kidney disease, cirrhosis, upper cavity venous syndrome, malnutrition, hypoproteinemia, etc. , at the same time can be seen systemic edema, chest fluid often appears on both sides.
clinical characteristics of this case are one-sided chest fluid, no other parts of edema, and in the examination did not find heart, liver, kidney changes and hypoproteinemia, so it is unlikely to consider leakage.
teacher: agree with everyone's analysis, chest fluid can be divided into oozing fluid and leakage.
Leaks have just been analyzed, seepage fluid can be caused by bacteria (including Bacillus tuberculosis), viruses, lique subsomes, fungi and parasites and other infections, autoimmune diseases such as acute rheumatoid fever, lupus erythematosus and so on can also be caused.
chest water is bloody, attention should be paid to chest malignancies.
addition, there are breasts.
as we all said, in order to judge the nature of chest fluid, we must do chest puncture, water test.
according to the appearance of chest water to do bacterial culture, smear check anti-acid bacteria or PCR-TB-DNA, mastosis determination and other tests can be identified.
now tell everyone chest water test results: appearance yellow, viscous, neutral 0.85, lymph 0.15, protein quantitative 4g/dl, sugar 2.1mmol/L, viscous protein qualitative test positive, bacterial culture results did not return.
E: Based on this result can be judged to be purulent thoracicitis.
: Agree with the classmate's judgment.
but why does this child develop pusy thoracicitis? Please analyze the possible causes.
Intern F: According to the characteristics of this child, in addition to the right chest fluid, there is still accompanied by fever, cough, left lung smell and small and medium blister sound, chest piece left lung a little shadow, so I think the development from pneumonia to pus chest is very likely.
teacher: In addition to pneumonia and pus chest, is there any other reason to cause pus chest? Intern B: In addition to pneumonia, pulmonary abscesses and bronchitis dilation can also cause pus chest.
there are still a few adjacent organs or tissue infections spread or penetrate, such as vertical inflammation, subsolamation, liver abscesses, etc. , in addition, chest trauma, surgery or puncture operations such as direct contamination is also possible.
: That's the right answer.
caused by pneumonia is the most common.
For the characteristics of this case, the child is young, sick, accompanied by fever, cough, left lung smell and small and medium blister sound, chest left lung has speckled shadow, all support the diagnosis of pneumonia.
pulmonary abscesses are visible in the X-ray abscess, if connected to the bronchitis, there is a liquid plane, bronchid dilation in the X-ray visible size ring-like light-transmission shadow is curly or honeycomb-like, these are different from pneumonia performance.
abscesses and liver abscesses can be further excluded by B super, in addition, the child has no history of chest trauma, surgery and puncture operation, caused by these reasons can also be excluded.
A: Teacher, how does pneumonia cause pus? Teacher: Caused by pathogenic bacteria in the lung infection lesions, directly or through the lymphatic tube intrusion into the thoracic surface.
please discuss the pathogen problem below.
pneumonia can be caused by a variety of pathogenic infections, such as bacteria, viruses, fungi, mycobacterium, chliropaths and so on.
treatment of different pathogens is different, so it is necessary to find out the pathogens.
Intern C: According to this child's acute illness, serious illness, rapid development, poisoning symptoms, blood like white blood cells increased, leaf increase, in addition to lung blisters and pus chest, so consider may be caused by Staphylococcus auspicrus.
: It's right to think about it before the results of chest water bacteria culture come back.
In pneumonia, the most common cause of pus chest bacteria are BLO, followed by E. coli, other bacteria including Streptococcus, Haemophilus influenzae, Bloccus pneumoniae, Creb, Green coli, anaerobic bacteria, etc., in addition, TB can also cause pus chest.
Staphylococcus aelobacter is highly pathogenic and can produce a variety of toxins and enzymes.
include: exotoxins, lectocin, enterotoxins, skin peeling and plasma clotting, hyaluraluric acid, etc., can cause widespread bleeding of the lungs, necrosis and multiple small abscesses.
can easily spread to other areas, causing migratory lesions.
most commonly found in newborns and infants.
clinical manifestations are characterized by flaccid high fever, obvious symptoms of poisoning, paleness, cough, difficulty breathing and susceptible to pus chest, pus chest and pulmonary herpes.
Intern F: Teacher, what are the different characteristics of pus caused by different bacteria? Teachers: Streptococcus pus is pale yellow, thinner, less adhesive; pneumococcal pus is yellow-green, thicker, more cellulose, more adhesion; anaerobic pus is green, smelly; The liquid is yellow, because staphylococcus release coagulation prompts more cellulose to be released from the liquid, condensation and deposition on the surface of the thoracic membrane, pus viscosity increased, between the thoracic membrane is also prone to adhesion, often more easily formed ensty or polyenthroid pus chest.
the characteristics of pus in the judgment of pathogens, can only be used as a reference, where chest fluid should be done pathogen culture and drug sense testing, bacteriology, and prepare for the choice of antibiotics.
intern E: Teacher, how did the lung blisters come into being? Teacher: fine bronchitis cavity due to inflammatory swelling, narrow, oozing material viscous, so that the bronchilla formed a flap part of the blockage, air inhalation is not easy to exhale, resulting in enlargement of the veins, the rupture of the vesicles, the fusion of multiple vesicles to form a pulmonary blisters, the size of which varies with the pressure inside the veins and the number of ruptured veles.
treatment should be used after a clear diagnosis has been made? Intern A: Chest puncture pumping.
intern B: chest closed drainage.
teacher: pus chest early pus is thinner, punctured pus is relatively easy, is a more commonly used treatment.
the rapid growth of pus should be 1 time a day, otherwise it can be 1 next day, until the symptoms of poisoning disappear, pus has been significantly reduced.
such as daily puncture pus, 3-4 days after the symptoms of poisoning has not been reduced, the reduction of pus is not obvious, indicating that the effect is not satisfied, should change the way of discharge.
Because multiple punctures increase the patient's pain and chest wall infection opportunities, and there is a risk of causing gas chest, the current tendency to early chest closed drainage, especially pus chest, more suitable for closed drainage.
but must be good at using and managing drain pipes to achieve the desired results.
early pus chest in the closed drainage, if the drainage tube can remain smooth, 1 to 2 days pus will be completely drained, the lung leaves all dilate, about 1 week can be pulled out of the tube.
in addition to chest discharge pus, what treatment measures are needed? Intern C: Anti-infection.
should choose drugs that are more effective against Staphylococcus acobacteria.
can choose ampicillin, chloramphenicol, benzodiacin, phthalates and gyromycin.
: It is best to choose sensitive erythrite for drug-sensitive trials based on thoracic cell culture.
these antibiotics are available until results are available.
, erythromycin, vancomycin, third-generation cephalosporin antibiotics, etc. are also available.
after determining the antibiotics to be used, how long should I use? Intern F: The course of treatment should be long, generally after normal body temperature to continue to take medication for 2-3 weeks, the total course of treatment 6 weeks.
: That's the right answer.
, unlike pneumonia in general, staphylococcus inflammation is stubborn and prone to recurrence, so the course of antibiotic use should be longer.
C: In addition to the above-mentioned abscess, anti-infection measures, but also pay attention to support therapy.
teacher: Yes.
Acute purulent thoracic inflammation when the protein consumption is large, staphylococcus infection on the tissue has a wide range of necrotizing destructive effects, its internal and external toxins and enzymes on the human body has a variety of harmful effects, so the disease often quickly malnutrition, low resistance throughout the body, anemia, etc., is one of the factors leading to a high rate of death.
treatment should pay attention to strengthen nutrition, if necessary, with intravenous input of nutritional formula fluids and actively carry out multiple blood transfusions, in order to achieve good results in treatment.
, as with other pneumoniaes, the necessary treatment should be done for symptoms such as oxygen absorption, anti-spasm sputum, keep the respiratory tract open, correct body fluid imbalance and so on.
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