肺炎

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肺炎的定義，是指肺部的肺泡出现發炎的症狀。肺炎可以發生在任何年齡組別的人身上，但以年幼及年長者，以及患有免疫力缺乏症或免疫系統比較差的人屬於高危患者，他們比較容易發病。而對於其他人，他們身體本身的免疫系統已有能力對抗輕微的感染。一般程況都會向病人處方抗生素來治療。此外，華人社會一般俗稱嚴重的肺炎作“肺癆”；若病況嚴重，可以致命。

[编辑] 病徵

• 一般病徵
  • 咳嗽，痰涎帶黃綠色
  • 发烧伴有寒战 (rigors)
  • Sharp or stabbing chest pain, worsened by deep breaths or coughs
  • Rapid, shallow breathing (painful quick breathing)
  • 气短
  • 發高燒 (體溫至少39.5°C或103°F)
  • Painful cough
• 罕見病徵
  • 咳血
  • 头疼，包括偏头疼
  • Excessive sweating and clammy skin
  • 食欲减退
  • 浑身疲惫
  • 面色苍白

如果不治療肺炎可能會導致敗血症和急性呼吸衰竭症候群.它們是沒有接受治療的病患主要的致死原因.

[编辑] 診斷

對於肺炎的診斷，胸腔X射線中肺部出現浸潤現象是診斷肺炎的黃金標準，支持性的診斷方法則是由病患的痰液或血液進行微生物的培養。當懷疑有肺炎時，通常會進行血液檢查：完全血球計數可以顯示出嗜中性球的增生(除了某些免疫不全或嗜中性球減少症的病患之外)。若病情發展為敗血症，病患的腎功能可能有下降的情形。在離子的測定方面，通常由於肺炎的肺部組織釋出抗尿激素而導致納離子的降低。 若為院內感染或是因免疫不全所造成的肺炎，其診斷會比較困難，甚至可能需要進行肺部的斷層掃描以區分可能造成肺炎的原因(例如肺栓塞)。若病患亦有其它的症狀或不適(例如血管炎，肉狀瘤病或是肺癌等)時，斷層掃描亦具有其應用性。

[编辑] Classification

There are several different classification schemes: microbiological, radiological, age-related, anatomical, point of acquiring infection. Generally, the following types are used:

• lobar - pneumonia that results in the consolidation of a pulmonary lobe (generally due to Streptococcus pneumoniae)
• multilobar - pneumonia that results in the consolidation of more than one lobe
• community-acquired - pneumonia in a patient who is not or has not recently been in the hospital
• hospital-acquired or nosocomial - pneumonia in a patient in a hospital (or recently discharged)
• "walking" - outdated term, pneumonia in a patient who is still able to walk, a mild pneumonia, usually due to mycoplasma
• pneumococcal - pneumonia due to S. pneumoniae.
• atypical - pneumonia due to either Mycoplasma, Chlamydia or Legionella.

The main classification used in medical journals is that between the point of infection: community-acquired and hospital-acquired. Furthermore, infections in the immunocompromised, as well as aspiration pneumonia, are usually treated as separate disease entities as they have other causal agents, as well as a different clinical course.

[编辑] Types of pneumonia

社區型肺炎

• 流行病特徵：社區型肺炎是嚴重的疾病。在英國是第四大主要死因，在美國則是第六大死因。85%的社區型肺炎的致病體是典型的細菌，包括了肺炎鏈球菌（Streptococcus pneumonia）、流行性感冒嗜血桿菌（Haemophilus influenzae）、卡他莫拉式菌（Moraxella catarrhalis）。剩下的15%則由所謂的非典型致病體造成，包括肺炎黴漿菌（Mycoplasma pneumonia）、肺炎披衣菌（Chlamydia pneumonia）、和退伍軍人菌屬（Legionella species）。一般而言，需氧的葛蘭式陰性桿菌（如綠膿桿菌（Pseudomonas aeruginosa）、靜止桿菌（Actinectobacter）、腸桿菌（[Enterobacter））較少造成社區型肺炎。
• 臨床特徵：典型的特徵包括咳嗽、有膿的痰、呼吸急促、肋膜胸痛、發燒和發抖。理學檢查上，可發現較高的呼吸速度、心跳和呼吸道堅實化。在老年人，症狀會變得較模糊不清且較不具專一性。老年人可能會伴有頭痛、不安、腹瀉、意識不清、跌倒和食欲減少等。胸部X光是診斷的標準。一般而言，當病人懷疑有社區型肺炎而只有肺部的症狀，並無其他器官的關連時，通常是由典型的致病體造成。而病人有肺炎且伴隨著其他器官的症狀且實驗室檢查也有變化時，可能是由非典型致病體造成。

[编辑] Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is a lung infection acquired after hospitalization for another illness or procedure. It is considered a separate clinical entity from CAP because the causes, microbiology, treatment and prognosis are different. Hospitalized patients have a variety of risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying cardiac and pulmonary diseases, achlorhydria and immune disorders. Additionally, pathogens thrive in hospitals that could not survive in other environments. These pathogens include resistant aerobic gram-negative rods, such as Pseudomonas, Enterobacter and Serratia, resistant gram positive cocci, such as MRSA. Because of risk factors, underlying morbidity and resistant bacteria, hospital-acquired pneumonia tends to be more deadly than its community counterpart. Antibiotics used for hospital-acquired pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and vancomycin. Multiple antibiotics are administered in combination in order to cover all the possible organisms effectively and rapidly, before the infectious agent can be known. Antibiotic choice varies from hospital to hospital as the likely pathogens and resistance patterns vary similarly.

[编辑] Other pneumonias

• Severe acute respiratory syndrome (SARS)
• Pneumocystis carinii pneumonia
• Bronchiolitis obliterans organizing pneumonia
• Eosinophilic pneumonia

[编辑] Pathophysiology

Pneumonia is an infectious disease by definition, and whether a patient is prone to develop pneumonia depends on the presence of pathogens but equally on the patient's immune system and other factors. 大多數的肺炎都並非傳染性，除非肺炎是由流行性感冒引起的。

Breathing problems, as often present in patients after a stroke, in Parkinson's disease, hospitalisation or surgery and mechanical ventilation can all increase the likelihood of pneumonia. Similarly, inability to clear sputum (as in cystic fibrosis) or retention of sputum (as in bronchiectasis) can lead to pneumonia.

After splenectomy (removal of the spleen), a patient is more prone to pneumonia due to the spleen's role in developing immunity against the polysaccharides on pneumococcus bacteria.

[编辑] Prevention

Vaccination with the pneumococcal polysaccharide vaccine is recommended for adults older than 65 and persons with chronic disease (except asthma). Also for Native Alaskans and certain Native Americans^{1 2} . Pneumoccocal pneumonia kills more Americans than all other diseases combined that could be partially prevented by vaccination¹ .

[编辑] Therapy

一般來說，治療肺炎大多投以抗生素治療；醫生會就肺炎的類型及病人的免疫力來評估用量。 Amoxicillin is used as first-line therapy in the vast majority of community patients, sometimes with added clarithromycin. In North America, where the atypical forms of community acquired pneumonia are becoming more common, clarithromycin, azithromycin, and the fluoroquinolones have displaced the penicillin-derived drugs as first line therapy. In hospitalized patients and immune deficient patients, local guidelines generally determine which combination of (generally intravenous) antibiotics is used.

[编辑] Prognosis and mortality

The clinical state of the patient at time of presentation is a strong predictor of the clinical course. Many clinicians use the Pneumonia Severity Score to calculate whether a patient requires admission to hospital, based on the severity of symptoms, underlying disease and age³ . In the United States mortality from pneumococcal pneumonia is 1 in 20, in cases where the disease progresses to blood poisoning, bacteremia, 2 of 10 die and where the disease affects the brain, meningitis, 3 of 10 die. ¹

[编辑] History of pneumonia

Before the advent of antibiotics, pneumonia was often fatal. When penicillin was discovered in the 20th century, it was the first causal therapy. Most community-acquired strains of S. pneumoniae are still penicillin-sensitive.

[编辑] Notable pneumonia sufferers

Many famous people throughout the years have succumbed to pneumonia and its complications. As it is a common cause of death in the chronically ill, this is not always reported in the press.

• A well known and tragically sudden death due to pneumonia was that of Muppets creator Jim Henson in the early 1990s.
• 19th Century Sharpshooter Calamity Jane.
• In 1989, Actor Jim Backus died of pneumonia, after suffering for years with Parkinson's Disease. Backus was best known for his roles as the voice of animated character, Mr. Magoo, and as Thurston Howell III on television's Gilligan's Island.
• Television producer and director, Bruce Paltrow, 58, died of the disease while traveling in Rome in 2002. Paltrow was survived at the time by his wife, actress Blythe Danner, and his daughter, actress Gwyneth Paltrow.
• In the late 30s, movie mogul Irving Thalberg was finally felled by pneumonia after suffering for years from heart problems. Thalberg died before even reaching his 40th birthday, and some say Louis B. Mayer, let alone Norma Shearer, never recovered from the loss of MGM's creative "boy wonder."
• In 2005, John Raitt, Broadway star of the 50s and 60s in such hits as The Pajama Game and Carousel, passed away due to complications from pneumonia. His daughter is pop and blues singer, Bonnie Raitt.
• Nicole DeHuff, an actress who played Teri Polo's sister in Meet the Parents, has died of causes related to pneumonia. She was 31 years and 41 days in age. The actress died Feb. 16, 2005, in Hollywood, four days after she reportedly checked into a Los Angeles hospital, was misdiagnosed and sent home with orders to take Tylenol.

[编辑] 註

• 註解1：

National guideline clearninghouse clinical practice guideline (USA): adult preventive health care - immunizations

• 註解2：

Center for Disease Control, United States, regarding vaccination with the pneumococcal polysaccharide vaccine (PDF)

• 註解3：

Halm EA, Teirstein AS. Management of community-acquired pneumonia. N Engl J Med 2002;347:2039-45. PMID 12490686.