Elderly patients with severe community-acquired pneumonia (SCAP) is a common refractory disease in the Department of respiration, the clinic
Elderly patients with severe community-acquired pneumonia (SCAP) is a common refractory disease in the Department of respiration, the clinical manifestations are often non-specific, more associated with the underlying disease, rapid progress has become a common cause of death in the elderly. The clinical features and treatment of 98 elderly patients with SCAP in our hospital from 2000 to 2010 were analyzed in order to improve the prognosis.
1 clinical data
1.1 general information: 98 cases of elderly SCAP patients were diagnosed according to 1999 (2006) the Chinese medical association respiratory disease branch of diagnostic criteria for community-acquired pneumonia guidelines for the diagnosis and treatment of severe pneumonia. Male 50 cases, female 48 cases, age greater than 65 years, the average (74 + 3), 80 cases with underlying diseases (81.5%).
1.2 clinical manifestations: 98 cases with mental symptoms in (haziness, drowsiness, coma) in 62 cases (63.3%); gastrointestinal symptoms (loss of appetite, nausea, vomiting) 50 cases (51%); 47 patients with symptoms of respiratory tract (47,9%); 42 cases of fever (42.8%); and 57 cases of pulmonary rales were heard. Single / multiple organ dysfunction, appear the proportion of high to low respiratory failure (1 type), circulatory dysfunction, toxic encephalopathy, gastrointestinal bleeding, renal dysfunction, few sepsis, most of these patients died.
1.3 laboratory examination: normal white blood cells, but neutrophils increased, anemia, elevated liver enzyme, myocardial ischemia ECG changes, beats, serum creatinine and urea nitrogen increased, cultivating low positive rate of sputum culture examination and blood pathogen, pathogenic bacteria from high to low incidence of Escherichia coli and Klebsiella pneumoniae (Fei Yan), Bauman Acinetobacter, few Staphylococcus aureus.
1.4 changes: lung CT shows: lobar pneumonia, bronchial pneumonia, or scattered patches: cloud shadow.
1.5 treatment principles
Active treatment of primary disease, blood culture and sputum culture and understanding of the relevant organ function detection, at the same time take the following treatment (1) used antibiotics used to hammer therapy: fungicides, wide coverage, adequate, early application, and then step down according to the illness. (2) correct life-threatening organ failure: such as fluid resuscitation strict detection, can be matched with the patients using noninvasive positive pressure ventilation in treatment of respiratory failure, application of endotoxin scavenger (4) nutrition: enteral nutrition, necessary nasogastric enteral nutrition liquid (5) to maintain water electrolyte and acid-base balance (6) to strengthen monitoring
1.6. In the 98 cases, there were cured in 55 cases, giving up treatment in 19 cases and death in 24 cases. Mortality 43%.
It is estimated that China's annual pneumonia patients in 2 million 500 thousand cases, in which the elderly accounted for 70%, because the function of failure, with the basis of disease, and in severe cases, with the social trend of aging and its incidence increased year by year, the elderly is the major cause of death in , this study in 98 cases, the mortality rate as high as 43% with a mortality rate of 75%, reported abroad declined .
Analysis of the elderly severe pneumonia in our hospital, we found the following characteristics (1) the clinical manifestations of neuropsychiatric and gastrointestinal symptoms, or only show shortness of breath, often covered by the original symptoms. (2) fewer positive lung signs. (3) with a single / multiple organ failure, respiratory, circulatory failure is the most common (4) increased the number of granulocytes, imaging is the main means of diagnosis, pathogenic bacteria mainly G- bacteria. (5) pneumonia in the aged condition changes, especially in the early control is not ideal, the condition is often a sudden turn for the worse and early discovery right, very important.
Treatment experience (1) as soon as possible the discovery of unknown causes of psychiatric symptoms or digestive tract and difficult to explain the difficulty of breathing, as early as the image (especially the lung CT) examination. Blood gas analysis, blood culture, sputum culture. (2) take Deescalation (de escalation therapy) treatment strategy, the application of this strategy to the attention of the crowd, according to the diagnostic standard of SCAP (MDR) and multi drug resistant pathogens infection risk factors such as individual drug selection, timely implementation of the initial empirical treatment (EMP IRIC therapy) continued back targeted therapy (target therapy) conversion, once with the correct diagnosis standard of SCAP, should be within 1 h selection scheme of broad-spectrum antibiotics and strong, is very successful treatment key. (3) to maintain the function of multiple organs in the body to prevent multiple organ failure. Hypoxemia or dyspnea, attention without the use of a respirator, trial of noninvasive ventilation, even sputum more patients can also use intermittent noninvasive ventilation. The efficacy of noninvasive ventilation for 1 to 2 h should be evaluated. If severe hypoxemia (oxygen and index PaO2 /FiO2 < 150) or bilateral alveolar infiltration occurs, emergency tracheal intubation is required. Circulatory failure of the liquid resuscitation under strict supervision to complete. (4) pay attention to nutritional support treatment, improve immunity, correct electrolyte disorder, eliminate inflammatory mediators. Can effectively improve the anti infection effect. (5) the rational treatment of basic diseases is the basis for reducing mortality, and the use of immune enhancers when necessary. In short, the early detection of severe pneumonia in elderly patients, and comprehensive treatment throughout the program, is the key to success.
Of course, we through the corresponding treatment, the success rate has been rising, but this group of elderly SCAP mortality is still as high as 43%, we analyze the likely etiology is the key.
 Sun Tieying, Liu Bing, and the clinical analysis of community acquired elderly hospitalized patients with. Chinese Journal of Geriatrics, 2005, 24 () 100-102
 Zhu Yinggang, Qu Kai Ming, difficulty and clinical strategy on elder patients with severe pneumonia. Chinese Journal of geriatrics 2008, 27 () 1-5