重症甲型流行性感冒15例诊治分析

Analysis on diagnosis and treatment of 15 cases with severe influenza A

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.

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.