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the treatment of nosocomial pneumonia in the elderly, what to do with nosocomial pneumonia in the elderly

the treatment of nosocomial pneumonia in the elderly, what to do with nosocomial pneumonia in the elderly

Knowledge of diagnosis and treatment of hospital-acquired pneumonia in the elderly

Treatment department: Department of Respiratory Medicine and Geriatrics Treatment cost: about (6000-10000 yuan) in the city's top three hospitals Cure rate: Treatment cycle: Treatment method: Western medicine treatment General treatment of hospital-acquired pneumonia in the elderly

One, treatment

Hospital-acquired pneumonia in the elderly must be treated with antibiotics as soon as possible, and comprehensive measures must be taken to strengthen nursing care to prevent complications, improve disease resistance, and strive for early recovery. The course of treatment should be individualized. Its length depends on the pathogen of the infection, the severity of the underlying disease, and the response to clinical treatment. Suggested course of treatment: Haemophilus influenzae 10-14 days, Enterobacteriaceae bacteria, Acinetobacter 14-21 days, Pseudomonas aeruginosa 21-28 days, Staphylococcus aureus (MSSA) 21-28 days, of which armour-resistant Oxycillin Staphylococcus aureus (MRSA) can appropriately extend the course of treatment. Pneumocystis carinii 14-21 days, Legionella, Mycoplasma and Chlamydia 14-21 days.

1. General treatment

During the entire process of the patient, careful care should be taken to encourage the patient to drink more water, eat nutrient-balanced, easily digestible semi-liquid food, and for those who cannot eat, supplement nutrition and fluids intravenously. Encourage patients to cough, expectorate sputum, moisturize the room, and give expectorants, and regularly tap the back to keep the airway open. Unless the cough is severe, sedatives and cough suppressants are generally not used. If the condition changes, suck sputum if necessary, and do a good job of psychological care to comfort the patient. In the acute phase, stay in bed and rest more. After the acute phase, if the condition improves, you should strengthen activities. Frail patients with high fever should be given physical cooling, and if necessary, drugs should be given to cool the body temperature to below 39℃.

2. Antibiotic treatment

Studies have shown that the incidence of hospital-acquired pneumonia in the elderly in China is increasing year by year. And drug-resistant pathogenic strains are increasing year by year. This is related to the acceleration of China's aging process and the irrational use of antibiotics. The principle of rational use of antibiotics. The absorption and distribution of drugs, metabolism and excretion rate of the elderly change greatly. With the increase of age, renal function gradually declines, aging, smoking, drug intake, diet, and underlying diseases. Human drug metabolism has a great influence. The reduction of visceral blood flow in the elderly reduces the clearance of drugs with high visceral clearance. These factors should be considered before antibiotics are used.

(1) Antiviral treatment:

Interferon can interfere with virus replication at the initial stage of infection, inhibit virus synthesis and promote phagocytosis by phagocytes. Amantadine can fight influenza virus and reduce the fever and systemic symptoms caused by it. In addition, Morpholinoguanidine (viral) and ribavirin (ribavirin) can treat influenza, parainfluenza and adenovirus pneumonia. Cytomegalovirus: First choice: ganciclovir alone or combined with intravenous immunoglobulin (IVIG) or cytomegalovirus high immunoglobulin. At present, there are no specific drugs for anti-viral infection, mainly for symptomatic treatment to improve hypoxia, supportive treatment, intensive care and other comprehensive treatments. Studies have shown that traditional Chinese medicines such as Radix Isatidis, Andrographis paniculata, Daqingye, Honeysuckle, Rhubarb, and underground car will also have certain effects.

(2) Antibiotic treatment:

In the early stage, before the bacterial culture and drug sensitivity results are obtained, the general distribution of bacteria in the hospital and the sputum Gram cell staining combined with the patient’s symptoms and signs can be used to initially determine the general type of pathogen infection. If it is considered to be a Gram-negative bacillus infection, it can be The third-generation cephalosporins such as cefoperazone, cefotaxime, ceftazidime, etc. are preferred, but if the patient's liver and kidney functions are good, an aminoglycoside drug can be used in combination with a β-lactam drug. If it is determined to be infected by Escherichia coli and Klebsiella, generally the second and third generation cephalosporins, aminoglycosides and quinolones are effective. When it is determined to be a Pseudomonas aeruginosa infection, generally piperacillin (oxypiperazine penicillin), ticarcillin (carboxythiophene penicillin), amikacin (amikacin), gentamicin, tobu Imipenem, aztreonam, imipenem (thiamycin imipenem), imipenem-cilastatin sodium (Taineng), ofloxacin (ofloxacin), cefoperazone and ceftazidime (complex Daxin) can be used, of which ceftazidime (Fudaxin), head

Sporoperazone and amikacin (amikacin) have the best effect, depending on the condition. Penicillin, lincomycin (lincomycin) and metronidazole (metronidazole) have a good effect on anaerobic infections. Because penicillin is prone to drug resistance, metronidazole (metronidazole) is more clinically used universal. In case of streptococcal infection, penicillins are the first choice. Staphylococcus aureus infections generally use vancomycin, cefmetazole and other cephalosporin antibiotics fosfomycin and quinolones. It is best to determine the medication according to the susceptibility test, such as β-lactamase-resistant strains (such as SRMA strain) , Can choose oxacillin (oxacillin), cloxacillin (o-cloxacillin), dicloxacillin (dicloxacillin) or nafcillin (ethoxynacillin). For Legionella infection, erythromycin and rifampicin are the first choices. Mycoplasma infection is usually treated with erythromycin. Pneumocystis carinii: Compound oxazole is the first choice.

(3) Antifungal treatment:

The main antifungal drugs are amphotericin B, ketoconazole, fluconazole, miconazole and flucytosine (5-fluorocytosine). Clinically, fluconazole and miconazole have fewer side effects and are used more frequently. Sulfonamides can be used for actinomycetes and cardial infections.

3. Treatment of underlying diseases

Hospital-acquired pneumonia in the elderly is often accompanied by various primary diseases, which directly affect the outcome of lung inflammation. Therefore, it should be taken seriously. For example, in patients with chronic renal insufficiency, due to increased basic metabolism in the body after pulmonary infection, protein breakdown products accumulate in the body, aggravating azotemia, and dialysis treatment is feasible. It is difficult to control pulmonary infections in diabetic patients, and it is necessary to control blood sugar in time to treat pulmonary inflammation. After surgery or patients with malnutrition, the lungs should be treated with nutritional support at the same time. Those with low immune function should pay attention to improving immune function.

4. Select the best plan

(1) Bacterial pneumonia:

Mild to moderate, second- and third-generation cephalosporins, β-lactams/β-lactamase inhibitors are preferred; fluoroquinolones or clindamycin combined with macrolides should be used for penicillin allergies; severe, broad-spectrum β-lactams/β-lactamase inhibitors or carbapenems (imipenem).

(2) Fungal pneumonia:

Application of fluconazole (Dafukang) treatment.

5. Rehabilitation

Rehabilitation treatment of hospital-acquired pneumonia is also called pulmonary physical therapy. Including instructing the patient to relax and perform breathing exercises, posture drainage, tapping or tapping the back and vibrating the chest, holding the chest in order to facilitate the patient's cough. All these manipulation techniques are designed to promote the clearance of secretions in the lungs.

(1) Patient education:

The purpose, meaning and methods of training should be explained in detail to the patient in advance to obtain the patient’s understanding and cooperation.

(2) Muscle relaxation training:

In terms of rehabilitation training, one of the purposes of muscle relaxation training is to relieve pain. There are 3 methods:

①Self-discipline training method: This is a method that starts from the sense of mental relaxation (quiet) and enters to eliminate physical tension. Concepts and language formulas are used in the introduction method, and the elements of self-hypnosis are very large.

②Progressive relaxation method: It is from one muscle group to another muscle group, consciously repeatedly practicing muscle tension and relaxation, so that the whole body gradually enters a state of relaxation. It is required to discharge self-suggestion, patients must have strong patience and persist in long-term training, and master complete muscle relaxation.

③Electromyography biofeedback: It uses surface electrodes to convert the electromechanical changes of muscle contraction and relaxation into sounds, pointer swings or display them with an oscilloscope. In addition, there are biofeedback of joint angle meter and pressure meter. Make the muscles contract or relax moderately, and then be used to stimulate, inhibit or enhance muscle strength.

(3) Breath training:

Allow the patient to use the diaphragm to perform abdominal breathing or partial chest breathing, which can turn shallow breathing into deep slow breathing, improve breathing efficiency, promote re-expansion of residual lungs, and prevent the formation of ineffective lungs.

(4) Exclusion of tracheal secretions:

① Cough promotion method:

Sputum expectoration requires full inhalation of air into the bronchi where there is sputum and cough up suddenly, so that the sputum will fly out of the bronchi.

②Position drainage:

For bedridden patients who have extensive secretions in the lungs but cannot effectively cough, the secretions cannot be fully eliminated by turning over to the left and right every half an hour. Improved body drainage can be used. Percussion or vibration of the lesion during exhalation is beneficial to sputum discharge. Common fluid levels are as follows:

A. Intersection of the right upper lobe: Sitting upright, tilting forward, backward or sideways according to the location of the lesion.

B. Front section: lying on your back, with the right side raised.

C. Posterior section: Lying on the left side, turning the face down 45°, supporting the posture with pillows.

D. Posterior part of the left upper blade tip: Sitting upright, leaning slightly forward or backward, or lying prone, raising the upper body by 30°.

E. Back section: Lie on your back, turn your body 45° to the right, raise the foot of the bed by 3

0cm, with head low and feet high.

F. Right middle lobe: Lie on your back, turn your body 45° to the left.

G. Lower lung lobe: lying prone, with raised abdomen or head down.

H. Front bottom section: Lie on your back, raise your hips and flex your knees, raise the foot of the bed 30cm, head down and feet high.

I. Side bottom section: Lying on the side with the affected side on top, the waist is raised, the foot of the bed is raised 30cm, and the head is low and the feet are high.

J. Back bottom section: lying on your stomach, raising your abdomen, raising the foot of the bed 30cm, head down and feet high.

③Manipulation therapy:

Hitting or tapping or vibrating the chest with hands or mechanical devices are necessary and effective methods to help patients get rid of secretions.

(5) Physical function training:

Mainly for the upper limbs, especially the recovery training of the normal range of motion of the joints and normal posture recovery training.

(6) Incremental exercise training:

Its greatest advantage is the redistribution of oxygen to highly efficient tissues. The easiest way is to do outdoor walking exercises at a pace that causes breathing difficulties. Outdoor activities in cold areas in winter may cause bronchial spasm, so you can use bicycles, bicycle exercise trainers or rowing exercise trainers. Patients feel good about themselves, and their exercise tolerance and work ability have improved.

(7) Routine chest rehabilitation treatment:

For critically ill patients, chest rehabilitation therapy can be performed once every 2 hours, and adjusted in time according to the treatment plan. It can be carried out in the following order and method, 2 to 4 times/d:

①Atomized inhalation (20min):

It can moisten the upper respiratory tract and help the liquefaction of secretions. Patients with fever can use cold air mist, but it is best to be warmed to increase moisture. The carrier gas is usually air with high oxygen content, which can be carried out through a mask or face mask using a humidifier or sprayer. If it is convenient, the patient can be taught to do breathing body or master cough at this time.

②Intermittent positive pressure breathing (15min):

It is controlled by the personnel engaged in inhalation therapy or nursing staff, so that the patient has a period of mild hyperventilation and strengthens the expansion of the lungs. This method is an effective way to release bronchodilators to the airway, reduce congestion and mucus The dissolving agent method can continuously maintain the necessary humidity of the airway.

③ Chest manipulation therapy (20min):

After doing aerosol inhalation and intermittent positive pressure breathing, postural drainage combined with chest vibration and percussion can achieve good results in clearing secretions. At this time, assistive measures can be given to patients undergoing ventilation therapy, such as direct intratracheal suction to stimulate the patient to cough, over-inflation through oxygen bag and mask, and drip into the trachea through the tracheal tube and tracheostomy tube before suction. brine.

2. Prognosis

Nosocomial pulmonary infections among the elderly rank first, and some areas continue to increase, with a fatality rate of 50%.

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