| disease | Bronchopneumonia |
| alias | Lobular Pneumonia, Bronchopneumonia |
Bronchopneumonia, also known as lobular pneumonia, is the most common type of pneumonia in children. The incidence of childhood pneumonia in developing countries is significantly higher than in developed countries, with higher morbidity and mortality rates. Similar to other developing nations, childhood pneumonia is a severe disease threatening the health of children in China, ranking first in both incidence and mortality rates. In China, pneumonia accounts for 24.5% to 65.2% of pediatric hospitalizations. Among the 1.05 million annual deaths in children under five years old, 300,000 are due to pneumonia, making it the leading cause of death in this age group. According to pediatric statistics from 16 domestic institutions, bronchopneumonia accounted for 93.7% of 22,504 hospitalized pneumonia cases, predominantly affecting infants and young children. Pneumonia often occurs during winter and spring or during sudden climate changes, though in some southern regions of China, it is more common in summer. Overcrowded indoor living conditions, poor ventilation, polluted air, and a high presence of pathogenic microorganisms increase the likelihood of pneumonia. Bronchopneumonia can be caused by bacteria or viruses. Based on pathological changes, it is classified into two types: general bronchopneumonia and interstitial bronchopneumonia. The former is primarily caused by bacteria, while the latter is mainly viral. Clinically, it is often broadly diagnosed as bronchopneumonia.
bubble_chart Etiology
In developed countries, viral pathogens are the main cause of pediatric pneumonia, while in developing countries, bacterial pathogens predominate. Generally, in bacterial bronchopneumonia, Haemophilus influenzae and Streptococcus pneumoniae account for over 60% of bacterial pneumonia cases.
Staphylococcus aureus is also an important pathogenic bacterium. Streptococci, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa are less common in infant and toddler pneumonia. Bacterial virulence is related to bacterial structure; bacteria with capsules can resist phagocytosis and exhibit greater virulence. The same bacterial species can be classified into several serotypes based on differences in capsule composition. Different serotypes have varying capsules and virulence levels. Haemophilus influenzae is divided into six serotypes (a-f). Among these, type b has the highest virulence and is one of the main pathogens causing pediatric sepsis, meningitis, and pneumonia, with its capsular polysaccharide being ribose phosphate. Pediatric pneumonia caused by Haemophilus influenzae often follows bronchitis, bronchiolitis, or sepsis and is more common before the age of 3. Non-encapsulated Haemophilus influenzae is non-typeable, has low virulence, and typically only causes upper respiratory infections. β-hemolytic streptococci may appear as secondary infections during measles or whooping cough, though this is rare. Group B hemolytic streptococci are a common pathogen for neonatal pneumonia abroad but have not yet received sufficient attention domestically. Coagulase-positive Staphylococcus aureus is also a common pathogen in severe pediatric pneumonia. Coagulase-negative staphylococci (primarily Staphylococcus epidermidis) have been increasingly isolated domestically in recent years. However, as opportunistic pathogens, they are prone to contamination during culture, and clinical judgment is required to confirm their role as pneumonia pathogens. Pneumonia caused by Escherichia coli is mainly seen in newborns and malnourished infants and can also occur secondary to other severe illnesses. Pneumonia caused by Klebsiella pneumoniae and Pseudomonas aeruginosa is relatively rare and usually secondary.
bubble_chart Pathological Changes
The pathological morphology of bronchopneumonia is divided into two major categories: general and interstitial.
1. General bronchopneumonia: The main lesions are scattered in the alveoli near the bronchial walls, with only mucosal inflammation in the bronchial walls. The alveolar capillaries are dilated and congested, with edema and inflammatory exudate in the alveoli. The serofibrinous exudate contains a large number of neutrophils, red blood cells, and pathogens. The lesions spread to the surrounding adjacent lung tissue through alveolar channels and bronchioles, presenting as small patchy focal inflammation, while interstitial lesions are often not prominent. Sometimes, small lesions merge to form a more extensive bronchopneumonia, but the pathological changes are not as uniform and dense as in lobar pneumonia. In the late stage [third stage], macrophages increase in the alveoli, engulfing large amounts of bacteria and cellular debris, leading to the dissolution and absorption of fibrinous exudate in the alveoli, resolution of inflammation, and re-aeration of the alveoli.
2. Interstitial pneumonia: The main lesions manifest as inflammation, edema, and inflammatory cell infiltration in the bronchial walls, bronchiolar walls, and alveolar walls, presenting as bronchiolitis, peribronchiolitis, and interstitial pneumonia. The spread is more extensive. When cells in the bronchiolar walls undergo necrosis, the lumen may be blocked by mucus, fibrin, and fragmented cells, leading to localized emphysema or atelectasis. Viral pneumonia is primarily interstitial pneumonia. However, sometimes focal inflammation invades the alveoli, resulting in the formation of hyaline membranes in the alveoli. In the advanced stage, a few cases may develop chronic interstitial fibrosis, as seen in adenovirus pneumonia.
1. General Symptoms The onset can be sudden or gradual. Sudden onset symptoms include fever, refusal to eat or vomiting, drowsiness or dysphoria, and wheezing. A few days of grade I upper respiratory tract infection may precede the illness. Early-stage body temperature is mostly between 38–39°C, but can reach around 40°C, with fever typically being remittent or regular.
Weak and small infants often have a gradual onset, with low-grade fever, and cough and lung signs are not obvious. Common symptoms include refusal to eat, choking on milk, vomiting, or difficulty breathing.
2. Respiratory Symptoms and Signs Cough and phlegm sounds in the throat are usually noticeable early on. Breathing rate increases, reaching 40–80 breaths per minute, causing the ratio of respiration to pulse to rise from 1:4 to around 1:2. Difficulty breathing is common, and in severe cases, there may be groaning during exhalation, flaring nostrils, three-concave sign, and cyanosis around the mouth and fingernails. Some children tilt their heads backward to ease breathing. If the child's neck is passively flexed forward, significant resistance may be observed. This should be distinguished from neck muscle rigidity.
Early chest signs are often subtle, with only coarse or slightly diminished breath sounds. Later, medium to coarse moist rales may be heard, along with mild dullness on percussion. After a few days, fine moist rales or crepitations may be audible. If lesions enlarge, tubular breath sounds and dullness on percussion may be present. If unilateral dullness or absent breath sounds are detected, pleural effusion or empyema should be considered.
The WHO Acute Respiratory Infection Control Program emphasizes that rapid breathing is a key indicator of pneumonia. Tachypnea is defined as: infants <2 months, ≥60 breaths/min; 2–12 months, ≥50 breaths/min; 1–5 years, ≥40 breaths/min. Severe pneumonia is marked by irritability or drowsiness, refusal to eat, lower chest wall retraction, and cyanosis. This provides a simple and practical diagnostic basis for primary healthcare workers and is worth promoting.
3. Symptoms and Signs of Other Systems More common in severe cases.
(1) Digestive Symptoms: Infants with pneumonia often experience vomiting, diarrhea, and abdominal pain. Vomiting usually follows severe coughing. Severe abdominal distension can elevate the diaphragm, compressing the chest and worsening breathing difficulty. Sometimes, lower lobe pneumonia can cause acute abdominal pain, which should be differentiated from surgical abdominal dysentery.
(2) Circulatory Symptoms: Severe pneumonia may lead to rapid pulse (160–200 beats/min or higher), disproportionate to fever and dyspnea, significant liver enlargement or rapid enlargement, pale complexion, cyanotic lips, or facial and limb edema with oliguria—signs of congestive heart failure. Cold extremities, perioral pallor, and weak pulse indicate peripheral circulatory failure.
(3) Neurological Symptoms: Common manifestations include dysphoria, drowsiness, or alternating between the two. Young infants are prone to convulsions, often due to high fever or calcium deficiency. If convulsions are accompanied by marked drowsiness or dysphoria, persistent unconsciousness, or even tonic muscle spasms, hemiplegia, or other brain signs, central nervous system complications such as meningitis, encephalitis, toxic or hypoxic encephalopathy should be considered.
4. X-ray Findings Using bronchopneumonia as an example, X-ray manifestations vary depending on the disease cause but share common features while also having distinct characteristics.
(1) Lesion Morphology: Bronchopneumonia primarily involves inflammatory exudate in the alveoli, spreading along the bronchi to affect lobules, segments, or lobes. X-ray findings may show nonspecific small patchy lung infiltrates, mostly in the lower lung fields, costophrenic angles, and medial zones, common in infants. Small patches may partially merge into larger infiltrates, resembling segmental or lobar pneumonia. If numerous small round lesions appear, suppurative infection should be considered.
(2) Atelectasis and lung qi swelling: Due to the blockage of secretions in the bronchi and exudates from pneumonia, atelectasis or lung qi swelling may occur. In pediatric pneumonia, lung qi swelling is one of the common early signs, and the occurrence of vesicular lung qi swelling and mediastinal emphysema during the course of the disease is also more frequent than in adults.
(3) Interstitial lung X-ray signs: The interstitial tissue of infants is well-developed, and when suffering from bronchopneumonia, interstitial X-ray signs may appear. Common manifestations include increased, blurred, or linear shadows in the middle and inner zones of both lungs, which may even aggregate into a reticular pattern. These interstitial changes contrast sharply with the hyperinflated and bright lung areas in the lower lung fields. Interstitial inflammatory reactions caused by influenza virus pneumonia, measles virus pneumonia, or whooping cough bacillus pneumonia can all exhibit these X-ray signs.
(4) Hilar X-ray signs: Most of the local lymph nodes around the hilum are not enlarged or only show deepened hilar shadows, or even perihilar infiltration.
(5) Pleural X-ray signs: Pleural changes are less common. Occasionally, unilateral or bilateral pleuritis or pleural effusion may occur.
Although bronchopneumonia caused by different diseases shares some common X-ray features, they are not identical. Therefore, it is essential to understand the X-ray manifestations of various types of pneumonia and closely correlate them with clinical symptoms to make an accurate diagnosis.
5. General course of the disease: After treatment, mild cases (usually older children with stronger constitutions) mostly recover within 1–2 weeks. Severe cases (mostly infants with weaker constitutions, often complicated by rickets or congenital diseases) tend to have a prolonged course, with slower resolution of chest signs and a higher risk of recurrence. Complications or seasonal diseases may further extend the duration of the illness.
bubble_chart Auxiliary Examination
1. Blood Picture In most children with bacterial pneumonia, the total white blood cell count is elevated, generally reaching (15–30)×109/L, and occasionally as high as 50×109/L. Granulocytes account for 0.60–0.90 of the total. However, in severe cases of Staphylococcus aureus or Gram-negative bacillary pneumonia, the white blood cell count may not rise or may even decrease. In viral pneumonia, the white blood cell count is often low or normal.
2. Bacterial Examination Making an accurate bacterial pathogen diagnosis that reflects lung lesions is relatively difficult. Lung puncture bacteriological examination is the most reliable and is considered the "gold standard," but it is rarely accepted by physicians and patients. Throat culture results generally do not reflect lower respiratory tract conditions. Sputum culture, especially secretions obtained via fiberoptic bronchoscopy, is more reliable but may still be contaminated. Bacteremia in bacterial pneumonia is transient, and due to widespread antibiotic misuse in the country and issues with culture methods, blood cultures yield positive results in only about 10% of cases. Antibody testing is retrospective and varies among individuals. Bacterial antigen detection for pediatric pneumonia etiology has developed rapidly in recent years and, as a rapid and simple diagnostic method, has certain value for widespread use. Although positive blood and urine antigens cannot definitively confirm that the pathogen components originate from the lungs, they do indicate a corresponding bacterial infection in the body.
3. Other Etiological Examinations Virological testing, particularly virus isolation, is the most reliable, reproducible, and specific method, but it is time-consuming, complex, and requires specific technical and equipment conditions. Serological testing for specific antibodies is diagnostically significant. For RSV infection, neutralization tests and enzyme-linked immunosorbent assays (ELISA) can be used; for adenovirus infection, complement fixation tests, neutralization tests, immunofluorescence techniques, and ELISA are commonly employed, with microhemagglutination inhibition tests being simpler and more widely used. For influenza virus infection, hemagglutination inhibition tests are used, while neutralization tests are applicable to nasal diseases virus and coronavirus infections. A fourfold or greater increase in serum antibody levels during the convalescent stage compared to the acute phase has diagnostic value. Rapid diagnostic methods for viruses currently in widespread use include immunofluorescence techniques, electron microscopy, and immunoenzyme techniques. Electron microscopy is complex, expensive, and difficult to popularize; immunoenzyme techniques commonly employ ELISA, enzyme-linked fluorescence, and immunoenzyme staining. Additionally, radioimmunoassay using isotope-labeled antibodies is available. In recent years, polymerase chain reaction (PCR) has been used to detect viral DNA in samples for early and rapid diagnosis. In mycoplasma diagnosis, the cold agglutination test is nonspecific and serves only as a reference; specific diagnostic methods include mycoplasma culture, serum antibody testing, and PCR detection.
4. Blood Gas Analysis, Blood Lactate, and Anion Gap (AG) Measurement For severe pneumonia cases with respiratory failure, these tests help assess the presence and severity of hypoxia, as well as the type and extent of electrolyte and acid-base imbalances, aiding in diagnosis, treatment, and prognosis evaluation.
Based on the acute onset, respiratory symptoms, and signs, clinical diagnosis is generally straightforward. When necessary, X-ray fluoroscopy, chest radiography, or bacterial culture of throat swabs and tracheal secretions, as well as viral isolation, can be performed. Other etiological tests include antigen and antibody detection. A significant increase in white blood cells and granulocytes, along with elevated serum C-reactive protein, aids in the diagnosis of bacterial pneumonia. A decrease or normal level of white blood cells is more indicative of viral pneumonia.
bubble_chart Treatment Measures
This article discusses the treatment of general pneumonia. An integration of Chinese and Western medicine and comprehensive measures should be adopted. Starting from the overall condition, strengthen nursing care, ensure rest, nutrition, and fluid intake, actively control infections, and prevent complications. Timely symptomatic treatment should be administered, including sedation, cough-suppressing and asthma-relieving, cardiac support, oxygen therapy, and correction of typical edema and electrolyte imbalances.
Mild bronchopneumonia often recovers quickly with appropriate treatment and can be managed in outpatient or home settings. Treatment with Chinese medicinals ventilating lung clearing heat and resolving phlegm or antibiotics usually leads to recovery within 1–2 weeks. For older children with milder conditions, penicillin can be used. For critically ill children, attention should be paid to hypoxia, toxic encephalopathy, heart failure, water and electrolyte imbalances, and other severe complications (e.g., pneumothorax, pyopneumothorax), with timely and appropriate intervention. Specific treatment methods are as follows:
1. General Treatment
(1) Nursing Care: The environment should be quiet and tidy. Provide patient and attentive care to keep the child in good spirits. Ensure adequate rest and avoid excessive therapeutic measures. Maintain good indoor ventilation for fresh air and a suitable temperature (around 20°C) and humidity (relative humidity of 60%). Dysphoria and restlessness can worsen hypoxia; sedatives such as chlorpromazine mixtures, phenobarbital, or chloral hydrate may be given. However, excessive sedatives should be avoided to prevent suppression of cough and difficulty in expectoration. Avoid using respiratory stimulants to prevent exacerbating the child's dysphoria.
(2) Diet: Maintain adequate fluid intake with liquid foods such as breast milk, cow’s milk, rice soup, vegetable broth, and fruit juice. Supplement with vitamins C, A, D, and B-complex. Calcium supplementation should also be provided. For prolonged cases, focus on strengthening nutrition to prevent malnutrition.
2. Antibiotic Therapy For bacterial pneumonia, identify the pathogen whenever possible, and begin sensitive antibiotic treatment after collecting bodily fluid samples for bacterial culture. Initially, penicillin is commonly used, administered intramuscularly four times daily at 200,000–400,000 units per dose [5u/(kg·d)], until 5–7 days after the temperature normalizes. For critically ill children, the dose may be increased 2–3 times or switched to intravenous infusion. If ineffective, switch to other antibiotics, typically based on clinical pathogen diagnosis or throat swab culture results for sexually transmitted disease bacteria. If sepsis is suspected, promptly collect blood for culture and drug sensitivity testing to guide medication selection. For cases of unknown cause, a combination of two antibiotics may be used initially. Currently, antibiotics, especially cephalosporins, are rapidly evolving; selection should be based on the condition, bacterial sensitivity, and the patient’s financial situation.
For Haemophilus influenzae pneumonia, use chloramphenicol, ampicillin, or second- or third-generation cephalosporins.
In neonates, consider infections by Group B Streptococcus and large intestine bacilli. For the former, penicillin is the first choice; for the latter, ampicillin, gentamicin, tobramycin, or amikacin, or second- or third-generation cephalosporins may be used.
Antibiotics should be continued until 5–7 days after the temperature normalizes. Stopping too early may fail to fully control the infection. Avoid antibiotic misuse to prevent microbial imbalance, drug resistance, and fungal infections.
For older children with milder conditions or in regions where sulfonamides are still effective, sulfonamides such as SIZ or SMZ may be used. Antibacterial synergists (e.g., TMP) can enhance the efficacy of sulfonamides and antibiotics and are often combined (e.g., SMZco).
3. Antiviral Therapy Broad-spectrum antibiotic therapy includes antiviral treatment. For suspected viral pneumonia, ribavirin may be tried via aerosol inhalation at 20mg/mL, 20–30mL, three times daily.
4.Chinese medicine therapy This disease belongs to the category of "wind-warmth invading the lung" and "lung heat cough and asthma" in the scope of warm febrile diseases in traditional Chinese medicine. Pediatric pneumonia has an acute onset and rapid changes, with pathogenic heat easily transitioning from the defensive and qi levels quickly into the nutrient and blood levels, thereby causing symptoms and signs in the heart and liver meridians. Therefore, it is clinically classified into mild and severe types for treatment, with attention paid to complications and the treatment during the stage of convalescence of pneumonia.
(1) Treatment of common pneumonia (pathogens in the defensive and qi aspects): The child presents with high fever, sweating or without sweating (usually less sweating in the early stage, differentiating between sweating and thirst when pathogens reach the qi aspect), rapid breathing, cough with phlegm, grade I dyspnea with flaring nostrils, flushed face and thirst, red throat, red tongue tip, yellow-white tongue coating, and floating rapid pulse. The treatment principle is to ventilate the lung, clear heat, and resolve phlegm. Commonly used is modified Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction (Má Xìng Shí Gān Tāng).
Prescription example: Ephedra 2g, Bitter Apricot Seed g, raw Gypsum 9g, Liquorice Root 2g, Lonicera 9g, Forsythia 9g, Calcitum 9g, cultivated purple perilla fruit 6g, Indigo and Clam Shell Powder 9g.
The following medications can be added based on symptoms: ① For fever without sweating, add fresh Reed Rhizome 15–30g; ② For fever with sweating, add Skullcap Root 6g or increase the dosage of raw Gypsum; ③ For severe cough, dyspnea, and excessive phlegm, add Tabasheer 6g and Radish Seed 6g; ④ For dry stools, add Trichosanthes Fruit 15–30g.
(2) Treatment of severe pneumonia (dual blazing of qi and blood or heat entering the nutrient-blood):
1) Dual blazing of qi (nutrient) and blood: Persistent high fever, cough and dyspnea, restlessness, gurgling phlegm, lethargy, thirst, red tongue body, yellow greasy and dry tongue coating, wiry rapid or slippery rapid pulse. The treatment principle is to clear lung heat and resolve phlegm to relieve dyspnea. Commonly used is modified Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction combined with Jade Lady Decoction (from "Systematic Differentiation of Warm Diseases," removing Achyranthes Root and Prepared Rehmannia Root, and adding fine Unprocessed Rehmannia Root and Scrophularia Root).
Prescription example: Ephedra 2g, Apricot g, raw Gypsum 18g, fresh Reed Rhizome and Cogongrass Rhizome 15g each, Skullcap Root 6g, Indigo 3g, Unprocessed Rehmannia Root 9g, Tabasheer 9g, Lonicera 9g, Forsythia 9g.
2) Heat entering nutrient-blood: Persistent high fever, worsening cough and dyspnea, marked rapid breathing and flaring nostrils, extreme respiratory difficulty, phlegm obstructing the throat, chest and abdominal distension and fullness, dysphoria and restlessness; or perioral cyanosis, cracked lips, deep red tongue body, thick yellow or greasy and foul tongue coating, wiry rapid or slippery rapid pulse. If a thin, rapid, and weak pulse appears, be alert for qi-yang exhaustion. The treatment principle is to clear the nutrient aspect and remove toxins, resolve phlegm to relieve dyspnea. Commonly used is modified Nutrient-Clearing Decoction.
Prescription example: Lonicera 15g, Forsythia 9g, Unprocessed Rehmannia Root 12g, Skullcap Root 9g, Scrophularia Root 15g, Tabasheer 9g, Red Peony Root 9g, Curcuma Root and Skullcap Root 9g, plus buffalo horn powder 0.5g taken infused, 2–3 times daily.
For the above two types of severe pneumonia, the following medications can be added based on symptoms: ① For high fever and convulsions, add Uncaria 12g and raw Abalone Shell 15g. ② For persistent high fever, add Purple Snow Bolus: 0.3–0.6g taken infused, 2–3 times daily. ③ For excessive phlegm, add Bamboo Juice 5–10ml mixed in, 2–3 times daily. ④ For unconsciousness, add Lotus Plumule 3g and Acorus 6g.
(3) Treatment of complications: Severe pneumonia is prone to symptoms and signs of healthy qi failing to overcome pathogens and qi-yang exhaustion. In such cases, integrated Chinese and Western medicine treatment is advisable. Common clinical complications include:
1) Pathogens overwhelming healthy qi: Toxic heat invading inward (toxic encephalopathy): Main manifestations include dull complexion, persistent high fever, unconsciousness and convulsions, stiff neck, cough and dyspnea, anorexia and loose stools, deep red tongue body, yellow and dry tongue coating, thin rapid or wiry rapid pulse. The treatment principle is to reinforce healthy qi and eliminate pathogens, open orifices, and expel phlegm. Commonly used is modified Three-Carapace Pulse-Restoring Decoction.
Prescription example: Raw Oyster Shell 12g, raw Tortoise Carapace 12g, raw Turtle Carapace 12g, Moutan Bark 9g, Lonicera 12g, Forsythia 9g, Lotus Plumule 3g, Acorus 3g, Curcuma Root 6g, plus buffalo horn powder 0.5g taken infused, 2–3 times daily.
The following medications can be added based on symptoms: ① For spasms, add Uncaria 12g and raw Abalone Shell 15g. ② For excessive phlegm, add Tabasheer 9g or Bamboo Juice 5–10ml, 2–3 times daily.
2) Healthy qi exhaustion, profuse phlegm obstruction (respiratory failure): Main manifestations include persistent high fever, grayish complexion and cold limbs, difficulty breathing, or shortness of breath and profuse sweating, unconsciousness and dysphoria, severe cough with thick sticky phlegm. Pale tongue body, scant and dry tongue coating, thin rapid and weak pulse. The treatment principle is to reinforce healthy qi and eliminate pathogens, tonify qi, and resolve phlegm. Commonly used is modified Pulse-Reinforcing Powder.
Prescription example: Ginseng 9g, Ophiopogon Tuber 9g, Schisandra Fruit 9g, Lily Bulb 12g, Sichuan Fritillary Bulb 9g, Apricot g, Lonicera 9g, Forsythia 9g, Curcuma Root 6g.
The following medications can be optionally added according to symptoms: ① For abdominal distension and fullness, add Magnolia Bark 6g. ② For heart yang on the verge of collapse with cold limbs, add Aconite Lateral Root 3～6g, or use Ginseng 6g and Aconite Lateral Root 3g, decocted to 200ml for oral administration or nasal feeding.
(4) Treatment of pneumonia at the convalescence stage: Although the pathogenic factors have diminished, the qi and yin are depleted, and residual pathogens remain, leading to persistent low-grade fever, cough, phlegm, and wheezing. The patient may appear lethargic with poor appetite. In cases where yin depletion is more severe, the tongue texture may appear tender and red, with scant and dry tongue coating. The treatment principle involves nourishing yin and clearing heat, often using Modified Ophiopogon Decoction (Shashen Maidong Tang). For cases with residual heat accompanied by severe cough and wheezing, the treatment focuses on clearing lung heat and suppressing cough and asthma, using Modified White-Draining Powder (Xiebai San).
Example Prescription 1: Glehnia Root (Shashen) 9g, Ophiopogon Tuber (Maidong) 9g, Polygala Root (Yuanzhi) 9g, Sichuan Fritillary Bulb (Chuanbei) 9g, Chinese Wolfberry Root-bark (Digupi) 9g, Poria (Fuling) 9g, Loquat Leaf (Pipaye) 9g.
Example Prescription 2: Chinese Wolfberry Root-bark (Digupi) 9g, Mulberry Bark (Sangbaipi) 9g, Liquorice Root (Gancao) 3g, Loquat Leaf (Pipaye) 9g, Aster Root (Ziwan) 9g, Indigo and Clam Shell Powder (Dai Ge San) 9g, Fresh Reed Rhizome (Xian Lugen) 15g, Germinated Barley (Sheng Maiya) 9g each.
Additional modifications based on symptoms: ① For low-grade fever, add Starwort Root (Yinchaihu) 9g, Blackend Swallowwort Root (Baiwei) 9g, Unprocessed Rehmannia Root (Sheng Dihuang) 9g. ② For severe cough, add Willowleaf Rhizome (Qianhu) 9g, Lily Bulb (Baihe) 9g. ③ For excessive phlegm, add Tabasheer (Tianzhuhuang) 6g. If the phlegm is thin and white, add Pummelo Peel (Huajuhong) 6g, Pinellia (Banxia) 6g, Coix Seed (Sheng Yiyiren) 9g.
5. Symptomatic Treatment
(1) Fever reduction and sedation: Generally, physical cooling methods are used first, such as cold compresses on the forehead or ice pillows. Antipyretic injections like Antondine or Analgin may be administered. For severe high fever, an intramuscular injection of chlorpromazine and promethazine combination may be used.
(2) Treatment for cough and asthma: Clear nasal secretions. For phlegm, use expectorants (e.g., ipecac syrup). Suction may be needed for excessive phlegm. Maintain indoor humidity at around 65% and encourage fluid intake. For severe cough and wheezing, administer an intramuscular injection of chlorpromazine and promethazine combination (Wintermin II) at 0.5–1mg/kg every 4–6 hours as needed. Mild cases may take oral medication. Outpatients may initially use promethazine alone. If ineffective, try "654-2 solution" (3–10mg or 0.3–1mg/kg intramuscularly twice daily). Short-term high-dose hydrocortisone is effective for sudden dyspnea-type pneumonia or bronchiolitis with severe wheezing—administer hydrocortisone intravenously at 5mg/kg every 6–8 hours for 2–4 doses. A 0.5% ephedrine nasal drop can reduce nasal mucosa swelling. Oral ephedrine (0.5–1mg/kg) relieves bronchospasm. Common expectorant and antitussive prescriptions for infants include:
Example Prescription 1: Milkwort Root (Yuanzhi) Tincture 2.5ml, Potassium Iodide 3g, Ammoniated Star Anise Spirit 2.5ml, Sodium Saccharin 0.04g, 5% Ethyl Paraben 0.4ml, add water to 100ml. Dosage: 1ml per year of age (for mild cough).
Example Prescription 2: Ephedrine 0.5g, Ammonium Chloride 7.5g, add water to 100ml. Dosage: 1ml per year of age (for wheezing and cough; avoid overdose—do not increase dosage beyond 4 years. Contraindicated in cases of tachycardia or severe dysphoria).
Example Prescription 3: 10% Ammonium Chloride Solution. Dosage: 1ml per year of age.
(3) Oxygen therapy: Severe cases require oxygen. For young children, use a nasal cannula with an oxygen flow rate of 0.5–1L per minute. For critical cases, use a mask with a flow rate of 2–4L per minute. For severe respiratory secretion blockage, dyspnea, or cyanosis, an oxygen tent or aerosol inhalation may be used.
(4) Treatment of heart failure: Infants and young children with severe pneumonia, as well as those with pneumonia complicated by congenital heart disease, often develop heart failure, manifesting as accelerated heart rate (up to 140–160 beats per minute), dysphoria, rapid liver enlargement within a short period, edema, pale or grayish complexion, and even cardiac enlargement and gallop rhythm. In addition to general measures such as oxygen therapy, dispelling phlegm, cough suppression, and sedation, cardiac glycosides should be administered early for heart failure. In critical cases, when strophanthin K is selected, two-thirds of the saturated dose may be given initially, followed by half of the initial dose repeated after 2–4 hours if necessary. For cedilanid (lanatoside C), half of the saturated dose (30–40 μg/kg) is given initially, followed by a quarter of the dose every 4–6 hours, administered twice in total to achieve digitalization. After calcium injection, digitalis drugs should not be administered until 6–8 hours later.
(5) Treatment of abdominal distension and fullness: First, a diluted soapy water enema (approximately 2%) can be administered, followed by catheter retention for gas expulsion. If ineffective, neostigmine can be used at a dosage of 0.03–0.04 mg/kg per intramuscular injection. For older children, the dosage can be calculated at 0.05–0.1 mg per dose. For severe cases of abdominal distension and fullness, gastrointestinal decompression may be employed to remove gastrointestinal contents and gas. Alternatively, phentolamine diluted with 5% glucose can be administered intravenously, often yielding good results. Another method involves applying crushed scallion and garlic paste to the umbilicus, combined with acupuncture and abdominal tuina. For abdominal distension and fullness caused by hypokalemia, a 10% potassium chloride solution can be administered orally at approximately 0.5 ml/kg per dose, 3–4 times daily.
(6) Treatment of disseminated intravascular coagulation (DIC): While actively treating pneumonia, correcting hypoxia and acidosis, improving microcirculation, and ensuring adequate fluid intake (preferably 70–90 ml/(kg·d)), dipyridamole (10 mg intramuscularly every 6 hours) or heparin (50 U/kg intravenously every 4–6 hours) may be administered. Alternatively, blood-activating and stasis-resolving medicinal compounds such as Salvia, Sichuan Lovage Rhizome, Rhizoma Sparganii, and Rhizoma Curcumae can be used.
6. Fluid Therapy: Generally, children with pneumonia can maintain fluid intake orally and do not require intravenous fluids. For those unable to eat, intravenous drip infusion may be administered. The total fluid volume should preferably be 60–80 ml/(kg·d), with infants requiring slightly more and older children slightly less. For children with high fever, severe wheezing, or microcirculatory dysfunction, the total fluid volume may be increased due to excessive insensible water loss. During the acute phase, children are prone to sodium retention, so sodium intake should not be excessive. For those without concurrent diarrhea, sodium should not exceed 3 mmol (equivalent to 20 ml of normal saline)/(kg·d). Intravenous fluids can be prepared as a 4:1 or 5:1 mixture of 10% glucose and normal saline. The infusion rate should not exceed 5 ml/(kg·h), and the duration should not be prolonged to avoid disrupting rest and position changes. Intravenous fluids should be discontinued once oral intake is possible. Caloric intake should aim to exceed 210–250 J/(kg·d). For severe cases, plasma or whole blood transfusions (20–50 ml per dose, repeated daily or every other day for 2–3 times if necessary) may be considered to enhance resistance.
For children with significant dehydration and metabolic acidosis, half to one-third isotonic sodium-containing fluids can be used to replenish the cumulative deficit, followed by the aforementioned fluids to maintain physiological needs.
In some cases, prolonged severe illness or large-volume fluid therapy may lead to hypocalcemia, manifesting as hand-foot convulsions or seizures. In such cases, 10–20 ml of 10% calcium gluconate should be administered intravenously slowly. Hypokalemia may also occur; if serum sodium falls below 125 mmol/L (125 mEq/L), hypertonic saline (3% saline at 6–12 ml/kg, which can raise serum sodium by 5–10 mmol/L (5–10 mEq/L)) should be injected while restricting fluid volume. Serum potassium is generally not low, but potassium salts should be supplemented appropriately if hypokalemia is present.
7. Hormone Therapy: Generally, adrenal corticosteroids are not required for pneumonia. In severe bacterial pneumonia, while controlling infection with effective antibiotics, hormones may be added under the following circumstances: ① Severe toxic symptoms, such as shock, toxic encephalopathy, or persistent hyperpyrexia (temperature above 40°C). ② Significant bronchospasm or excessive secretions. ③ Early pleural effusion, where hormones may be applied locally to prevent pleural membrane adhesion. Short-term treatment (no longer than 3–5 days) is preferable. Typically, intravenous hydrocortisone at 5–10 ml/(kg·d) or oral prednisone at 1–2 mg/(kg·d) is administered. For hormone use exceeding 5–7 days, tapering the dose upon discontinuation is advisable.
Hormones are generally not used for viral pneumonia. However, short-term use may be considered for severe wheezing in bronchiolitis.
8. Physical Therapy For children with persistent rales, light therapy or electrotherapy can be used. For prolonged cases, back skin stimulation or mustard plaster application on the chest and back, or cupping therapy may also be employed. These methods stimulate the skin of the chest and back, causing congestion, thereby reducing pulmonary congestion and promoting the absorption of lung exudates and the disappearance of rales. Mustard plaster application is relatively mild and can be used for infants under 1 year old; cupping therapy has a stronger effect and should only be used for older children. These stimulating therapies are contraindicated in critically ill patients or those with heart failure.
9. Treatment of Complications Common complications of pneumonia include diarrhea, vomiting, abdominal distension and fullness, and lung qi swelling. More severe complications include empyema, pyopneumothorax, lung abscess, pericarditis, and meningitis. The treatment methods are detailed in the specialized sections discussing these conditions.
The prognosis depends on the child's age, whether pulmonary inflammation can be controlled in time, the quantity and virulence of the infecting bacteria, their sensitivity to antibiotics, the child's immune status, and the presence of severe complications, among other factors. In recent years, due to timely diagnosis and the adoption of an integration of Chinese and Western medicine comprehensive treatment, the mortality rate of pneumonia has significantly decreased, and complications have also markedly reduced. However, special attention should be paid to weak and small infants with pneumonia due to their low resistance, extensive pathological involvement, and tendency for prolonged disease course. The younger the age, the higher the incidence and mortality rate of pneumonia, especially among newborns and low-birth-weight infants. Pneumonia complicating malnutrition, rickets, congenital heart disease, measles, whooping cough, or chronic bronchitis has a poorer prognosis. Pneumonia complicated by pyopneumothorax, airway obstruction, toxic encephalopathy, heart failure, or respiratory failure also worsens the prognosis. From the perspective of pathogens, staphylococcal pneumonia is prone to complications and often has a prolonged course, while pneumonia caused by Haemophilus influenzae and Klebsiella pneumoniae is also relatively severe. According to observations at Beijing Children's Hospital from 1974 to 1979, cases with blood gas analysis showing pH <7.25, PaCO2 >70mmHg, severe hypoxemia (PaO<50mmHg when inhaling oxygen at a concentration above 40%), and/or hyperlactatemia (blood lactate level > normal value + 2 standard deviations) had a higher mortality rate.
To prevent pneumonia, the following measures should be emphasized.
1. Strengthen care and physical exercise. During infancy, attention should be paid to nutrition, timely addition of complementary foods, and cultivating good dietary and hygiene habits, with ample exposure to sunlight. Preventing rickets and malnutrition is key to avoiding severe pneumonia. Physical exercise from an early age, indoor ventilation, frequent outdoor activities or sleeping outdoors can enhance the body's cold resistance and adaptability to environmental temperature changes, reducing the likelihood of respiratory infections and pneumonia.
2. Prevent acute respiratory infections and respiratory epidemics. Infants and young children should be kept away from individuals with respiratory infections as much as possible, especially since weaker infants are more prone to developing pneumonia after infection. Focus on preventing and treating respiratory epidemics that can lead to severe pneumonia, such as whooping cough, influenza, adenovirus, and measles infections. Extra caution is needed for children with immunodeficiency diseases or those on immunosuppressants.
3. Prevent complications and secondary infections. Infants and young children already suffering from pneumonia have weakened immunity and are susceptible to other illnesses. Active prevention of complications with severe outcomes, such as empyema and pyopneumothorax, is essential. In hospital wards, children with different pathogens should be isolated as much as possible. Convalescent-stage patients and newly admitted children should also be separated. Healthcare workers should practice strict disinfection and isolation when dealing with different patients. In recent years, there have been reports of using Chinese medicinals like Atractylodes Rhizome and Mugwort for fumigation to reduce airborne pathogens, which can help prevent cross-infection.
Complications are rare with early and correct treatment. The most common complication of bronchopneumonia is varying degrees of lung qi swelling or atelectasis, which gradually resolves as the pneumonia is treated. Persistent atelectasis or recurrent pneumonia can lead to bronchiectasis or cor pulmonale. Bacterial pneumonia may be complicated by empyema, pyopneumothorax, lung abscess, pericarditis, or sepsis, which are more common in Staphylococcus aureus pneumonia. Some cases of pneumonia may also be complicated by toxic encephalopathy. A few severe cases of pneumonia in children may develop disseminated intravascular coagulation, gastrointestinal bleeding, or jaundice. Some children with pneumonia may rapidly progress to respiratory failure, which can be life-threatening. Severe pneumonia in children can also lead to fluid and electrolyte imbalances and acid-base disturbances, particularly hyponatremia, mixed acidosis, and lactic acidosis, which require special attention.
For the differential diagnosis of various types of pneumonia, please refer to Table 24-12.
Table 24-12 Key Clinical Differential Points of Major Acute Pneumonias
| Lobar Pneumonia (Pneumococcal) | Bronchopneumonia (Pneumococcal, etc.) | Staphylococcus Aureus Pneumonia | Adenovirus Pneumonia | Parainfluenza Virus Pneumonia | Bronchiolitis | Mycoplasma Pneumonia | Eosinophilic Pneumonia | |
| Common Age Groups | Older Children | Infants and Young Children | Any Age | 6 Months to 2 Years | Infants | Young Infants | Children, Young Children | Children, Young Children |
| Fever Pattern | Sudden Onset, High Sustained Fever | Variable | Remittent | Sustained or Remittent High Fever | Grade II Fever | Low or No Fever, Occasionally High Fever | Irregular | Often Not High |
| Duration of Fever (Days) | Around 2 Weeks | 1–2 Weeks | 1–3 Weeks | 1–3 Weeks | 1–8 Days | 1–5 Days | Over 1 Week | About 1 Week |
| General Condition | Severe, May Present with Shock | Milder | Severe Toxicity, May Present with Rash | Severe Toxicity, Early Drowsiness | Milder | Severe Wheezing | Frequent Cough | Mostly Mild |
| Lung Signs | Early Signs Not Obvious | Diffuse | Diffuse | Signs Appear After 3–5 Days | Diffuse | Emphysema, Wheezing, Rales | Rare or Localized | Mostly Unremarkable |
| X-ray Findings | Entire Lobe or Segment | Mostly Patchy | Common Abscesses, Bullae, Pyopneumothorax | Large Consolidations, Some with Effusion | Small Patches, May Show Emphysema | Mostly Lung Hyperinflation or Patchy Shadows | Unilateral Patchy Shadows | Flocculent Shadows or Migratory |
| White Blood Cell Count | Significantly Increased | Mostly Increased | Increased or Decreased | Most normal or decreased | Mostly normal or decreased | Mostly decreased or normal | Mostly normal or elevated | Eosinophils 20-70% |
| Penicillin treatment | Effective | May be effective | Large dose may be effective | Ineffective | Ineffective | Ineffective | Ineffective | Ineffective |
Note: ①The duration of fever in bacterial pneumonia can be influenced by treatment.
②Influenza viral pneumonia clinically resembles adenoviral pneumonia but is milder.
③The diagnosis of Mycoplasma pneumonia often relies on a positive cold agglutinin test and serum antibody detection.
In infancy, it is often necessary to differentiate from pulmonary tuberculosis and other conditions causing dyspnea:
(1)Pulmonary tuberculosis: Differentiation should emphasize family history of tuberculosis, tuberculin test, and long-term clinical observation. Pulmonary tuberculosis on X-ray often shows significant lung lesions with relatively mild clinical symptoms, the two often being disproportionate.
(2)Other conditions causing dyspnea: Laryngeal obstruction diseases generally present with hoarseness and croup-like symptoms. If the child's breathing deepens, acidosis should be considered. Dyspnea in asthma is more pronounced during expiration. Although infantile paroxysmal tachycardia may present with symptoms like tachypnea and cyanosis, it is characterized by episodic tachycardia and can be confirmed by electrocardiogram.
