Aspiration pneumonia in the elderly

Introduction to aspiration pneumonia in the elderly Aspiration pneumonia mainly refers to the secretions of the oropharynx and the stomach, the reflux of the esophagus is inhaled into the lower respiratory tract, reaching the alveolar and the terminal respiratory tract, and the inflammatory lesions of the lungs are caused by the pathogenic microorganisms entering the lower respiratory tract. The most common route, aspiration pneumonia accounts for a large proportion of senile pneumonia. basic knowledge The proportion of sickness: 0.01% Susceptible people: the elderly Mode of infection: non-infectious Complications: respiratory failure, disturbance of consciousness, arrhythmia, shock, sepsis, emphysema, hypertension, heart disease

The cause of aspiration pneumonia in the elderly

(1) Causes of the disease

1. Bacterial transplantation in the oropharynx is an important factor in causing aspiration pneumonia.

2. Gastroesophageal reflux chronic stomach disease, gastrointestinal dysfunction, decreased secretion of gastric juice, decreased gastric acid and other factors can increase the chance of aspiration.

3. Radiological, physical, chemical and other factors can also cause pneumonia.

(two) pathogenesis

Aspiration pneumonia is common in the clinic. Inhalation is a common phenomenon. Studies and statistics show that 45% to 50% of normal people may have aspiration during sleep, including those with recessive aspiration. Patients with conscious disorder Up to 70%, its pathogenesis is:

1. Local immune defense dysfunction: The immune defense mechanism of the normal respiratory tract has a mucus-ciliary delivery system. The alveolar macrophages keep the respiratory tract below the tracheal carina as sterile and can eliminate the tiny foreign bodies in the lower respiratory tract to keep the respiratory tract clean. Decreased anatomy and function of the respiratory system, weakened respiratory protective reflexes, and reduced local immune defense function.

(1) swallowing reflex, swallowing movement is a reflective movement to prevent foreign matter from entering the airway, and is related to brain activity. Experiments have shown that older people over 65 years old have longer swallowing time than young people, and the elderly, sleep, and long-term bed rest. Dementia can reduce the reflex, the atrophy of the laryngeal mucosa in the elderly, and the loss of sensation of the throat often causes dysphagia, making it easy for food to break into the lower respiratory tract and cause pneumonia.

(2) Cough reflex refers to the reflex cough that occurs when foreign matter invades the respiratory tract. It is a protective reflex to remove foreign matter in the respiratory tract. This reflex is gradually reduced with age, especially for elderly people with different degrees of dementia. obvious.

(3) The ciliary capacity of the respiratory tract, and the tiny foreign bodies that invade the distal part of the respiratory tract are mainly excluded by the system. In the elderly, especially chronic lung diseases such as chronic bronchitis and asthma, this ability can be reduced, and the lower respiratory tract is easily It is related to the invasion and colonization of pathogenic microorganisms, and the colonization of the lower respiratory tract by smoking and slow-moving.

2. Decreased systemic immune function: After 60 years old, the body's immunity gradually decreases, the thymus tissue volume is significantly reduced compared with younger ones, and the number and function of immune cells are also decreased. Therefore, the anti-infective capacity of the elderly is weakened, and the elderly are malnourished. Hypertension, cardiac insufficiency, and high incidence of chronic diseases such as diabetes are risk factors for the development of aspiration pneumonia after pathogenic microorganisms invade the lower respiratory tract.

3. Increased bacterial transplantation in oropharynx: Pulmonary infection is mainly caused by inhalation of oropharyngeal pathogens, and the proportion of lung infection caused by blood is very small. The bacteria in the oropharynx are caused by inhaled pulmonary infection. An important factor is often the presence of oropharyngeal bacteria and subsequent pulmonary infection.

(1) Under normal circumstances, the enzyme protein and SIgA in saliva can prevent bacteria from adhering on the surface of the mucosa. The bacteria cannot colonize the surface of the mucosa, but the secretion attached to the mucous membrane adheres, and the secretion is removed, and the normal flora in the oral cavity is The balance between the two is due to the unreasonable use of antibiotics, tracheal intubation, and nasal feeding, which leads to the proliferation of the bacteria, the aging of the elderly, the reduction of the secretory IgA in the trachea and the decrease of the enzyme protein in the saliva. The antibacterial mechanism of the pharynx is destroyed, which may cause the growth of oropharyngeal bacteria to increase. In the case of impaired respiratory defense mechanism, aspiration, transplantation in the lower respiratory tract, further infection, in recent years, with the extensive application of antibiotics, especially Unreasonable drug use, drug-resistant strains are continuously produced. Once drug resistance is produced, sensitive bacteria are killed in large quantities, and drug-resistant bacteria multiply and germs are dysfunctional, especially when it is located in the pharynx, tonsil crypts and other places where antibiotics are difficult to reach. It becomes an endogenous fixed source, and repeated aspiration causes repeated inhalation of pulmonary infection.

(2) Gastroesophageal reflux: chronic stomach disease, gastrointestinal dysfunction, decreased secretion of gastric juice, decreased gastric acid and other factors can increase the oropharynx bacterial planting. Under normal circumstances, the pH of the gastric juice is <2, and bacteria are difficult to colonize. And survival, if the pH rises above 4, the bacteria can multiply and colonize the stomach wall, and then move to the oral cavity. This situation is more common in the elderly, heavy drinking, long-term nasal feeding, use of antacids and H2 Body block drugs, reflux esophagitis, etc., and the long-term placement of the nasal feeding tube not only helps the bacteria to adhere to the surface, but also a large amount of nasal feeding, which can cause the pH in the stomach to rise, the stomach to over-expand and increase the reflux. A large number of bacteria in the stomach are propagated and migrated to the oral cavity along the nasogastric tube.

The pathogens causing bacterial aspiration pneumonia are complex. The normal flora colonizing the pharyngeal population of the healthy old population includes Streptococcus mutans and Streptococcus mutans, a small number of Streptococcus pneumoniae, Haemophilus influenzae, anaerobic bacteria, and fungi. For Candida, Geotrichum, etc., the main aerobic and facultative anaerobic bacteria are Streptococcus pneumoniae, Staphylococcus aureus, hemolytic streptococcus and other Gram-positive cocci and Escherichia coli, pneumonia Gram-negative bacilli such as bacillus, Pseudomonas aeruginosa, but only 2% to 6%, generally not more than 10%, some Enterobacteria, Pseudomonas aeruginosa can be detected, but the number of bacteria is not much, These floras are interdependent and maintain a dynamic balance. In poorly hygienic oral cavity, anaerobic bacteria are often parasitic, and pathogenic anaerobic bacteria are Gram-positive staining (such as Streptococcus pneumoniae), and anaerobic bacteria are Gram-negative staining (such as Clostridium, Bacteroides fragilis, Clostridium perfringens, melanin-producing bacteria, etc.), anaerobic bacteria often form mixed infections with other pathogens in the lungs, and their secretions often have malodor as anaerobic One of the characteristics of the pathogenesis of bacteria.

Community aspiration pneumonia is caused by anaerobic bacteria alone, 60%, facultative mixed infections account for 30%, pathogenic bacteria should be more common with Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Gram negative The proportion of bacilli accounts for 20%, but in recent years, due to the increase of impoverishment and the increase of medical expenses, the out-of-hospital treatment has increased significantly. In addition, the proportion of antibiotics outside the hospital is widespread and irrational, and the proportion is still increasing, making the pathogens of out-of-hospital infection more Infectious.

Mycoplasma pneumoniae infection can cause small epidemics (such as wards, families), mixed infection accounts for 50%. In recent years, bacterial resistance has increased, mainly related to pathogen changes and irrational use of antibiotics. The current resistance rate is not complete. The statistics are up to 35%.

Aspiration pneumonia is related to the position of the inhaled body. It occurs in the posterior segment of the upper lobe and the dorsal segment of the inferior lobe. The anatomical right common bronchus is steep and straight, the diameter of the tube is thick, and it is more prone to the left lobe. It is easy to occur in the lower lung when sitting. .

Bacterial aspiration pneumonia: senile pneumonia is mostly bronchial pneumonia, which can account for 80% to 90%. Pathogens invade through the trachea, causing inflammation of the bronchioles, terminal bronchioles and alveoli. Microscopically, tracheal and bronchial epithelial degeneration and necrosis are observed. Exfoliation, ulceration and hyperplasia, progress can spread to the bronchioles and alveoli, diffuse lymphocytic infiltration of the bronchioles, congestion, edema, and expansion around the bronchi, producing pulmonary interstitial alveolar edema, alveolar filled with red blood cells, mononuclear Cells, macrophages and cellulose can also be characterized by hypostatic pneumonia, due to cough weakness, retention of respiratory secretions, localized pulmonary congestion and alveolar collapse, formation of atelectasis and obstructive pneumonia, and on the other hand due to gravity The effect of the action causes the fluid to overflow from the blood vessels to form pulmonary interstitial alveolar edema.

Sometimes anaerobic infection can cause lung abscess, which can be manifested as extensive purulent inflammatory lesions of lung tissue. Inflammation mainly involves the lobe, lung segment, and further tissue necrosis forms a cavity or abscess.

Typical lobar pneumonia is rare, and the pathology is inflammation of the lungs and lung segments.

The pathophysiology of chemical aspiration pneumonia is that after inhaling gastric contents, gastric acid stimulates the bronchus to cause strong bronchospasm, followed by acute inflammatory reaction of the bronchial epithelium and inflammatory infiltration around the bronchi, and the gastric juice entering the alveoli rapidly spreads to the surrounding lung tissue, alveolar Epithelial cell destruction, degeneration and involvement of capillary wall, increased permeability of vascular wall and destruction of alveolar capillary wall, formation of interstitial pulmonary edema, alveolar edema, edema and hemorrhage gradually formed after several days and formed by transparent membrane, long time It can cause fibrosis. At the same time, it can bring the pharynx colonization into the lungs, produce secondary bacterial infection mainly caused by anaerobic infection, form lung abscess, pulmonary edema weakens the elasticity of lung tissue, and reduces compliance. Reduced volume, combined with destruction of alveolar type II cells, decreased alveolar surfactant, small airway closure, alveolar atrophy caused by atelectasis, insufficient alveolar ventilation, decreased ventilation/blood flow ratio, increased arterial shunt, resulting in hypoxemia Symptoms, massive exudation of blood vessels or reflex vasodilation can occur with low hypovolemia The pathological process of blood pressure hydrocarbons is similar to that of gastric acid inhalation. Because of its low surface tension, it spreads extensively in the lungs after inhalation, and inactivates surfactants. It is more prone to atelectasis and pulmonary edema, leading to severe hypoxemia. , producing acute respiratory distress syndrome.

The severity of chemical aspiration pneumonia is related to the concentration of hydrochloric acid in the inhaled gastric juice, the amount of inhalation and the distribution in the lung. The pH of inhaled gastric acid <2.5 can seriously damage the lung tissue, and the inhalation of liquid as low as 50 ml can cause damage. The pathologically inhaled particulate matter of obstructive aspiration pneumonia, which blocks the airway, causes atelectasis and obstructive pneumonia.

Lipid pneumonia: refers to the pulmonary inflammatory lesions caused by inhalation of oily or lipid substances. The pathological changes occur depending on the oil quality and inhalation. Mineral oils such as paraffin are inert substances, and the lungs are rapidly emulsified by inhalation. It is swallowed by macrophages and transported away by lymphatic vessels. If leftover residue can cause pulmonary fibrosis, vegetable oil can be emulsified, but it will not be hydrolyzed by lung esterase, so it will not harm the lungs. Animal oil can be Hydrolysis of the lung esterase releases fatty acids, causing a significant inflammatory response, similar to inhaled chemical pneumonia.

Elderly aspiration pneumonia prevention

The incidence of aspiration pneumonia is mainly due to aspiration, reducing the incidence of aspiration pneumonia in the elderly is mainly to prevent aspiration, especially chemical inhalation pneumonia, obstructive aspiration pneumonia, lipid-free pneumonia has no special effective treatment, heavy In prevention.

Susceptibility to aspiration pneumonia is sleep state, taking sedatives, dementia, cerebrovascular disease, prolonged bed rest, chronic lung disease, general anesthesia, tracheal intubation, tracheotomy, chest and abdomen surgery, long-term nasal feeding, so its tertiary prevention And related measures are:

Primary prevention

It is targeted at healthy people and asymptomatic patients, taking individual defense measures, disease-free and disease-free, strengthening health education and publicity for the elderly, avoiding risk factors that can cause oral bacterial colonization and aspiration, and strengthening oral hygiene. After the meal, the sitting position should be kept for 2 hours to reduce the reflux of the esophagus and stomach. The drugs for improving circulation and softening vascular drugs should be used to prevent the occurrence of cerebrovascular diseases, so that the brain function can be enhanced, and the reflexive central activities can be enhanced. Drinking, smoking, and caution should be used. Sedatives, antacids and H2 receptor blockers, strengthen exercise, enhance physical fitness, prevent colds, protect susceptible populations, keep indoor air fresh, circulate, inject flu vaccine or regularly apply immune enhancement to people with low immunity Agent.

2. Screening for existing risk factors in the preclinical stage, but showing no clinical symptoms, timely treatment of related diseases, emphasis on oral, upper respiratory tract chronic infections such as periodontitis, suppurative tonsillitis, sinusitis, teeth Slot abscess, do not use liquid paraffin nasal drops or laxatives. For long-term nasal feeding, it is advisable to change the stomach tube regularly, strengthen oral care for patients with unconsciousness, avoid coughing, and have chronic stomach disease and gastroesophageal reflux. Timely medication, promote gastrointestinal motility, reduce food reflux, drugs that can enhance cough and swallow reflexes for the elderly (but now drugs are being developed, such as capsaicin and drugs that inhibit SP breakdown), patients undergoing surgery anesthesia Nursing is very important, do not empty the stomach, take the head low and lateral position for comatose patients, and take surgical treatment for some patients with recurrent pneumonia who have poor effect on internal medicine:

1 stomach jejunum ostomy.

2 laryngeal orthopedic surgery to preserve the occurrence and swallowing function.

3 tracheotomy, laryngeal atresia, this is the cure method, but because it significantly reduces the quality of life of patients, it is difficult to be accepted by patients and their families. The focus of tertiary prevention is early detection, early diagnosis, and should be hospitalized immediately after diagnosis. Rejuvenate patients as much as possible to improve their quality of life.

The role of community health care in the prevention of senile pneumonia is very important. Regular visits and guidance for susceptible populations, strengthening management and protection measures, guiding family members to care for the elderly, and protective isolation if necessary.

Elderly aspiration pneumonia complications Complications, respiratory failure, disturbance of consciousness, arrhythmia, shock, sepsis, emphysema, hypertension, heart disease

Respiratory failure leads the way, followed by electrolyte and acid-base balance disorders, disturbance of consciousness, arrhythmia, shock, sepsis and sepsis, heart failure, multiple organ failure, etc. , poor compensatory or repair function, or the original chronic disease, organ function decline, infection further aggravates the decline of organ function, and some organs are usually on the verge of exhaustion. Under the stimulation of certain incentives, they appear more rapidly. Multiple organs are involved or fail, among which chronic bronchitis, emphysema, hypertension, heart disease, and arrhythmia are more common.

Symptoms of aspiration pneumonia in the elderly Common symptoms Difficulty breathing, inability to cough, rust, phlegm, low heat, loss of appetite, inability to cough, gastrointestinal symptoms, dysfunction, bloody wheezing

Bacterial inhalation pneumonia

Multiple onset attacks, senile pneumonia due to advanced age or associated with basic diseases, atypical symptoms, often lack of pneumonia pulmonary symptoms, and high incidence, high mortality, complications, and more aspiration caused by pre-occurrence History and related risk factors, but 29% were unintentional aspirations, silently inhaled during sleep or other conditions.

(1) Symptoms:

1 typical symptoms: manifested as chills, fever, chest pain, cough, cough, rust and other typical respiratory symptoms, rarely seen in the elderly, with fever, cough, cough up to (60%), even if symptoms are mild Only cough and weakness, difficulty in sputum sputum, white sputum or purulent sputum, coughing a large amount of pus sputum after the formation of lung abscess (indicating anaerobic infection), very few people with high fever, mostly low fever, body temperature below 38 °C, It is rare to have chills, chest pain, hemoptysis is rare, and typical rust color is rare.

2 atypical symptoms: the most common manifestation of senile pneumonia is the deterioration of the patient's health: loss of appetite, anorexia, fatigue, discomfort, decreased mobility, acute disturbance of consciousness, nausea, vomiting, weight loss, urinary incontinence and even insanity. Or only manifested as the deterioration or slow recovery of the original underlying diseases. The earliest symptoms in the elderly are often accelerated breathing, tachycardia (30% to 60%), and dyspnea often occurs 3 to 4 earlier than other clinical manifestations. Days, so the onset and duration of pneumonia in the elderly is difficult to determine.

3 There are a few other symptoms of gastrointestinal symptoms, such as vomiting, diarrhea, bloating, etc. or associated with respiratory symptoms.

(2) Signs:

1 The typical signs of lung consolidation are rare, and the stimuli are enhanced in the lesions.

In 225% of cases, the lungs were able to hear wet voices, and more (49%) could not hear the wet voice.

Dry sound can be heard in part 3.

4 1/4 of no abnormal signs.

5 can appear as a pleural effusion when there is empyema.

2. Chemical aspiration pneumonia

Symptoms: There is a history of aspiration or cough, which is related to the cause. It is asymptomatic at first, and can be symptomatic after a few hours of inhalation (more than 2 hours): mainly due to wheezing caused by reflex laryngeal spasm and bronchial irritation. Cough, difficulty breathing, unconsciousness, inhalation often no obvious symptoms, and sudden dyspnea after 1 to 2 days, cyanosis, cough sputum foam, blood, esophageal and bronchospasm caused by aspiration pneumonia after eating Sudden cough and shortness of breath.

Signs: tachycardia, hypotension, low body temperature 32%, both lungs can smell wet, wheezing.

3. Lipid pneumococcal pneumonia is prone to occur in young children, frail, elderly people with Parkinson's disease, pulmonary vascular disease and rheumatoid arthritis. Symptoms: cough, cough, difficulty breathing, signs: both lungs can be heard To the sputum pronunciation, X-ray signs of the lungs: early detail, knotted, interstitial fibrosis at the bottom of the lungs, sometimes multiple granulomas in the reticular shadow, miliary appearance, and lungs with connective tissue disease The qualitative fibrosis is similar, and it is also a limited mass.

4. The symptoms of obstructive aspiration pneumonia depend on the size of the inhaled substance. Inhalation of a large foreign body can cause sudden suffocation and death in the airway. Blocking in the small airway can cause atelectasis or obstructive pneumonia, and a corresponding cough and cough. Shortness of breath and other symptoms.

Examination of aspiration pneumonia in the elderly

Bacterial aspiration pneumonia

(1) blood picture: leukocytosis is generally in (10 ~ 15) × 109g / L, but half of the patients have no obvious increase in white blood cells, but 90% of cases can have nuclear left shift, sometimes visible neutrophils in neutrophils 50% can have anemia.

(2) ESR increases.

(3) prone to electrolyte imbalance: low sodium, low potassium is more common, especially when eating poorly, vomiting, diarrhea and diuretics.

(4) often associated with hypoproteinemia, ALB <39g / L or less, death cases are more common, associated with reduced anti-infective capacity of such patients.

(5) Pathogen examination: It is an important basis for the diagnosis of bacterial aspiration pneumonia, including sputum smear, picture examination of sputum and lower respiratory tract secretions, bacterial culture of blood stasis and pleural fluid.

The most common specimens with high specificity for bacterial examination are sputum and lower respiratory tract secretions.

(6) The bacteriological examination of sputum is an important method to determine the pathogenic diagnosis of senile pneumonia. The basis for selecting appropriate antibiotics should be done before the use of antibiotics. The actual clinical situation is to make lung infection or pneumonia. The diagnosis is relatively easy, but it is difficult to judge the pathogen. Because the respiratory tract discharge ability of the elderly is weakened and it is not well matched, the specimens left by the sputum often cannot represent the condition of the lower respiratory tract. Therefore, the collection of qualified sputum specimens is very important.

1 sputum 3 times, cough up the deep sputum, put it in the sterile box, immediately send the test, while sputum smear: squamous epithelial cells <10 / HP, white blood cells > 25 / HP, or the ratio of the two (White blood cells/epithelial cells) <1:2.5, the sputum specimen is highly reliable.

2 ring nail membrane puncture suction method.

3 bronchoscopy plus protective brush to take sputum method: in some severe or empiric treatment of senile pneumonia is urgently required for reliable pathogenic examination, but other methods are easy to be affected by the impact of pollution, the most commonly used The technique is fiberoptic bronchoscopy (biopsy, lavage, protective brush sampling) or percutaneous lung biopsy. This is an invasive diagnostic technique that is difficult, dangerous, and protective in the elderly with comorbidities (PSB). And alveolar lavage (BAL) two methods to reduce the contamination of the specimen by the upper respiratory tract, PSB is ideal, sensitivity is 70%, specificity is 90%, BAL specimens are more extensive, it is the preferred method.

(7) Bacterial culture requires different methods, aerobic, anaerobic special medium culture.

Direct smear gram staining microscopy is simple and easy to perform, with early diagnostic value, especially for Streptococcus pneumoniae, Staphylococcus and Gram-negative bacilli, which can be used to determine whether the dominant bacteria in the sputum are Gram-negative bacilli or Gram Positive cocci, which are not affected by the application of antibiotics in a short period of time, but are difficult to detect for mycoplasma, chlamydia, virus, and Legionella.

Blood and pleural fluid and alveolar lavage fluid culture accuracy is high, but the positive rate is low, which limits its clinical value. Serum antibody detection is often used for mycoplasma, Legionella and other pathogens that are difficult to separate, and it takes a long time to guide treatment.

DNA probe and polymerase chain reaction (PCR) are molecular biology techniques that have emerged in recent years. They can be used for pathogenic diagnosis of infectious diseases. DNA probes can directly detect pathogen antigens. PCR is an in vitro amplification technique for DNA. Increased, the combination of the two increases the sensitivity and specificity, and can be used for infections such as viruses and chlamydia.

(8) Antigen detection: Clinically, immunofluorescence, enzyme chain immunoadsorption experiments, convective immunoelectrophoresis, synergistic agglutination experiments, etc. are used in clinical practice. After application of antibiotics, bacteria are killed, and bacterial culture is negative, but the antigenic substance exists up to 2 Over the week, the detection of antigens can make a pathogen diagnosis. This method is simple and rapid. It can be used to determine the infection of mycoplasma, bacteria and other diseases. For example, Legionella pneumonia can be directly fluorescent antibody staining in blood, sputum, pleural fluid and urine. Out of the antigen.

2. Chemical aspiration pneumonia

Blood gas analysis: Hypoxemia, with ARDS can be accompanied by carbon dioxide retention, metabolic acidosis.

Bacterial aspiration pneumonia

Imaging examination: Lung X-ray lacks the specificity of diagnosis, but the most effective auxiliary diagnosis method for diagnosing pulmonary infection, at the beginning of the elderly, especially in the case of dehydration and leukopenia, the chest radiograph may be normal Bronchial pneumonia, that is, lobular pneumonia, is a patchy blurred image distributed along the lung texture. The density is uneven and can be fused into a larger sheet. The lesions are mostly found in the lower lungs of the two lungs. The abscess and fluid level in the dense shadow, the pus rupture into the thoracic cavity can be seen in the pleural effusion or liquid-chest signs, typical lobar pneumonia is rare, showing the uniformity of the lung, segment or sub-segment Shadow.

2. Chemical aspiration pneumonia

Imaging: the blurred shape of the irregular shape of the lungs, its distribution is related to the inhalation position, more common in the lower part of the lung, more in the right lung, but there is a flaky, cloud-like spread from the double hilar. Signs of pulmonary edema.

Diagnosis and differential diagnosis of aspiration pneumonia in the elderly

diagnosis

According to the medical history, the clinical features of various types of inhaled pneumonia: cough, cough and lung signs, plus various auxiliary examinations, especially X-ray and CT examination, is not difficult to diagnose.

Differential diagnosis

Older pneumonia sometimes needs to be differentiated from the following diseases.

1. Heart failure: early heart failure has cough, cough pink foam, etc., but it is difficult to breathe, palpitation is more prominent, can not be supine, dense wet voice at the bottom of the lungs, PaO2 is significantly reduced, PaO2 is normal or reduced More history of heart disease than pneumonia.

2. Pulmonary embolism: Patients with pulmonary embolism often have fever, cough, hemoptysis, and shortness of breath, but it has sudden onset and obvious chest pain. Electrocardiogram often has typical dynamic changes of SIQIITIII and V1~2T wave inversion, pulmonary P wave, right branch Conduction block is different from pneumonia, and if necessary, radionuclide lung ventilation / perfusion scan to identify.

3. Tuberculosis: for fever, cough, cough, X-ray chest film visible obvious shadow, generally anti-infective treatment effect should be considered in the possibility of tuberculosis, carefully trace the history, the existence of old tuberculosis on X-ray chest, lymphocytes Increased, tuberculosis test and tuberculin test, polymerase chain reaction (PCR) test, etc. help to identify.

4. Others: Patients with gastrointestinal symptoms should be distinguished from acute gastroenteritis; shock pneumonia is differentiated from shock caused by other causes.

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