内科学教学课件：呼吸系统疾病

1、呼吸系统疾病 （急性呼吸道感染,Acute Respiratory Infection,目的,1 、了解小儿呼吸系统的解剖生理特点 2、熟悉上呼吸道感染、急性支气管炎、毛细支气管 炎的病因、临床表现、诊断及治疗 3、熟悉支气管肺炎的病理生理 4、熟悉支气管肺炎的病因、并发症、实验室检查及 鉴别诊断 5、掌握支气管肺炎的临床表现，诊断及治疗,重点和难点,1.支气管肺炎的临床表现、诊断及治疗 2.几种不同病原体肺炎的临床特点,The most common disease in the childhood,WHY,第一节小儿呼吸系统解剖生理特点,一、解剖特点 (anatomy,一）上呼吸道 (up

2、per respiratory tract,cricoid cartilage,Nose no hairs of vestibule of nose narrowed nasal cavity rich blood vessels in mucosa,Auditory tube(咽鼓管) is short, wide and horizontal tympanitis(中耳炎,Pharynx,Pharyngeal tonsil(咽扁桃体) develops well at 410 years old tonsillitis after 1315years old it atrophy,Thro

3、at: narrowed cavity, rich blood vessels in mucosa asphyxia(窒息,二）下呼吸道 (lower respiratory tract,the movement of epithelium s cilia is weak,20 million alveoli(肺泡) at birth underdeveloped elastic fibers atelectasis(肺不张) failure of lung function,三）胸廓 (thorax,二、生理特点(Physiology) ： one rapid (the rate of re

4、spiration ) two lower (the volume of tidal volume,TV潮气量) ( total lung capacity ,TLC肺活量) one high (the resistance of the airway,三、免疫特点(Immunology,the nonspecific immune reaction is low the specific immune reaction is low,第二节 急性上呼吸道感染 ( Acute Upper Respiratory Infection,AURI,病因etiology Rhinovirus Stre

5、ptococcus Respiratory syncytial virus Staphylococcus Influenza virus S.pneumoniae aureus Parainfluenza virus Haemophilus Influenzae Coronavirus Adenovirus Enterovirus,临床表现clinical manifestations,2 、局部(local): nasal irritation, nasal discharge, sneezing(喷嚏) , sore throat, cough,1 、全身(systematic): fev

6、er, headache, myalgia(肌痛), malaise(疲乏) and diarrhea(腹泻,3 、两种特殊类型上感,疱疹性咽峡炎(herpangina) fever laryngitis(咽炎) discrete ulcerative(溃疡) lesion in the mouth,咽结合膜热(pharyngo-conjunctival fever,fever laryngitis(咽炎) conjunctivitis(结膜炎,并发症(complications,otitis media(中耳炎) Sinusitis(鼻窦炎) enlarged cervical nodes(

7、颈淋巴结肿大,诊断及鉴别诊断 (diagnosis and differential diagnosis) Measles(麻疹) Poliomyelitis(脊髓灰质炎) Encephalitis(脑炎,治疗 (treatment) nonpharmacologic therapy pharmacologic therapy 预防 (prevention,第三节 急性支气管炎 (acute bronchitis,etiology,细菌和病毒混合感染较常见,Clinical manifestations,1 、Systematic,2 、 Local: cough, sputum roughe

8、ning of breath sounds dry and/or moist rales(啰音),changeful,Eczema(湿疹,1 、一般治疗(nonspecific therapy) 2 、抗生素(antibiotics) 3 、对症治疗 pulmonary drainage by frequent shifts in position relieve wheezing,chest X ray Treatment,第五节 毛细支气管炎（bronchiolitis,Etiology and epidemiology,呼吸道合胞病毒 (respiratory syncytial vir

9、us， RSV,副流感病毒，腺病毒、肺炎支原体(mycoplasmal pneumoniae,人类偏肺病毒（hMPV,鼻病毒 (Rhinovirus,广东、广西以夏秋季多发,病变部位在直径为75300m的气道,Pathophysiology,免疫机制：抗RSV IgE 可溶性因子 接种RSV疫苗严重毛支炎 过敏体质者RSV或其他病毒感染更易引 起毛支炎,Clinical manifestations, 2 years old, especially about 6 months,diffuse wheezing,low-grade fever In severe case , cyanosis

10、(紫绀), failure of lung function,Laboratory findings,1、病原学： 标本：咽拭子或鼻咽分泌物 方法：免疫荧光、免疫酶技术、PCR 2、 胸片：不同程度肺气肿或肺不张，肺 纹理增粗,可见散在的小实变影,Diagnosis and differential diagnosis,Treatment,1 、支持治疗 1 ) Humidified oxygen 2) intravenous hydration 3) nebulization,2 、 Antivirus therapy Ribavirin,3 、平喘治疗 1 ) 支气管扩张剂(Broncho

11、dilator therapy ): 喘乐宁+爱喘乐 雾化吸入,2) 皮质激素: 琥珀酸氢化可的松、 甲基强的松龙静脉用药 或普米克令舒雾化吸入,4 、RSV特异治疗 1) RSV-IVIG (治疗) 2) RSV单克隆抗体-Palivizumab (预防,5 、治疗合并症 酸中毒(acidosis)、心衰、呼衰,Prognosis,50% of hospitalized patients will wheeze later in childhood asthma,第六节 肺炎 ( pneumonia,Definition 不同病原体或其他因素（吸入有 毒气体、羊水、胎粪、油脂类） 所致肺部（

12、肺泡及间质）炎症,分类病理、病因、病程、病情、典型及非典 型、住院 48 小时前、后发生(CAP,HAP,支气管肺炎 （ bronchopneumonia ） Etiology Respiratory syncytial virus s.pneumoniae Adenovirus Streptococcus Influenza virus Staphylococcus aureus Parainfluenza virus Haemophilus Influenza Enterovirus Mycoplasma Chlamydia,organisms(virus、bacteria） toxin

13、upper respiratory infection bronchitis pneumonia,通气障碍,换气障碍,二氧化碳潴留(hypercapnia,低O2血症 (hypoxemia,Heart failure,acidnosis gastrointestinal bleeding,toxical enteroparalysis,toxinemia,toxical myocarditis,toxical encephalopathy,Dysfunction of gas exchange,Dysfunction of ventilation,Pulmonary Arterioles pr

14、essure,Pulmonary Arterioles contraction,tissue of lung inflammation,Bronchial mucous inflammation,Clinical manifestations,1.体温改变(fever) 2.咳嗽(cough,3.呼吸困难(dyspnea) nasal flaring retraction of the supraclavicular intercostal and subcostal areas tachypnea(呼吸急促,4 、紫绀 (cyanosis,5 、肺部体征： 固定的，较密集的中小水泡音 (Fi

15、xed,diffuse,fine moist rales) 在肺底及脊柱旁较多,重症肺炎 (severe pneumonia,1 ）心血管系统(Cardiology) after giving oxygen ,sedatives 1 ）dysphoria extremely，serious cyanosis (烦躁不安,2 ） HR180 /min，heart sound low or gallop rhythm(奔马率,3 ） RR60 /min 4 ）liver enlarge quickly 5 ）oliguria or anuria,edema (少尿或无尿,2 ）神经系统(Neuro

16、logy,中毒性脑病(toxical encephalopathy) 脑膜炎(meningitis,嗜睡(lethargy) 昏迷(coma) 惊厥(convulsion) 前囟隆起(bulging fontanelle,3 ）消化系统(Gastroenterology) 消化道出血 gastrointestinal bleeding, asphaltic stool,腹胀 abdomen distension,complication,脓胸 (empyema,diffuse haziness shadow,气胸 (pneumothorax,the air in the left pleura

17、l cavity has collapsed the left lung, shifting the heart and mediastinal structures to the right,液气胸(pyopneumothorax,肺大疱(pneumatocele,black no vein,X 线检查： (Chest X-Ray) 小斑片状阴影 (patchy infiltrates) 以中下肺野及 内中带明显,实验室检查(laboratory findings) 1、末梢血 WBC 计数及分类 2 、病原学检查：病毒、细菌、其他,Diagnosis and differential di

18、agnosis,1. Bronchitis 2. TB,几种不同病原体肺炎的特点 1 、金黄色葡萄菌肺炎 (staphylococcus aureus pneumonia) 急、重、快,肺组织破坏严重易出现并发症，可有肺外迁 徒病灶,皮疹 (rash,白细胞总数及中性粒细胞增高,scarlatina-like rash,2 、腺病毒肺炎(adenovirus pneumonia) 急、重 肺部体征出现较晚 易发生其他系统功能障碍 X线特点:病灶易融合 病程迁延,3、革兰氏阴性杆菌性肺炎 (Gram-negative bacillary pneumonia) 多见于4 岁小儿,起病亚急性,全身中

19、毒症状重，易并发脓胸、脑膜炎、 败血症、心包炎等,胸片多样化，可呈支气管肺炎，大叶性肺 炎或肺段实变改变，常伴胸腔积液征,外周血白细胞增高,4 、肺炎支原体肺炎 (mycoplasma pneumoniae pneumonia) 年长儿：亚急性起病 刺激性咳嗽突出, 肺部体征轻或无,婴幼儿：喘憋(wheezing) X 线表现：肺门影增浓 支肺炎改变 间质性肺炎改变 均一的实变影,5 、衣原体肺炎,沙眼衣原体肺炎 (chlamydia trachomatis pneumonia ) 多见于6 个月婴儿 起病缓慢，一般不发热 X 线为间质性病变为主 (interstitial infiltrate,肺炎衣原体肺炎: (chlamydial pneumonia) 常见于5 岁小儿 起病隐匿，无发热， 咳嗽可持续 12月， 两肺可闻干湿罗音 胸片为浸润病灶表现,treatment,一般治疗 病原治疗 抗生素原则(principle of antibiotic) 抗生素停药时间 抗病毒 (antivirus,Symptomatic measures : 氧疗(