病理学-呼吸系统资料讲解课件

呼吸系统疾病TheRespiratorySystem第四章呼吸系统疾病第四章快速气体交换

Rapidgasexchange

VentilationPerfusionDiffusion

清洁空气肺的结构与功能快速气体交换肺的结构与功能MucosaSubmucosaCartilageMusclesBronchusMucosaSubmucosaCartilageMuscleBronchialepitheliumBronchialepitheliumKulchitskycellsKulchitskycellsBronchialSubmucosalGlandsBronchialSubmucosalGlandsAlveoliAlveoliTherespiratorymembraneTherespiratorymembrane病原体

Pathogen空气contaminatedairexposure

鼻咽部菌群

nasopharyngealfloraaspiration宿主防御功能下降

Compromiseddefensemechanisms肺部疾病

othercommonlungdisease免疫缺陷Immunodeficiency生活方式

Lifestyle肺部感染PulmonaryInfections病原体Pathogen肺部感染PulmonaryIn病理学——呼吸系统资料讲解课件分类Classification根据解剖和影像学

Anatomyandradiography根据病因

Etiology根据在哪获得

SettinginwhichtheyariseCommunity-Acquired

Hospital-acquired

(nosocomial)分类Classification根据解剖和影像学一、细菌性肺炎

大叶性肺炎（95%肺炎链球菌）小叶性肺炎军团菌性肺炎（肺炎+全身毒血症状）一、细菌性肺炎大叶性肺炎小叶性肺炎大叶性肺炎小叶性肺炎大叶性肺炎患者杨某，男，20岁，学生。酗酒后遭雨淋，于当天晚上突然起病，寒颤、高热、呼吸困难、胸痛，继而咳嗽，咳铁锈色痰，其家属急送当地医院就诊。听诊，左肺下叶有大量湿性啰音；触诊语颤增强；血常规：WBC：17X109/L；X线检查，左肺下叶有大片致密阴影。

典型病例1患者杨某，男，20岁，学生。酗酒后遭雨淋，于当入院经抗生素治疗，病情好转，各种症状逐渐消失；X线检查，左肺下叶的大片致密阴影缩小2/3面积。病人于入院后第7天自感无症状出院。冬季征兵体检，X线检查左肺下叶有约3cmX2cm大小不规则阴影，周围边界不清，怀疑为“支气管肺癌”。在当地医院即做左肺下叶切除术。病理检查，肺部肿块肉眼为红褐色肉样，镜下为肉芽组织。

入院经抗生素治疗，病情好转，各种症状逐渐消失；X线检查，左肺大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎Intheerabeforeantibiotics…充血水肿期

Hyperemiaandedema红肝期

Redhepatization灰肝期

Grayhepatization溶解消散期

Resolution(hopefully)Intheerabeforeantibiotics…Hyperemiaandedema，12-24hours

Hyperemiaandedema，12-24hourRedhepatization2-3daysRedhepatization2-3days病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件Grayhepatization，3-4daysGrayhepatization，3-4days病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件并发症complications肺脓肿，脓胸，脓气胸败血症，脓毒败血症，感染性休克肺肉质变并发症complications肺脓肿，脓胸，脓气胸小叶性肺炎小叶性肺炎小叶性肺炎小叶性肺炎FilledwithexudateAeratedlung小叶性肺炎FilledwithexudateAeratedlun小叶性肺炎小叶性肺炎并发症Complications心力衰竭、呼吸衰竭肺脓肿、脓胸、脓毒败血症

支气管扩张并发症Complications心力衰竭、呼吸衰竭Organization

OrganizationAbscessformationAbscessformationAbscessformationAbscessformationPurulentpleuritisPurulentpleuritisHemorrhagicPneumoniabyPseudomonasaeruginosaHemorrhagicPneumoniaPseudomonaspneumoniaPseudomonaspneumoniaKlebsiellapneumoniaKlebsiellapneumonia二、病毒性肺炎/三、支原体性肺炎轻者为急性间质性肺炎，旧称不典型性肺炎atypical缺乏实变体征WBC轻度升高重者为急性呼吸窘迫症ARDS肺泡弥漫性损伤透明膜形成二、病毒性肺炎/三、支原体性肺炎轻者为急性间质性肺炎，旧称ViralpneumoniaViralpneumoniaAtypicalpneumoniaAtypicalpneumoniaSevereAcuteRespiratorySyndrome(SARS)SevereAcuteRespiratorySyndrPneumoniaintheImmunocompromisedHost机会致病原

opportunisticagents常为多重感染

bacteria

(P.aeruginosa,Mycobacteriumspp.,L.pneumophila,andListeriamonocytogenes)viruses

(cytomegalovirusandherpesvirus)fungi

(P.jiroveci,Candidaspp.,Aspergillusspp.,andCryptococcusneoformans)PneumoniaintheImmunocompromCMVinfectionsCMVinfections病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件

insituhybridizationinsituhybridizationSputumcytologyfromanAIDSpatient(Papanicolaou)(Giemsa)SputumcytologyfromanAIDSpPneumocystisPneumonia

PneumocystisPneumonia病理学——呼吸系统资料讲解课件(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPne(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPnePneumocystiscariniiinbronchiallavagefromanAIDSpatient(Grocott‘ssilver)Pneumocystiscariniiinbronch(Papanicolaou)(Immunostaining)(Papanicolaou)(Immunostaining慢性阻塞性肺病(COPD)

ChronicObstructivePulmonaryDiseaselimitationofairflowusuallyresultingfromanincreaseinresistancecausedbypartialorcompleteobstructionatanylevel肺气肿Emphysema慢性支气管炎Chronicbronchitis支气管扩张Bronchiectasis哮喘Asthma慢性阻塞性肺病(COPD)

ChronicObstrFEV1/FVCFEV1/FVCClinicalTermAnatomicSiteMajorPathologicChangesEtiologySigns/SymptomsChronicbronchitisBronchusBronchioleMucusglandhyperplasia,hypersecretionInflammatoryscarringTobaccosmoke,airpollutantsCough,sputumproductionCough,dyspneaBronchi-ectasisBronchusAirwaydilationandscarringPersistentorsevereinfectionsCough,purulentsputum,feverAsthmaBronchusSmoothmusclehyperplasia,excessivemucus,inflammationImmunologicorundefinedcausesEpisodicwheezing,cough,dyspneaEmphysemaAcinusAirspaceenlargement,walldestructionTobaccosmokeDyspneaClinicalTermAnatomicSiteMajo

我国国家“十五”课题最新统计数据（2005年公布）显示40岁以上人口COPD患病率为8%。估计全国有2500万人罹患此病，每年因COPD死亡的人数达100万，致残人数达500～1000万，COPD居我国疾病负担的首位。我国国家“十五”课题最新统计数据（2005年公布慢性支气管炎ChronicbronchitisApersistentcoughproductiveofsputumforatleast3months,inatleast2consecutiveyears单纯型Simple…喘息型

Asthmatic…阻塞型

obstructive…

慢性支气管炎ChronicbronchitisAper病因etiology吸烟和空气污染

Cigarettesmokingandairpollutants感染

Microbialinfection

Secondaryrole使炎症持续，加重症状

maintainingtheinflammationandexacerbatingsymptoms病因etiology吸烟和空气污染发病机制Pathogenesis多痰——粘液分泌亢进

Hypersecretionofmucus大气道病变

largebronchialinvolvement粘液腺增生，杯状细胞分泌亢进

Hypertrophyofmucousglandsandamarkedincreaseinmucin-secretinggobletcells发病机制Pathogenesis多痰——粘液分泌亢进气道阻塞

Airflowobstruction小气道炎症和管壁纤维化

inflammation,bronchiolarwallfibrosis

杯状细胞化生，细支气管痰栓形成

gobletcellmetaplasiawithmucuspluggingofthebronchiolarlumen并发肺气肿

coexistentemphysema

发病机制Pathogenesis气道阻塞Airflowobstruction发病机制PinnerperichondriumbasallaminaChronicbronchitisNormalbronchusinnerperichondriumbasallaminChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchiolitis

luminalandmucuschronicinflammationChronicbronchiolitisluminal肺气肿

EmphysemaAbnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchioles,accompaniedbydestructionoftheirwallswithoutobviousfibrosis指呼吸性细支气管、肺泡管、肺泡囊、肺泡因组织弹性减弱而过度充气伴有肺泡间隔破坏，致使肺容积增大的病理状态肺气肿

EmphysemaAbnormalperman病理类型腺泡(小叶)中央型

Centriacinar…

全腺泡(小叶)型

Panacinar…腺泡(小叶)周围型

Distalacinar…不规则型

Irregular…obstructionSpontaneouspneumothoraxasymptomatic病理类型腺泡(小叶)中央型Centriacinar…o病理学——呼吸系统资料讲解课件发病机理Pathogenesis发病机理PathogenesisCentriacinaremphysemaCentriacinaremphysema病理学——呼吸系统资料讲解课件BullousemphysemaBullousemphysemaCentriacinaremphysemaCentriacinaremphysema病理学——呼吸系统资料讲解课件

InadequateventilationLessperfusionNarrowedbronchioleInadequateventilationConditionsRelatedtoEmphysema间质性肺气肿

Mediastinal(interstitial)emphysema代偿性肺气肿

Compensatoryemphysema阻塞性过充气

Obstructiveoverinflation瘢痕旁肺气肿

Paracicatricalemphysema老年性肺气肿

SenileemphysemaConditionsRelatedtoEmphysem病理学——呼吸系统资料讲解课件COPD的临床表现RespiratoryfailureRightheartfailureCOPD的临床表现RespiratoryfailureRiPinkpuffer桶状胸

BarrelchestPinkpuffer桶状胸支气管扩张症BronchiectasisPermanentdilationofbronchiandbronchiolescausedbydestructionofthemuscleandelasticsupportingtissueresultingfromorassociatedwithchronicnecrotizinginfections

继发于持续性感染或阻塞

Secondarytopersistinginfectionorobstruction

诊断依靠病史和影像学支气管扩张症BronchiectasisPermanentPredisposingconditions支气管阻塞

Bronchialobstruction肿瘤Tumor异物Foreignbodies

先天性或遗传性疾病

Congenitalorhereditaryconditions

CysticfibrosisKartagenersyndrome坏死性化脓性肺炎

Necrotizing,orsuppurative,pneumonia

Predisposingconditions支气管阻塞CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)Bronchiectasis57yearoldwomanwithalonghistoryofrecurrentrespiratorytractinfectionsandepisodesofhemoptysisBronchiectasis57yearoldwomaBronchiectasis

BronchiectasisBronchiectasisDuetopneumoniaBronchiectasisBronchiectasisBronchiectasisBronchiectasis

PurulentexudationinthelumenDestructionofliningepitheliumScarringofthebronchialwallBronchiectasisPurulentexudatHRCTscansofbronchiectasisHRCTscansofbronchiectasis支气管扩张症的临床表现咳嗽，咳脓臭痰

Severe,persistentcoughwithmucopurulentsputum,sometimesfetid咯血

Flecksofbloodinsputumorfrankhemoptysis

严重病例及合并症支气管扩张症的临床表现咳嗽，咳脓臭痰肺间质疾病ILD肺弥漫性纤维化肺顺应性减弱，容量减小已知病因和特发性间质性肺炎肺间质疾病ILD肺弥漫性纤维化Selectedcausesofchronicinterstitiallungdisease

OccupationalandenvironmentalexposureAsbestosisSilicosisHypersensitivitypneumonitisDrugortreatmentrelatedChemotherapeuticagentsIonizingirradiationOxygenImmunologiclungdiseaseSarcoidosisWegnergranulomatosisCollagenvasculardiseaseGoodpasturesyndromeMiscellaneousPostacuterespiratorydistresssyndromeIdiopathicpulmonaryfibrosisSelectedcausesofchronicint杵状指（趾）Clubbingofdigits杵状指（趾）HoneycomblungHoneycomblung病理学——呼吸系统资料讲解课件矽肺Silicosis职业病

Occupationaldiseases吸入二氧化硅粉尘引起

Inhalationofcrystallinesilica致残和致死

Disablingandfatal病理：硅结节形成广泛的肺纤维化

矽肺Silicosis职业病Occupational病理学——呼吸系统资料讲解课件发病机制Pathogenesis直径<5μm的硅尘沉积于肺间质肺泡巨噬细胞引发和持续肺损伤和纤维化

Alveolarmacrophageisakeycellularelementintheinitiationandperpetuationoflunginjuryandfibrosis发病机制Pathogenesis直径<5μm的硅尘沉积于Silicosis

asliceoflungfroma61yoceramicsworkerSilicosisasliceoflungfrom矽结节

Silicosis矽结节Silicosis病理学——呼吸系统资料讲解课件临床表现Clinicalcourse早期常为体检发现

usuallydetectedinroutinechestradiographs晚期表现：呼吸困难shortnessofbreath肺心病corpulmonale合并TBincreasedsusceptibilitytoTB可能致癌

carcinogenic(controversial)临床表现Clinicalcourse早期常为体检发现uSilicosis

Silicosis急性呼吸窘迫征(ARDS)

AcuteRespiratoryDistressSyndrome进行性呼吸衰竭

AcuteonsetofDyspneaHypoxemiaBilateralpulmonaryinfiltrates(X-ray)Noevidenceofleft-sidedheartfailure病理：弥漫性肺泡损伤

DiffuseAlveolarDamage(DAD)常伴多器官衰竭

MultipleOrganDysfunctionSyndrome(MODS)急性呼吸窘迫征(ARDS)

AcuteRespiratDirectLungInjuryIndirectLungInjuryCommonCausesPneumoniaSepsisAspirationofgastriccontentsSeveretraumawithshockUncommonCausesPulmonarycontusionCardiopulmonarybypassFatembolismAcutepancreatitisNear-drowningDrugoverdoseInhalationalinjuryTransfusionofbloodproductsReperfusioninjuryafterlungtransplantationUremiaClinicalDisordersAssociatedwithdevelopingARDSDirectLungInjuryIndirectLun发病机制Pathogenesis广泛内皮和肺泡I型、II型上皮损伤

Endothelialandepithelial(IandII)damage肺水肿

alveolarflooding气体交换丧失

lossofdiffusioncapacity

表面活性物质异常

surfactantabnormalities

促炎和抗炎介质的失衡

Imbalanceofpro-inflammatoryandanti-inflammatorymediators发病机制Pathogenesis广泛内皮和肺泡I型、II病理学——呼吸系统资料讲解课件病理变化Morphology急性渗出期

AcuteExudativeStage水肿

Edema(interstitialandalveolar)

透明膜形成

Hyalinemembranes

肺泡塌陷

Manyalveolicollapse

增生期ProliferativeStageII型肺泡上皮增生肺泡内机化Intra-alveolarfibrosis病理变化Morphology急性渗出期AcuteExuwideningoftheinterstitiumARDSwideningoftheinterstitiumHyalinemembranesHyalinemembranesHyalinemembranes

HyalinemembranesHyalinemembranes

HyalinemembranesHealingstage

HealingstageHealingstage

HealingstagesuvivingpatientARDSsuvivingpatientARDS临床表现Clinicalfeatures肺顺应性差

Poorpulmonarycompliance难治性低氧血症

Poorresponsetooxygen血管床进行性减少

Pulmonaryvascularbedisprogressivelyobliterated易感染

Pronetobacteriainfection临床表现Clinicalfeatures肺顺应性差预后PrognosisDependssuccessfullytreatementsbeforeextensivefibrosis40-70%mortalityHigh-dosesteroidsfailedConservativetherapyhelpsConsiderableinterestinthequalityofsurvivals预后PrognosisDependssuccessfuLUNGTUMORSMetastatictumorsPrimarytumorsBRONCHOGENICCARCINOMAOthers

bronchialcarcinoidsmesenchymalmalignanciesLymphomasafewbenignlesions

95%5%LUNGTUMORSMetastatictumors9慢性肺动脉高压症和肺心病（自学）概念病因发病机制病理变化临床病理联系思考题：试述慢性支气管炎并发肺心病的发病机制。慢性肺动脉高压症和肺心病（自学）概念思考题：肺癌癌症死因第一位

causeofcancer-relateddeaths发病率随年龄和烟龄增长

"pack-yearssmoked".确诊的病人一半以上已有远处转移distantmetastaticdisease5年生存率约为15%5-yearsurvival肺癌癌症死因第一位病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件肺癌的临床病理分型肺小细胞癌

Smallcelllungcancer(SCLC)肺非小细胞癌

Non-small-celllungcancer(NSCLC)

鳞癌Squamouscellcarcinoma

腺癌Adenocarcinomas大细胞癌Largecellcarcinomas

肺癌的临床病理分型肺小细胞癌SCLCKulchitskycell起源hADH(hyponatremia/waterintoxication)ACTH(Cushing'ssyndrome)中央型

Centrallylocatedmasses坏死常见

Necrosisisinvariablypresentandmaybeextensive燕麦细胞癌

OatcellcarcinomaSCLCKulchitskycell起源SCLCSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLC鳞状细胞癌病人大多有吸烟史

Closelycorrelatedwithasmokinghistory中央型

Tendtoarisecentrallyinmajorbronchi常见空洞

Cavitationisnotuncommon副癌综合征

Preneoplasticlesions

鳞状细胞癌病人大多有吸烟史SquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinoma病理学——呼吸系统资料讲解课件SquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinoma病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件Metaplaisa?Anaplasia?Dysplasia?Metaplaisa?Anaplasia?Dysplas腺癌Adenocarcinoma周围型多见

peripherallylocated是女性和非吸烟者常见的肺癌类型常发生自肺周边部疤痕处

arisinginrelationtoperipherallungscars生长缓慢但早期转移支气管肺泡干细胞起源

Bronchioalveolarstemcellsorigin腺癌Adenocarcinoma周围型多见peripAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinoma细支气管肺泡癌(BAC)

BronchioloalveolarcarcinomaAdistinctsubtypeofadenocarcinoma弥漫型多见multiplediffusenodulesGrowingalongpreexistingstructuresandpreservationofalveolararchitecture分为粘液型和无粘液型

mucinous/nonmucinoussubtypes细支气管肺泡癌(BAC)

BronchioloalveoBACBACBACBACBACBACPrecursorlesionsofADCAAHBACPrecursorlesionsofADCAAHBAC低分化癌，排除SCLC,SCCorADCCellsarenot-columnarinshapeDonotcontainmucousDonotshowsquamousdifferentiationDonothaveneuroendocrinepropertiesorsmallcellcharacteristics可发生与任何部位

ariseanywhereinlungs大部分与吸烟有关，预后差

smoking-related,curesarerare大细胞癌低分化癌，排除SCLC,SCCorADC大细胞癌LargecellcarcinomaLargecellcarcinoma肺癌的临床表现原发灶引起的症状

Symptomsduetoprimarytumor原发灶蔓延引起的症状

Symptomsduetolocoregionalspread转移引起的问题

Metastaticdisease副肿瘤综合征

Paraneoplasticsyndromes肺癌的临床表现原发灶引起的症状中央型肺癌

Centraltumorscough,dyspnea,肺不张atelectasis,阻塞后肺炎，喘息

咯血hemoptysis周围型肺癌

Peripheraltumorscough,dyspnea胸水pleuraleffusion疼痛severepainDuetoprimarytumor中央型肺癌CentraltumorsDuetoprDuetolocoregionalspread上腔静脉综合征

Superiorvenacavaobstruction声音嘶哑

Hoarseness肩膀和上臂疼痛Horner’ssyndrome吞咽困难

Dysphagia心包积液

PericardialeffusionDuetolocoregionalspread上腔静脉病理学——呼吸系统资料讲解课件眼球内陷asunkeneyeball(enophthalmia)

瞳孔缩小，对光反射异常上睑下垂droopyuppereyelid患侧面部无汗Horner'sSyndromeNormalAbnormal眼球内陷asunkeneyeball(enophtMetastaticdisease脑

brain(mentalorneurologicchanges)肝

liver(hepatomegaly)骨

bones(pain)Metastaticdisease脑brain(menParaneoplasticsyndromesHypercalcemiaCushingsyndromeHyponatremiaNeuromuscularsyndromesHematologicmanifestationsClubbingofthefingersBlindnessanddementia3%to10%ofallpatientsParaneoplasticsyndromesHypercMetastaticcarcinomaMetastaticcarcinomadilatedlymphaticchanneldilatedlymphaticchannelTransesophagealEchocardiogram6/22,8daysbeforedeath,…showedthickeningoftheleafletsofthePVandoneoftwopedunculatedvegetations,Therewasnovalvarinsufficiency.TransesophagealEchocardiogramRadiographicFindings

6/26,4daysbeforedeath,afrontalfilmshowingtherightlungdemonstratedmultipleareasofmass-likeconsolidation,atleasttwoofwhichshowedcentralcavitation.Therewasasmallrighteffusion.Theleftlungappearednormal.RadiographicFindings6/264/xx-6/19

inanotherhospital,“feelingbad”

6/19…“2daysofincreasingconfusion”6/30…dieHepatitisCEnd-stagerenaldiseaseRkneeandLwristsepticarthritisintravenousdruguseRkneeandLwristsepticarthritisBacteremiaNocardiacmurmurLungsareclear6/22PVvegetations6/26lungmasses,cavitatedpleuraleffusion4/xx-6/19inanotherhospital,AutopsyFindings

PulmonicvalveNormalpulmonicvalveAutopsyFindingsPulmonicval

Therightlungweighed1000gandtheleft,900g(normalabout250gapiece).Therighthadafibrinouspleuritis.Afterdistensionwithformalinandfixation,oneslicefromtheleftlungshowedtwoyellowishlesions.Therightlungweighed100Asliceoftherightlowerlobeshowedtwolesions.AsliceoftherightlowerlobPulmonicvegetationPulmonicvegetationThrombusinoneofthesegmentalarteriesThrombusinoneofthesegmentthesamearterythesamearteryAnothervesselAnothervessel病理诊断DiagnosesInfectiveendocarditis

(methicillinresistantS.aureus)InfectedemboliInfectivepulmonaryarteritisInfected,cavitatedinfarcts,lung.病理诊断DiagnosesInfectiveendoca呼吸系统疾病TheRespiratorySystem第四章呼吸系统疾病第四章快速气体交换

Rapidgasexchange

VentilationPerfusionDiffusion

清洁空气肺的结构与功能快速气体交换肺的结构与功能MucosaSubmucosaCartilageMusclesBronchusMucosaSubmucosaCartilageMuscleBronchialepitheliumBronchialepitheliumKulchitskycellsKulchitskycellsBronchialSubmucosalGlandsBronchialSubmucosalGlandsAlveoliAlveoliTherespiratorymembraneTherespiratorymembrane病原体

Pathogen空气contaminatedairexposure

鼻咽部菌群

nasopharyngealfloraaspiration宿主防御功能下降

Compromiseddefensemechanisms肺部疾病

othercommonlungdisease免疫缺陷Immunodeficiency生活方式

Lifestyle肺部感染PulmonaryInfections病原体Pathogen肺部感染PulmonaryIn病理学——呼吸系统资料讲解课件分类Classification根据解剖和影像学

Anatomyandradiography根据病因

Etiology根据在哪获得

SettinginwhichtheyariseCommunity-Acquired

Hospital-acquired

(nosocomial)分类Classification根据解剖和影像学一、细菌性肺炎

大叶性肺炎（95%肺炎链球菌）小叶性肺炎军团菌性肺炎（肺炎+全身毒血症状）一、细菌性肺炎大叶性肺炎小叶性肺炎大叶性肺炎小叶性肺炎大叶性肺炎患者杨某，男，20岁，学生。酗酒后遭雨淋，于当天晚上突然起病，寒颤、高热、呼吸困难、胸痛，继而咳嗽，咳铁锈色痰，其家属急送当地医院就诊。听诊，左肺下叶有大量湿性啰音；触诊语颤增强；血常规：WBC：17X109/L；X线检查，左肺下叶有大片致密阴影。

典型病例1患者杨某，男，20岁，学生。酗酒后遭雨淋，于当入院经抗生素治疗，病情好转，各种症状逐渐消失；X线检查，左肺下叶的大片致密阴影缩小2/3面积。病人于入院后第7天自感无症状出院。冬季征兵体检，X线检查左肺下叶有约3cmX2cm大小不规则阴影，周围边界不清，怀疑为“支气管肺癌”。在当地医院即做左肺下叶切除术。病理检查，肺部肿块肉眼为红褐色肉样，镜下为肉芽组织。

入院经抗生素治疗，病情好转，各种症状逐渐消失；X线检查，左肺大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎大叶性肺炎Intheerabeforeantibiotics…充血水肿期

Hyperemiaandedema红肝期

Redhepatization灰肝期

Grayhepatization溶解消散期

Resolution(hopefully)Intheerabeforeantibiotics…Hyperemiaandedema，12-24hours

Hyperemiaandedema，12-24hourRedhepatization2-3daysRedhepatization2-3days病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件Grayhepatization，3-4daysGrayhepatization，3-4days病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件并发症complications肺脓肿，脓胸，脓气胸败血症，脓毒败血症，感染性休克肺肉质变并发症complications肺脓肿，脓胸，脓气胸小叶性肺炎小叶性肺炎小叶性肺炎小叶性肺炎FilledwithexudateAeratedlung小叶性肺炎FilledwithexudateAeratedlun小叶性肺炎小叶性肺炎并发症Complications心力衰竭、呼吸衰竭肺脓肿、脓胸、脓毒败血症

支气管扩张并发症Complications心力衰竭、呼吸衰竭Organization

OrganizationAbscessformationAbscessformationAbscessformationAbscessformationPurulentpleuritisPurulentpleuritisHemorrhagicPneumoniabyPseudomonasaeruginosaHemorrhagicPneumoniaPseudomonaspneumoniaPseudomonaspneumoniaKlebsiellapneumoniaKlebsiellapneumonia二、病毒性肺炎/三、支原体性肺炎轻者为急性间质性肺炎，旧称不典型性肺炎atypical缺乏实变体征WBC轻度升高重者为急性呼吸窘迫症ARDS肺泡弥漫性损伤透明膜形成二、病毒性肺炎/三、支原体性肺炎轻者为急性间质性肺炎，旧称ViralpneumoniaViralpneumoniaAtypicalpneumoniaAtypicalpneumoniaSevereAcuteRespiratorySyndrome(SARS)SevereAcuteRespiratorySyndrPneumoniaintheImmunocompromisedHost机会致病原

opportunisticagents常为多重感染

bacteria

(P.aeruginosa,Mycobacteriumspp.,L.pneumophila,andListeriamonocytogenes)viruses

(cytomegalovirusandherpesvirus)fungi

(P.jiroveci,Candidaspp.,Aspergillusspp.,andCryptococcusneoformans)PneumoniaintheImmunocompromCMVinfectionsCMVinfections病理学——呼吸系统资料讲解课件病理学——呼吸系统资料讲解课件

insituhybridizationinsituhybridizationSputumcytologyfromanAIDSpatient(Papanicolaou)(Giemsa)SputumcytologyfromanAIDSpPneumocystisPneumonia

PneumocystisPneumonia病理学——呼吸系统资料讲解课件(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPne(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPnePneumocystiscariniiinbronchiallavagefromanAIDSpatient(Grocott‘ssilver)Pneumocystiscariniiinbronch(Papanicolaou)(Immunostaining)(Papanicolaou)(Immunostaining慢性阻塞性肺病(COPD)

ChronicObstructivePulmonaryDiseaselimitationofairflowusuallyresultingfromanincreaseinresistancecausedbypartialorcompleteobstructionatanylevel肺气肿Emphysema慢性支气管炎Chronicbronchitis支气管扩张Bronchiectasis哮喘Asthma慢性阻塞性肺病(COPD)

ChronicObstrFEV1/FVCFEV1/FVCClinicalTermAnatomicSiteMajorPathologicChangesEtiologySigns/SymptomsChronicbronchitisBronchusBronchioleMucusglandhyperplasia,hypersecretionInflammatoryscarringTobaccosmoke,airpollutantsCough,sputumproductionCough,dyspneaBronchi-ectasisBronchusAirwaydilationandscarringPersistentorsevereinfectionsCough,purulentsputum,feverAsthmaBronchusSmoothmusclehyperplasia,excessivemucus,inflammationImmunologicorundefinedcausesEpisodicwheezing,cough,dyspneaEmphysemaAcinusAirspaceenlargement,walldestructionTobaccosmokeDyspneaClinicalTermAnatomicSiteMajo

我国国家“十五”课题最新统计数据（2005年公布）显示40岁以上人口COPD患病率为8%。估计全国有2500万人罹患此病，每年因COPD死亡的人数达100万，致残人数达500～1000万，COPD居我国疾病负担的首位。我国国家“十五”课题最新统计数据（2005年公布慢性支气管炎ChronicbronchitisApersistentcoughproductiveofsputumforatleast3months,inatleast2consecutiveyears单纯型Simple…喘息型

Asthmatic…阻塞型

obstructive…

慢性支气管炎ChronicbronchitisAper病因etiology吸烟和空气污染

Cigarettesmokingandairpollutants感染

Microbialinfection

Secondaryrole使炎症持续，加重症状

maintainingtheinflammationandexacerbatingsymptoms病因etiology吸烟和空气污染发病机制Pathogenesis多痰——粘液分泌亢进

Hypersecretionofmucus大气道病变

largebronchialinvolvement粘液腺增生，杯状细胞分泌亢进

Hypertrophyofmucousglandsandamarkedincreaseinmucin-secretinggobletcells发病机制Pathogenesis多痰——粘液分泌亢进气道阻塞

Airflowobstruction小气道炎症和管壁纤维化

inflammation,bronchiolarwallfibrosis

杯状细胞化生，细支气管痰栓形成

gobletcellmetaplasiawithmucuspluggingofthebronchiolarlumen并发肺气肿

coexistentemphysema

发病机制Pathogenesis气道阻塞Airflowobstruction发病机制PinnerperichondriumbasallaminaChronicbronchitisNormalbronchusinnerperichondriumbasallaminChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchiolitis

luminalandmucuschronicinflammationChronicbronchiolitisluminal肺气肿

EmphysemaAbnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchioles,accompaniedbydestructionoftheirwallswithoutobviousfibrosis指呼吸性细支气管、肺泡管、肺泡囊、肺泡因组织弹性减弱而过度充气伴有肺泡间隔破坏，致使肺容积增大的病理状态肺气肿

EmphysemaAbnormalperman病理类型腺泡(小叶)中央型

Centriacinar…

全腺泡(小叶)型

Panacinar…腺泡(小叶)周围型

Distalacinar…不规则型

Irregular…obstructionSpontaneouspneumothoraxasymptomatic病理类型腺泡(小叶)中央型Centriacinar…o病理学——呼吸系统资料讲解课件发病机理Pathogenesis发病机理PathogenesisCentriacinaremphysemaCentriacinaremphysema病理学——呼吸系统资料讲解课件BullousemphysemaBullousemphysemaCentriacinaremphysemaCentriacinaremphysema病理学——呼吸系统资料讲解课件

InadequateventilationLessperfusionNarrowedbronchioleInadequateventilationConditionsRelatedtoEmphysema间质性肺气肿

Mediastinal(interstitial)emphysema代偿性肺气肿

Compensatoryemphysema阻塞性过充气

Obstructiveoverinflation瘢痕旁肺气肿

Paracicatricalemphysema老年性肺气肿

SenileemphysemaConditionsRelatedtoEmphysem病理学——呼吸系统资料讲解课件COPD的临床表现RespiratoryfailureRightheartfailureCOPD的临床表现RespiratoryfailureRiPinkpuffer桶状胸

BarrelchestPinkpuffer桶状胸支气管扩张症BronchiectasisPermanentdilationofbronchiandbronchiolescausedbydestructionofthemuscleandelasticsupportingtissueresultingfromorassociatedwithchronicnecrotizinginfections

继发于持续性感染或阻塞

Secondarytopersistinginfectionorobstruction

诊断依靠病史和影像学支气管扩张症BronchiectasisPermanentPredisposingconditions支气管阻塞

Bronchialobstruction肿瘤Tumor异物Foreignbodies

先天性或遗传性疾病

Congenitalorhereditaryconditions

CysticfibrosisKartagenersyndrome坏死性化脓性肺炎

Necrotizing,orsuppurative,pneumonia

Predisposingconditions支气管阻塞CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)Bronchiectasis57yearoldwomanwithalonghistoryofrecurrentrespiratorytractinfectionsandepisodesofhemoptysisBronchiectasis57yearoldwomaBronchiectasis

BronchiectasisBronchiectasisDuetopneumoniaBronchiectasisBronchiectasisBronchiectasisBronchiectasis

PurulentexudationinthelumenDestructionofliningepitheliumScarringofthebronchialwallBronchiectasisPurulentexudatHRCTscansofbronchiectasisHRCTscansofbronchiectasis支气管扩张症的临床表现咳嗽，咳脓臭痰

Severe,persistentcoughwithmucopurulentsputum,sometimesfetid咯血

Flecksofbloodinsputumorfrankhemoptysis

严重病例及合并症支气管扩张症的临床表现咳嗽，咳脓臭痰肺间质疾病ILD肺弥漫性纤维化肺顺应性减弱，容量减小已知病因和特发性间质性肺炎肺间质疾病ILD肺弥漫性纤维化Selectedcausesofchronicinterstitiallungdisease

OccupationalandenvironmentalexposureAsbestosisSilicosisHypersensitivitypneumonitisDrugortreatmentrelatedChemotherapeuticagentsIonizingirradiationOxygenImmunologiclungdiseaseSarcoidosisWegnergranulomatosisCollagenvasculardiseaseGoodpasturesyndromeMiscellaneousPostacuterespiratorydistresssyndromeIdiopathicpulmonaryfibrosisSelectedcausesofchronicint杵状指（趾）Clubbingofdigits杵状指（趾）HoneycomblungHoneycomblung病理学——呼吸系统资料讲解课件矽肺Silicosis职业病

Occupationaldiseases吸入二氧化硅粉尘引起

Inhalationofcrystallinesilica致残和致死

Disablingandfatal病理：硅结节形成广泛的肺纤维化

矽肺Silicosis职业病Occupational病理学——呼吸系统资料讲解课件发病机制Pathogenesis直径<5μm的硅尘沉积于肺间质肺泡巨噬细胞引发和持续肺损伤和纤维化

Alveolarmacrophageisakeycellularelementintheinitiationandperpetuationoflunginjuryandfibrosis发病机制Pathogenesis直径<5μm的硅尘沉积于Silicosis

asliceoflungfroma61yoceramicsworkerSilicosisasliceoflungfrom矽结节