呼吸系统疾病基础知识概述英文

同学们好！呼吸系统疾病

RespiratorySystemDisease湘雅医院儿科郑湘榕

婴幼儿上感、2种特殊类型上感的特点支气管肺炎临床表现、重症肺炎特点支气管肺炎的诊断、治疗支气管哮喘的临床表现、诊断和治疗重点IntroduceInpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.Whychildrenaresosusceptibletoacuterespiratoryinfections?anatomic

physiologicalfeatures

Thechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40-44/min<1year30/min2-3years24/min4-7years22/min8-14years20/minChildrenRespiratorySystemPhysiologicFeatureRespiratorytype

RespiratorytypeofabdomenRespiratorytypeofchestabdomen

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanopathyThreeconcavesign

ＡuscultationExamineMethod急性性上上呼呼吸吸道道感感染染（AURI））AcuteUpperRespiratoryInfectionEtiologyＶirus：：Ｏccupy90%Ｂacteria：：ＳecondaryStreptococuspyogensPneumococcuＨaemophilusinfluenzaeCommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestationsCommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽咽部部充充血血，，扁扁桃桃体体肿肿大大)Lymphadenectasisinsubmaxilla(有有时时下下颌颌、、淋淋巴巴结结肿肿大大)Rashwhenenterovirusinfection(肠道病病毒感染染时可出出现皮疹疹)ClinicalManifestationsSpecialAURI柯萨奇病病毒A组感染夏秋好发发高热、咽咽痛、流流涎咽腭弓、、软腭处处有疱疹疹疱疹破溃溃后可形形成溃疡疡病程1周左左右ClinicalManifestationsHerpangina疱疹性咽咽峡炎Pharyngo-conjunctivalfever咽结合膜膜热腺病毒3，7型所所致春夏发病病，可小小流行发热、咽咽炎、结结合膜炎炎咽部充血血、结合合膜充血血，颈部部、耳耳后淋巴巴结肿大大病程1~2周周ClinicalManifestationsSpecialAURISchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplicationsAntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatmentDefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatmentPneumonia肺炎ChildrenfamiliardiseaseInworld,Occupy1/3-1/4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39.5timesofschoolagePneumoniaPneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinitionOncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：：1~3monthsClassification1OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification2OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification3OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification4ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification5OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification6支气管肺炎炎BronchopneumoniaEtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniaePathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswallPathologicphysiology气道炎症循环系统神经系统水电解质消化系统肺A压增高中毒性心肌炎心衰代酸中毒性肠麻痹胃肠粘膜屏障功能脑水肿颅压呼酸K+↑水钠储留毒血症通气不足PaO2↓,PaCO2↑换气障碍PaO2↓↓ClinicalmanifestationMildsymptomaticrespiratorysystemfeverrespiratorydistressnasalflaring,retractions,cyonosistachypneacoughrales<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailureClinicalmanifestSeveresymptomaticHeartfailure呼吸突然然加快，，>60次/分分心率突然然增快婴儿>180次次/分幼幼儿>160次次/分突然烦躁躁不安、、面色发发灰心音明显显低钝，，奔马率率，颈静静脉怒张张肝大肋下下3cm以上尿少、下下肢浮肿肿ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomaticClinicalmanifestDICBp四肢凉，脉速速弱，出血SLADHNa+≤130mmol/L渗透压<270mOsm/LEdemaSeveresymptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratorydataBloodbloodroutinebacteriainfect：：WBC↑、、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandcultureLaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis支气管肺炎正常胸片大叶性肺炎正常胸片fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosisDifferentiationacute

bronchitisrales、tachypneaforeignbodiesinbronchihistoryofforeignbodies、、suddencough、respiratorydistress、、lowerofbreathtoneorwheezingtuberculosishistoryofTBcontact、PPDtest、PPD-IgGIgM、X-ray、ralesTreatmentgeneraltreatmentBalanceofwaterandelectrolyte3%Nacl12ml/L→↑Na+10mmol/LTemperature18-20℃Humidity60%FoodnutritiveTreatmentControlinfectionvirus：：noidealdruglikevirozolmycoplasma、、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、、fullperiodoftreatment,firstselectPeniccilinTreatment抗生素使用原则根据药敏选药药adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道浓浓度高的药物物adoptdrugswhichcanfinallyinfiltratelungtissue足量足疗程重症静脉给药药inseverecase,drugsshouldbeadministedbyvein,fulldose,fullperiodTreatment抗生素选择肺炎链球菌：：PNC,阿莫西林，红红霉素金黄色葡萄球球菌：苯唑西西林、氯唑西西林、万古、、利福平流感嗜血杆菌菌：阿莫西林林+克拉维酸钾或或舒巴坦大肠杆菌和肺肺炎杆菌：头头孢曲松或头头孢噻肟绿脓杆菌：替替卡西林钠克克拉维酸钾或或头孢哌酮肺炎支原体或或衣原体：大大环内酯Treatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasmapneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，，fullperiodis6weekstreatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、cyanosis、asthmasuppress、、"toxicappearance,"methods:bynosecanal0.5~1L/min，40%；byveil2~4L/min,50%~60%mechanismventilate（respirefailture）holdingrespiratorytractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorbTreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥妥拉拉明明0.5mg/kgivgtt10%GS20mltreatagainstsymptomsTreatmenttreatofHeartfailure镇静静给氧氧强心心：：西西地地兰兰减轻轻心心脏脏负负荷荷treatagainstsymptomsTreatment合并并中中毒毒性性脑脑病病的治治疗疗脱水水：：甘甘露露醇醇改善善通通气气改善善脑脑微微循循环环止痉痉：：地地西西泮泮地塞塞米米松松营养养神神经经treatagainstsymptomsTreatment糖皮皮质质激激素素应用用适应应症症：：①喘憋憋重重,呼呼吸吸衰衰竭竭②全全身身中毒毒症症状状重重③感感染染性性休休克克④脑脑水水肿肿琥珀珀酸酸氢氢化化可可的的松松5~10mg/kg.d地塞塞米米松松0.1~0.3mg/kg.divgtt2~3次次/日日×3~5天天甲基基强强的的松松龙龙2~4mg/kg.次ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolveWhatifpatientsfailstorecover?Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen病毒毒性性肺炎炎呼吸吸道道合合胞胞病病毒毒肺肺炎炎腺病病毒毒肺肺炎炎2岁岁，，2~6月月多多见见喘憋、呼呼吸困难难，可合合并呼衰、心心衰哮鸣音，，细湿罗罗音小点片状状影，肺肺气肿肺肺不张间质性肺肺炎6月~2岁中毒症状状重，稽稽留热，，咳剧，喘喘憋，呼呼吸困难难出现晚，，湿罗音音或肺实实变胸片改变变出现早早，肺气气肿，片状状影或融融合年龄症状胸片体征细菌性肺炎葡萄球菌菌肺炎新生儿，，婴幼儿儿急、重、、快，弛弛张热或或稽留热热，咳嗽，呼呼吸困难难，呻吟吟，易致致迁徒化脓脓病灶，，并发脓脓胸，脓脓气胸，肺肺大疱中细湿罗罗音，出出现早，，皮疹浸润影，，持续时时间较长长，易变变，可见多发发性肺脓脓肿，脓脓胸，脓脓气胸等<4岁慢，重，，发热，，痉挛性性咳嗽，呼呼吸困难难，发绀绀。易致迁徒徒化脓病病灶，易易并发脓胸湿罗音或或实变大叶性肺肺炎、支支气管肺肺炎、肺实变年龄症状体征胸片革兰阴性性杆菌肺肺炎肺炎支原原体肺炎炎年长儿，，婴幼儿儿发热、刺刺激性咳咳嗽，多多系统病病变不明显，，婴幼儿儿可有呼呼吸困难难，喘憋，哮哮鸣音，，湿罗音音肺门影增增浓；支支气管肺肺炎改变变；间质性肺肺炎；均均一实变变影<6月起病慢，，无发热热，先URI症状后咳咳、喘、、气促，，部分伴结膜膜炎湿罗音，，持续时时间长间质性炎炎症，过过度充气气、片状影，，持续时时间长年龄症状体征胸片沙眼衣原原体肺炎炎支衣原体体肺炎支气管哮哮喘bronchialasthma发展史asthma-喘息，2000年前就就有对哮哮喘的详详细描述述过去认为为是一种种平滑肌肌功能异异常性疾疾病80年代代以来通通过支气气管黏膜膜活检，，认识到哮哮喘是气气道慢性性炎症性性疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,respiratorydistress,cough特征气道慢性炎炎症：此为为哮喘主要要特征可逆性的气气流受限：：指气流受受限可被支支气管扩张剂所逆逆转气道高反应应性：对正正常气道无无反应或很很小反（AHR）应的刺激产产生收缩反反应pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening病理生理急性支气管管痉挛：速速发型哮喘喘反应（IgE依赖）气道壁肿胀胀：迟发型型哮喘反应应（炎症诱诱导）粘液栓形成成：难治疗疗的气流受受限气道重塑：：不可逆的的气道狭窄窄核心气流受限atopy是指对普通通环境中常常见的变应应原产生IgE介导反应的的易感性，，有明显的的家族遗传传倾向。特应性哮喘、过敏敏性鼻炎、、湿疹、食食物过敏等等导致哮喘发发生最确定定的危险因因素pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-adrenalglandnerve-adrenalglandnervePneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistoryClinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticusauxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力呼呼气容积/用力肺活量量，低于于70-75％提示示气流受限限）PEFR（呼气风流速速，其日间间变异率>20%,使用支扩扩剂后增加加20%可可诊断哮哮喘）Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegaspcough1month,antibioticstreatisinvalidbronchodilatorscanre