内科学 呼吸系统总论瞿介明

第一页，共五十六页，2022年，8月28日IntroductionTheRespiratorySystemStructureDetail

第二页，共五十六页，2022年，8月28日2Introduction第三页，共五十六页，2022年，8月28日3IntroductionDeathRateof10MainDiseasesinCertainRegionin2006(China)

Rank

City

County

CauseDeathRate1/100000

%

CauseDeathRate1/100000

%

12345678910MalignantNeoplasmsCerebrovascularDiseaseHeartDiseaseDiseasesoftheRespiratorySystemInjury&PoisoningEndocrine,Nutritional&MetabolicDiseasesDiseasesoftheDigestiveSystemDiseaseoftheGenitourinarySystemDiseaseoftheNervousSystemMentalDisorders

144.5793.6990.7269.2932.3617.5915.617.284.953.4427.2517.6617.1013.066.103.322.941.370.930.65MalignantNeoplasmsCerebrovascularDiseaseDiseasesoftheRespiratorySystemHeartDiseaseInjury&PoisoningDiseasesoftheDigestiveSystemEndocrine,Nutritional&MetabolicDiseasesDiseaseoftheGenitourinarySystemDiseaseoftheNervousSystemMentalDisorders

130.23105.4884.9471.8446.1217.008.166.654.163.7725.1420.3616.4013.878.903.281.571.280.800.73Total90.41Total92.32第四页，共五十六页，2022年，8月28日4Majortasks:

Whatdisease?(disease’sdiagnosis)Howtodealwithit?(disease’smanagement)第五页，共五十六页，2022年，8月28日5ClinicalPresentation第六页，共五十六页，2022年，8月28日6Commonpresentingsymptoms:Dyspnea(shortnessofbreath)CoughLesscommonsymptoms:Hemoptysis(thecoughingupofblood)Chestpain(oftenwithapleuriticcharacteristics)History第七页，共五十六页，2022年，8月28日7Acute(overaperiodofhourstodays):

AcuteattackofasthmaAcutepulmonaryedemaBacterialpneumoniaPneumothoraxPulmonaryembolusHistoryDyspnea第八页，共五十六页，2022年，8月28日8Subacute(overdaystoweeks):AsthmaChronicbronchitisPleuraleffusionCongestiveheartfailurePneumocystiscariniipneumoniainpatientswithAIDSWegener'sgranulomatosis,eosinophilicpneumonia,BronchiolitisobliteranswithorganizingpneumoniaGuillain-Barresyndrome,myastheniagravis

HistoryDyspnea第九页，共五十六页，2022年，8月28日9Chronic(overmonthstoyears):

COPDChronicinterstitiallungdiseaseChroniccardiacdiseaseHistoryDyspnea第十页，共五十六页，2022年，8月28日10

Acuteorchronic?

Seasonalorassociatedwithwheezing?Associatedwithsymptomssuggestiveofpostnasaldriporgastroesophagealreflux?Associatedwithfeverorsputum?Anyassociateddiseasesorriskfactorsfordisease(e.g.,cigarettesmoking,riskfactorsforinfectionwithHIV,environmentalexposures)?HistoryCough第十一页，共五十六页，2022年，8月28日11Originatingfromtheairways:

Bronchitis,Bronchiectasis,Cysticfibrosis,Bronchogeniccarcinoma,BronchialcarcinoidtumorsOriginatingfromthepulmonaryparenchyma:Pneumonia,Lungabscess,Tuberculosis,InfectionwithAspergillus,Goodpasture’ssyndrome,Idiopathicpulmonaryhemosiderosis(IPH)Originatingfromthevasculature:Thromboembolicdiseases,ArteriovenousmalformationsHistoryHemoptysis第十二页，共五十六页，2022年，8月28日12Usuallyoriginatingfrominvolvementoftheparietalpleura:PleuritisPneumothoraxNeoplasmPulmonaryembolismPneumoniaHistoryChestpain第十三页，共五十六页，2022年，8月28日13

ThenumberofyearsofsmokingTheintensity(i.e.,numberofpacksperday)TheintervalsincesmokingcessationAhistoryofsignificantsecondhand(passive)exposuretosmokeHistoryHistoryofsmoking第十四页，共五十六页，2022年，8月28日14Respiratorydisordersassociatedwithsmoking:ChronicobstructivelungdiseaseNeoplasiaSpontaneouspneumothoraxRespiratorybronchiolitis-interstitiallungdiseaseEosinophilicgranulomaofthelungPulmonaryhemorrhagewithGoodpasture'ssyndromeHistoryHistoryofsmoking第十五页，共五十六页，2022年，8月28日15

Occupational(detailedoccupationalandpersonalhistories)orAvocational(hobbies,homeenvironment)

Inorganicdusts(asbestos,silicadusts)associatedwithpneumoconiosiswhileorganicantigens(molds,animalproteins)associatedwithhypersensitivitypneumonitisHistoryExposuretoinhaledagents第十六页，共五十六页，2022年，8月28日16

Systemicrheumaticdiseases

RiskfactorsforAIDS

Treatmentofnonrespiratorydisease(immunosuppressiveagents,cancerchemotherapy,radiationtherapy,amiodarone,ß-blockingagents,angiotensin-convertingenzymeinhibitors(ACEI))

HistoryCoexistingnonrespiratorydiseases第十七页，共五十六页，2022年，8月28日17Geneticcomponent:

Cysticfibrosisα1-antitrypsindeficiencyPulmonaryhypertensionPulmonaryfibrosisAsthmaHistoryFamilyhistory第十八页，共五十六页，2022年，8月28日18

TherateandpatternofbreathingThedepthandsymmetryoflungexpansionPhysicalExaminationInspection第十九页，共五十六页，2022年，8月28日19

Thesymmetryoflungexpansion,confirmingthefindingsobservedbyinspectionVibrationproducedbyspokensoundsFocaltendernessPhysicalExaminationPalpation第二十页，共五十六页，2022年，8月28日20

TherelativeresonanceordullnessofthetissueunderlyingthechestwallPhysicalExaminationPercussion第二十一页，共五十六页，2022年，8月28日21

ThequalityandintensityofthebreathsoundsThepresenceofextra,oradventitioussoundsTheprimaryadventitious(abnormal)soundsthatcanbeheardincludecrackles(rales),wheezes,andrhonchiOtheradventitioussoundsincludepleuralfrictionrubsandstridorPhysicalExaminationAuscultation第二十二页，共五十六页，2022年，8月28日22PhysicalExaminationTypicalChestExaminationFindingsinSelectedClinicalConditionsPercussionTactileFremitusBreathSoundsVocalResonanceAdventitiousSoundsConsolidationoratelectasis(withpatentairway)DullIncreasedBronchialBronchophony,whisperedpectoriloquy,egophonyCracklesConsolidationoratelectasis(withblockedairway)DullDecreasedDecreasedDecreasedAbsentAsthmaResonantNormalVesicularNormalWheezingInterstitiallungdiseaseResonantNormalVesicularNormalCracklesEmphysemaHyperresonantDecreasedDecreasedDecreasedAbsentorWheezingPneumothoraxHyperresonantDecreasedDecreasedDecreasedAbsentPleuraleffusionDullDecreasedDecreasedDecreasedAbsentorpleuralfrictionrub第二十三页，共五十六页，2022年，8月28日23AdditionalDiagnosticEvaluation第二十四页，共五十六页，2022年，8月28日24

Collectedeitherbyspontaneousexpectorationorafterinhalationofanirritatingaerosol,suchashypertonicsalineQualifiedsample:Squamousepithelialcells<10/HP,WBC>25/HPorWBC/Squamousepithelialcells>2.5

CollectionofSputum第二十五页，共五十六页，2022年，8月28日25

Stainingandcultureformycobacteriaorfungi

Cultureforviruses

StainingforPneumocystiscarinii(especiallyinapatientinfectedwithHIV)

CytologicstainingformalignantcellsTheuseofpolymerasechainreaction(PCR)amplificationandDNAprobesCollectionofSputum第二十六页，共五十六页，2022年，8月28日26ArterialBloodGasesMechanismsofhypoxemia:AdecreaseininspiredPO2HypoventilationShuntingV/Qmismatching第二十七页，共五十六页，2022年，8月28日27ArterialBloodGasesMechanismofhypercapnia:IncreasedCO2productionDecreasedventilatorydrive("won'tbreathe")Malfunctionoftherespiratorypumporincreasedairwaysresistance("can'tbreathe")Inefficiencyofgasexchange(increaseddeadspaceorV/Qmismatch)第二十八页，共五十六页，2022年，8月28日28RoutineRadiographyPosteroanterior(PA)DIL第二十九页，共五十六页，2022年，8月28日29RoutineRadiographyAnteroposterior(AP)ARDS第三十页，共五十六页，2022年，8月28日30ChestRadiographyRheumatoidnodule(oneorseveralnodules):Vascularmalformation,BronchogeniccystLocalizedopacification(infiltrate):Pneumonia(bacterial,atypical,mycobacterial,orfungalinfection),Neoplasm,Radiationpneumonitis,Bronchiolitisobliteranswithorganizingpneumonia(BOOP),Bronchocentricgranulomatosis,PulmonaryinfarctionMajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(1)第三十一页，共五十六页，2022年，8月28日31ChestRadiography

MajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(1)

Diffuseinterstitialdisease:Idiopathicpulmonaryfibrosis,Pulmonaryfibrosiswithsystemicrheumaticdisease,Sarcoidosis,Drug-inducedlungdisease,Pneumoconiosis,Hypersensitivitypneumonitis,Infection(Pneumocystis,viralpneumonia),Eosinophilicgranuloma第三十二页，共五十六页，2022年，8月28日32ChestRadiographyDiffusealveolardisease:Cardiogenicpulmonaryedema,AcuterespiratorydistresssyndromeDiffusealveolarhemorrhage:Infection(Pneumocystis,viralorbacterialpneumonia),SarcoidosisDiffusenodulardisease:Metastaticneoplasm,Hematogenousspreadofinfection(bacterial,mycobacterial,fungal),Pneumoconiosis,EosinophilicgranulomaMajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(2)第三十三页，共五十六页，2022年，8月28日33ComputedTomography

DistinguishingvariousdensitiesParticularlyvaluableinassessinghilarandmediastinaldiseaseIdentifyingareasoffatdensityorcalcificationinpulmonarynodulesAssessmentinthestagingoflungcancerDistinguishingvascularfromnonvascularstructures第三十四页，共五十六页，2022年，8月28日34CTscandemonstratingamediastinalmassComputedTomography第三十五页，共五十六页，2022年，8月28日35High-resolutionCTscanfromapatientwithidiopathicpulmonaryfibrosis.scatteredreticulardensities(arrows)ComputedTomography第三十六页，共五十六页，2022年，8月28日36Idiopathicpulmonaryfibrosis.High-resolutionCTimageshowsbibasal,peripheralpredominantreticularabnormalitywithTractionbronchiectasisandhoneycombingComputedTomography第三十七页，共五十六页，2022年，8月28日37exudativephaseofARDSinwhichdependentalveolaredemaandatelectasispredominateComputedTomography第三十八页，共五十六页，2022年，8月28日38ComputedTomography

HelicalCTscanningCTangiographyHigh-resolutionCT(HRCT),thethicknessofindividualcrossisapproximately1to2mmVirtualbronchoscopy第三十九页，共五十六页，2022年，8月28日39PET

Positronemissiontomographic(PET)scanning

isincreasinglybeingusedtoidentifymalignantlesionsinthelungbasedontheirincreaseduptakeandmetabolismofglucoseThetechniqueinvolvesinjectionofaradiolabeledglucoseanalogue,18F-fluoro-2-deoxyglucose

(FDG),whichistakenupbymetabolicallyactivemalignantcells第四十页，共五十六页，2022年，8月28日40PulmonaryAngiography

ThepulmonaryarterialsystemcanbevisualizedIncasesofpulmonaryembolism,pulmonaryangiographydemonstratestheconsequencesofanintravascularclot—eitheradefectinthelumenofavessel(a"fillingdefect")oranabrupttermination("cutoff")ofthevesselWithadvancesinCT1scanning,traditionalpulmonaryangiographyisincreasinglybeingreplacedbyCTangiography第四十一页，共五十六页，2022年，8月28日41ThoracentesisEffusiontobeclassifiedaseitherexudativeortransudativeExudativepleuraleffusionsmeetatleastoneofthefollowingcriteria:pleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6

pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserum第四十二页，共五十六页，2022年，8月28日42PulmonaryFunctionTestThetwomeasurementsoflungvolumecommonlyusedforrespiratorydiagnosis:Totallungcapacity(TLC)Residualvolume(RV)ThevolumeofgasthatisexhaledfromthelungsingoingfromTLCtoRVisthevitalcapacity(VC)DisturbancesinVentilatoryFunction第四十三页，共五十六页，2022年，8月28日43PulmonaryFunctionTestLungvolumes,shownbyblockdiagrams(left)andbyaspirographictracing(right)*Totallungcapacity(TLC)*Vitalcapacity(VC)*Residualvolume(RV)*Inspiratorycapacity(IC)*Expiratoryreservevolume(ERV)*Functionalresidualcapacity(FRC)DisturbancesinVentilatoryFunction第四十四页，共五十六页，2022年，8月28日44PulmonaryFunctionTestanormaltracing(A)obstructive(B)parenchymalrestrictive(C)Disease*Forcedvitalcapacity(FVC)*Forcedexpiratoryvolume(FEV)*Forcedexpiratoryflow(FEF)DisturbancesinVentilatoryFunction第四十五页，共五十六页，2022年，8月28日45PulmonaryFunctionTestThreemaincategoriesofdiseaseareassociatedwithloweredDLCO:InterstitiallungdiseaseEmphysemaPulmonaryvasculardiseaseAnelevatedDLCOmaybeusefulinthediagnosisofalveolarhemorrhage,asinGoodpasture'ssyndromeDiffusingCapacity第四十六页，共五十六页，2022年，8月28日46PulmonaryFunctionTestFlow-volumecurvesindifferentconditions:O,obstructivedisease;R(P),parenchymalrestrictivedisease;

R(E),extraparenchymalrestrictivediseasewithlimi