呼吸系统课件

病理學管毅剛高雄榮民總醫院胸腔外科主任呼吸系统_1病理學為醫學領域的一門分支學科專門探討疾病在個體發生的起因發展及變化以及整個過程對患者產生的各種影響。呼吸系统_1呼吸系統呼吸系统_1呼吸系統上呼吸道疾病鼻腔、咽和喉；常見但致命疾病少見急性、慢性發炎息肉腫瘤肺臟和氣道疾病含氣管及支氣管胸膜及胸膜腔疾病呼吸系统_1急性、慢性發炎(1)感染性鼻炎(infectiousrhinitis)俗稱感冒(commoncold)病毒感染常見病源：腺病毒、鼻病毒、伊科(echo)病毒卡他性(catarrhal)鼻腔炎症過敏性鼻炎(allergicrhinitis)IgE增加→組織胺分泌增加鼻黏膜嗜酸性白血球浸潤季節性過敏性鼻炎﹕花粉熱(hayfever)過敏原：花粉、黴菌孢子常年性過敏性鼻炎(perennialallergicrhinitis)以屋內塵蟎、真菌等微生物引發本病為主呼吸系统_1鼻息肉(Nasalpolyp)反覆鼻炎引起之鼻腔突起物非真正腫瘤可引起鼻腔阻塞手術治療，但容易復發呼吸系统_1Paranasalsinus呼吸系统_1急性、慢性發炎(2)鼻竇炎(sinusitis)Paranasalsinus發炎卡他性炎症鼻炎→鼻竇炎急性→慢性鼻竇炎→顱腔骨髓炎和顱內感染呼吸系统_1急性、慢性發炎(3)咽炎(pharyngitis)和扁桃腺炎(tonsilitis)常同時發生多為病毒感染，但續發性細菌感染亦常見鏈球菌感染→風濕熱、腎小球腎炎嚴重扁桃腺炎需手術治療呼吸系统_1呼吸系统_1急性、慢性發炎(4)急性會厭炎(acuteepiglottitis)好發於嬰幼兒多為流行性感冒嗜血桿菌引起可引起嚴重上呼吸道阻塞而死亡喉炎(laryngitis) 感染、過敏、吸煙或其他化學性刺激引起白喉(diphtheria)：喉部偽膜呼吸系统_1聲帶息肉(vocalcordpolyp)

聲帶結節(vocalcordnodule)吸煙或過度使用聲帶如教師、牧師、歌手、小販(singer’snodule,teacher’snodule,screamer’snodule)聲音沙啞手術治療呼吸系统_1上呼吸道腫瘤(1)鼻腔及副鼻竇腫瘤乳突狀瘤(papilloma)：三型，少數演變為惡性鱗狀細胞癌(squamouscellcarcinoma)鼻咽癌(nasopharyngealcarcinoma)廣東腫瘤(Cantontumor)EB(Epstein-Barrvirus)成年男性癌症死亡第13位(2002年)鼻涕帶血、留鼻血、鼻塞、頸部淋巴結腫大顱底侵襲未分化癌(undifferentiatedcarcinoma)或鱗狀細胞癌未分化癌中常有癌細胞浸潤於淋巴組織間→又稱淋巴上皮瘤(lymphoepithelioma)放射線治療呼吸系统_1Nasopharyngealcarcinoma呼吸系统_1上呼吸道腫瘤(2)喉癌(laryngealcarcinoma)中老年男性吸煙漸進性聲音沙啞、吞嚥困難、頸部淋巴結腫大多為鱗狀細胞癌呼吸系统_1laryngealcarcinoma呼吸系统_1呼吸系统_1肺臟和氣道疾病2002年非癌症之主要死亡原因肺炎：第7位支氣管炎、肺氣腫及氣喘：第11位結核病：第12位國人十大癌症死亡原因肺癌：男性第2位女性第1位呼吸系统_1炎症支氣管炎肺炎大葉性肺炎支氣管肺炎間質性肺炎吸入性肺炎肺膿瘍呼吸系统_1支氣管炎(Bronchitis)急性支氣管炎(acutebronchitis)感染或其他刺激物大多數自癒，少數併發肺炎可氣道阻塞慢性支氣管炎(chronicbronchitis)二年、每年三個月、持續帶痰咳嗽吸煙氣管及支氣管黏液腺肥大，呼吸道上皮鱗狀化生細支氣管(bronchiole)亦常有發炎及管腔變窄可併發肺氣腫，氣道阻塞呼吸系统_1肺炎

(pneumonia,pneumonitis)感染性肺炎細菌性肺炎大葉性肺炎、支氣管肺炎發燒、不適、咳嗽、有痰、胸痛及呼吸困難非典型肺炎(atypicalpneumonia)間質性肺炎非感染性炎症吸入化學物質呼吸系统_1Pneumonia(RLL)呼吸系统_1呼吸系统_1支氣管肺炎

(bronchopneumonia,lobularpneumonia)氣管炎或支氣管炎的延伸可形成多發性病灶兒童、老人葡萄球菌、鏈球菌、嗜血桿菌慢性心衰竭及癌末病人常見呼吸系统_1大葉性肺炎(lobarpneumonia)炎症波及肺葉絕大部分或一整個或多個肺葉肺炎鏈球菌(Streptococcuspneumoniae)四階段水腫充血期紅色肝變期(redhepatization)：大量滲出液內含紅血球、嗜中性白血球、纖維蛋白灰色肝變期(grayhepatization)：紅血球遭破壞、纖維蛋白化膿性滲出液持續存在消解期(resolution)：滲出液堅實化後被酵素分解，再被巨噬細胞吞噬移除併發症：胸膜炎、胸膜腔滲液、胸膜腔積膿、肺膿腫、敗血症、腦膜炎、心內膜炎、關節炎等呼吸系统_1Lobarpneumonia呼吸系统_1呼吸系统_1間質性肺炎

(interstitialpneumonitis)肺泡中隔和間質組織炎症Atypicalpneumonia肺炎黴漿菌(mycoplasmapneumoniae)、病毒或其他細菌Idiopathicinterstitialpneumonia肺臟纖維化疾病呼吸系统_1呼吸系统_1SARS(1)

(SevereAcuteRespiratorySyndrome)2003年，Hanoi，Dr.UrbaniAtypicalpneumoniaChina,Hongkong,Taiwan,TorantoofCanada,SingaporeCoronavirus(冠狀病毒)呼吸系统_1呼吸系统_1呼吸系统_1呼吸系统_1呼吸系统_1SARS(2)

(SevereAcuteRespiratorySyndrome)飛沫、接觸體液傳染潛伏期3-7天、可能超過十天症狀(Fig11-6)，出現症狀後始具傳染力X-rayandCT：肺部浸潤Pathology:patchyorganizingpneumonia,diffusealveolardamage,respiratorydistresssyndrome(呼吸窘迫),respiratoryfailure(呼吸衰竭)電子顯微鏡：SARSvirusintypeIIpneumocytesNovaccineMortalityrate:15%呼吸系统_1吸入性肺炎(aspirationpneumonia)氣體、液體、固體微粒引起細菌感染、機械性阻塞及化學性傷害溺水、酒醉、昏迷、虛弱、食道或神經病變的病患污水、胃液和食物多為支氣管肺炎呼吸系统_1Aspirationpnemonia

Sup.Segment,RLL呼吸系统_1肺膿腫(pulmonaryabscess)局部化膿性病變病因：口咽部手術、上呼吸道感染、頭頸部膿腫、支氣管擴張併發症：胸膜炎、腦膜炎、腦膿腫、全身性感染呼吸系统_1氣喘(asthma)支氣管通道收縮引起的陣發性呼吸困難及wheezing，又稱支氣管氣喘(bronchialasthma)心因性氣喘呼吸系统_1氣喘(asthma)分類外因性過敏性原因，又稱allergicasthma過敏原：花粉、塵螨、毛或微生物兒童期開始反覆發病IgE非過敏性原因Infectiousasthma:常為病毒感染Occupationalasthma:有機或無機物質引起內因性可經由drugs,pressure,sport,chemicalsubstanceorinfection引起Mechanism:notclear呼吸系统_1呼吸系统_1呼吸系统_1氣喘(asthma)病理小支氣管及細支氣管為黏液阻塞黏液中可發現Eosinophil,Curschmannspiral,Charcot-Leydencrystal管壁水腫及炎症細胞浸潤管壁平滑肌spasm及肥大黏膜下層黏液腺增大Statusasthmaticus呼吸系统_1呼吸系统_1支氣管擴張症(bronchiectasis)破壞管壁結構或增加外在牽引力支氣管和細支氣管不正常且永久性的擴大Etiology:TB,pneumonia,tumor,foreignbody,asthma,chronicbronchitis,cysticfibrosis,congenitalabnormality局部性或瀰漫性症狀：chronicproductivecough,respiratorydifficulty,clubbingfinger,fever,pulmonaryabscess,cyanosis,corpulmonale,brainabscess,etc.呼吸系统_1呼吸系统_1肺膨脹不全(atelectasis)先天性 PrematurebabyAssociatedwithhyalinemembranedisease(neonatalrespiratorydistresssyndrome,lackofsurfactant)後天性因支氣管、肺臟或胸膜疾病引起的肺臟塌陷及無氣狀態易引起感染胸痛、呼吸困難、cyanosis；無咳嗽或咳血呼吸系统_1呼吸系统_1肺氣腫(emphysema)肺臟腺泡不正常且永久性的擴大無纖維化現象LargerpulmonarycompliancethannormalindividualsBarrelchestBroaderdefinitionincludesSenileemphysema,compensatoryemphysema,obstructiveoverinflation,interstitialemphysema呼吸系统_1肺氣腫(emphysema)呼吸系统_1呼吸系统_1ChronicObstructivePulmonaryDisease(COPD)RespiratorydifficultyandairwayobstructionEmphysema,chronicbronchiolitis,brochiectasia,bronchialasthmaPinkpufferEmphysema,olderage,rapidandshortrespiration,adequateoxygenation,nocyanosisBluebloaterChronicbronchiolitis,youngerage,muchsputum,corpulmonale,cyanosis,swelling呼吸系统_1呼吸系统_1PulmonaryedemaandpulmonarycongestionLeftheartfailureMacrophageinalveoli(heartfailurecell)Browninduration:血鐵質堆積+纖維化呼吸系统_1PulmonaryembolismEmbolifromveinoflowerextremitiesChestpain,respiratorydifficulty,pulmonaryinfarction,suddendeath呼吸系统_1AdultRespiratoryDistressSyndrome(ARDS)DiffusealveolardamageAcuterespiratoryfailureOverallmortality:>50%Etiology:shock,infection,sepsis,fatembolism,drowning,aspirationoftoxicsubstance,irradiation,drugsPathology:Exudativephase(acutephase):intra-alveolaredema,exudate,aggregationofinflammatorycells,typeIIpulmonarycellshyperplasia,hyalinemembraneinalveoliOrganizingphase:fibroblasthyperplasiainalveolarwall,hyalinemembraneremovedbymacrophage,fibrosisofalveolarseptum,cysticchangeoflungparenchyma呼吸系统_1ARDS呼吸系统_1Pneumoconiosis呼吸系统_1TumorofLung肺癌最常見，多為bronchogeniccarcinomaNo.1cancerdeathinwesterncountryNo.2cancerdeathinTaiwan(2002)中老年男性常見女性增加中：吸煙女性增加Etiology:smoking,airpollution,chemicalsubstance,radiation,geneticfactor,scarcancerSmokingOddsratio:10Amount,duration80%oflungcancerpatientsaresmokers呼吸系统_1肺癌種類Non-smallcellcarcinomaSquamouscellcarcinomaHilum,largerairway,1/3ofalllungCa,smokingAdenocarcinoma1/3,femaleandnon-smoker,scarcancerBronchioloalveolarcarcinoma沿肺泡壁生長，易誤為間質性肺炎LargecellcarcinomaLesscommonSmallcellcarcinoma1/5,paraneoplasticsyndrome,hilum,smoking,oatcellcarcinoma,poorprognosis,chemotherapy呼吸系统_1呼吸系统_1ClinicalsymptomsandComplicationCough,weightloss,chestpain,dyspnea,hemoptysis,pneumonia,pleuraleffusion,hoarseness,dysphagia,ribdestruction,lungabscess,feverSuperiorvenacavalsyndromeHornersyndromeApicaltumor,PancoasttumorCervicalsympatheticganglioninvasionIpsilateralptosis,miosis,andnotsweatingintheforeheadParaneoplasticsyndromeEndocrineabnormalities,hypercalcemia,clubbingfinger呼吸系统_1呼吸系统_1TreatmentandPrognosis

ofLungCancerWorst:smallcellcancer,chemotherapyorradiationNSCLC:surgeryMetastaticlungcancer:Multiple,frombreast,stomach,colon,ovary,uterus,prostate,bone,liveretc.Hamartoma,carcinoid呼吸系统_1OtherlungdiseasesSarcoidosisGranuloma,hilarlymphnodesorskin,eyes,liver,spleenandbonemarrowAsteroidbodyandSchaumannbodyinmultinucleatedgiantcellScandinavianandblackpeopleGoodprognosis,spontaneousresolution>50%,steroid呼吸系统_1胸膜及胸膜腔疾病Visceralpleura,parietalpleura,pleuralcavity,pleuralfluidPleuraleffusionIncreasedhydrostaticpressure:CHFDecreasedoncoticpressure:Nephroticsyndrome,livercirrosisIncreasedvascularpermeability:pleuritis,pneumonia,TB,lungabscess,pulmonaryinfarction,bronchiectasis,metastaticcancer,systemicinfectionorinflammationImpairedlymphaticdrainage:mediastinalmalignancyincreasednegativepressureinpleuralcavity:atelectasis呼吸系统_1Pleuraleffusion呼吸系统_1FluidinPleuralCavityExudateInflammatorypleuraleffusion,parapneumonicpleuraleffusionIncreasedvascularpermeabilityduetoinflammatorypleuraldiseasesPyothorax,empyemabacteriaorfungusAdhesion,fibrosis,obliterationofpleuralcavity,limitationoflungexpansionTransudateImbalanceofhydrostaticandoncoticpressureHydrothoraxHemothoraxtrauma,rupturedaorticaneurysm,coagulopathy,inflammation,tumorChylothoraxThoracicductinjury,impaire