04 呼吸系统疾病课件

04呼吸系统疾病呼吸系统疾病

04呼吸系统疾病婴幼儿上感、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04呼吸系统疾病Inpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.04呼吸系统疾病Whychildrenaresosusceptibletoacuterespiratoryinfections?04呼吸系统疾病04呼吸系统疾病anatomic

physiologicalfeatures

Thechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.04呼吸系统疾病ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40-44/min<1year30/min2-3years24/min4-7years22/min8-14years20/min04呼吸系统疾病ChildrenRespiratorySystemPhysiologicFeatureRespiratorytype

RespiratorytypeofabdomenRespiratorytypeofchestabdomen

04呼吸系统疾病

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanopathyThreeconcavesign

ＡuscultationExamineMethod04呼吸系统疾病急性上呼吸道感染（AURI）

AcuteUpperRespiratoryInfection04呼吸系统疾病EtiologyＶirus：Ｏccupy90%

Ｂacteria：Ｓecondary

Streptococuspyogens

PneumococcuＨaemophilusinfluenzae04呼吸系统疾病CommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestations04呼吸系统疾病CommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽部充血，扁桃体肿大)Lymphadenectasisinsubmaxilla(有时下颌、淋巴结肿大)Rashwhenenterovirusinfection(肠道病毒感染时可出现皮疹)ClinicalManifestations04呼吸系统疾病SpecialAURI柯萨奇病毒A组感染夏秋好发高热、咽痛、流涎咽腭弓、软腭处有疱疹疱疹破溃后可形成溃疡病程1周左右ClinicalManifestationsHerpangina疱疹性咽峡炎04呼吸系统疾病Pharyngo-conjunctivalfever咽结合膜热

腺病毒3，7型所致春夏发病，可小流行发热、咽炎、结合膜炎咽部充血、结合膜充血，颈部、耳后淋巴结肿大病程1~2周ClinicalManifestationsSpecialAURI04呼吸系统疾病SchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplications04呼吸系统疾病AntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatment04呼吸系统疾病DefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatment04呼吸系统疾病Pneumonia肺炎

04呼吸系统疾病ChildrenfamiliardiseaseInworld,Occupy1/3-1/4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39.5timesofschoolage

Pneumonia04呼吸系统疾病PneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinition04呼吸系统疾病OncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：1~3monthsClassification104呼吸系统疾病OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification204呼吸系统疾病OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification304呼吸系统疾病OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification404呼吸系统疾病ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification504呼吸系统疾病OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification604呼吸系统疾病支气管肺炎

Bronchopneumonia04呼吸系统疾病EtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniae

04呼吸系统疾病PathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswall04呼吸系统疾病04呼吸系统疾病04呼吸系统疾病Pathologicphysiology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↓04呼吸系统疾病ClinicalmanifestationMild

symptomaticrespiratorysystemfeverrespiratory

distressnasalflaring,retractions,cyonosistachypnea

cough

rales<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分04呼吸系统疾病ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailure04呼吸系统疾病ClinicalmanifestSeveresymptomaticHeartfailure呼吸突然加快，>60次/分心率突然增快

婴儿>180次/分幼儿>160次/分突然烦躁不安、面色发灰心音明显低钝，奔马率，颈静脉怒张肝大肋下3cm以上尿少、下肢浮肿04呼吸系统疾病ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomatic04呼吸系统疾病ClinicalmanifestDICBp四肢凉，脉速弱，出血SLADHNa+

≤130mmol/L渗透压<270mOsm/LEdemaSeveresymptomatic04呼吸系统疾病ComplicationsComplicationpneumatocelepyopneumothoraxempyema04呼吸系统疾病LaboratorydataBloodbloodroutinebacteriainfect：WBC↑、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandculture04呼吸系统疾病LaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis04呼吸系统疾病支气管肺炎正常胸片04呼吸系统疾病大叶性肺炎正常胸片04呼吸系统疾病fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosis04呼吸系统疾病Differentiationacute

bronchitisrales、tachypneaforeignbodiesinbronchihistoryofforeignbodies、suddencough、respiratorydistress、lowerofbreathtoneorwheezingtuberculosishistoryofTBcontact、PPDtest、PPD-IgGIgM、X-ray、rales04呼吸系统疾病TreatmentgeneraltreatmentBalanceofwaterandelectrolyte3%Nacl12ml/L→↑Na+10mmol/L

Temperature18-20℃

Humidity60%Foodnutritive04呼吸系统疾病TreatmentControlinfectionvirus：noidealdruglikevirozolmycoplasma、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、fullperiodoftreatment,firstselectPeniccilin04呼吸系统疾病Treatment抗生素使用原则

根据药敏选药adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道浓度高的药物adoptdrugswhichcanfinallyinfiltratelungtissue足量足疗程重症静脉给药inseverecase,drugsshouldbeadministedbyvein

,fulldose,fullperiod

04呼吸系统疾病Treatment抗生素选择

肺炎链球菌：PNC,阿莫西林，红霉素金黄色葡萄球菌：苯唑西林、氯唑西林、万古、利福平流感嗜血杆菌：阿莫西林+克拉维酸钾或舒巴坦大肠杆菌和肺炎杆菌：头孢曲松或头孢噻肟绿脓杆菌：替卡西林钠克拉维酸钾或头孢哌酮肺炎支原体或衣原体：大环内酯

04呼吸系统疾病Treatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasma

pneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，fullperiodis6weeks04呼吸系统疾病treatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、

cyanosis、asthmasuppress、"toxicappearance,"methods:bynosecanal0.5~1L/min，40%；byveil2~4L/min,50%~60%mechanismventilate（

respirefailture）holdingrespiratory

tractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorb04呼吸系统疾病TreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥拉明0.5mg/kgivgtt

10%GS20mltreatagainstsymptoms04呼吸系统疾病TreatmenttreatofHeartfailure镇静给氧强心：西地兰减轻心脏负荷

treatagainstsymptoms04呼吸系统疾病Treatment合并中毒性脑病的治疗脱水：甘露醇改善通气改善脑微循环止痉：地西泮地塞米松营养神经treatagainstsymptoms04呼吸系统疾病Treatment糖皮质激素应用适应症：①喘憋重,呼吸衰竭②全身中毒症状重③感染性休克

④脑水肿琥珀酸氢化可的松5~10mg/kg.d地塞米松0.1~0.3mg/kg.d

ivgtt2~3次/日×3~5天甲基强的松龙2~4mg/kg.次04呼吸系统疾病ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolve04呼吸系统疾病Whatifpatientsfailstorecover?Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen04呼吸系统疾病病毒性肺炎呼吸道合胞病毒肺炎腺病毒肺炎2岁，2~6月多见喘憋、呼吸困难，可合并呼衰、心衰哮鸣音，细湿罗音小点片状影，肺气肿肺不张间质性肺炎6月~2岁中毒症状重，稽留热，咳剧，喘憋，呼吸困难出现晚，湿罗音或肺实变

胸片改变出现早，肺气肿，片状影或融合年龄症状胸片体征04呼吸系统疾病细菌性肺炎葡萄球菌肺炎新生儿，婴幼儿急、重、快，弛张热或稽留热，咳嗽，呼吸困难，呻吟，易致迁徒化脓病灶，并发脓胸，脓气胸，肺大疱中细湿罗音，出现早，皮疹浸润影，持续时间较长，易变，可见多发性肺脓肿，脓胸，脓气胸等<4岁慢，重，发热，痉挛性咳嗽，呼吸困难，发绀。易致迁徒化脓病灶，易并发脓胸湿罗音或实变大叶性肺炎、支气管肺炎、肺实变年龄症状体征胸片革兰阴性杆菌肺炎04呼吸系统疾病肺炎支原体肺炎年长儿，婴幼儿发热、刺激性咳嗽，多系统病变不明显，婴幼儿可有呼吸困难，喘憋，哮鸣音，湿罗音肺门影增浓；支气管肺炎改变；间质性肺炎；均一实变影<6月起病慢，无发热，先URI症状后咳、喘、气促，部分伴结膜炎湿罗音，持续时间长间质性炎症，过度充气、片状影，持续时间长年龄症状体征胸片沙眼衣原体肺炎支衣原体肺炎

04呼吸系统疾病

支气管哮喘

bronchialasthma

04呼吸系统疾病发展史asthma-喘息，2000年前就有对哮喘的详细描述过去认为是一种平滑肌功能异常性疾病80年代以来通过支气管黏膜活检，认识到哮喘是气道慢性炎症性疾病04呼吸系统疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,respiratorydistress,cough04呼吸系统疾病特征气道慢性炎症：此为哮喘主要特征可逆性的气流受限：指气流受限可被支气管扩张剂所逆转气道高反应性：对正常气道无反应或很小反（AHR）应的刺激产生收缩反应04呼吸系统疾病pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening04呼吸系统疾病病理生理急性支气管痉挛：速发型哮喘反应（IgE依赖）气道壁肿胀：迟发型哮喘反应（炎症诱导）粘液栓形成：难治疗的气流受限气道重塑：不可逆的气道狭窄核心气流受限04呼吸系统疾病atopy是指对普通环境中常见的变应原产生IgE介导反应的易感性，有明显的家族遗传倾向。特应性哮喘、过敏性鼻炎、湿疹、食物过敏等导致哮喘发生最确定的危险因素04呼吸系统疾病pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen

-

adrenalglandnerve

-

adrenalglandnerve

PneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistory04呼吸系统疾病Clinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticus04呼吸系统疾病auxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力呼气容积/用力肺活量，低于70-75％提示气流受限）PEFR（呼气风流速，其日间变异率>20%,使用支扩剂后增加20%可诊断哮喘）04呼吸系统疾病Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegasp04呼吸系统疾病cough

1month,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexcludeothercoughdiseaseDiagnoseofcoughvariantasthma04呼吸系统疾病therapyPrinciple:long-term、persistence、standard、individuationPeri