呼吸系統(tǒng)疾病基礎(chǔ)知識概述（英文版）

同學(xué)們好！呼吸系統(tǒng)統(tǒng)疾病RespiratorySystemDisease湘雅醫(yī)院院兒科鄭鄭湘榕榕嬰幼兒上上感、2種特殊類類型上感感的特點點支氣管肺肺炎臨床床表現(xiàn)、、重癥肺肺炎特點點支氣管肺肺炎的診診斷、治治療支氣管哮哮喘的臨臨床表現(xiàn)現(xiàn)、診斷斷和治療療重點IntroduceInpediatricoutpatient,6o%%patientsareacuterespiratoryinfections.Inpediatricward,25%%patientsarePneumonia..Thefirstcauseofchildren’sdeathinChinaisPneumonia..Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.Whychildrenaresosusceptibletoacuterespiratoryinfections?anatomicphysiologicalfeaturesThechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40--44/min<1year30/min2-3years24/min4-7years22/min8-14years20/minChildrenRespiratorySystemPhysiologicFeatureRespiratorytypeRespiratorytypeofabdomenRespiratorytypeofchestabdomenＰhysicalexaminationinspectionChangeofrespiratoryrateCyanopathyThreeconcavesignＡuscultationExamineMethod急性上呼呼吸道感感染（AURI）AcuteUpperRespiratoryInfectionEtiologyＶirus：Ｏccupy90%Ｂacteria：ＳecondaryStreptococuspyogensPneumococcuＨaemophilusinfluenzaeCommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestationsCommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽部充充血，扁扁桃體腫腫大)Lymphadenectasisinsubmaxilla(有時下下頜、淋淋巴結(jié)腫腫大)Rashwhenenterovirusinfection(腸道病病毒感染染時可出出現(xiàn)皮疹疹)ClinicalManifestationsSpecialAURI柯薩奇病病毒A組感染夏秋好發(fā)發(fā)高熱、咽咽痛、流流涎咽腭弓、、軟腭處處有皰疹疹皰疹破潰潰后可形形成潰瘍瘍病程1周左左右ClinicalManifestationsHerpangina皰疹性咽咽峽炎Pharyngo-conjunctivalfever咽結(jié)合膜膜熱腺病毒3，7型所所致春夏發(fā)病病，可小小流行發(fā)熱、咽咽炎、結(jié)結(jié)合膜炎炎咽部充血血、結(jié)合合膜充血血，頸部部、耳耳后淋巴巴結(jié)腫大大病程1~2周周ClinicalManifestationsSpecialAURISchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplicationsAntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatmentDefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatmentPneumonia肺炎ChildrenfamiliardiseaseInworld,Occupy1/3-1//4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39..5timesofschoolage

PneumoniaPneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,,respiratorydistressandralesDefinitionOncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<<1monthChronic：>3monthsDeferred：1~3monthsClassification1OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification2OntheetiologyMycoplasmaChlamydia,,parasites,,fungiNoninfectionscausesClassification3OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,,concomitantmanifestationsofotherorgansystemsarepresentClassification4ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,,(SARS)coronavirusClassification5OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification6支氣管肺肺炎BronchopneumoniaEtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniaePathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswallPathologicphysiology氣道炎癥癥循環(huán)系統(tǒng)統(tǒng)神經(jīng)系統(tǒng)統(tǒng)水電解質(zhì)質(zhì)消化系統(tǒng)統(tǒng)肺A壓增高中毒性心肌炎心衰代酸中毒性腸麻痹胃腸粘膜膜屏障功能能腦水腫顱壓呼酸K+↑水鈉儲留留毒血癥通氣不足足PaO2↓,PaCO2↑換氣障礙礙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嬰兒>180次次/分幼幼兒>160次次/分突然煩躁躁不安、、面色發(fā)發(fā)灰心音明顯顯低鈍，，奔馬率率，頸靜靜脈怒張張肝大肋下下3cm以上尿少、下下肢浮腫腫ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomaticClinicalmanifestDICBp四肢涼，，脈速弱弱，出血SLADHNa+≤130mmol/L滲透壓<270mOsm/LEdemaSeveresymptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratorydataBloodbloodroutinebacteriainfect：：WBC↑、N↑leftshiftofnucleusvirusinfect：：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandcultureLaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis支氣管肺肺炎正常胸片片大葉性肺肺炎正常胸片片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抗生素使用原則則根據(jù)藥敏敏選藥adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸吸道濃度度高的藥藥物adoptdrugswhichcanfinallyinfiltratelungtissue足量足療程重癥靜脈脈給藥inseverecase,drugsshouldbeadministedbyvein,fulldose,,fullperiodTreatment抗生素選擇

肺炎鏈球球菌：PNC,,阿莫西林林，紅霉霉素金黃色葡葡萄球菌菌：苯唑唑西林、、氯唑西西林、萬萬古、利利福平流感嗜血血桿菌：：阿莫西西林+克拉維酸酸鉀或舒舒巴坦大腸桿菌菌和肺炎炎桿菌：：頭孢曲曲松或頭頭孢噻肟肟綠膿桿菌菌：替卡卡西林鈉鈉克拉維維酸鉀或或頭孢哌哌酮肺炎支原原體或衣衣原體：：大環(huán)內(nèi)內(nèi)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酚妥拉明明0.5mg/kgivgtt10%GS20mltreatagainstsymptomsTreatmenttreatofHeartfailure鎮(zhèn)靜給氧強心：西西地蘭減輕心臟臟負荷treatagainstsymptomsTreatment合并中毒毒性腦病病的治療脫水：甘甘露醇改善通氣氣改善腦微微循環(huán)止痙：地地西泮地塞米松松營養(yǎng)神經(jīng)經(jīng)treatagainstsymptomsTreatment糖皮質(zhì)激激素應(yīng)用適應(yīng)癥：：①喘憋重,,呼吸衰衰竭②全身中毒癥狀狀重③感染性性休克④腦水腫腫琥珀酸氫氫化可的的松5~10mg/kg.d地塞米松松0.1~0.3mg/kg.divgtt2~3次次/日日×3~5天天甲基強的的松龍2~4mg/kg.次ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis--decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolveWhatifpatientsfailstorecover??Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen病毒性肺炎呼吸道合合胞病毒毒肺炎腺病毒肺肺炎2歲，2~6月多見見喘憋、呼呼吸困難難，可合合并呼衰、心心衰哮鳴音，，細濕羅羅音小點片狀狀影，肺肺氣腫肺肺不張間質(zhì)性肺肺炎6月~2歲中毒癥狀狀重，稽稽留熱，，咳劇，喘喘憋，呼呼吸困難難出現(xiàn)晚，，濕羅音音或肺實實變

胸片改變變出現(xiàn)早早，肺氣氣腫，片狀狀影或融融合年齡癥狀胸片體征細菌性肺炎葡萄球菌菌肺炎新生兒，，嬰幼兒兒急、重、、快，弛弛張熱或或稽留熱熱，咳嗽，呼呼吸困難難，呻吟吟，易致致遷徒化膿膿病灶，，并發(fā)膿膿胸，膿膿氣胸，肺肺大皰中細濕羅羅音，出出現(xiàn)早，，皮疹浸潤影，，持續(xù)時時間較長長，易變變，可見多發(fā)發(fā)性肺膿膿腫，膿膿胸，膿膿氣胸等<4歲慢，重，，發(fā)熱，，痙攣性性咳嗽，呼呼吸困難難，發(fā)紺紺。易致遷徒徒化膿病病灶，易易并發(fā)膿胸濕羅音或或?qū)嵶兇笕~性肺肺炎、支支氣管肺肺炎、肺實變年齡癥狀體征胸片革蘭陰性性桿菌肺肺炎肺炎支原原體肺炎炎年長兒，，嬰幼兒兒發(fā)熱、刺刺激性咳咳嗽，多多系統(tǒng)病病變不明顯，，嬰幼兒兒可有呼呼吸困難難，喘憋，哮哮鳴音，，濕羅音音肺門影增增濃；支支氣管肺肺炎改變變；間質(zhì)性肺肺炎；均均一實變變影<6月起病慢，，無發(fā)熱熱，先URI癥狀后咳咳、喘、、氣促，，部分伴結(jié)膜膜炎濕羅音，，持續(xù)時時間長間質(zhì)性炎炎癥，過過度充氣氣、片狀影，，持續(xù)時時間長年齡癥狀體征胸片沙眼衣原原體肺炎炎支衣原體體肺炎

支氣管哮哮喘bronchialasthma發(fā)展史asthma--喘息，2000年前就就有對哮哮喘的詳詳細描述述過去認為為是一種種平滑肌肌功能異異常性疾疾病80年代代以來通通過支氣氣管黏膜膜活檢，，認識到哮哮喘是氣氣道慢性性炎癥性性疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,respiratorydistress,,cough特征氣道慢性性炎癥：：此為哮哮喘主要要特征可逆性的的氣流受受限：指指氣流受受限可被被支氣管管擴張劑所所逆轉(zhuǎn)氣道高反反應(yīng)性：：對正常常氣道無無反應(yīng)或或很小反反（AHR））應(yīng)的刺激激產(chǎn)生收收縮反應(yīng)應(yīng)pathologynakedeye：：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening病理生理理急性支氣氣管痙攣攣：速發(fā)發(fā)型哮喘喘反應(yīng)（（IgE依賴）氣道壁腫腫脹：遲遲發(fā)型哮哮喘反應(yīng)應(yīng)（炎癥癥誘導(dǎo)））粘液栓形形成：難難治療的的氣流受受限氣道重塑塑：不可可逆的氣氣道狹窄窄核心氣流受限限atopy是指對普普通環(huán)境境中常見見的變應(yīng)應(yīng)原產(chǎn)生生IgE介導(dǎo)反應(yīng)應(yīng)的易感感性，有有明顯的的家族遺遺傳傾向向。特應(yīng)性哮喘、過過敏性鼻鼻炎、濕濕疹、食食物過敏敏等導(dǎo)致哮喘喘發(fā)生最最確定的的危險因因素pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-adrenalglandnerve-adrenalglandnervePneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistoryClinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara--sympathesisdrugcannotreliefin24hoursstatusasthmaticusauxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力力呼氣容容積/用力肺活活量，，低于70-75％提提示氣流流受限））PEFR（呼氣風(fēng)流流速，其其日間變變異率>>20%%,使用用支擴劑劑后增加加20%%可診診斷哮喘喘）Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegaspcough1month,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitive