呼吸系統(tǒng)疾病基礎知識概述英文

同學們好！呼吸系統(tǒng)疾病

RespiratorySystemDisease湘雅醫(yī)院兒科鄭湘榕

嬰幼兒上感、2種特殊類型上感的特點支氣管肺炎臨床表現(xiàn)、重癥肺炎特點支氣管肺炎的診斷、治療支氣管哮喘的臨床表現(xiàn)、診斷和治療重點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，，扁扁桃桃體體腫腫大大)Lymphadenectasisinsubmaxilla(有有時時下下頜頜、、淋淋巴巴結結腫腫大大)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、結結合膜炎炎咽部充血血、結合合膜充血血，頸部部、耳耳后淋巴巴結腫大大病程1~2周周ClinicalManifestationsSpecialAURISchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplicationsAntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatmentDefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatmentPneumonia肺炎ChildrenfamiliardiseaseInworld,Occupy1/3-1/4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39.5timesofschoolagePneumoniaPneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinitionOncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：：1~3monthsClassification1OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification2OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification3OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification4ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification5OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification6支氣管肺炎炎BronchopneumoniaEtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniaePathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswallPathologicphysiology氣道炎癥循環(huán)系統(tǒng)神經(jīng)系統(tǒng)水電解質(zhì)消化系統(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屏障功能腦水腫顱壓呼酸K+↑水鈉儲留毒血癥通氣不足PaO2↓,PaCO2↑換氣障礙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，脈速速弱，出血SLADHNa+≤130mmol/L滲透壓<270mOsm/LEdemaSeveresymptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratorydataBloodbloodroutinebacteriainfect：：WBC↑、、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandcultureLaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis支氣管肺炎正常胸片大葉性肺炎正常胸片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抗生素使用原則根據(jù)藥敏選藥藥adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道濃濃度高的藥物物adoptdrugswhichcanfinallyinfiltratelungtissue足量足療程重癥靜脈給藥藥inseverecase,drugsshouldbeadministedbyvein,fulldose,fullperiodTreatment抗生素選擇肺炎鏈球菌：：PNC,阿莫西林，紅紅霉素金黃色葡萄球球菌：苯唑西西林、氯唑西西林、萬古、、利福平流感嗜血桿菌菌：阿莫西林林+克拉維酸鉀或或舒巴坦大腸桿菌和肺肺炎桿菌：頭頭孢曲松或頭頭孢噻肟綠膿桿菌：替替卡西林鈉克克拉維酸鉀或或頭孢哌酮肺炎支原體或或衣原體：大大環(huán)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酚妥妥拉拉明明0.5mg/kgivgtt10%GS20mltreatagainstsymptomsTreatmenttreatofHeartfailure鎮(zhèn)靜靜給氧氧強心心：：西西地地蘭蘭減輕輕心心臟臟負負荷荷treatagainstsymptomsTreatment合并并中中毒毒性性腦腦病病的治治療療脫水水：：甘甘露露醇醇改善善通通氣氣改善善腦腦微微循循環(huán)環(huán)止痙痙：：地地西西泮泮地塞塞米米松松營養(yǎng)養(yǎng)神神經(jīng)經(jīng)treatagainstsymptomsTreatment糖皮皮質(zhì)質(zhì)激激素素應用用適應應癥癥：：①喘憋憋重重,呼呼吸吸衰衰竭竭②全全身身中毒毒癥癥狀狀重重③感感染染性性休休克克④腦腦水水腫腫琥珀珀酸酸氫氫化化可可的的松松5~10mg/kg.d地塞塞米米松松0.1~0.3mg/kg.divgtt2~3次次/日日×3~5天天甲基基強強的的松松龍龍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歲歲，，2~6月月多多見見喘憋、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特征氣道慢性炎炎癥：此為為哮喘主要要特征可逆性的氣氣流受限：：指氣流受受限可被支支氣管擴張劑所逆逆轉(zhuǎn)氣道高反應應性：對正正常氣道無無反應或很很小反（AHR）應的刺激產(chǎn)產(chǎn)生收縮反反應pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening病理生理急性支氣管管痙攣：速速發(fā)型哮喘喘反應（IgE依賴）氣道壁腫脹脹：遲發(fā)型型哮喘反應應（炎癥誘誘導）粘液栓形成成：難治療療的氣流受受限氣道重塑：：不可逆的的氣道狹窄窄核心氣流受限atopy是指對普通通環(huán)境中常常見的變應應原產(chǎn)生IgE介導反應的的易感性，，有明顯的的家族遺傳傳傾向。特應性哮喘、過敏敏性鼻炎、、濕疹、食食物過敏等等導致哮喘發(fā)發(fā)生最確定定的危險因因素pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-adrenalglandnerve-adrenalglandnervePneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistoryClinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticusauxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力呼呼氣容積/用力肺活量量，低于于70-75％提示示氣流受限限）PEFR（呼氣風流速速，其日間間變異率>20%,使用支擴擴劑后增加加20%可可診斷哮哮喘）Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegaspcough1month,antibioticstreatisinvalidbronchodilatorscanre