呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述呼吸系統(tǒng)疾病

RespiratorySystemDisease湘雅醫(yī)院兒科鄭湘榕

2呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述嬰幼兒上感、2種特殊類型上感的特點(diǎn)支氣管肺炎臨床表現(xiàn)、重癥肺炎特點(diǎn)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(diǎn)3呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述IntroduceInpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.4呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Whychildrenaresosusceptibletoacuterespiratoryinfections?5呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述6呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述anatomic

physiologicalfeatures

Thechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.7呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40-44/min<1year30/min2-3years24/min4-7years22/min8-14years20/min8呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ChildrenRespiratorySystemPhysiologicFeatureRespiratorytype

RespiratorytypeofabdomenRespiratorytypeofchestabdomen

9呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanopathyThreeconcavesign

ＡuscultationExamineMethod10呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述急性上呼吸道感染（AURI）

AcuteUpperRespiratoryInfection11呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述EtiologyＶirus：Ｏccupy90%

Ｂacteria：Ｓecondary

Streptococuspyogens

PneumococcuＨaemophilusinfluenzae12呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述CommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestations13呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述CommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽部充血，扁桃體腫大)Lymphadenectasisinsubmaxilla(有時(shí)下頜、淋巴結(jié)腫大)Rashwhenenterovirusinfection(腸道病毒感染時(shí)可出現(xiàn)皮疹)ClinicalManifestations14呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述SpecialAURI柯薩奇病毒A組感染夏秋好發(fā)高熱、咽痛、流涎咽腭弓、軟腭處有皰疹皰疹破潰后可形成潰瘍病程1周左右ClinicalManifestationsHerpangina皰疹性咽峽炎15呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Pharyngo-conjunctivalfever咽結(jié)合膜熱

腺病毒3，7型所致春夏發(fā)病，可小流行發(fā)熱、咽炎、結(jié)合膜炎咽部充血、結(jié)合膜充血，頸部、耳后淋巴結(jié)腫大病程1~2周ClinicalManifestationsSpecialAURI16呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述SchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplications17呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述AntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatment18呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述DefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatment19呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Pneumonia肺炎

20呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ChildrenfamiliardiseaseInworld,Occupy1/3-1/4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39.5timesofschoolage

Pneumonia21呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述PneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinition22呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述OncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：1~3monthsClassification123呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification224呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification325呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification426呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification527呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification628呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述支氣管肺炎

Bronchopneumonia29呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述EtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniae

30呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述PathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswall31呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述32呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述33呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Pathologicphysiology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(chǔ)留毒血癥通氣不足PaO2↓,PaCO2↑

換氣障礙PaO2↓34呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述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35呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailure36呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ClinicalmanifestSeveresymptomaticHeartfailure呼吸突然加快，>60次/分心率突然增快

嬰兒>180次/分幼兒>160次/分突然煩躁不安、面色發(fā)灰心音明顯低鈍，奔馬率，頸靜脈怒張肝大肋下3cm以上尿少、下肢浮腫37呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomatic38呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ClinicalmanifestDICBp四肢涼，脈速弱，出血SLADHNa+

≤130mmol/L滲透壓<270mOsm/LEdemaSeveresymptomatic39呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ComplicationsComplicationpneumatocelepyopneumothoraxempyema40呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述LaboratorydataBloodbloodroutinebacteriainfect：WBC↑、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandculture41呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述LaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis42呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述支氣管肺炎正常胸片43呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述大葉性肺炎正常胸片44呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosis45呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Differentiationacute

bronchitisrales、tachypneaforeignbodiesinbronchihistoryofforeignbodies、suddencough、respiratorydistress、lowerofbreathtoneorwheezingtuberculosishistoryofTBcontact、PPDtest、PPD-IgGIgM、X-ray、rales46呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述TreatmentgeneraltreatmentBalanceofwaterandelectrolyte3%Nacl12ml/L→↑Na+10mmol/L

Temperature18-20℃

Humidity60%Foodnutritive47呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述TreatmentControlinfectionvirus：noidealdruglikevirozolmycoplasma、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、fullperiodoftreatment,firstselectPeniccilin48呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Treatment抗生素使用原則

根據(jù)藥敏選藥adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道濃度高的藥物adoptdrugswhichcanfinallyinfiltratelungtissue足量足療程重癥靜脈給藥inseverecase,drugsshouldbeadministedbyvein

,fulldose,fullperiod

49呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Treatment抗生素選擇

肺炎鏈球菌：PNC,阿莫西林，紅霉素金黃色葡萄球菌：苯唑西林、氯唑西林、萬(wàn)古、利福平流感嗜血桿菌：阿莫西林+克拉維酸鉀或舒巴坦大腸桿菌和肺炎桿菌：頭孢曲松或頭孢噻肟綠膿桿菌：替卡西林鈉克拉維酸鉀或頭孢哌酮肺炎支原體或衣原體：大環(huán)內(nèi)酯

50呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Treatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasma

pneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，fullperiodis6weeks51呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述treatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、

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

respirefailture）holdingrespiratory

tractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorb52呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述TreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥拉明0.5mg/kgivgtt

10%GS20mltreatagainstsymptoms53呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述TreatmenttreatofHeartfailure鎮(zhèn)靜給氧強(qiáng)心：西地蘭減輕心臟負(fù)荷

treatagainstsymptoms54呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Treatment合并中毒性腦病的治療脫水：甘露醇改善通氣改善腦微循環(huán)止痙：地西泮地塞米松營(yíng)養(yǎng)神經(jīng)treatagainstsymptoms55呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Treatment糖皮質(zhì)激素應(yīng)用適應(yīng)癥：①喘憋重,呼吸衰竭②全身中毒癥狀重③感染性休克

④腦水腫琥珀酸氫化可的松5~10mg/kg.d地塞米松0.1~0.3mg/kg.d

ivgtt2~3次/日×3~5天甲基強(qiáng)的松龍2~4mg/kg.次56呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolve57呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Whatifpatientsfailstorecover?Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen58呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述病毒性肺炎呼吸道合胞病毒肺炎腺病毒肺炎2歲，2~6月多見(jiàn)喘憋、呼吸困難，可合并呼衰、心衰哮鳴音，細(xì)濕羅音小點(diǎn)片狀影，肺氣腫肺不張間質(zhì)性肺炎6月~2歲中毒癥狀重，稽留熱，咳劇，喘憋，呼吸困難出現(xiàn)晚，濕羅音或肺實(shí)變

胸片改變出現(xiàn)早，肺氣腫，片狀影或融合年齡癥狀胸片體征59呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述細(xì)菌性肺炎葡萄球菌肺炎新生兒，嬰幼兒急、重、快，弛張熱或稽留熱，咳嗽，呼吸困難，呻吟，易致遷徒化膿病灶，并發(fā)膿胸，膿氣胸，肺大皰中細(xì)濕羅音，出現(xiàn)早，皮疹浸潤(rùn)影，持續(xù)時(shí)間較長(zhǎng)，易變，可見(jiàn)多發(fā)性肺膿腫，膿胸，膿氣胸等<4歲慢，重，發(fā)熱，痙攣性咳嗽，呼吸困難，發(fā)紺。易致遷徒化膿病灶，易并發(fā)膿胸濕羅音或?qū)嵶兇笕~性肺炎、支氣管肺炎、肺實(shí)變年齡癥狀體征胸片革蘭陰性桿菌肺炎60呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述肺炎支原體肺炎年長(zhǎng)兒，嬰幼兒發(fā)熱、刺激性咳嗽，多系統(tǒng)病變不明顯，嬰幼兒可有呼吸困難，喘憋，哮鳴音，濕羅音肺門影增濃；支氣管肺炎改變；間質(zhì)性肺炎；均一實(shí)變影<6月起病慢，無(wú)發(fā)熱，先URI癥狀后咳、喘、氣促，部分伴結(jié)膜炎濕羅音，持續(xù)時(shí)間長(zhǎng)間質(zhì)性炎癥，過(guò)度充氣、片狀影，持續(xù)時(shí)間長(zhǎng)年齡癥狀體征胸片沙眼衣原體肺炎支衣原體肺炎

61呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述

支氣管哮喘

bronchialasthma

62呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述發(fā)展史asthma-喘息，2000年前就有對(duì)哮喘的詳細(xì)描述過(guò)去認(rèn)為是一種平滑肌功能異常性疾病80年代以來(lái)通過(guò)支氣管黏膜活檢，認(rèn)識(shí)到哮喘是氣道慢性炎癥性疾病63呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述特征氣道慢性炎癥：此為哮喘主要特征可逆性的氣流受限：指氣流受限可被支氣管擴(kuò)張劑所逆轉(zhuǎn)氣道高反應(yīng)性：對(duì)正常氣道無(wú)反應(yīng)或很小反（AHR）應(yīng)的刺激產(chǎn)生收縮反應(yīng)65呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening66呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述病理生理急性支氣管痙攣：速發(fā)型哮喘反應(yīng)（IgE依賴）氣道壁腫脹：遲發(fā)型哮喘反應(yīng)（炎癥誘導(dǎo)）粘液栓形成：難治療的氣流受限氣道重塑：不可逆的氣道狹窄核心氣流受限67呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述atopy是指對(duì)普通環(huán)境中常見(jiàn)的變應(yīng)原產(chǎn)生IgE介導(dǎo)反應(yīng)的易感性，有明顯的家族遺傳傾向。特應(yīng)性哮喘、過(guò)敏性鼻炎、濕疹、食物過(guò)敏等導(dǎo)致哮喘發(fā)生最確定的危險(xiǎn)因素68呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-

adrenalglandnerve

-

adrenalglandnerve

PneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistory69呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Clinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticus70呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述auxiliaryexaminationX-raylungfunctionskintestFEV1/FVC（一秒用力呼氣容積/用力肺活量，低于70-75％提示氣流受限）PEFR（呼氣風(fēng)流速，其日間變異率>20%,使用支擴(kuò)劑后增加20%可診斷哮喘）71呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegasp72呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述cough1month,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexcludeothercoughdiseaseDiagnoseofcoughvariantasthma73呼吸系統(tǒng)疾病基礎(chǔ)知識(shí)概述therapyPrinciple:long-term、persistence、standard、individuationPeriodofonset:antiin