呼吸系統(tǒng)課件

病理學(xué)管毅剛高雄榮民總醫(yī)院胸腔外科主任呼吸系統(tǒng)_1病理學(xué)為醫(yī)學(xué)領(lǐng)域的一門分支學(xué)科專門探討疾病在個體發(fā)生的起因發(fā)展及變化以及整個過程對患者產(chǎn)生的各種影響。呼吸系統(tǒng)_1呼吸系統(tǒng)呼吸系統(tǒng)_1呼吸系統(tǒng)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(fā)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統(tǒng)_1急性、慢性發(fā)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)鼻腔炎癥過敏性鼻炎(allergicrhinitis)IgE增加→組織胺分泌增加鼻黏膜嗜酸性白血球浸潤季節(jié)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(nèi)塵蟎、真菌等微生物引發(fā)本病為主呼吸系統(tǒng)_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(shù)治療，但容易復(fù)發(fā)呼吸系統(tǒng)_1Paranasalsinus呼吸系統(tǒng)_1急性、慢性發(fā)炎(2)鼻竇炎(sinusitis)Paranasalsinus發(fā)炎卡他性炎癥鼻炎→鼻竇炎急性→慢性鼻竇炎→顱腔骨髓炎和顱內(nèi)感染呼吸系統(tǒng)_1急性、慢性發(fā)炎(3)咽炎(pharyngitis)和扁桃腺炎(tonsilitis)常同時發(fā)生多為病毒感染，但續(xù)發(fā)性細(xì)菌感染亦常見鏈球菌感染→風(fēng)濕熱、腎小球腎炎嚴(yán)重扁桃腺炎需手術(shù)治療呼吸系統(tǒng)_1呼吸系統(tǒng)_1急性、慢性發(fā)炎(4)急性會厭炎(acuteepiglottitis)好發(fā)於嬰幼兒多為流行性感冒嗜血桿菌引起可引起嚴(yán)重上呼吸道阻塞而死亡喉炎(laryngitis) 感染、過敏、吸煙或其他化學(xué)性刺激引起白喉(diphtheria)：喉部偽膜呼吸系統(tǒng)_1聲帶息肉(vocalcordpolyp)

聲帶結(jié)節(jié)(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(shù)治療呼吸系統(tǒng)_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(shù)演變?yōu)閻盒憎[狀細(xì)胞癌(squamouscellcarcinoma)鼻咽癌(nasopharyngealcarcinoma)廣東腫瘤(Cantontumor)EB(Epstein-Barrvirus)成年男性癌癥死亡第13位(2002年)鼻涕帶血、留鼻血、鼻塞、頸部淋巴結(jié)腫大顱底侵襲未分化癌(undifferentiatedcarcinoma)或鱗狀細(xì)胞癌未分化癌中常有癌細(xì)胞浸潤於淋巴組織間→又稱淋巴上皮瘤(lymphoepithelioma)放射線治療呼吸系統(tǒng)_1Nasopharyngealcarcinoma呼吸系統(tǒng)_1上呼吸道腫瘤(2)喉癌(laryngealcarcinoma)中老年男性吸煙漸進(jìn)性聲音沙啞、吞嚥困難、頸部淋巴結(jié)腫大多為鱗狀細(xì)胞癌呼吸系統(tǒng)_1laryngealcarcinoma呼吸系統(tǒng)_1呼吸系統(tǒng)_1肺臟和氣道疾病2002年非癌癥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(jié)核?。旱?2位國人十大癌癥死亡原因肺癌：男性第2位女性第1位呼吸系統(tǒng)_1炎癥支氣管炎肺炎大葉性肺炎支氣管肺炎間質(zhì)性肺炎吸入性肺炎肺膿瘍呼吸系統(tǒng)_1支氣管炎(Bronchitis)急性支氣管炎(acutebronchitis)感染或其他刺激物大多數(shù)自癒，少數(shù)併發(fā)肺炎可氣道阻塞慢性支氣管炎(chronicbronchitis)二年、每年三個月、持續(xù)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(xì)支氣管(bronchiole)亦常有發(fā)炎及管腔變窄可併發(fā)肺氣腫，氣道阻塞呼吸系統(tǒng)_1肺炎

(pneumonia,pneumonitis)感染性肺炎細(xì)菌性肺炎大葉性肺炎、支氣管肺炎發(fā)燒、不適、咳嗽、有痰、胸痛及呼吸困難非典型肺炎(atypicalpneumonia)間質(zhì)性肺炎非感染性炎癥吸入化學(xué)物質(zhì)呼吸系統(tǒng)_1Pneumonia(RLL)呼吸系統(tǒng)_1呼吸系統(tǒng)_1支氣管肺炎

(bronchopneumonia,lobularpneumonia)氣管炎或支氣管炎的延伸可形成多發(fā)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統(tǒng)_1大葉性肺炎(lobarpneumonia)炎癥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(nèi)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(xù)存在消解期(resolution)：滲出液堅實化後被酵素分解，再被巨噬細(xì)胞吞噬移除併發(fā)癥：胸膜炎、胸膜腔滲液、胸膜腔積膿、肺膿腫、敗血癥、腦膜炎、心內(nèi)膜炎、關(guān)節(jié)炎等呼吸系統(tǒng)_1Lobarpneumonia呼吸系統(tǒng)_1呼吸系統(tǒng)_1間質(zhì)性肺炎

(interstitialpneumonitis)肺泡中隔和間質(zhì)組織炎癥Atypicalpneumonia肺炎黴漿菌(mycoplasmapneumoniae)、病毒或其他細(xì)菌Idiopathicinterstitialpneumonia肺臟纖維化疾病呼吸系統(tǒng)_1呼吸系統(tǒng)_1SARS(1)

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

(SevereAcuteRespiratorySyndrome)飛沫、接觸體液傳染潛伏期3-7天、可能超過十天癥狀(Fig11-6)，出現(xiàn)癥狀後始具傳染力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%呼吸系統(tǒng)_1吸入性肺炎(aspirationpneumonia)氣體、液體、固體微粒引起細(xì)菌感染、機(jī)械性阻塞及化學(xué)性傷害溺水、酒醉、昏迷、虛弱、食道或神經(jīng)病變的病患污水、胃液和食物多為支氣管肺炎呼吸系統(tǒng)_1Aspirationpnemonia

Sup.Segment,RLL呼吸系統(tǒng)_1肺膿腫(pulmonaryabscess)局部化膿性病變病因：口咽部手術(shù)、上呼吸道感染、頭頸部膿腫、支氣管擴(kuò)張併發(fā)癥：胸膜炎、腦膜炎、腦膿腫、全身性感染呼吸系統(tǒng)_1氣喘(asthma)支氣管通道收縮引起的陣發(fā)性呼吸困難及wheezing，又稱支氣管氣喘(bronchialasthma)心因性氣喘呼吸系統(tǒng)_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(fā)病IgE非過敏性原因Infectiousasthma:常為病毒感染Occupationalasthma:有機(jī)或無機(jī)物質(zhì)引起內(nèi)因性可經(jīng)由drugs,pressure,sport,chemicalsubstanceorinfection引起Mechanism:notclear呼吸系統(tǒng)_1呼吸系統(tǒng)_1呼吸系統(tǒng)_1氣喘(asthma)病理小支氣管及細(xì)支氣管為黏液阻塞黏液中可發(fā)現(xiàn)Eosinophil,Curschmannspiral,Charcot-Leydencrystal管壁水腫及炎癥細(xì)胞浸潤管壁平滑肌spasm及肥大黏膜下層黏液腺增大Statusasthmaticus呼吸系統(tǒng)_1呼吸系統(tǒng)_1支氣管擴(kuò)張癥(bronchiectasis)破壞管壁結(jié)構(gòu)或增加外在牽引力支氣管和細(xì)支氣管不正常且永久性的擴(kuò)大Etiology:TB,pneumonia,tumor,foreignbody,asthma,chronicbronchitis,cysticfibrosis,congenitalabnormality局部性或瀰漫性癥狀：chronicproductivecough,respiratorydifficulty,clubbingfinger,fever,pulmonaryabscess,cyanosis,corpulmonale,brainabscess,etc.呼吸系統(tǒng)_1呼吸系統(tǒng)_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(tài)易引起感染胸痛、呼吸困難、cyanosis；無咳嗽或咳血呼吸系統(tǒng)_1呼吸系統(tǒng)_1肺氣腫(emphysema)肺臟腺泡不正常且永久性的擴(kuò)大無纖維化現(xiàn)象LargerpulmonarycompliancethannormalindividualsBarrelchestBroaderdefinitionincludesSenileemphysema,compensatoryemphysema,obstructiveoverinflation,interstitialemphysema呼吸系統(tǒng)_1肺氣腫(emphysema)呼吸系統(tǒng)_1呼吸系統(tǒng)_1ChronicObstructivePulmonaryDisease(COPD)RespiratorydifficultyandairwayobstructionEmphysema,chronicbronchiolitis,brochiectasia,bronchialasthmaPinkpufferEmphysema,olderage,rapidandshortrespiration,adequateoxygenation,nocyanosisBluebloaterChronicbronchiolitis,youngerage,muchsputum,corpulmonale,cyanosis,swelling呼吸系統(tǒng)_1呼吸系統(tǒng)_1PulmonaryedemaandpulmonarycongestionLeftheartfailureMacrophageinalveoli(heartfailurecell)Browninduration:血鐵質(zhì)堆積+纖維化呼吸系統(tǒng)_1PulmonaryembolismEmbolifromveinoflowerextremitiesChestpain,respiratorydifficulty,pulmonaryinfarction,suddendeath呼吸系統(tǒng)_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呼吸系統(tǒng)_1ARDS呼吸系統(tǒng)_1Pneumoconiosis呼吸系統(tǒng)_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呼吸系統(tǒng)_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(zhì)性肺炎LargecellcarcinomaLesscommonSmallcellcarcinoma1/5,paraneoplasticsyndrome,hilum,smoking,oatcellcarcinoma,poorprognosis,chemotherapy呼吸系統(tǒng)_1呼吸系統(tǒng)_1ClinicalsymptomsandComplicationCough,weightloss,chestpain,dyspnea,hemoptysis,pneumonia,pleuraleffusion,hoarseness,dysphagia,ribdestruction,lungabscess,feverSuperiorvenacavalsyndromeHornersyndromeApicaltumor,PancoasttumorCervicalsympatheticganglioninvasionIpsilateralptosis,miosis,andnotsweatingintheforeheadParaneoplasticsyndromeEndocrineabnormalities,hypercalcemia,clubbingfinger呼吸系統(tǒng)_1呼吸系統(tǒng)_1TreatmentandPrognosis

ofLungCancerWorst:smallcellcancer,chemotherapyorradiationNSCLC:surgeryMetastaticlungcancer:Multiple,frombreast,stomach,colon,ovary,uterus,prostate,bone,liveretc.Hamartoma,carcinoid呼吸系統(tǒng)_1OtherlungdiseasesSarcoidosisGranuloma,hilarlymphnodesorskin,eyes,liver,spleenandbonemarrowAsteroidbodyandSchaumannbodyinmultinucleatedgiantcellScandinavianandblackpeopleGoodprognosis,spontaneousresolution>50%,steroid呼吸系統(tǒng)_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呼吸系統(tǒng)_1Pleuraleffusion呼吸系統(tǒng)_1FluidinPleuralCavityExudateInflammatorypleuraleffusion,parapneumonicpleuraleffusionIncreasedvascularpermeabilityduetoinflammatorypleuraldiseasesPyothorax,empyemabacteriaorfungusAdhesion,fibrosis,obliterationofpleuralcavity,limitationoflungexpansionTransudateImbalanceofhydrostaticandoncoticpressureHydrothoraxHemothoraxtrauma,rupturedaorticaneurysm,coagulopathy,inflammation,tumorChylothoraxThoracicductinjury,impaire