04 呼吸系統(tǒng)疾病課件

04呼吸系統(tǒng)疾病呼吸系統(tǒng)疾病

04呼吸系統(tǒng)疾病嬰幼兒上感、2種特殊類(lèi)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)04呼吸系統(tǒng)疾病Inpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.04呼吸系統(tǒng)疾病Whychildrenaresosusceptibletoacuterespiratoryinfections?04呼吸系統(tǒng)疾病04呼吸系統(tǒng)疾病anatomic

physiologicalfeatures

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

RespiratorytypeofabdomenRespiratorytypeofchestabdomen

04呼吸系統(tǒng)疾病

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanopathyThreeconcavesign

ＡuscultationExamineMethod04呼吸系統(tǒng)疾病急性上呼吸道感染（AURI）

AcuteUpperRespiratoryInfection04呼吸系統(tǒng)疾病EtiologyＶirus：Ｏccupy90%

Ｂacteria：Ｓecondary

Streptococuspyogens

PneumococcuＨaemophilusinfluenzae04呼吸系統(tǒng)疾病CommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestations04呼吸系統(tǒng)疾病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)ClinicalManifestations04呼吸系統(tǒng)疾病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04呼吸系統(tǒng)疾病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ClinicalManifestationsSpecialAURI04呼吸系統(tǒng)疾病SchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplications04呼吸系統(tǒng)疾病AntivirusdrugsOseltamivirRibovirin3-5daysAntibioticsPenicillinSMZ3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatment04呼吸系統(tǒng)疾病DefervesceDrugsPhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatment04呼吸系統(tǒng)疾病Pneumonia肺炎

04呼吸系統(tǒng)疾病ChildrenfamiliardiseaseInworld,Occupy1/3-1/4inthedeathofchildrenunder5yearsofageInchina,Occupymorethan1/4inpaediatricwardThehospitalizationnumberofinfantandtoddleris39.5timesofschoolage

Pneumonia04呼吸系統(tǒng)疾病PneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinition04呼吸系統(tǒng)疾病OncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：1~3monthsClassification104呼吸系統(tǒng)疾病OntheetiologyVirusRSV(respiratorysyncytialvirus)AdenovirusInfluenzaParainfluenzaBacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetypeClassification204呼吸系統(tǒng)疾病OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification304呼吸系統(tǒng)疾病OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification404呼吸系統(tǒng)疾病ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification504呼吸系統(tǒng)疾病OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification604呼吸系統(tǒng)疾病支氣管肺炎

Bronchopneumonia04呼吸系統(tǒng)疾病EtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniae

04呼吸系統(tǒng)疾病PathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswall04呼吸系統(tǒng)疾病04呼吸系統(tǒng)疾病04呼吸系統(tǒng)疾病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↓04呼吸系統(tǒng)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呼吸系統(tǒng)疾病ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailure04呼吸系統(tǒng)疾病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04呼吸系統(tǒng)疾病ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomatic04呼吸系統(tǒng)疾病ClinicalmanifestDICBp四肢涼，脈速弱，出血SLADHNa+

≤130mmol/L滲透壓<270mOsm/LEdemaSeveresymptomatic04呼吸系統(tǒng)疾病ComplicationsComplicationpneumatocelepyopneumothoraxempyema04呼吸系統(tǒng)疾病LaboratorydataBloodbloodroutinebacteriainfect：WBC↑、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandculture04呼吸系統(tǒng)疾病LaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis04呼吸系統(tǒng)疾病支氣管肺炎正常胸片04呼吸系統(tǒng)疾病大葉性肺炎正常胸片04呼吸系統(tǒng)疾病fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosis04呼吸系統(tǒng)疾病Differentiationacute

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

Temperature18-20℃

Humidity60%Foodnutritive04呼吸系統(tǒng)疾病TreatmentControlinfectionvirus：noidealdruglikevirozolmycoplasma、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、fullperiodoftreatment,firstselectPeniccilin04呼吸系統(tǒng)疾病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

04呼吸系統(tǒng)疾病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

04呼吸系統(tǒng)疾病Treatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasma

pneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，fullperiodis6weeks04呼吸系統(tǒng)疾病treatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、

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

respirefailture）holdingrespiratory

tractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorb04呼吸系統(tǒng)疾病TreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥拉明0.5mg/kgivgtt

10%GS20mltreatagainstsymptoms04呼吸系統(tǒng)疾病TreatmenttreatofHeartfailure鎮(zhèn)靜給氧強(qiáng)心：西地蘭減輕心臟負(fù)荷

treatagainstsymptoms04呼吸系統(tǒng)疾病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)treatagainstsymptoms04呼吸系統(tǒng)疾病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04呼吸系統(tǒng)疾病ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolve04呼吸系統(tǒng)疾病Whatifpatientsfailstorecover?Youshouldconsider--NoninfectiousconditionResistancetodrugNewnosocomialpathogen04呼吸系統(tǒng)疾病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04呼吸系統(tǒng)疾病細(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04呼吸系統(tǒng)疾病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(mén)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

04呼吸系統(tǒng)疾病

支氣管哮喘

bronchialasthma

04呼吸系統(tǒng)疾病發(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04呼吸系統(tǒng)疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,respiratorydistress,cough04呼吸系統(tǒng)疾病特征氣道慢性炎癥：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)04呼吸系統(tǒng)疾病pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening04呼吸系統(tǒng)疾病病理生理急性支氣管痙攣：速發(fā)型哮喘反應(yīng)（IgE依賴(lài)）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04呼吸系統(tǒng)疾病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04呼吸系統(tǒng)疾病pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen

-

adrenalglandnerve

-

adrenalglandnerve

PneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistory04呼吸系統(tǒng)疾病Clinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticus04呼吸系統(tǒng)疾病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）04呼吸系統(tǒng)疾病Diagnoseofchildfoodasthmagasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegasp04呼吸系統(tǒng)疾病cough

1month,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexcludeothercoughdiseaseDiagnoseofcoughvariantasthma04呼吸系統(tǒng)疾病therapyPrinciple:long-term、persistence、standard、individuationPeri