病理学——呼吸系统.ppt

呼吸系统疾病TheRespiratorySystem 第四章 快速气体交换RapidgasexchangeVentilationPerfusionDiffusion清洁空气 肺的结构与功能 Mucosa Submucosa Cartilage Muscles Bronchus Bronchialepithelium Kulchitskycells BronchialSubmucosalGlands Alveoli Therespiratorymembrane 病原体Pathogen空气contaminatedairexposure鼻咽部菌群nasopharyngealfloraaspiration宿主防御功能下降Compromiseddefensemechanisms肺部疾病othercommonlungdisease免疫缺陷Immunodeficiency生活方式Lifestyle 肺部感染PulmonaryInfections 分类Classification 根据解剖和影像学Anatomyandradiography根据病因Etiology根据在哪获得SettinginwhichtheyariseCommunity AcquiredHospital acquired nosocomial 一 细菌性肺炎 大叶性肺炎 95 肺炎链球菌 小叶性肺炎军团菌性肺炎 肺炎 全身毒血症状 小叶性肺炎 大叶性肺炎 患者杨某 男 20岁 学生 酗酒后遭雨淋 于当天晚上突然起病 寒颤 高热 呼吸困难 胸痛 继而咳嗽 咳铁锈色痰 其家属急送当地医院就诊 听诊 左肺下叶有大量湿性啰音 触诊语颤增强 血常规 WBC 17X109 L X线检查 左肺下叶有大片致密阴影 典型病例1 入院经抗生素治疗 病情好转 各种症状逐渐消失 X线检查 左肺下叶的大片致密阴影缩小2 3面积 病人于入院后第7天自感无症状出院 冬季征兵体检 X线检查左肺下叶有约3cmX2cm大小不规则阴影 周围边界不清 怀疑为 支气管肺癌 在当地医院即做左肺下叶切除术 病理检查 肺部肿块肉眼为红褐色肉样 镜下为肉芽组织 大叶性肺炎 大叶性肺炎 大叶性肺炎 Intheerabeforeantibiotics 充血水肿期Hyperemiaandedema红肝期Redhepatization灰肝期Grayhepatization溶解消散期Resolution hopefully Hyperemiaandedema 12 24hours Redhepatization2 3days Grayhepatization 3 4days 并发症complications 肺脓肿 脓胸 脓气胸败血症 脓毒败血症 感染性休克肺肉质变 小叶性肺炎 小叶性肺炎 Filledwithexudate Aeratedlung 小叶性肺炎 小叶性肺炎 并发症Complications 心力衰竭 呼吸衰竭肺脓肿 脓胸 脓毒败血症支气管扩张 Organization Abscessformation Abscessformation Purulentpleuritis HemorrhagicPneumoniabyPseudomonasaeruginosa Pseudomonaspneumonia Klebsiellapneumonia 二 病毒性肺炎 三 支原体性肺炎 轻者为急性间质性肺炎 旧称不典型性肺炎atypical缺乏实变体征WBC轻度升高重者为急性呼吸窘迫症ARDS肺泡弥漫性损伤透明膜形成 Viralpneumonia Atypicalpneumonia SevereAcuteRespiratorySyndrome SARS PneumoniaintheImmunocompromisedHost 机会致病原opportunisticagents常为多重感染bacteria P aeruginosa Mycobacteriumspp L pneumophila andListeriamonocytogenes viruses cytomegalovirusandherpesvirus fungi P jiroveci Candidaspp Aspergillusspp andCryptococcusneoformans CMVinfections insituhybridization SputumcytologyfromanAIDSpatient Papanicolaou Giemsa PneumocystisPneumonia silverstain PneumocystisPneumonia silverstain PneumocystisPneumonia PneumocystiscariniiinbronchiallavagefromanAIDSpatient Grocott ssilver Papanicolaou Immunostaining 慢性阻塞性肺病 COPD ChronicObstructivePulmonaryDisease limitationofairflowusuallyresultingfromanincreaseinresistancecausedbypartialorcompleteobstructionatanylevel肺气肿Emphysema慢性支气管炎Chronicbronchitis支气管扩张Bronchiectasis哮喘Asthma FEV1 FVC 我国国家 十五 课题最新统计数据 2005年公布 显示40岁以上人口COPD患病率为8 估计全国有2500万人罹患此病 每年因COPD死亡的人数达100万 致残人数达500 1000万 COPD居我国疾病负担的首位 慢性支气管炎Chronicbronchitis Apersistentcoughproductiveofsputumforatleast3months inatleast2consecutiveyears单纯型Simple 喘息型Asthmatic 阻塞型obstructive 病因etiology 吸烟和空气污染Cigarettesmokingandairpollutants感染MicrobialinfectionSecondaryrole使炎症持续 加重症状maintainingtheinflammationandexacerbatingsymptoms 发病机制Pathogenesis 多痰 粘液分泌亢进Hypersecretionofmucus大气道病变largebronchialinvolvement粘液腺增生 杯状细胞分泌亢进Hypertrophyofmucousglandsandamarkedincreaseinmucin secretinggobletcells 气道阻塞Airflowobstruction小气道炎症和管壁纤维化inflammation bronchiolarwallfibrosis杯状细胞化生 细支气管痰栓形成gobletcellmetaplasiawithmucuspluggingofthebronchiolarlumen并发肺气肿coexistentemphysema 发病机制Pathogenesis innerperichondrium basallamina Chronicbronchitis Normalbronchus Chronicbronchitis Chronicbronchitis Chronicbronchiolitis luminalandmucus chronicinflammation 肺气肿Emphysema Abnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchioles accompaniedbydestructionoftheirwallswithoutobviousfibrosis指呼吸性细支气管 肺泡管 肺泡囊 肺泡因组织弹性减弱而过度充气伴有肺泡间隔破坏 致使肺容积增大的病理状态 病理类型 腺泡 小叶 中央型Centriacinar 全腺泡 小叶 型Panacinar 腺泡 小叶 周围型Distalacinar 不规则型Irregular obstruction Spontaneouspneumothorax asymptomatic 发病机理Pathogenesis Centriacinaremphysema Bullousemphysema Centriacinaremphysema InadequateventilationLessperfusionNarrowedbronchiole ConditionsRelatedtoEmphysema 间质性肺气肿Mediastinal interstitial emphysema代偿性肺气肿Compensatoryemphysema阻塞性过充气Obstructiveoverinflation瘢痕旁肺气肿Paracicatricalemphysema老年性肺气肿Senileemphysema COPD的临床表现 Respiratoryfailure Rightheartfailure Pinkpuffer 桶状胸Barrelchest 支气管扩张症Bronchiectasis Permanentdilationofbronchiandbronchiolescausedbydestructionofthemuscleandelasticsupportingtissueresultingfromorassociatedwithchronicnecrotizinginfections继发于持续性感染或阻塞Secondarytopersistinginfectionorobstruction诊断依靠病史和影像学 Predisposingconditions 支气管阻塞Bronchialobstruction肿瘤Tumor异物Foreignbodies先天性或遗传性疾病CongenitalorhereditaryconditionsCysticfibrosisKartagenersyndrome坏死性化脓性肺炎Necrotizing orsuppurative pneumonia CysticFibrosis CF CysticFibrosis CF Bronchiectasis 57yearoldwomanwithalonghistoryofrecurrentrespiratorytractinfectionsandepisodesofhemoptysis Bronchiectasis BronchiectasisDuetopneumonia Bronchiectasis Bronchiectasis PurulentexudationinthelumenDestructionofliningepitheliumScarringofthebronchialwall HRCTscansofbronchiectasis 支气管扩张症的临床表现 咳嗽 咳脓臭痰Severe persistentcoughwithmucopurulentsputum sometimesfetid咯血Flecksofbloodinsputumorfrankhemoptysis严重病例及合并症 肺间质疾病ILD 肺弥漫性纤维化肺顺应性减弱 容量减小已知病因和特发性间质性肺炎 SelectedcausesofchronicinterstitiallungdiseaseOccupationalandenvironmentalexposureAsbestosisSilicosisHypersensitivitypneumonitisDrugortreatmentrelatedChemotherapeuticagentsIonizingirradiationOxygenImmunologiclungdiseaseSarcoidosisWegnergranulomatosisCollagenvasculardiseaseGoodpasturesyndromeMiscellaneousPostacuterespiratorydistresssyndromeIdiopathicpulmonaryfibrosis 杵状指 趾 Clubbingofdigits Honeycomblung 矽肺Silicosis 职业病Occupationaldiseases吸入二氧化硅粉尘引起Inhalationofcrystallinesilica致残和致死Disablingandfatal病理 硅结节形成广泛的肺纤维化 发病机制Pathogenesis 直径 5 m的硅尘沉积于肺间质肺泡巨噬细胞引发和持续肺损伤和纤维化Alveolarmacrophageisakeycellularelementintheinitiationandperpetuationoflunginjuryandfibrosis Silicosis asliceoflungfroma61yoceramicsworker 矽结节Silicosis 临床表现Clinicalcourse 早期常为体检发现usuallydetectedinroutinechestradiographs晚期表现 呼吸困难shortnessofbreath肺心病corpulmonale合并TBincreasedsusceptibilitytoTB可能致癌carcinogenic controversial Silicosis 急性呼吸窘迫征 ARDS AcuteRespiratoryDistressSyndrome 进行性呼吸衰竭AcuteonsetofDyspneaHypoxemiaBilateralpulmonaryinfiltrates X ray Noevidenceofleft sidedheartfailure病理 弥漫性肺泡损伤DiffuseAlveolarDamage DAD 常伴多器官衰竭MultipleOrganDysfunctionSyndrome MODS 发病机制Pathogenesis 广泛内皮和肺泡I型 II型上皮损伤Endothelialandepithelial IandII damage肺水肿alveolarflooding气体交换丧失lossofdiffusioncapacity表面活性物质异常surfactantabnormalities促炎和抗炎介质的失衡Imbalanceofpro inflammatoryandanti inflammatorymediators 病理变化Morphology 急性渗出期AcuteExudativeStage水肿Edema interstitialandalveolar 透明膜形成Hyalinemembranes肺泡塌陷Manyalveolicollapse增生期ProliferativeStageII型肺泡上皮增生肺泡内机化Intra alveolarfibrosis wideningoftheinterstitiumARDS Hyalinemembranes Hyalinemembranes Hyalinemembranes Healingstage Healingstage suvivingpatientARDS 临床表现Clinicalfeatures 肺顺应性差Poorpulmonarycompliance难治性低氧血症Poorresponsetooxygen血管床进行性减少Pulmonaryvascularbedisprogressivelyobliterated易感染Pronetobacteriainfection 预后Prognosis Dependssuccessfullytreatementsbeforeextensivefibrosis40 70 mortalityHigh dosesteroidsfailedConservativetherapyhelpsConsiderableinterestinthequalityofsurvivals LUNGTUMORS MetastatictumorsPrimarytumorsBRONCHOGENICCARCINOMAOthersbronchialcarcinoidsmesenchymalmalignanciesLymphomasafewbenignlesions 95 5 慢性肺动脉高压症和肺心病 自学 概念病因发病机制病理变化临床病理联系 思考题 试述慢性支气管炎并发肺心病的发病机制 肺癌 癌症死因第一位causeofcancer relateddeaths发病率随年龄和烟龄增长 pack yearssmoked 确诊的病人一半以上已有远处转移distantmetastaticdisease5年生存率约为15 5 yearsurvival 肺癌的临床病理分型 肺小细胞癌Smallcelllungcancer SCLC 肺非小细胞癌Non small celllungcancer NSCLC 鳞癌Squamouscellcarcinoma腺癌Adenocarcinomas大细胞癌Largecellcarcinomas SCLC Kulchitskycell起源hADH hyponatremia waterintoxication ACTH Cushing ssyndrome 中央型Centrallylocatedmasses坏死常见Necrosisisinvariablypresentandmaybeextensive燕麦细胞癌Oatcellcarcinoma SCLC Oatcellcarcinoma SCLC Oatcellcarcinoma SCLC 鳞状细胞癌 病人大多有吸烟史Closelycorrelatedwithasmokinghistory中央型Tendtoarisecentrallyinmajorbronchi常见空洞Cavitationisnotuncommon副癌综合征Preneoplasticlesions Squamouscellcarcinoma Squamouscellcarcinoma Squamouscellcarcinoma Squamouscellcarcinoma Squamouscellcarcinoma Metaplaisa Anaplasia Dysplasia 腺癌Adenocarcinoma 周围型多见peripherallylocated是女性和非吸烟者常见的肺癌类型常发生自肺周边部疤痕处arisinginrelationtoperipherallungscars生长缓慢但早期转移支气管肺泡干细胞起源Bronchioalveolarstemcellsorigin Adenocarcinoma Adenocarcinoma Adenocarcinoma 细支气管肺泡癌 BAC Bronchioloalveolarcarcinoma Adistinctsubtypeofadenocarcinoma弥漫型多见multiplediffusenodulesGrowingalongpreexistingstructuresandpreservationofalveolararchitecture分为粘液型和无粘液型mucinous nonmucinoussubtypes BAC BAC BAC PrecursorlesionsofADC AAH BAC 低分化癌 排除SCLC SCCorADCCellsarenot columnarinshapeDonotcontainmucousDonotshowsquamousdifferentiationDonothaveneuroendocrinepropertiesorsmallcellcharacteristics可发生与任何部位ariseanywhereinlungs大部分与吸烟有关 预后差smoking related curesarerare 大细胞癌 Largecellcarcinoma 肺癌的临床表现 原发灶引起的症状Symptomsduetoprimarytumor原发灶蔓延引起的症状Symptomsduetolocoregionalspread转移引起的问题Metastaticdisease副肿瘤综合征Paraneoplasticsyndromes 中央型肺癌Centraltumorscough dyspnea 肺不张atelectasis 阻塞后肺炎 喘息咯血hemoptysis周围型肺癌Peripheraltumorscough dyspnea胸水pleuraleffusion疼痛severepain Duetoprimarytumor Duetolocoregionalspread 上腔静脉综合征Superiorvenacavaobstruction声音嘶哑Hoarseness肩膀和上臂疼痛Horner ssyndrome吞咽困难Dysphagia心包积液Pericardialeffusion 眼球内陷asunkeneyeball enophthalmia 瞳孔缩小 对光反射异常上睑下垂droopyuppereyelid患侧面部无汗 Horner sSyndrome Normal Abnormal Metastaticdisease 脑brain mentalorneurologicchanges 肝liver hepatomegaly 骨bones pain Paraneoplasticsyndromes HypercalcemiaCushingsyndromeHyponatremiaNeuromuscularsyndromesHematologicmanifestationsClubbingofthefingersBlindnessanddementia 3 to10 ofallpatients Metastaticcarcinoma dilatedlymphaticchannel TransesophagealEchocardiogram 6 22 8daysbeforedeath showedthickeningoftheleafletsofthePVandoneoftwopedunc