呼吸系统疾病 ppt课件

同学们好 呼吸系统疾病RespiratorySystemDisease 湘雅医院儿科郑湘榕 婴幼儿上感 2种特殊类型上感的特点支气管肺炎临床表现 重症肺炎特点支气管肺炎的诊断 治疗支气管哮喘的临床表现 诊断和治疗 重点 Introduce Inpediatricoutpatient 6o patientsareacuterespiratoryinfections Inpediatricward 25 patientsarePneumonia Thefirstcauseofchildren sdeathinChinaisPneumonia Pneumoniaistheworld sleadingcauseofdeathamongchildren Itkillsnearlytwomillionchildrenunderagefiveeveryyear Whychildrenaresosusceptibletoacuterespiratoryinfections anatomicphysiologicalfeatures Thechildren srespiratorylumensarenarrow bloodflowisabundant Thechildren srepertoryabilityislow Thechildren slocalimmunityislow ChildrenRespiratorySystemPhysiologicFeature Respiratoryrate Neonate40 44 min 1year30 min2 3years24 min4 7years22 min8 14years20 min ChildrenRespiratorySystemPhysiologicFeature Respiratorytype RespiratorytypeofabdomenRespiratorytypeofchestabdomen hysicalexaminationinspectionChangeofrespiratoryrateCyanopathyThreeconcavesign uscultation ExamineMethod 急性上呼吸道感染 AURI AcuteUpperRespiratoryInfection Etiology irus ccupy90 acteria econdaryStreptococuspyogensPneumococcu aemophilusinfluenzae CommonAURI Localsymptomismild Ininfantandtoddler Systemicsymptomissevere Complicationsarecommon ClinicalManifestations CommonAURI hysicalexamination Congestionofpharyngealportion antiadoncus 咽部充血 扁桃体肿大 Lymphadenectasisinsubmaxilla 有时下颌 淋巴结肿大 Rashwhenenterovirusinfection 肠道病毒感染时可出现皮疹 ClinicalManifestations SpecialAURI 柯萨奇病毒A组感染夏秋好发高热 咽痛 流涎咽腭弓 软腭处有疱疹疱疹破溃后可形成溃疡病程1周左右 ClinicalManifestations Herpangina疱疹性咽峡炎 Pharyngo conjunctivalfever咽结合膜热 腺病毒3 7型所致春夏发病 可小流行发热 咽炎 结合膜炎咽部充血 结合膜充血 颈部 耳后淋巴结肿大病程1 2周 ClinicalManifestations SpecialAURI Schoolage Tympanitis sinusitis Abscessofpharynxposterior wall Laryngitis bronchitis Infant toddler Pneumonia Glomerulonephritis Rheumaticfever Complications Antivirusdrugs Oseltamivir Ribovirin 3 5days Antibiotics Penicillin SMZ 3 5days Seversymptomatic Secondarybacteriaaffection Treatment Defervesce Drugs Physicsmethods Febrilconvulsion Calm Stopconvulsion Defervesce Treatment Pneumonia 肺炎 Childrenfamiliardisease Inworld Occupy1 3 1 4inthedeathofchildrenunder5yearsofage Inchina Occupymorethan1 4inpaediatricward Thehospitalizationnumberofinfantandtoddleris39 5timesofschoolage Pneumonia Pneumoniaisaninflammationoftheparenchymaofthelungs Itiscausedbymicroorganismsornoninfectiouscauses Manifestedbyfever cough tachypnea respiratorydistressandrales Definition Oncourseofillness Acute 3monthsDeferred 1 3months Classification1 Ontheetiology VirusRSV respiratorysyncytialvirus AdenovirusInfluenzaParainfluenza BacteriaStreptococuspneumoniaeStaphylococusaureusHaemophilusinfluenzaetype Classification2 Ontheetiology Mycoplasma Chlamydia parasites fungi Noninfectionscauses Classification3 Ontheseverityofillness Mildsymptomatic SeveresymptomaticBesidessymptomsofrespiratorysystem concomitantmanifestationsofotherorgansystemsarepresent Classification4 ontypicalofclinicalmanifestation Typicalpneumonia untypicalpneumoniaSevereacuterespiratorysyndrome SARS coronavirus Classification5 OnOccurrenceRegion CommunityAcquiredPneumoniaCAP HospitalAcquiredPneumoniaHAP Classification6 支气管肺炎 Bronchopneumonia Etiology virus MaincauseofpneumoniaindevelopedcountryRSV bacteria MaincauseofpneumoniaindevelopingcountryS pneumoniae Pathology Pathologicphysiology 气道炎症 循环系统 神经系统 水电解质 消化系统 肺A压增高 中毒性心肌炎 心衰 代酸 中毒性肠麻痹 胃肠粘膜屏障功能 脑水肿 颅压 呼酸 K 水钠储留 毒血症 通气不足PaO2 PaCO2 换气障碍PaO2 Clinicalmanifestation Mildsymptomatic respiratorysystem fever respiratorydistressnasalflaring retractions cyonosis tachypnea cough rales 5yearsRR 30次 分 Clinicalmanifestation Severesymptomatic circularsystemsymptom Cardiacmuscleinflammation Heartfailure Clinicalmanifest Severesymptomatic Heartfailure 呼吸突然加快 60次 分心率突然增快婴儿 180次 分幼儿 160次 分突然烦躁不安 面色发灰心音明显低钝 奔马率 颈静脉怒张肝大肋下3cm以上尿少 下肢浮肿 Clinicalmanifest nervalsystem Lighthypoxia irritability lethargy Severhypoxia hydrocephalus digestivesystem alimentarycanalbleeding Poisoningintestinepalsy Severesymptomatic Clinicalmanifest DIC Bp 四肢凉 脉速弱 出血 SLADH Na 130mmol L渗透压 270mOsm L Edema Severesymptomatic Complications Complication pneumatocele pyopneumothorax empyema Laboratorydata Blood bloodroutine bacteriainfect WBC N leftshiftofnucleusvirusinfect WBC L abnormallymphcell bacteriainfect CRP virusinfect CRPnormal CRP NBT bacteriainfect 10 virusinfect 10 Pathogeny virusseparate Germiculture sputumforGramstainandculture Laboratorydata X ray shadowofdotandspote emphysemaatelectasis 支气管肺炎 正常胸片 大叶性肺炎 正常胸片 fever cough tachypnea respiratorydistressandrales X ray diagnosis Differentiation foreignbodiesinbronchi historyofforeignbodies suddencough respiratorydistress lowerofbreathtoneorwheezing Treatment generaltreatment Balanceofwaterandelectrolyte3 Nacl12ml L Na 10mmol L Temperature18 20 Humidity60 Foodnutritive Treatment Controlinfection virus noidealdruglikevirozol mycoplasma chlamydiaselecterythromycin bactrria theprincipleofsensitivityefficiency fullperiodoftreatment firstselectPeniccilin Treatment 抗生素使用原则 根据药敏选药adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道浓度高的药物adoptdrugswhichcanfinallyinfiltratelungtissue足量足疗程重症静脉给药inseverecase drugsshouldbeadministedbyvein fulldose fullperiod Treatment 抗生素选择 肺炎链球菌 PNC 阿莫西林 红霉素金黄色葡萄球菌 苯唑西林 氯唑西林 万古 利福平流感嗜血杆菌 阿莫西林 克拉维酸钾或舒巴坦大肠杆菌和肺炎杆菌 头孢曲松或头孢噻肟绿脓杆菌 替卡西林钠克拉维酸钾或头孢哌酮肺炎支原体或衣原体 大环内酯 Treatment fullperiodoftreatment aftertemperaturenormal5 7daysorclinicalsymptomdisappearing3daysMycoplasmapneumonia 2 3weeksStaphylococusaureus aftertemperaturenormal2weeks fullperiodis6weeks treatagainstsymptoms Treatment oxygentreat PaO2 dyspnea cyanosis asthmasuppress toxicappearance methods bynosecanal0 5 1L min 40 byveil2 4L min 50 60 mechanismventilate respirefailture holdingrespiratorytractunobstructed removesputum pulverization relievespasmensureliquidabsorb Treatment treatofothersymp defervescecalm treatofwindy supplyKaliumPoisoningintestinepalsy fasting decompressofstomachandintestine酚妥拉明0 5mg kgivgtt10 GS20ml treatagainstsymptoms Treatment treatofHeartfailure 镇静给氧强心 西地兰减轻心脏负荷 treatagainstsymptoms Treatment 合并中毒性脑病的治疗 脱水 甘露醇改善通气改善脑微循环止痉 地西泮地塞米松营养神经 treatagainstsymptoms Treatment 糖皮质激素应用 适应症 喘憋重 呼吸衰竭 全身中毒症状重 感染性休克 脑水肿 琥珀酸氢化可的松5 10mg kg d地塞米松0 1 0 3mg kg divgtt2 3次 日 3 5天甲基强的松龙2 4mg kg 次 ResponsetotreatmentinotherwiseuncomplicatedCAP Fever fallsin2daysLeucocytosis decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4 12weekstoresolve Whatifpatientsfailstorecover Youshouldconsider NoninfectiousconditionResistancetodrugNewnosocomialpathogen 病毒性肺炎 呼吸道合胞病毒肺炎 腺病毒肺炎 2岁 2 6月多见喘憋 呼吸困难 可合并呼衰 心衰哮鸣音 细湿罗音小点片状影 肺气肿肺不张间质性肺炎 6月 2岁中毒症状重 稽留热 咳剧 喘憋 呼吸困难出现晚 湿罗音或肺实变胸片改变出现早 肺气肿 片状影或融合 年龄 症状 胸片 体征 细菌性肺炎 葡萄球菌肺炎 新生儿 婴幼儿急 重 快 弛张热或稽留热 咳嗽 呼吸困难 呻吟 易致迁徒化脓病灶 并发脓胸 脓气胸 肺大疱中细湿罗音 出现早 皮疹浸润影 持续时间较长 易变 可见多发性肺脓肿 脓胸 脓气胸等 4岁慢 重 发热 痉挛性咳嗽 呼吸困难 发绀 易致迁徒化脓病灶 易并发脓胸湿罗音或实变大叶性肺炎 支气管肺炎 肺实变 年龄 症状 体征 胸片 革兰阴性杆菌肺炎 肺炎支原体肺炎 年长儿 婴幼儿发热 刺激性咳嗽 多系统病变不明显 婴幼儿可有呼吸困难 喘憋 哮鸣音 湿罗音肺门影增浓 支气管肺炎改变 间质性肺炎 均一实变影 6月起病慢 无发热 先URI症状后咳 喘 气促 部分伴结膜炎湿罗音 持续时间长间质性炎症 过度充气 片状影 持续时间长 年龄 症状 体征 胸片 沙眼衣原体肺炎 支衣原体肺炎 支气管哮喘bronchialasthma 发展史 asthma 喘息 2000年前就有对哮喘的详细描述过去认为是一种平滑肌功能异常性疾病80年代以来通过支气管黏膜活检 认识到哮喘是气道慢性炎症性疾病 Definition chronicairwayinflammation airwayhyperreactivity AHR reversibleairwayobstruction manifestedbywheezing respiratorydistress cough 特征 气道慢性炎症 此为哮喘主要特征可逆性的气流受限 指气流受限可被支气管扩张剂所逆转气道高反应性 对正常气道无反应或很小反 AHR 应的刺激产生收缩反应 pathology nakedeye emphysema mucusblotscope inflammatorycellinfiltrate glandhyperplasiabasalmembrancethickening 病理生理 急性支气管痉挛 速发型哮喘反应 IgE依赖 气道壁肿胀 迟发型哮喘反应 炎症诱导 粘液栓形成 难治疗的气流受限气道重塑 不可逆的气道狭窄 核心 气流受限 atopy 是指对普通环境中常见的变应原产生IgE介导反应的易感性 有明显的家族遗传倾向 特应性 哮喘 过敏性鼻炎 湿疹 食物过敏等 导致哮喘发生最确定的危险因素 pathogenesis immunityfactor atopy IgE nerveenergyfactor adrenalglandnerve adrenalglandnerve Pneumogastricnerve variousinflammatorycellsintoairway AHR Inheritfactor geneticdisease familyhistory Clinicalmanifest olderchildrensensitizininduceinfantandtoddlerviralinfectioninduce periodofonsetsymptomsofbronchialspasm cough gaspcatabasismaynosignsandsymptoms rapidseriousattack reasonableutilizepara sympathesisdrugcannotreliefin24hours statusasthmaticus auxiliaryexamination X ray lungfunction skintest FEV1 FVC 一秒用力呼气容积 用力肺活量 低于70 75 提示气流受限 PEFR 呼气风流速 其日间变异率 20 使用支扩剂后增加20 可诊断哮喘 Diagnoseofchildfoodasthma gasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegasp cough 1month antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexcludeothercoughdisease Diagnoseofcoughvariantasthma therapy Principle