呼吸系统疾病6

呼 吸 系 统 疾 病,复 习,一呼吸系统组成及特点气管 支气管 小支气管 细支气管 终末细支气管 肺泡 肺泡囊 肺泡管 呼吸性细支气管*肺导气部 *肺呼吸部*小气道 *肺小叶 *肺腺泡,二肺组织学 气管和支气管的组织结构：分三层，粘膜上皮含三种细胞,粘膜上皮中含假复层或单层纤毛柱状上皮，杯状细胞和神经内分泌细胞,细支气管：上皮成分，不含软骨和腺体,肺泡上皮：分I型和II型，数量和功能,Microscopic structure of the alveolar wall. Note that the basement membrane (yellow) is thin on one side and widened where it is continuous with the interstitial space. Portions of interstitial cells are shown.,trachea,bronchiole,pulmonary alveoli,三 呼吸系统的防御装置:,*黏液-纤毛排送系统 210m*肺泡巨噬细胞 2000g，可达2500g两肺散在分布的灰白色斑片，病变区质地变实严重者整个大叶实变，似大叶性肺炎.,镜下观：,以细支气管为中心的肺急性纤维素性化脓性炎细支气管壁大量中性粒细胞浸润，组织坏死；肺泡腔内充满大量中性粒细胞、巨噬细胞、纤维素及脱落的肺泡上皮细胞，其内含军团杆菌肺泡壁血管扩张、充血纤维素性胸膜炎,肺的病理变化,小脓肿,病 毒 性 肺 炎,Viral Pneumonia,病原：常见为流感病毒,其次为呼吸道合胞 病毒、腺病毒、副流感病毒、麻疹病 毒、单纯疱疹病毒和巨细胞病毒年龄分布：儿童多见,病 理 变 化,小叶间隔和肺泡壁增宽间质充血水肿淋巴细胞、单核细胞浸润肺泡一般不累及重者有肺泡的浆液纤维素性炎巨细胞包涵体形成,病毒包涵体性状： 约红细胞大小，常呈嗜酸性红染，其周围有透明晕。,病毒包涵体位置：在增生的上皮细胞中 仅在细胞浆：呼吸道合胞病毒 胞浆和胞核：麻疹病毒 仅在细胞核：腺病毒、单纯疱疹病毒 巨细胞病毒,Cytomegalovirus distinct nuclear cytoplasmic inclusions in the lung,Cells from the blister in showing glassy intra-nuclear herpes simplex inclusion bodies,Measles giant cells in the lung. Note the glassy eosinophilic intranuclear and cytoplasmic inclusions,Severe acute respiratory syndrome,严重急性呼吸综合征,病原体：冠状病毒 病理改变：主要在肺 肉眼：肿胀、重量增加、切面实变，似大叶性肺炎 镜下：急性弥漫性肺泡损伤改变，如肺水肿、纤维素渗出、透明膜形成，巨噬细胞聚集和II型肺泡上皮脱落，肺泡上皮融合成多核巨细胞，胞质内病毒包涵体形成。,支原体性肺炎,Mycoplasmal Pneumonia,概 念,支原体是一种介于细菌与病毒间的微生物，引起间质性肺炎改变，在肺炎支原体被发现以前，被称为原发性非典型肺炎。种类多，但仅肺炎支原体能引起呼吸道疾病。,传播途径 ：多经飞沫感染年龄分布：青少年，并随年龄增长而降低。X-ray: 肺部节段性的纹理增强及网状或斑片状阴影。不易与病毒性肺炎鉴别：肺炎支原体培养确诊。,病 理 变 化,肉眼：病变常仅累及一个肺叶，以下叶多见，病灶呈节段性分布。镜下：病变主要发生在肺间质，肺泡间隔明显增宽，充血、水肿，伴大量淋巴细胞、浆细胞和单核细胞浸润，肺泡腔一般无渗出物。,间质性肺炎：肺泡间隔增宽，大量炎细胞浸润,Pneumocystis Pneumonia,卡氏肺孢菌性肺炎,Pneumocystis Pneumonia病原体：原认为是原虫易感者：几乎每人出生后都受过感染，但呈隐性感染；AIDS、营养不良的婴幼儿、免疫功能抑制者,间质性肺炎改变肺泡腔内充满大量泡沫性渗出物银染可显示泡沫性渗出物和巨噬细胞内的肺孢菌。46微米；新月形、足球样或头盔样；囊壁厚，内有12微米大小之滋养体。,慢性阻塞性肺病chronic obstructive pulmonary disease, COPD,1.病因及发病机制 *感染因素 *理化因素 *过敏因素 *吸 烟,一慢性支气管炎(chronic bronchitis),2.病理变化 (1) 粘膜上皮的损伤与修复 (2) 腺体的变化 (3)平滑肌、软骨的改变 (4)管壁充血，慢性炎细胞浸润,3.临床病理联系: 咳嗽 咳痰 喘息4.并发症: 肺气肿 慢性肺源性心脏病,肺气肿pulmonary emphysema,指呼吸细支气管、肺泡管、肺泡囊和肺泡因过度充气呈持久性过度扩张，并伴有肺泡间隔破坏，以致肺组织弹性减弱,容积增大的一种病理状态。,概念,2.病因及发病机制 (1) 慢性支气管炎 (2)1抗胰蛋白酶缺乏，弹性蛋白酶增多、活性增高 。,3.分类及病理变化 (1)肺泡性肺气肿(alveolar emphysema) 阻塞性肺气肿腺泡中央型(centriacinar emphysema),全腺泡型 (panacinar emphysema) 肺大泡(bullae lung) *,Centriacinar emphysema. Central areas show marked emphysematous damage (E), surrounded by relatively spared alveolar spaces.,Panacinar emphysema involving the entire pulmonary architecture,腺泡周围型(periacinar emphysema) (2)间质性肺气肿(interstitial emphysema)(3)其它 瘢痕旁肺气肿(不规则型肺肿) (paracicatrical emphysema) 老年性肺气肿(老年性肺过度充气) (senile emphysema) 代偿性肺气肿(非真性肺气肿) (compensatory emphysema),(1)肉眼 体积膨大 边缘钝圆 色泽灰白 弹性差,病变特点,(2)镜下,5. 临床表现,(1)呼气性呼吸困难(2)桶状胸 (3)胸片,肺功能检查(4)并发症： 肺心病 自发性气胸 呼吸衰竭及肺性脑病,支气管扩张症bronchiectasis,1.概念：肺内支气管管腔持久性扩张伴管壁纤维性增厚的慢性化脓性疾病。2.病因及发病机理 (1)感染 (2)遗传因素:,3.病理变化,部位肉眼,镜下,The bronchial wall shows acute and chronic inflammation. The lumen is filled with inflammatory exudate,(1)慢性咳嗽、大量脓痰、反复咯血、胸痛、感染中毒症状。临床确诊:支气管碘油造影。 (2)并发症:肺炎、肺脓肿、脓胸、脓气胸、肺气肿、肺心病,4.临床表现,肺尘埃沉着症 pneumoconiosis,病灶在哪？,1.概述 2.病因及发病机理 (1)病因:游离SiO2 进入肺泡的硅尘微粒去路：,肺硅沉着症(silicosis),(2)机理: 肺泡巨噬细胞吞噬硅尘硅尘与溶酶体融合SiO2与水聚合成硅酸硅酸的羟基与溶酶体膜内脂蛋白中氢原子形成氢键损伤溶酶体膜的稳定性或完整性溶酶体膜通透性增高或破裂大量水解酶溢到巨噬细胞胞浆内巨噬细胞自溶崩解（释放硅尘及致纤维化因子、炎症介质）。,3.病变,基本病变: 硅结节形成和弥漫性肺间质纤维化 特征性病变: 硅结节(silicotic nodule) 肉眼: 边界清楚，直径2-5mm，圆形或椭圆形，灰白色，质硬，有砂样感。晚期直径可超过2cm，中央可形成空洞。,Advanced silicosis seen on transection of lung. Scarring has contracted the upper lobe into a small dark mass (arrow). Note the dense pleural thickening.,镜下: 细胞性硅结节纤维性胶原性硅结节:由呈同心圆状或旋涡状排列的、已发生玻璃样变的胶原纤维构成,中央常有内膜增厚或闭塞的小血管。,Several coalescent collagenous silicotic nodules.,肺间质纤维化,(1)肺结核病:硅肺结核silicotuberculosis (2)肺源性心脏病 间质弥漫纤维化 硅结节内小血管闭塞性血管内膜炎 (3)慢性支气管炎及阻塞性肺气肿 (4)自发性气胸 5.病理与临床联系,4.并发症,鼻咽癌nasopharyngeal carcinoma,1、病因 EB病毒(Epstein-Barr Virus,EBV) 环境因素 遗传因素,(1)部位: (2)肉眼: 结节型;菜花型;溃疡型;黏膜下型 (3)镜下: . 鳞状细胞癌: . 腺癌 . 未分化癌(鼻咽型未分化癌;泡状核细胞癌),2、病变,3、扩散与转移: (1)直接蔓延 (2) 淋巴道转移 * 咽后淋巴结 颈上深淋巴结群 (3)血道转移,4、临床与病理联系： 头痛、鼻塞、回缩性涕血、耳鸣，听力减退、复视、颅神经受损症状和体征、颈部肿块,肺癌lung cancer,(1) 吸烟 (2) 空气污染 (3) 职业因素 (4) 病毒 (5) 基因的改变,1.病因,(1) 肉眼类型:中央型central carcinomaof the lung,2.病变,周围型(peripheral carcinoma of the lung)弥漫型(diffuse carcinoma of the lung),* 隐性肺癌,(2)镜下:, 鳞癌, 腺癌,细支气管肺泡癌(bronchioalvolar carcinoma),特殊类型腺癌:, 小细胞癌 small cell carcinoma,metastatic small cell lung cancer Electron micrograph,大细胞癌,腺鳞癌(混合性癌),4.病理与临床联系,(1)常见早期症状 (2)胸腔血性积液(3)局限性肺气肿或肺萎陷(4)上腔静脉综合征(5)交感神经麻痹综合征(Horner综合征)(6)上肢疼痛及手部肌肉萎缩:侵犯壁丛神经(7)肺外症状:副肿瘤综合征 *早期诊断,A 54-year-old male presents with several problems involving his face and pain in his shoulder. He states that he has smoked 2 packs of cigarettes a day for almost 40 years. Physical examination reveals ptosis of his left upper eyelid, constriction of his left pupil, and lack of sweating (anhidrosis) on the left side of his face. No other neurologic abnormalities are found.,练习题,This individual most likely has a. A bronchioloalveolar carcinoma involving the left upper lobeb. A small cell carcinoma involving the hilum of his left lungc. A squamous cell carcinoma involving the left mainstem bronchusd. An adenocarcinoma involving the apex of his left lunge. An endobronchial carcinoid tumor involving the right mainstem bronchus,Question,A 39-year-old female presents with a cough and increasing short- ness of breath. A chest x-ray is interpreted by the radiologist as show-ing a rightlower lobe (RLL) pneumonia. No mass lesions are seen. The woman istreated with antibiotics, but her symptoms do not im-prove. On her return visit, the area of consolidation appears to be in-creased. Bronchoscopy is performed. No bronchial masses are seen, but a transbronchial biopsy is obtained in an area of mucosal erythe-ma in the RLL. After the diagnosis is made, the RLL is removed and a section from this specimen reveals welldifferentiated mucus-secret-ing columnar epithelial cells that infiltrate from alveolus to alveolus.,What is the correct diagnosis? a. Bronchioloalveolar carcinoma b. Carcinoid c. Large cell carcinoma d. Small cell carcinoma e. Squamous cell carcinoma,Question,A 67-year-old male long-term smoker presents with weight loss, a persistent cough, fever, chest pain, and hemoptysis. Physical exam-ination reveals a cachectic male with clubbing of his fingers and dull-ness to percussion over his right lower lobe. A chest x-ray reveals a 3.5-cm hilar mass on the right and postobstructive pneumonia of the right lower lobe. Sputum cytology is suspicious for malignant cells. Histologic examination of a transbronchial biopsy specimen reveals infiltrating groups of cells with scant cytoplasm. No glandular struct-ures or kera