内科学呼吸系统总论

2023.9Introductionto

RespiratorySystemJiemingQu第1页IntroductionTheRespiratorySystemStructureDetail

2第2页Introduction3第3页IntroductionDeathRateof10MainDiseasesinCertainRegionin2023(China)

Rank

City

County

CauseDeathRate1/100000

%

CauseDeathRate1/100000

%

12345678910MalignantNeoplasmsCerebrovascularDiseaseHeartDiseaseDiseasesoftheRespiratorySystemInjury&PoisoningEndocrine,Nutritional&MetabolicDiseasesDiseasesoftheDigestiveSystemDiseaseoftheGenitourinarySystemDiseaseoftheNervousSystemMentalDisorders

144.5793.6990.7269.2932.3617.5915.617.284.953.4427.2517.6617.1013.066.103.322.941.370.930.65MalignantNeoplasmsCerebrovascularDiseaseDiseasesoftheRespiratorySystemHeartDiseaseInjury&PoisoningDiseasesoftheDigestiveSystemEndocrine,Nutritional&MetabolicDiseasesDiseaseoftheGenitourinarySystemDiseaseoftheNervousSystemMentalDisorders

130.23105.4884.9471.8446.1217.008.166.654.163.7725.1420.3616.4013.878.903.281.571.280.800.73Total90.41Total92.324第4页Majortasks:

Whatdisease?(disease’sdiagnosis)Howtodealwithit?(disease’smanagement)5第5页ClinicalPresentation6第6页Commonpresentingsymptoms:Dyspnea(shortnessofbreath)CoughLesscommonsymptoms:Hemoptysis(thecoughingupofblood)Chestpain(oftenwithapleuriticcharacteristics)History7第7页Acute(overaperiodofhourstodays):

AcuteattackofasthmaAcutepulmonaryedemaBacterialpneumoniaPneumothoraxPulmonaryembolusHistoryDyspnea8第8页Subacute(overdaystoweeks):AsthmaChronicbronchitisPleuraleffusionCongestiveheartfailurePneumocystiscariniipneumoniainpatientswithAIDSWegener'sgranulomatosis,eosinophilicpneumonia,BronchiolitisobliteranswithorganizingpneumoniaGuillain-Barresyndrome,myastheniagravis

HistoryDyspnea9第9页Chronic(overmonthstoyears):

COPDChronicinterstitiallungdiseaseChroniccardiacdiseaseHistoryDyspnea10第10页

Acuteorchronic?

Seasonalorassociatedwithwheezing?Associatedwithsymptomssuggestiveofpostnasaldriporgastroesophagealreflux?Associatedwithfeverorsputum?Anyassociateddiseasesorriskfactorsfordisease(e.g.,cigarettesmoking,riskfactorsforinfectionwithHIV,environmentalexposures)?HistoryCough11第11页Originatingfromtheairways:

Bronchitis,Bronchiectasis,Cysticfibrosis,Bronchogeniccarcinoma,BronchialcarcinoidtumorsOriginatingfromthepulmonaryparenchyma:Pneumonia,Lungabscess,Tuberculosis,InfectionwithAspergillus,Goodpasture’ssyndrome,Idiopathicpulmonaryhemosiderosis(IPH)Originatingfromthevasculature:Thromboembolicdiseases,ArteriovenousmalformationsHistoryHemoptysis12第12页Usuallyoriginatingfrominvolvementoftheparietalpleura:PleuritisPneumothoraxNeoplasmPulmonaryembolismPneumoniaHistoryChestpain13第13页

ThenumberofyearsofsmokingTheintensity(i.e.,numberofpacksperday)TheintervalsincesmokingcessationAhistoryofsignificantsecondhand(passive)exposuretosmokeHistoryHistoryofsmoking14第14页Respiratorydisordersassociatedwithsmoking:ChronicobstructivelungdiseaseNeoplasiaSpontaneouspneumothoraxRespiratorybronchiolitis-interstitiallungdiseaseEosinophilicgranulomaofthelungPulmonaryhemorrhagewithGoodpasture'ssyndromeHistoryHistoryofsmoking15第15页

Occupational(detailedoccupationalandpersonalhistories)orAvocational(hobbies,homeenvironment)

Inorganicdusts(asbestos,silicadusts)associatedwithpneumoconiosiswhileorganicantigens(molds,animalproteins)associatedwithhypersensitivitypneumonitisHistoryExposuretoinhaledagents16第16页

Systemicrheumaticdiseases

RiskfactorsforAIDS

Treatmentofnonrespiratorydisease(immunosuppressiveagents,cancerchemotherapy,radiationtherapy,amiodarone,ß-blockingagents,angiotensin-convertingenzymeinhibitors(ACEI))

HistoryCoexistingnonrespiratorydiseases17第17页Geneticcomponent:

Cysticfibrosisα1-antitrypsindeficiencyPulmonaryhypertensionPulmonaryfibrosisAsthmaHistoryFamilyhistory18第18页

TherateandpatternofbreathingThedepthandsymmetryoflungexpansionPhysicalExaminationInspection19第19页

Thesymmetryoflungexpansion,confirmingthefindingsobservedbyinspectionVibrationproducedbyspokensoundsFocaltendernessPhysicalExaminationPalpation20第20页

TherelativeresonanceordullnessofthetissueunderlyingthechestwallPhysicalExaminationPercussion21第21页

ThequalityandintensityofthebreathsoundsThepresenceofextra,oradventitioussoundsTheprimaryadventitious(abnormal)soundsthatcanbeheardincludecrackles(rales),wheezes,andrhonchiOtheradventitioussoundsincludepleuralfrictionrubsandstridorPhysicalExaminationAuscultation22第22页PhysicalExaminationTypicalChestExaminationFindingsinSelectedClinicalConditionsPercussionTactileFremitusBreathSoundsVocalResonanceAdventitiousSoundsConsolidationoratelectasis(withpatentairway)DullIncreasedBronchialBronchophony,whisperedpectoriloquy,egophonyCracklesConsolidationoratelectasis(withblockedairway)DullDecreasedDecreasedDecreasedAbsentAsthmaResonantNormalVesicularNormalWheezingInterstitiallungdiseaseResonantNormalVesicularNormalCracklesEmphysemaHyperresonantDecreasedDecreasedDecreasedAbsentorWheezingPneumothoraxHyperresonantDecreasedDecreasedDecreasedAbsentPleuraleffusionDullDecreasedDecreasedDecreasedAbsentorpleuralfrictionrub23第23页AdditionalDiagnosticEvaluation24第24页

Collectedeitherbyspontaneousexpectorationorafterinhalationofanirritatingaerosol,suchashypertonicsalineQualifiedsample:Squamousepithelialcells<10/HP,WBC>25/HPorWBC/Squamousepithelialcells>2.5

CollectionofSputum25第25页

Stainingandcultureformycobacteriaorfungi

Cultureforviruses

StainingforPneumocystiscarinii(especiallyinapatientinfectedwithHIV)

CytologicstainingformalignantcellsTheuseofpolymerasechainreaction(PCR)amplificationandDNAprobesCollectionofSputum26第26页ArterialBloodGasesMechanismsofhypoxemia:AdecreaseininspiredPO2HypoventilationShuntingV/Qmismatching27第27页ArterialBloodGasesMechanismofhypercapnia:IncreasedCO2productionDecreasedventilatorydrive("won'tbreathe")Malfunctionoftherespiratorypumporincreasedairwaysresistance("can'tbreathe")Inefficiencyofgasexchange(increaseddeadspaceorV/Qmismatch)28第28页RoutineRadiographyPosteroanterior(PA)DIL29第29页RoutineRadiographyAnteroposterior(AP)ARDS30第30页ChestRadiographyRheumatoidnodule(oneorseveralnodules):Vascularmalformation,BronchogeniccystLocalizedopacification(infiltrate):Pneumonia(bacterial,atypical,mycobacterial,orfungalinfection),Neoplasm,Radiationpneumonitis,Bronchiolitisobliteranswithorganizingpneumonia(BOOP),Bronchocentricgranulomatosis,PulmonaryinfarctionMajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(1)31第31页ChestRadiography

MajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(1)

Diffuseinterstitialdisease:Idiopathicpulmonaryfibrosis,Pulmonaryfibrosiswithsystemicrheumaticdisease,Sarcoidosis,Drug-inducedlungdisease,Pneumoconiosis,Hypersensitivitypneumonitis,Infection(Pneumocystis,viralpneumonia),Eosinophilicgranuloma32第32页ChestRadiographyDiffusealveolardisease:Cardiogenicpulmonaryedema,AcuterespiratorydistresssyndromeDiffusealveolarhemorrhage:Infection(Pneumocystis,viralorbacterialpneumonia),SarcoidosisDiffusenodulardisease:Metastaticneoplasm,Hematogenousspreadofinfection(bacterial,mycobacterial,fungal),Pneumoconiosis,EosinophilicgranulomaMajorRespiratoryDiagnoseswithCommonChestRadiographicPatterns(2)33第33页ComputedTomography

DistinguishingvariousdensitiesParticularlyvaluableinassessinghilarandmediastinaldiseaseIdentifyingareasoffatdensityorcalcificationinpulmonarynodulesAssessmentinthestagingoflungcancerDistinguishingvascularfromnonvascularstructures34第34页CTscandemonstratingamediastinalmassComputedTomography35第35页High-resolutionCTscanfromapatientwithidiopathicpulmonaryfibrosis.scatteredreticulardensities(arrows)ComputedTomography36第36页Idiopathicpulmonaryfibrosis.High-resolutionCTimageshowsbibasal,peripheralpredominantreticularabnormalitywithTractionbronchiectasisandhoneycombingComputedTomography37第37页exudativephaseofARDSinwhichdependentalveolaredemaandatelectasispredominateComputedTomography38第38页ComputedTomography

HelicalCTscanningCTangiographyHigh-resolutionCT(HRCT),thethicknessofindividualcrossisapproximately1to2mmVirtualbronchoscopy39第39页PET

Positronemissiontomographic(PET)scanning

isincreasinglybeingusedtoidentifymalignantlesionsinthelungbasedontheirincreaseduptakeandmetabolismofglucoseThetechniqueinvolvesinjectionofaradiolabeledglucoseanalogue,18F-fluoro-2-deoxyglucose

(FDG),whichistakenupbymetabolicallyactivemalignantcells40第40页PulmonaryAngiography

ThepulmonaryarterialsystemcanbevisualizedIncasesofpulmonaryembolism,pulmonaryangiographydemonstratestheconsequencesofanintravascularclot—eitheradefectinthelumenofavessel(a"fillingdefect")oranabrupttermination("cutoff")ofthevesselWithadvancesinCT1scanning,traditionalpulmonaryangiographyisincreasinglybeingreplacedbyCTangiography41第41页ThoracentesisEffusiontobeclassifiedaseitherexudativeortransudativeExudativepleuraleffusionsmeetatleastoneofthefollowingcriteria:pleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6

pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserum42第42页PulmonaryFunctionTestThetwomeasurementsoflungvolumecommonlyusedforrespiratorydiagnosis:Totallungcapacity(TLC)Residualvolume(RV)ThevolumeofgasthatisexhaledfromthelungsingoingfromTLCtoRVisthevitalcapacity(VC)DisturbancesinVentilatoryFunction43第43页PulmonaryFunctionTestLungvolumes,shownbyblockdiagrams(left)andbyaspirographictracing(right)*Totallungcapacity(TLC)*Vitalcapacity(VC)*Residualvolume(RV)*Inspiratorycapacity(IC)*Expiratoryreservevolume(ERV)*Functionalresidualcapacity(FRC)DisturbancesinVentilatoryFunction44第44页PulmonaryFunctionTestanormaltracing(A)obstructive(B)parenchymalrestrictive(C)Disease*Forcedvitalcapacity(FVC)*Forcedexpiratoryvolume(FEV)*Forcedexpiratoryflow(FEF)DisturbancesinVentilatoryFunction45第45页PulmonaryFunctionTestThreemaincategoriesofdiseaseareassociatedwithloweredDLCO:InterstitiallungdiseaseEmphysemaPulmonaryvasculardiseaseAnelevatedDLCOmaybeusefulinthediagnosisofalveolarhemorrhage,asinGoodpasture'ssyndromeDiffusingCapacity46第46页PulmonaryFunctionTestFlow-volumecurvesindifferentconditions:O,obstructivedisease;R(P),