内科学教学课件：PNEUMONIA

1PNEUMONIA2ContentsGeneralInformationCAPHAPCharacteristicsofpneumonia3PARTⅠ

GeneralInformation4inflammatoryillnessofthelunglungparenchyma/alveolarinflammationandabnormalalveolarfillingwithfluidDefinitionnormallung5IncidenceOneofmostcommonillnessinallagegroupsTheannualincidenceinthecommunity:5–11/1000adultpopulationTheincidenceofCAP

requiringadmissiontohospital:1.1-4/1000

population;22%-42%ofadultswithCAPareadmittedtohospital5%-10%ofadultsadmittedtohospitalwithCAP

aremanagedonanICU6Mortalitythesixthmostcommoncausesofdeathworldwide

#1leadingcauseofdeathfrominfectiousdiseaseThereportedmortalityrateofadultswithCAPmanagedinthecommunityintheUKisverylowatlessthan1%ThereportedmortalityrateofadultsadmittedtohospitalwithCAPintheUKhasvariedbetween5.7%-12%ThemortalityrateofpatientswithsevereCAPrequiringadmissiontoanICUintheUKishighatover50%7PneumoniaInduced:

TypeⅠ(PaO2↓)？

TypeⅡ(PaO2↓、PaCO2↑)？

RespiratoryFailurePathophysiology8Normallung:air-filledalveoliresponsibleforabsorbingoxygenfromtheatmospherePathophysiologyPneumonia:alveolifilledwithinflammationanddebris,keepingoxygenfromreachingthebloodstreamAirwayDiseasePneumonia9airbornedropletsinhaled,orthroughthebloodstream,ormigratetothelungsdirectlyfromanearbyinfectioninvadethespacesbetweencellsandbetweenalveolithroughconnectingporestriggerstheimmunesystemtosendneutrophilstothelungsTheneutrophilsengulf

andkilltheoffendingorganisms,andalsoreleasecytokines,causingactivationofimmunesystem.Thisleadstothefever,chills,andfatigueTheneutrophils,bacteria,andfluidfromsurroundingbloodvesselsfillthealveoliandinterruptnormaloxygentransportationPathophysiology10Etiological/MicrobiologicalClassificationAnatomical/RadiologicalClassificationCombinedClinicalClassificationClassification11SoMany

Classification？Classification12LobarpneumoniaBronchopneumoniaInterstitialpneumoniaAnatomical/Radiologicalclassification13Etiological/MicrobiologicalclassificationInfectionwithbacteria,viruses,fungi,orparasitesChemicalorphysicalinjurytothelungsImmunologicalInjuryUnknowncauses14Community-acquiredpneumonia(CAP)Hospital-acquiredpneumonia(HAP)--Ventilatorassociatedpneumonia(VAP)Healthcare-associatedpneumonia(HCAP)Immunocompromisedhostpneumonia(ICHP)Combinedclinicalclassification15Fever,headaches,sweaty,jointpainsormuscleachesCough,shortnessofbreath,pleuriticchestpainLossofappetite,fatigue,nausea,vomitingSymptoms16DecreasedexpansionIncreasedvocalresonanceDulledpercussionBronchialbreathing,RalesSighs17Medicalhistory

Physicalexamination

Laboratory

examination

--Radiologicalexamination

--MicrobiologicalexaminationDiagnosis18Radiological

examinationChestplainfilmCTUltrasound19normalchestx-rayRadiologicalexaminationshadowingfrompneumoniaintherightlung20MicrobiologicalexaminationGramstainSpecialstainCulturecultureshouldbeobtainedpriortoantibiotics21Culture--sputumqualifiedsputum

<10epithelialcells&>25PMN’sperfieldquantitativeculture107,106,105,104cfu/mlsemi-quantitativeculture

++++,+++,++,+22Lowrespiratorytractspecimentranstrachealaspiration,TTAendotrachealaspiration,ETAprotectedspecimenbrush,PSBbronchialalveolarlavage,BALlungaspiration,LA23bloodpleuralfluidsOther

specimen24ClinicalDiagnosis

(ChineseGuideline)1.新近出现的咳嗽、咳痰或原有呼吸道疾病症状加重，并出现脓性痰，伴或不伴胸痛2.发热3.肺实变体征和(或)闻及湿性啰音4.WBC>10×109/L或<4×109/L，伴或不伴细胞核左移5.胸部X线检查显示片状、斑片状浸润性阴影或间质性改变，伴或不伴胸腔积液25肺炎诊断标准:那一条最重要？

MostWanted?ClinicalDiagnosis26ClinicalDiagnosis以上1～4项中任何1项加第5项Category5:MostImportant?27ClinicalDiagnosis

除外肺结核、肺部肿瘤、非感染性肺间质性疾病、肺水肿、肺不张、肺栓塞、肺嗜酸性粒细胞浸润症及肺血管炎等！！！ExcludeEveryDiseaseThatCanMimicPneumoniaBeforeDiagnosisEstablished28PneumoniaSeverityIndex(ATS--PSI)Respiratoryrate>30/minuteSystolicbloodpressure<90

mmHgTemperature<35°Cor≥40°CPulse≥125/minuteArterialpH<7.35Bloodureanitrogen≥30

mg/dl(9

mmol/liter)Sodium<130

mmol/literGlucose≥250

mg/dl(14

mmol/liter)Hematocrit<30%PartialpressureofarterialO2<60mmHg30day29BTS--CURB-6530Severity—ATS/IDSAMajorcriteriaInvasivemechanicalventilationSepticshockwiththeneedforvasopressorsMinorcriteria

Respiratoryrate>30breaths/minPaO2/FiO2ratio<250MultilobarinfiltratesConfusion/disorientationUremia(BUNlevel>20mg/dL)Leukopenia(WBCcount<4000cells/mm3)Thrombocytopenia(plateletcount<100,000cells/mm3)Hypothermia(coretemperature<36℃)Hypotensionrequiringaggressivefluidresuscitation1major3minor31General

ManagementRestHomecareFluidsOxygentreatmentMechanicalventilation32AntimicrobialTreatmentTargetedTreatmentEmpiricTreatment33中国成人CAP监测资料刘又宁，陈民钧，赵铁梅等.中华结核和呼吸杂志，2006,29;3-8中国城市成人社区获得性肺炎665例病原学多中心调查病原体检出百分率34中国CAP致病原的构成情况上海地区CAP的致病原构成情况(n=244)黄海辉，张婴元，黄绍光等.中国抗感染化疗杂志.2003；6：321-324注：部分病例为混合感染，14岁以下儿童占30.8%（75/244）病原体检出百分率35AntimicrobialTreatmentLocalSusceptibilitySurveillance瑞金医院细菌耐药性监测报告36Pharmokinetics/Pharmodynamics(PK/PD)

concentration-timecurve37AntimicrobialTreatmentpharmokinetics/pharmodynamics(PK/PD)--T>MIC%(penicillin)--Cmax/MIC(8-10)(quinolones)38AppropriatelytreatingunderlyingillnessesVaccination

PneumococcalpneumoniavaccineHaemophilusinfluenzaetypebvaccineInfluenzavaccineMedicationsAmantadine(金刚脘胺)Rimantadine(金刚乙胺)Zanamivir(扎那米韦)Oseltamivir(奥司他韦/达菲)Prevention39RatesofPCV7-typeInvasivePneumococcalDiseaseamongAdults,U.S.,1998/99-2006>80yrs65-79yrs50-64yrs18-49yrs40PARTⅡCAP41infectiouspneumoniainapersonwhohasnotrecentlybeenhospitalizedmostcommontypeofpneumoniaCommunity-acquiredpneumoniaCAP42PathogenPrevalence（%）

Spneumoniae（肺炎链球菌）20–60Hinfluenzae（流感嗜血杆菌）3–10Oralanaerobes（口腔厌氧菌）6–10Saureus（金黄色葡萄球菌）3–5OtherGram-negativebacteria（其他革兰阴性菌）3–10Respiratoryviruses（呼吸道病毒）2–15Lpneumophila（嗜肺军团菌）2–8Cpneumoniae（肺炎衣原体）

5–17Community-acquiredpneumoniaCAP43InitialempirictherapyforsuspectedCAP

outpatient:previouslyhealthyNorecentantibiotictherapy

Amacrolide(大环内酯)ordoxycycline(多西环素)RecentantibiotictherapyArespiratoryfluoroquinolone(呼吸氟喹诺酮)aloneAnadvancedmacrolide(大环内酯)plushigh-doseamoxicillin(阿莫西林)Anadvancedmacrolide(大环内酯)plushigh-dose

amoxicillin-clavulanate(阿莫西林/克拉维酸)44InitialempirictherapyforsuspectedCAP

outpatient:comorbiditiesNorecentantibiotictherapy

Anadvancedmacrolide(大环内酯)orarespiratoryfluoroquinolone(呼吸氟喹诺酮)Recentantibiotictherapy

Arespiratoryfluoroquinolone(呼吸氟喹诺酮)aloneoranadvancedmacrolide(大环内酯)plus

β-lactam

(β内酰胺类)

Suspectedaspirationwithinfection

Amoxicillin-clavulanate(阿莫西林/克拉维酸)orclindamycin(克林霉素)Influenzawithbacterialsuperinfection(细菌二重感染)

Aβ-lactam(β内酰胺类)orarespiratoryfluoroquinolone(呼吸氟喹诺酮)45InitialempirictherapyforsuspectedCAP

InpatientNorecentantibiotictherapy

Arespiratoryfluoroquinolone(呼吸氟喹诺酮)aloneoranadvancedmacrolide(大环内酯)plusab-lactam(β内酰胺类)

Recentantibiotictherapy

Anadvancedmacrolide(大环内酯)plusab-lactam(β内酰胺类)orarespiratoryfluoroquinolone(呼吸氟喹诺酮)alone(regimenselectedwilldependonnatureofrecentantibiotictherapy)46InitialempirictherapyforsuspectedCAP

ICUPseudomonasinfectionisnotanissue

Ab-lactampluseitheranadvancedmacrolideorarespiratoryfluoroquinolonePseudomonasinfectionisnotanissuebutpatienthasab-lactamallergy

Arespiratoryfluoroquinolone,withorwithoutclindamycinPseudomonasinfectionisanissue(1)anantipseudomonalagentplusciprofloxacin(环丙沙星)(2)anantipseudomonalagentplusanaminoglycosideplusarespiratoryfluoroquinoloneoramacrolidePseudomonasinfectionisanissuebutthepatienthasab-lactamallergy(1)aztreonam(氨曲南)pluslevofloxacin(左氧氟沙星)(2)aztreonamplusmoxifloxacin(莫西沙星)orgatifloxacin(格替沙星),withorwithoutanaminoglycoside(氨基糖苷类)47PARTⅢ

HAP48Pneumoniaacquiredduringorafterhospitalizationforanotherillnessorprocedurewithonsetatleast48hrsafteradmissionThecauses,microbiology,treatmentandprognosisaredifferentfromthoseofcommunity-acquiredpneumoniaHospital-acquiredpneumoniaHAP49Ventilator-AssociatedPneumonia

VAPPneumoniaacquired48hrs

afterintubation50HAPriskfactors

MechanicalventilationProlongedmalnutritionUnderlyingheartandlungdiseasesDecreasedamountsofstomachacidImmunedisturbancesExposedtomoredangerousbacteriaEndotrachealintubationincreasesriskofdevelopingpneumoniaby

6to21fold51CausesGram-negativebacterium

Klebsiellapneumoniae(肺炎克雷伯杆菌)Pseudomonasaeruginosa（铜绿假单胞菌）

Acinetobacterbaumannii(鲍曼不动杆菌)methicillin-resistantStaphylococcusaureus

(MRSA,耐甲氧西林金黄色葡萄球菌)52ClassificationEarlyHAP

admission≤5d

mechanicalventilation≤4d

LateHAPadmission>5d

mechanicalventilation>4d

53PARTⅣ

Characteristicsofpneumonia

causedbydifferentmicro-organism54StreptococcuspneumoniaeorpneumococcusGram-positive

diplococcusmostcommonbacterialcauseofpneumoniaStreptococcuspneumoniae55ClinicalCharacteristicsPrecededbyaviralillnessAcuteonsetofhighfever--oftenwithrigorsProductivecoughPleuralpainDyspnea56ClinicalCharacteristicsTypicalchestradiography:lobarconsolidationCavitationisnotafeatureofSpneumoniaepneumonia57ChestXRay58Inthe1960s,nearlyallstrainsofS.pneumoniaeweresusceptibletopenicillinincreasingprevalenceofpenicillinresistance,especiallyinareasofhighantibioticusealsoresistanttocephalosporins,macrolides,tetracycline,clindamycinandthequinolonesMostisolatesremainsusceptibletovancomycinAntibioticTreatment59Penic.Resist.ofS.pneumoniae,200160Gram-positivecoccus,whichappearsasgrape-likeclustersCoagulase-positiveColoniesaregoldenandstronglyhemolyticonbloodagarStaphylococcus

aureus61ClinicalCharacteristicsCAP:notcommon

withinfluenzaWithhigh-riskdiseasesreceivingcorticosteroidsorimmunosuppressantsHAP:commonlungabscesses(肺脓肿)pneumatoceles(肺气囊肿)empyema(脓胸)62Chest

X

RayMultilobarconsolidation(实变)Cavitation(空洞)Pneumatocoeles(肺气囊肿)Spontaneouspneumothorax(气胸)63ChestXRay64Antibiotic

TreatmentMethicillin-resistantS.aureus(MRSA,耐甲氧西林金黄色葡萄球菌)Vancomyciniseffectiveformosthospital-acquiredMRSAvancomycin-resistantstrainshaveappeared65协和医院57.3%北京医院74.9%华山医院80.4%瑞金医院67.0%新疆医科大学附属第一医院31.0%广医一附院74.7%武汉同济医院58.1%重医一附院33.3%甘肃省人民医院64.8%浙大一附院53.9%汪复，朱德妹,胡付品等.2007年中国CHINET细菌耐药性监测.中国感染与化疗杂志2007，8(5):325-333.MRSA：全国各医院分离率66KlebsiellapneumoniaeGram-negative,rodshapedbacterium67ClinicalCharacteristicssuddenonsethighfeverHemoptysis(currantjellysputum)affectsoneoftheupperlobesofthelungLobarpneumonia:destructivechangesabscessformationCavitationpleuraladhesionsEmpyema68ChestX

Ray

bulginginterlobarfissure(叶间裂明显增厚)cavitaryabscesses(易形成空洞性脓肿)69TreatmentKlebsiellapossessesachromosomalclassAbeta-lactamase(β-内酰胺酶)givingitinherentresistancetoampicillinManystrainshaveacquiredanextended-spectrumbeta-lactamase(ESBL,超广谱β-内酰胺酶)withadditionalresistancetocarbenicillin(羧苄西林),ampicillin（氨苄西林）,quinolones（喹诺酮）,andincreasinglytoceftazidime(头孢他啶)70TreatmentKlebsiellaorganismsareESBL-producingorganisms,resistanttomultipleantibioticscarbapenemsarepreferredforESBL-producingstrains（产ESBL菌株：碳青霉烯类优先）71HighRateofESBL-producingBacteriainChina(CHINET)WangFu,CHINET2006surveillanceofbacterialresistanceinChina.ClinJinfectChemother2008;8(1):1-972Resistantrate(%)ResistantrateofK.pneumoniaeinChina,2007（CHINET）WangFu,CHINET2006surveillanceofbacterialresistanceinChina.ClinJinfectChemother2008;8(5):325-333ImipenemMeropenemPiperacillin/tazobactamcefepimeCefoperazone/sulbactamAmikacinCiprofloxacinCeftazidime73Pseudomonas

Pneumoniaopportunisticpathogen,infectingthosewhohaveweakenedimmunesystems(机会性致病菌)secondmostcommoncauseofnosocomialpneumoniaandthemostcommoncauseofpneumoniainintensivecareunits(院内感染常见)ManyPseudomonasareresistanttocertainantibiotics,makinginfectionsdifficulttotreat(多耐药)74MultipleDrugResistantCommonresistantpathogensincludemethicillin-resistantStaphylococcusaureusmultidrugresistantPseudomonasaeruginosamultidrugresistantAcinetobacterspeciesESBL-producingstrainsofEscherichiacoliandKlebsiellapneumoniae75MycoplasmaPneumoniaeVerysmallbacteriumUnlikebacteria,lacksacellwall.resistanttotheeffectsofpenicillinsandotherbeta-lactamantibiotics,whichactbydisruptingthebacterialcellwallUnlikevirusesdonotneedahostcellforreplication76ClinicalCharacteristicGradualonsetCommoninhealthypatientsyoungerthan40years,withthehighestratein5-20yearoldsProlongedparoxysmalcoughduetotheinhibitionofciliarymovementLackofsputumproductionWealthofextra-pulmonarysymptoms77CommonsymptomsHeadacheFever(maybehigh)ChillsExcessivesweatingCough-Usuallydry

-UsuallywithoutphlegmorbloodChestpainSorethroatLesssymptomsSkinlesionsorrashEyepainorsorenessMuscleachesandjointstiffnessNecklump(肿块)RapidbreathingEarpainSymptoms

and

Sighs78DiagnosisSerologytests:4-foldorgreaterincreaseordecreaseinpairedseratitersorasingletitergreaterthanorequalto1:32Serumcoldagglutination(冷凝集试验)isanonspecifictestforMpneumoniae,butfindingsarepositivein50%-70%ofpatientsafter7-10daysofinfection79ChestX

Ray80TreatmentMacrolideQuinolones81Legionnaire’sPneumonia82Legionella

pneumophilia

coolingtowers,HVAC（heating,ventilating,andairconditioning）systems,airconditioners,soil

83CommonsymptomsFatigueFever(oftenhigh)Chillsandmuscleaches

Drycough

ChestpainwithcoughingorbreathingLossofappetiteHeadacheSymptomsifserious

ShortnessofbreathAbdominalpain

Nausea,vomiting,ordiarrheaMentalproblems,confusion,ormemorylossabnormalliverfunctiontestselevatedserumcreatinekinaseSymptoms

and

Sighs84DiagnosisBloodtest--antibodiestoLegionella（IgMorIgG）Urinetests--Legionellaproteins85TreatmentQuinolones/喹诺酮（左氧氟沙星，莫西沙星）macrolides/大环内酯(azithromycin/阿奇霉素,clarithromycin/罗红霉素,erythromycin/红霉素)Tetracycline/四环素Rifampin/利福平86ViralPneumonia87Riskfactorformoreseriousviralpneumoniaimpairedimmunesystems

HIV(人类免疫缺陷病毒)transplantpatients(移植病人)youngchildren(heartdefects)elderlymedicationstosuppresstheirimmunesystems88Commoncauses

Influenzavirus(流感病毒)Parainfluenzavirus(副流感病毒)Respiratorysyncytialvirus(RSV,呼吸合胞病毒)Adenoviruses(腺病毒)Rhinovirus(鼻病毒)Metapneumovirus(偏肺病毒)Avian(禽流感病毒)

Rarecauses

Herpessimplexvirus(HSV,单纯疱疹),innewbornsVaricella-zostervirus(VZV,带状疱疹)Cytomegalovirus(CMV,巨细胞病毒),inpeoplewithimmunesystemproblemsCauses89Viralpneumonia:Interstitialpatternwithfinelinesradiatingfromthehila(肺门).ThereisahazytransparencyreductionChestXRay90influenzaAorB:oseltamivir(奥司他韦)orzanamivir(扎那米韦)Respiratorysyncytialvirus(RSV,呼吸合胞病毒):ribavirin(利巴韦林)Herpessimplexvirus(单纯疱疹)

andvaricella-zostervirus(带状疱疹):aciclovir(阿昔洛韦)Cytomegalovirus(巨细胞病毒):ganciclovir(更昔洛韦)SARScoronavirus(严重急性呼吸综合征冠状病毒),adenovirus(腺病毒),hantavirus(汉坦病毒),orparainfluenzavirus(副流感病毒):supportiveTreatment91SwineA-H1N1fluvirus

92Rapidlyprogressingbasalandaxialinterstitial/alveolarconsolidationanddiffuseground-glassopacitiesarethedistinguishingfeaturesofswineA-H1N1fluonchestx-rayandCTFluinfectioninpatient24hoursafterclinicaldiagnosisisshownonx-ray(left)andonCTslices(right)Chestx-raystrackpatientstatus48(B)and72hours(C)afterdiagnosis93Theradiograph(PanelA)showsbilateralalveolaropacitiesinthebaseofbothlungsthatprogressedandbecameconfluent

Thespecimen(PanelB,hematoxylinandeosin)showsnecrosisofbronchiolarwalls(toparrow),aneutrophilicinfiltrate(middlearrow),anddiffusealveolardamagewithprominenthyalinemembranes(bottomarrow).Bacterialcultureswerenegativeonadmission,andnoevidenceofbacterialinfectionofthelungswasfound.Thepatientultimatelydied94呼吸衰竭RespiratoryFailure上海交通大学医学院附属瑞金医院呼吸科时国朝95DefinitionVentilation(通气)andgasexchange(换气)dysfunctioncausedbyvariouscausesLeadstohypoxia(低氧血症)withorwithouthypercarpnia(高碳酸血症)96DiagnosisAtsealevel,excludedintracardiacanatomicshunt(心内解剖分流)anddecreasedcardiacoutput(心输出量)Bloodgasanalysis(inhaledair)

PaO2<8kPa(60mmHg)PaCO2>6.67kPa(50mmHg)97EtiologyAirwayDiseaseLungDiseasePulmonaryvesculardiseaseChestwall&pleuraldiseaseCentral&peripheralnervesystemdysfunction98阻塞性通气功能障碍99肺炎100肺不张101胸腔积液102肺栓塞103间质性肺病104105ClassificationBloodgasanalysisPhysiologyPathophysiologyOnset106Classification

（Bloodgasanalysis）Hypoxia（TypeⅠ,hypoxemic）PaO2<60mmHgPaCO2↓ornormalHypercapnia（TypeⅡ）PaO2

<60mmHgPaCO2

>50mmHg107Classification（Physiology）Ventilatory(typeII,hypercapnic)ObstructiverespiratoryfailureRestrictiverespiratoryfailureNonventilatory(typeI,normcapnic)108FlowvolumeAlveolaductAirwayrespiratorymembrane

109Respiratoryairwaydisease:

ObstructiverespiratoryfailureNormalvolumeflowFlowrate↓(FEV1)uncomparablewith(VC)↓FEV1/FVC<70%110Thoracicbulging

Anteroposteriordiameter111BarrelchestNormalCOPD

AnteroposteriordiameterObstructiverespiratoryfailure112Barrelchest113Restrictiverespiratoryfailure114RestrictiveventilationfailureThoracicdeformity115Alveoladuct:

RestrictiverepiratoryfailureFlowrate↓comparablewithVC↓

FEV1/VCnormalvolume

flow116Vessleorrespiratorymembranedysfunction:

nonventilatoryRF117Classification

（Pathophysiology）PumpFailurePulmonaryfailure118Classification（onset）Acuterespiratoryfailure

OriginalnormalrespiratoryfunctionAcuteonsetCompensationunavailableChronicrespiratoryfailure

underlinechronicrespiratorydisease

GraduallyDeterioratedoracuteattackcompensationavailable

PH7.35-7.45(Hypercapnia)119急性肺损伤与急性呼吸窘迫综合征Acutelunginjury,ALIAcuterespiratorydistresssyndrome,ARDS120急性肺损伤（Acutelunginjury）成人呼吸窘迫综合症（AdultRespiratoryDistressSyndrome）渗出性肺水肿（Increased-permeabilitypulmonaryedema）非心源性肺水肿（Noncardiacpulmonaryedema）121Acuterespiratory

distresssyndromeNormalpeople,acuteonsetSecondarytoacuteextrapulmonaryorintrapulmonaryseveredisease(severeinfection,shock,burns,severetrauma,DIC,

majorsurgery）Acute,progressive,difficulttocorrectedrespiratorydistressandhypoxiaExcludedcardiogenicreasons122ARDS直接损伤弥漫性肺部感染胃内容物误吸溺水毒性气体吸入高浓度氧吸入肺挫伤间接损伤脓毒血症/全身炎症反应严重胸外创伤大量输血或输血相关急性肺损伤心肺旁路胰腺炎烧伤休克123PathogenesisSevereinfection,shock,burnsNeutrophil,Macrophages,PlateletactivatingfactorReleaseinflammatorymediatorsandcytokinesPulmonaryvascularpermeability↑Pulmonaryedema,transparentmembrane,fibrosis124PathophysiologyDiffuselunginjury,lungcirculationdysfunctionPulmonaryvascularendothelininjuryLunginterstialalveolaredemaOxygendiffusedysfunctionhypoxiaRespirationdistressAlveolarwallinjuryatelectasisIntrapulmonaryshunt↑,Pulmonarycompliance↓125DiagonosisEtiologyofARDS,onsetquickly24hrs-5daysRespiratorydistress,R>35bpmX-ray:BilateralinfiltrationHypoxianotimprovedunderroutineoxygenation(Oxygenindex)PaO2/FIO2≤200mmHgPaO2/FIO2≤300Excludeleftheartfailure，PCWP≤18mmHg126ARDS127ARDSexudativeandfibroticphases128TreatmentEtiologytreatment:TraumainfectionShocketcOxygenation:highconcentrationObject:SaO2>90%Mechanicalventilation

Positiveendexpirationpressure,PEEPsmallvolume

permissiveHypercapnicventilation129TreatmentReducelungandsystemicinflammationsystemicCorticosteroids,Antioxidants,SurfactantFluidbalanceNutritionsupport

Intensivecareunit130SystemiccorticosteroidsEarly,highdose,shortduration？Inhibitfiberosis131Who’sWatchingthePatient?132AcuteRespiratoryDistressSyndrome

TheBerlinDefinitionJAMA.2012;307(23):2526-2533JAMA.2012;307(23):2526-2533JAMA.2012;307(23):2526-2533JAMA.2012;307(23):2526-2533133慢性呼吸衰竭Chronicrespiratoryfailure134chroniclungdiseaseleadingtograduallyimpairmentofrespiratoryfunction,eventuallydeveloprespiratoryfailure.(eg:COPD,tuberculosis,interstitialdisease,neuromusculardiseasesect.Esp.COPD)

Definition

135Etiology

BronchialpulmonarydiseaseCOPD,Asthma,tuberculosis,Bronchiectasis,interstitiallungdisease…SeverethoracicdeformityTuberculosis,Ankylosing,Spondylitis,Pleuralthickening,thoracicoperationPulmonaryvasculardiseasePulmonaryhypertension,pulmonaryarteryembolism,pulmonaryprimaryarteritisNeuromusculardiseasePolio,Musculardystrophy肌营养不良,Obesityandpoorventilationsyndrome136PathogenesisHypoventilationVentilation/perfusionimbalanceDiffusionabnormalityFIO2137PathogenesisAlveolarhypoventilation

(Normal:4L/min)Restrictive限制性，Obstructive阻塞性

CarbondioxideWatervapourOxygenNitrogen138139PathogenesisDiffusionimpairment指O2

、CO2等气体通过肺泡膜进行交换的物理弥散过程发生障碍肺泡弥散面积减少（emphysema）呼吸膜增厚弥散时间（interstitiallungdisease）O2的弥散能力仅为CO2的1/20，弥散障碍通常以低氧血症为主

140141142PathogenesisVentilation-perfusionimbalance（通气/血流比例失调）正常成人静息状态下，通气/血流比值约为0.8，通气/血流比例失调见于以下两种情况：

1、部分肺泡通气不足比值降低，静脉血未能充分氧合，形成肺动-静脉样分流,又称功能性分流。2、部分肺泡血流不足比值增高，吸入气体不能与血液进行充分交换，又称为死腔样通气。通气/血流比例失调，只产生低氧血症，而无二氧化碳潴留。143pathogenesisIntrapulmonaryA-Vshunt（肺内动-静脉解剖分流增加）

肺动脉内的静脉血未经氧合直接流入肺静脉，导致低氧血症，常见于肺动-静脉瘘提高吸氧浓度不能提高分流静脉血的血氧分压144pathogenesisoxygenconsumption↑(氧耗量增加)fever,chill,cramp,dispnea145146Theinfluenceof

hypoxiaandhypercarponia1471、Hypoxia

脑耗氧量占全身1⁄5～1/4，停止供氧4-5分钟可引起不可逆的脑损害PaO2<60mmHg：注意力不集中、智力和视力轻度减退

PaO2<40～50mmHg：头痛、嗜睡、精神错乱

PaO2<30mmHg：昏迷

PaO2<20mmHg：数分钟出现不可逆神经细胞损伤

（一）Tocentralnervesystem

1482、CO2retention（PulmonaryEncephalopathy

）

肺性脑病:

缺氧和CO2潴留导致的神经精神障碍症候群表现头痛、头晕、烦躁不安、精神错乱、嗜睡、昼夜颠倒、抽搐、昏迷等。

缺O2和CO2潴留可造成细胞内钠和水增加，引起脑细胞水肿，从而引起脑组织充血、水肿和引起颅内压增高，甚至脑疝149（二）Influenceonrespiration缺氧刺激外周化学感受器（颈动脉窦、主动脉体），反射性地引起通气量增加CO2是强的呼吸中枢兴奋剂,PaCO2上升过高，呼吸抑制及麻醉

150（三）Influenceonheartandcirculation缺O2和CO2潴留均可刺激心脏，使心率加快，心搏量增加，血压上升缺氧对心血管中枢直接抑制酸中毒抑制细胞和组织携氧能力冠状动脉严重缺氧可导致心室颤动或心脏骤停缺O2和CO2潴留引起肺动脉小血管收缩，导致肺动脉高压，右心负荷加重--肺源性心脏病151（四）Influenceonliverandkidneyfunction缺氧可引起谷丙转氨酶上升严重缺氧和CO2潴留引起肾血管痉挛，肾功能障碍，少尿和氮质血症152（五）Influenceondigestivesystem应激性溃疡胃肠粘膜糜烂、坏死、出血

消化不良食欲不振

153（六）Influenceonbloodsystem慢性缺氧红细胞生成素增加，继发红细胞增多，血液携氧量增加血粘稠度增加，加重肺循环和右心负担，易引起DIC等并发症154（七）InfluenceonAcid-baseandElectrolytebalance

严重缺O2时，无氧酵解增加，导致代谢性酸中毒；酸中毒时，细胞内外离子发生转移，细胞内酸中毒和高钾血症pH=PK+LogHCO3-/PaCO2

HCO3-肾脏调节（1～3天）PaCO2肺脏调节（数小时）155Clinicalmanifestation156ClinicalmanifestationPrimarysymptomdeteriorate

Dysfunctionofmulti-organcausedbyhypoxiaandCO2retention157Dyspnea症状：轻者仅感呼吸费力，重者呼吸劳累窘迫，大汗淋漓，甚至窒息体征：呼吸频率、节律和幅度变化吸气性呼吸困难呼气性呼吸困难中枢性呼吸困难158临床表现:重度

:不能说话.前倾体位.紫绀躁动，出汗RF>30P>120SAO2%<90%（空气）危重

:意识不清.呼吸暂停、衰竭心血管衰竭听诊沉默肺159Cyanosis周围循环毛细血管血液中还原血红蛋白超过每分升5g，口唇、指甲、舌头等处出现紫绀；红细胞增多者紫绀明显，贫血者紫绀不明显；严重休克，末梢循环差者，即使PaO2正常也可出现紫绀皮肤色素、心功能可影响紫绀表现。160cyanosis161Cyanosis162Psychological&neurologicalsymptom急性呼衰较慢性呼衰明显急性缺氧：精神紊乱、燥狂、昏迷、抽搐等症状；慢性缺氧：智力和定向功能障碍CO2潴留肺性脑病早期为兴奋症状，如失眠、烦躁；重度CO2潴留可引起抽搐、嗜睡、昏迷163Car