同學(xué)們好 呼吸系統(tǒng)疾病RespiratorySystemDisease 湘雅醫(yī)院兒科鄭湘榕 嬰幼兒上感 2種特殊類型上感的特點支氣管肺炎臨床表現(xiàn) 重癥肺炎特點支氣管肺炎的診斷 治療支氣管哮喘的臨床表現(xiàn) 診斷和治療 重點 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 扁桃體腫大 Lymphadenectasisinsubmaxilla 有時下頜 淋巴結(jié)腫大 Rashwhenenterovirusinfection 腸道病毒感染時可出現(xiàn)皮疹 ClinicalManifestations SpecialAURI 柯薩奇病毒A組感染夏秋好發(fā)高熱 咽痛 流涎咽腭弓 軟腭處有皰疹皰疹破潰后可形成潰瘍病程1周左右 ClinicalManifestations Herpangina皰疹性咽峽炎 Pharyngo conjunctivalfever咽結(jié)合膜熱 腺病毒3 7型所致春夏發(fā)病 可小流行發(fā)熱 咽炎 結(jié)合膜炎咽部充血 結(jié)合膜充血 頸部 耳后淋巴結(jié)腫大病程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 支氣管肺炎 Bronchopneumonia Etiology virus MaincauseofpneumoniaindevelopedcountryRSV bacteria MaincauseofpneumoniaindevelopingcountryS pneumoniae Pathology Pathologicphysiology 氣道炎癥 循環(huán)系統(tǒng) 神經(jīng)系統(tǒng) 水電解質(zhì) 消化系統(tǒng) 肺A壓增高 中毒性心肌炎 心衰 代酸 中毒性腸麻痹 胃腸粘膜屏障功能 腦水腫 顱壓 呼酸 K 水鈉儲留 毒血癥 通氣不足PaO2 PaCO2 換氣障礙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 分心率突然增快嬰兒 180次 分幼兒 160次 分突然煩躁不安 面色發(fā)灰心音明顯低鈍 奔馬率 頸靜脈怒張肝大肋下3cm以上尿少 下肢浮腫 Clinicalmanifest nervalsystem Lighthypoxia irritability lethargy Severhypoxia hydrocephalus digestivesystem alimentarycanalbleeding Poisoningintestinepalsy Severesymptomatic Clinicalmanifest DIC Bp 四肢涼 脈速弱 出血 SLADH Na 130mmol L滲透壓 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 支氣管肺炎 正常胸片 大葉性肺炎 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 抗生素使用原則 根據(jù)藥敏選藥adoptsensitivedrugsonthebasisofpathogenicbacterium用下呼吸道濃度高的藥物adoptdrugswhichcanfinallyinfiltratelungtissue足量足療程重癥靜脈給藥inseverecase drugsshouldbeadministedbyvein fulldose fullperiod Treatment 抗生素選擇 肺炎鏈球菌 PNC 阿莫西林 紅霉素金黃色葡萄球菌 苯唑西林 氯唑西林 萬古 利福平流感嗜血桿菌 阿莫西林 克拉維酸鉀或舒巴坦大腸桿菌和肺炎桿菌 頭孢曲松或頭孢噻肟綠膿桿菌 替卡西林鈉克拉維酸鉀或頭孢哌酮肺炎支原體或衣原體 大環(huán)內(nèi)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 鎮(zhèn)靜給氧強心 西地蘭減輕心臟負(fù)荷 treatagainstsymptoms Treatment 合并中毒性腦病的治療 脫水 甘露醇改善通氣改善腦微循環(huán)止痙 地西泮地塞米松營養(yǎng)神經(jīng) treatagainstsymptoms Treatment 糖皮質(zhì)激素應(yīng)用 適應(yīng)癥 喘憋重 呼吸衰竭 全身中毒癥狀重 感染性休克 腦水腫 琥珀酸氫化可的松5 10mg kg d地塞米松0 1 0 3mg kg divgtt2 3次 日 3 5天甲基強的松龍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歲 2 6月多見喘憋 呼吸困難 可合并呼衰 心衰哮鳴音 細(xì)濕羅音小點片狀影 肺氣腫肺不張間質(zhì)性肺炎 6月 2歲中毒癥狀重 稽留熱 咳劇 喘憋 呼吸困難出現(xiàn)晚 濕羅音或肺實變胸片改變出現(xiàn)早 肺氣腫 片狀影或融合 年齡 癥狀 胸片 體征 細(xì)菌性肺炎 葡萄球菌肺炎 新生兒 嬰幼兒急 重 快 弛張熱或稽留熱 咳嗽 呼吸困難 呻吟 易致遷徒化膿病灶 并發(fā)膿胸 膿氣胸 肺大皰中細(xì)濕羅音 出現(xiàn)早 皮疹浸潤影 持續(xù)時間較長 易變 可見多發(fā)性肺膿腫 膿胸 膿氣胸等 4歲慢 重 發(fā)熱 痙攣性咳嗽 呼吸困難 發(fā)紺 易致遷徒化膿病灶 易并發(fā)膿胸濕羅音或?qū)嵶兇笕~性肺炎 支氣管肺炎 肺實變 年齡 癥狀 體征 胸片 革蘭陰性桿菌肺炎 肺炎支原體肺炎 年長兒 嬰幼兒發(fā)熱 刺激性咳嗽 多系統(tǒng)病變不明顯 嬰幼兒可有呼吸困難 喘憋 哮鳴音 濕羅音肺門影增濃 支氣管肺炎改變 間質(zhì)性肺炎 均一實變影 6月起病慢 無發(fā)熱 先URI癥狀后咳 喘 氣促 部分伴結(jié)膜炎濕羅音 持續(xù)時間長間質(zhì)性炎癥 過度充氣 片狀影 持續(xù)時間長 年齡 癥狀 體征 胸片 沙眼衣原體肺炎 支衣原體肺炎 支氣管哮喘bronchialasthma 發(fā)展史 asthma 喘息 2000年前就有對哮喘的詳細(xì)描述過去認(rèn)為是一種平滑肌功能異常性疾病80年代以來通過支氣管黏膜活檢 認(rèn)識到哮喘是氣道慢性炎癥性疾病 Definition chronicairwayinflammation airwayhyperreactivity AHR reversibleairwayobstruction manifestedbywheezing respiratorydistress cough 特征 氣道慢性炎癥 此為哮喘主要特征可逆性的氣流受限 指氣流受限可被支氣管擴張劑所逆轉(zhuǎn)氣道高反應(yīng)性 對正常氣道無反應(yīng)或很小反 AHR 應(yīng)的刺激產(chǎn)生收縮反應(yīng) pathology nakedeye emphysema mucusblotscope inflammatorycellinfiltrate glandhyperplasiabasalmembrancethickening 病理生理 急性支氣管痙攣 速發(fā)型哮喘反應(yīng) IgE依賴 氣道壁腫脹 遲發(fā)型哮喘反應(yīng) 炎癥誘導(dǎo) 粘液栓形成 難治療的氣流受限氣道重塑 不可逆的氣道狹窄 核心 氣流受限 atopy 是指對普通環(huán)境中常見的變應(yīng)原產(chǎn)生IgE介導(dǎo)反應(yīng)的易感性 有明顯的家族遺傳傾向 特應(yīng)性 哮喘 過敏性鼻炎 濕疹 食物過敏等 導(dǎo)致哮喘發(fā)生最確定的危險因素 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 一秒用力呼氣容積 用力肺活量 低于70 75 提示氣流受限 PEFR 呼氣風(fēng)流速 其日間變異率 20 使用支擴劑后增加20 可診斷哮喘 Diagnoseofchildfoodasthma gasprecurrentattackslungwheezingralesbronchodilatorsisvalidexcludeotherdiseasethatcancausegasp cough 1month antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexcludeothercoughdisease Diagnoseofcoughvariantasthma therapy Principle