同學們好！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、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、診斷和治療重點IntroduceInpediatricoutpatient,6o%patientsareacuterespiratoryinfections.Inpediatricward,25%patientsarePneumonia.Thefirstcauseofchildren’sdeathinChinaisPneumonia.Pneumoniaistheworld'sleadingcauseofdeathamongchildren.Itkillsnearlytwomillionchildrenunderagefiveeveryyear.Whychildrenaresosusceptibletoacuterespiratoryinfections?breathedin(inspired)breathedout(expired)NasopharynxOrapharynxLarynxEpiglottisTracheaRightbronchiLeftbronchiAlveolianatomic

physiologicalfeatures

Thechildren’srespiratorylumensarenarrow,bloodflowisabundant.Thechildren’srepertoryabilityislow.Thechildren’slocalimmunityislow.ChildrenRespiratorySystemPhysiologicFeatureRespiratoryrateNeonate40-44/min<1year30/min2-3years24/min4-7years22/min8-14years20/minChildrenRespiratorySystemPhysiologicFeatureRespiratorytypeAbdominalrespirationThoracicabdominalrespiration

Ｐhysicalexaminationinspection

ChangeofrespiratoryrateCyanosisThreedepressionssign

ＡuscultationExamineMethod

Ａuscultation吸氣喘鳴（inspiratorystrider）呼氣喘息（expiratorywheeze）哮鳴音中、粗濕羅音細濕羅音ExamineMethod急性上呼吸道感染（AURI）

AcuteUpperRespiratoryInfectionEtiologyＶirus：Ｏccupy90%

Ｂacteria：Ｓecondary

Streptococuspyogens

PneumococcuＨaemophilusinfluenzaeCommonAURILocalsymptomismildIninfantandtoddlerSystemicsymptomissevereComplicationsarecommonClinicalManifestationsSchoolageTympanitis,sinusitisAbscessofpharynxposterior-wallLaryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumaticfeverComplicationsCommonAURIＰhysicalexamination

Congestionofpharyngealportion,antiadoncus(咽部充血，扁桃體腫大)Lymphadenectasisinsubmaxilla(有時下頜、淋巴結腫大)Rashwhenenterovirusinfection(腸道病毒感染時可出現皮疹)ClinicalManifestationsSpecialAURI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ClinicalManifestationsHerpangina皰疹性咽峽炎Pharyngo-conjunctivalfever咽結合膜熱

腺病毒3，7型所致春夏發(fā)病，可小流行發(fā)熱、咽炎、結合膜炎咽部充血、結合膜充血，頸部、耳后淋巴結腫大病程1~2周ClinicalManifestationsSpecialAURIAntivirusdrugs中藥Ribovirin3-5daysAntibioticsPenicillinCephalosporin

Macrocycliclactone3-5daysSeversymptomatic;SecondarybacteriaaffectionTreatmentDefervesceDrugs：對乙酰氨基酚，布洛芬PhysicsmethodsFebrilconvulsionCalmStopconvulsionDefervesceTreatment中國0-5歲兒童急性發(fā)熱診斷處理指南2008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、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、診斷和治療重點Pneumonia肺炎

ChildrenfamiliardiseaseIntroductionPneumoniaaffects156millionchildrenundertheageof5yrsLeadingcauseofmortalityinunder5yrsMostofthesedeaths–preventableMosteffectiveintervention-EarlydiagnosisandappropriatemanagementThehospitalizationnumberofinfantandtoddleris39.5timesofschoolageWilliamsetal.LancetInfectDis,2002

World’sbiggestkillerIntroductionPneumonia(18%)anddiarrhea(15%)aretheleadingkillersinchildren.Theytooknearly3millionchildrenlivesin2008alone.(兩種疾病在2008年一年就奪走三百萬兒童的生命)?Inchildrenages0-59months:0-59月的兒童?Pneumoniacausednearly1.6mdeaths?Diarrheacausedmorethan1.3mdeathsBlacketal,Lancet2010PneumoniaisaninflammationoftheparenchymaofthelungsItiscausedbymicroorganismsornoninfectiouscausesManifestedbyfever,cough,tachypnea,respiratorydistressandralesDefinitionOncourseofillnessOnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

Acute：<1monthChronic：>3monthsDeferred：1~3monthsClassification1OnanatomicbasisBronchopneumoniaLobarpneumoniaInterstitialpneumonia

OntheetiologyMycoplasmaChlamydia,parasites,fungiNoninfectionscausesClassification3OntheseverityofillnessMildsymptomaticSeveresymptomaticBesidessymptomsofrespiratorysystem,concomitantmanifestationsofotherorgansystemsarepresentClassification4ontypicalofclinicalmanifestationTypicalpneumoniauntypicalpneumoniaSevereacuterespiratorysyndrome,(SARS)coronavirusClassification5OnOccurrenceRegionCommunityAcquiredPneumoniaCAPHospitalAcquiredPneumoniaHAPClassification6支氣管肺炎

BronchopneumoniaEtiologyvirusMaincauseofpneumoniaindevelopedcountryRSVbacteriaMaincauseofpneumoniaindevelopingcountryS.pneumoniae

PathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatoryeffutionofalveolusInterstitialpneumoniahyperaemia、edema、inflammatoryeffutionofbronchiawall、bronchiolewall、alveoluswallPathologicphysiology氣道炎癥循環(huán)系統(tǒng)神經系統(tǒng)水電解質消化系統(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↓ClinicalmanifestationMild

symptomaticrespiratorysystemfeverrespiratory

distressnasalflaring,retractions,cyonosistachypnea

cough

rales<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分Rapidbreathing

Clinicalmanifestation<2monthsRR≧60次/分2-12monthsRR≧50次/分1-5yearsRR≧40次/分>5yearsRR≧30次/分ClinicalmanifestationSeveresymptomaticcircularsystemsymptomCardiacmuscleinflammationHeartfailureClinicalmanifestSeveresymptomaticHeartfailure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ClinicalmanifestnervalsystemLighthypoxia：irritability，lethargySeverhypoxia：hydrocephalusdigestivesystemalimentarycanalbleedingPoisoningintestinepalsySeveresymptomaticClinicalmanifestDICBp四肢涼，脈速弱，出血SLADHNa+

≤130mmol/L滲透壓<270mOsm/LEdemaSeveresymptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratorydataBloodbloodroutinebacteriainfect：WBC↑、N↑leftshiftofnucleusvirusinfect：WBC↓、L↑abnormallymphcellbacteriainfect：CRP↑virusinfect：CRPnormalCRPNBTbacteriainfect：〉10%virusinfect：〈10%PathogenyvirusseparateGermiculturesputumforGramstainandcultureLaboratorydataX-rayshadowofdotandspoteemphysemaatelectasis支氣管肺炎正常胸片大葉性肺炎正常胸片fever,cough,tachypnea,respiratorydistressandralesX-raydiagnosisDifferentiationacute

bronchitisrales、tachypneaforeignbodiesinbronchihistoryofforeignbodies、suddencough、respiratorydistress、lowerofbreathtoneorwheezingtuberculosishistoryofTBcontact、PPDtest、PPD-IgGIgM、X-ray、ralesTreatmentgeneraltreatmentBalanceofwaterandelectrolyte3%Nacl12ml/L→↑Na+10mmol/L

Temperature18-20℃

Humidity60%FoodnutritiveTreatmentControlinfectionvirus：noidealdruglikevirozolmycoplasma、chlamydiaselecterythromycinbactrria：theprincipleofsensitivityefficiency、fullperiodoftreatment,firstselectPeniccilinTreatment抗生素使用原則

根據藥敏選藥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

Bacteria,thecommonestpathogenDespitevariationinstudyresults,S.Pneumoniae,Staphaureus,Hinfluenzae

IdentifiedasmajorpathogensindevelopingcountriesPneumonia:Microorganisms

Pneumonia:microorganismsMixedinfection:8-40%(Viral/bacterialormorethan1bacteria)

MostcommoncombinationSpneumoniae+RSVorSpneumoniae+MycoplasmaKabirARML.AetiologyofALRTIininfancy’2003Organismisolationrate:11.69%Staphaureus (42%)

StrepPneumoniae (20%)

HInfluenzae (7%)

Paeroginosa (5.3%) comingup- previouslynot recognizedSeverepneumoniaEvaluationAntimicrobialResearch(SPEAR)’2007Allweresusceptibleto3rdgencephalosporinTreatmentfullperiodoftreatmentaftertemperaturenormal5~7daysorclinicalsymptomdisappearing3daysMycoplasma

pneumonia：2~3weeksStaphylococusaureus：aftertemperaturenormal2weeks，fullperiodis6weekstreatagainstsymptomsTreatmentoxygentreatPaO2↓：dyspnea、

cyanosis、asthmasuppress、"toxicappearance,"methods:bynosecanal0.5~1L/min，40%；byveil2~4L/min,50%~60%mechanismventilate（

respirefailture）holdingrespiratory

tractunobstructedremovesputum、pulverization、relievespasmensureliquidabsorbTreatmenttreatofothersympdefervescecalmtreatofwindysupplyKaliumPoisoningintestinepalsy：fasting、decompressofstomachandintestine酚妥拉明0.5mg/kgivgtt

10%GS20mltreatagainstsymptomsTreatmenttreatofHeartfailure鎮(zhèn)靜給氧強心：西地蘭減輕心臟負荷

treatagainstsymptomsTreatment中毒性腦病治療脫水：甘露醇改善通氣擴血管藥物：酚妥拉明，654-2止痙：安定，魯米那糖皮質激素：地塞米松神經營養(yǎng)

treatagainstsymptomsTreatment糖皮質激素應用適應癥：①喘憋重,呼吸衰竭②全身中毒癥狀重③感染性休克

④腦水腫琥珀酸氫化可的松5~10mg/kg.d地塞米松0.1~0.3mg/kg.d

ivgtt2~3次/日×3~5天甲基強的松龍2~4mg/kg.次ResponsetotreatmentinotherwiseuncomplicatedCAP?Fever-fallsin2daysLeucocytosis-decreasesin4daysPhysicalfindingspersistslightlylongerChestradiographicabnormalitiesmaytake4-12weekstoresolveWhatifpatientsfailstorecover?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，細濕羅音小點片狀影，肺氣腫肺不張間質性肺炎6月~2歲中毒癥狀重，稽留熱，咳劇，喘憋，呼吸困難出現晚，濕羅音或肺實變

胸片改變出現早，肺氣腫，片狀影或融合年齡癥狀胸片體征細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，肺大皰中細濕羅音，出現早，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)膿胸濕羅音或實變大葉性肺炎、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，部分伴結膜炎濕羅音，持續(xù)時間長間質性炎癥，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描述過去認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，認識到哮喘是氣道慢性炎癥性疾病Definitionchronicairwayinflammationairwayhyperreactivity(AHR)reversibleairwayobstructionmanifestedbywheezing,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氣道高反應性：對正常氣道無反應或很小反（AHR）應的刺激產生收縮反應pathologynakedeye：emphysema,mucusblotscope:inflammatorycellinfiltrate，glandhyperplasiabasalmembrancethickening病理生理急性支氣管痙攣：速發(fā)型哮喘反應（IgE依賴）氣道壁腫脹：遲發(fā)型哮喘反應（炎癥誘導）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)境中常見的變應原產生IgE介導反應的易感性，有明顯的家族遺傳傾向。特應性哮喘、過敏性鼻炎、濕疹、食物過敏等導致哮喘發(fā)生最確定的危險因素pathogenesisimmunityfactoratopy,IgE↑nerveenergyfactorinductionfactorinfectionofrespiratorytractmanykindsofallergen-

adrenalglandnerve

-

adrenalglandnerve

PneumogastricnervevariousinflammatorycellsintoairwayAHRInheritfactorgeneticdiseasefamilyhistoryClinicalmanifestolderchildrensensitizininduceinfantandtoddlerviralinfectioninduceperiodofonsetsymptomsofbronchialspasm-cough,gaspcatabasismaynosignsandsymptomsrapidseriousattack,reasonableutilizepara-sympathesisdrugcannotreliefin24hoursstatusasthmaticusauxiliaryexaminationX-raylungfunctionskintestFEV1/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（呼氣風流速，其日間變異率>20%,使用支擴劑后增加20%可診斷哮喘）Diagnoseofchildrenasthmagasprecurrentattackslungwheezingralesreversibleairwayobstructionexcludeotherdiseasethatcancausegaspcough4weeks,antibioticstreatisinvalidbronchodilatorscanrelievecoughhypersensitivehistoryorallergiafamilyhistoryairwayishyperreactivityexc