病理生理学-呼吸系统课件(同名1474)

病理生理学系病理生理学系Department of Pathophysiology高高远远生生呼吸衰竭呼吸衰竭Respiratory Failure1完整ppt呼吸全呼吸全过过程程RespirationRespiration肺通气肺通气pulmonarypulmonaryventilationventilation肺肺换换气气gasgasexchangeexchangein thein thelungslungs组织换组织换气气gasgasexchangeexchangein the in the tissuestissues细细胞氧化代胞氧化代谢谢cellularcellularrespirationrespiration气体血液气体血液运运输输gas transportgas transportin the bloodin the blood 外呼吸外呼吸 external external respirationrespiration 内呼吸内呼吸 internal internal respirationrespiration2完整ppt3完整pptSymbolsP P PressurePressurePartial pressurePartial pressureA AAlveolarAlveolara aarterialarterialv vvenousvenousV VVolume of gas/unit timeVolume of gas/unit timeQ QVolume of blood/unit timeVolume of blood/unit time.4完整ppt呼吸衰竭呼吸衰竭(Respiratory Failure)(Respiratory Failure)外呼吸功能外呼吸功能严严重障碍重障碍 PaO PaO2 ,2 ,伴有伴有或不伴有或不伴有PaCOPaCO2 2 的病理的病理过过程。程。判断判断标标准：准：PaOPaO2 2 60mmHg 50mmHg 50mmHg (正常：正常：40 mmHg)40 mmHg)呼吸功能不全呼吸功能不全(Respiratory Insufficiency)(Respiratory Insufficiency)5完整ppt呼衰的呼衰的类类型型Classification of Classification of Respiratory failureRespiratory failure1.1.按按PaCOPaCO2 2 是否升高：是否升高：低氧血症型（低氧血症型（I I型）型）低氧血症伴高碳酸血症（低氧血症伴高碳酸血症（IIII型）型）2.2.按主要按主要发发病机制：病机制：通气障碍型通气障碍型 换换气障碍型气障碍型3.3.按病按病变变部位：部位：中枢性和外周性中枢性和外周性6完整ppt一、呼衰的原因和一、呼衰的原因和发发病机制病机制 Respiratory Failure:The Causes and the Mechanisms.肺通气肺通气功能功能障碍障碍 Disorders in Pulmonary Ventilation.肺肺换换气气功能功能障碍障碍 Disorders in Gas Exchange of the Lungs 7完整ppt （一）肺通气（一）肺通气功能功能障碍障碍:Disorders in Pulmonary Ventilation1.1.限制性通气不足限制性通气不足:肺泡肺泡扩张扩张受限受限2.2.2.2.阻塞性通气不足阻塞性通气不足:呼吸道阻呼吸道阻塞或狭窄塞或狭窄 气道阻力增加。气道阻力增加。8完整ppt1.1.限制性通气不足限制性通气不足（RestrictiveHypoventilation）：）：肺泡肺泡扩张扩张受限受限中枢神中枢神经经受受损损,周周围围神神经经受受损损,呼吸肌本身呼吸肌本身 收收缩缩功能障碍。功能障碍。肺充血和肺充血和严严重肺重肺纤维纤维化化,肺泡表面活性物肺泡表面活性物 质质减少。减少。胸廓和胸膜本身病胸廓和胸膜本身病变变。呼吸肌活呼吸肌活呼吸肌活呼吸肌活动动动动障碍障碍障碍障碍肺肺肺肺顺应顺应顺应顺应性降低性降低性降低性降低胸廓胸廓胸廓胸廓顺应顺应顺应顺应降低降低降低降低胸腔胸腔胸腔胸腔积积积积液和气胸液和气胸液和气胸液和气胸9完整ppt气道阻力气道阻力(正常人平静呼吸正常人平静呼吸)：80%:80%:直径直径 2mm 2mm 气管气管 20%:20%:直径直径 2mm 2mm 气管气管病因：气管病因：气管痉挛痉挛 肿胀肿胀 纤维纤维化化 渗出渗出物物 异物异物 肿肿瘤瘤 气道内外气道内外压压力改力改变变2.2.阻塞性通气不足阻塞性通气不足（Obstructive Hypoventilation):呼吸道阻塞或呼吸道阻塞或狭窄狭窄 气道阻力增加。气道阻力增加。10完整ppt阻塞位于胸外，表阻塞位于胸外，表现为现为吸气性呼吸困吸气性呼吸困难难 (Inspiratory Dyspnea)呼气呼气吸气吸气11完整ppt阻塞位于胸内，表阻塞位于胸内，表现为现为呼气性呼吸困呼气性呼吸困难难 (Exspiratory Dyspnea)呼气呼气吸气吸气12完整ppt用力呼气用力呼气时时等等压压点点(isobaric(isobaric point)point)移向小气道移向小气道02520+353520202030正常人正常人0152020+3525202020肺气肺气肿肿慢性支气管炎慢性支气管炎0+353515252020202013完整ppt问题问题 ：呼吸衰竭呼吸衰竭?限制性通气不足的定限制性通气不足的定义义及其及其发发生原因生原因?胸内胸内、胸外气道阻塞在呼吸中的差异胸外气道阻塞在呼吸中的差异?14完整ppt（二）弥散障碍（二）弥散障碍 Diffusion Impairment Diffusion Impairment1.1.弥散面弥散面积积减少减少2.2.弥散膜厚度增加弥散膜厚度增加3.3.弥散弥散时间缩时间缩短短15完整ppt毛毛细细血管内皮血管内皮细细胞胞肺泡肺泡I I型型细细胞胞基膜基膜红细红细胞胞肺泡肺泡-毛毛细细血管膜血管膜Alveolar-Capillary MembraneAlveolar-Capillary Membrane(弥散膜弥散膜,diffusion membrane)diffusion membrane)16完整ppt1.1.弥散面弥散面积积减少减少(Decrease in (Decrease in the Surface Area of the the Surface Area of the Membrane)Membrane)正常成人肺泡面正常成人肺泡面积积：70 m2静息静息时换时换气面气面积积：40 m2弥散面弥散面积积减少：减少：肺不肺不张张，肺，肺实变实变，肺叶切除等。肺叶切除等。17完整ppt2.2.弥散膜厚度增加弥散膜厚度增加(Increase in the(Increase in the Thickness of the Membrane)Thickness of the Membrane)肺泡膜厚度：肺泡膜厚度：1 1 m mM M弥散距离：弥散距离：5 5 m mM M弥散膜厚度增加：弥散膜厚度增加：肺水肺水肿肿，肺泡，肺泡透明膜形成，肺透明膜形成，肺纤维纤维化，肺泡毛化，肺泡毛细细血管血管扩张扩张等。等。18完整ppt3.3.弥散弥散时间缩时间缩短短(Shortening in the (Shortening in the Diffusion Time)Diffusion Time)正常静息状正常静息状态态：血流通血流通过过毛毛细细血管血管时间时间:0.75 s0.75 s 弥散弥散弥散弥散时间时间时间时间：0.25 s0.25 s弥散弥散弥散弥散时间缩时间缩时间缩时间缩短短短短:心心心心输输输输出量增加出量增加出量增加出量增加,肺血流加快肺血流加快肺血流加快肺血流加快19完整pptSolubility CoefficientSolubility Coefficient(vol/vol,760 mmHg):(vol/vol,760 mmHg):O O2 2:0.0240.024 CO CO2 2:0.570.5720完整ppt正常静息状正常静息状正常静息状正常静息状态态态态下：下：下：下：每分每分每分每分钟钟钟钟肺泡肺泡肺泡肺泡通气量（通气量（通气量（通气量（V V V VA A A A)：4L4L4L4L 每分每分每分每分钟钟钟钟肺血肺血肺血肺血流量（流量（流量（流量（Q):Q):Q):Q):5L5L5L5LV V V VA A A A/Q:/Q:/Q:/Q:0.80.80.80.8.（三）肺泡通气与血流比例失（三）肺泡通气与血流比例失调调Ventilation-Perfusion Imbalance21完整pptV VA A.V VA A/Q /Q 0.8 =0.8 0.8 0.80.8 =0.8 0.8 0.8 0.8 0.8 0.8 0.83.3.部分肺泡血流不足部分肺泡血流不足(Alveolar(Alveolar Perfusion Insufficiency)Perfusion Insufficiency)死腔死腔样样通气通气(dead space like(dead space like ventilationventilation）26完整ppt血液氧和二氧化碳解离曲血液氧和二氧化碳解离曲线线Oxygen and Carbon DioxideDissociation Curves27完整ppt问题问题：弥散障碍的弥散障碍的发发生机制生机制?功能性分流功能性分流,静脉血静脉血掺杂掺杂?解剖分流解剖分流,真性分流真性分流?死腔死腔样样通气通气?28完整ppt肺泡肺泡-毛毛细细血管膜血管膜(alveolar capillary membrane)损伤损伤引起的急性呼吸衰竭。引起的急性呼吸衰竭。病因：感染（病因：感染（肺炎，肺炎，败败血症等）血症等），休克，休克，严严重重创伤创伤，吸入毒物或胃酸等。吸入毒物或胃酸等。（四）（四）急性呼吸窘迫急性呼吸窘迫综综合征合征Acute Respiratory Distress Syndrome(ARDS)Severe acute respiratory syndrome(SARS)is a good example of a probable infectious pneumonia that pathologically and clinically is ARDS.Experts have speculated that the cause is from a corona virus that may be transmitted via respiratory secretions and develops after 2-11 days of a febrile illness.29完整ppt30完整pptARDSARDS发发生机制生机制(Pathogenesis)肺泡膜肺泡膜内皮内皮细细胞胞损伤损伤致病致病因子因子释释放中性粒放中性粒细细胞胞趋趋化因子化因子中性粒中性粒细细胞聚胞聚集，集，释释放氧自放氧自由基、蛋白由基、蛋白酶酶、炎症介炎症介质质肺肺水水肿肿死腔死腔样样通气通气肺泡肺泡型型上皮上皮细细胞胞损伤损伤表面活表面活性物性物质质合成合成支气管支气管痉挛痉挛血管收血管收缩缩微血栓微血栓肺泡膜肺泡膜通透性通透性肺不肺不张张功能性功能性分流分流PaOPaO2 2PaCOPaCO2 231完整ppt A previously healthy 23-year-old male sustained numerous traumatic crush,burn,and smoke inhalation injuries during a landing accident in an airplane.His initial B.P.was 80/50 mmHg,and he was immediately infused with saline at the maximal rate.In the ER he was intubated and had no signs of pneumothorax.His orthopedic injuries and burns were treated.The ventilator was placed on the assist-control mode with the initial settings of inspired O2 concentration at 40%,respiration rate at 12/min,and tidal volume at 900 ml.Arterial blood gas measurements were:pH=7.47,PCO2 of 33 mmHg,and PO2 of 62 mmHg.Clinical Case 32完整ppt 24 hrs.after admission,the patient becomes agitated and his respiration rate increased to 30/min.His minute ventilation also increased from 8.5 l/min to 20 l/min.Airway pressure increased from 18 to 65 cm H2O.Repeat arterial blood gas measurement of PO2 indicated 35 mmHg and chest x-ray now showed diffuse infiltrates in a white out pattern.Clinical Case 33完整ppt The diagnosis of ARDS is contingent upon 5 factors:1.Hypoxemia,2.Diffuse pulmonary infiltrates on radiography,3.Absence of congestive heart failure,4.Decreased lung compliance(effective static compliance 25-35 ml/cm H2O),and 5.Appropriate antecedent history.Currently,there are no specific laboratory tests for ARDS.A definitive diagnosis is made when these signs and symptoms are linked with diffuse alveolar damage.Clinical Case 34完整ppt急性呼吸窘迫急性呼吸窘迫综综合征合征(ARDS)(ARDS)的概念及的概念及发发生生机制机制?问题问题：35完整ppt二、二、呼衰呼衰时时机体功能和代机体功能和代谢变谢变化化 Functional and Metabolic Change in Respiratory Failure（一）酸碱平衡紊乱（一）酸碱平衡紊乱(acid-base(acid-base balance disturbance)balance disturbance)和和电电解解质变质变化化呼酸呼酸:型型呼衰呼衰 C CO O2 2潴留潴留 血血 K K+,血血 ClCl-呼碱：呼碱：I I型呼衰型呼衰 肺肺过过度通气度通气 血血 K K+,血血 ClCl-代酸：代酸：严严重缺氧重缺氧 无氧代无氧代谢谢 乳酸乳酸36完整ppt（二）呼吸系（二）呼吸系统统的的变变化化(Changes in(Changes in Respiratory System)Respiratory System)1.1.呼吸呼吸调节调节(Regulation of Respiration)(Regulation of Respiration)2.2.的的变变化化外周化学外周化学感受器感受器中枢化学中枢化学感受器感受器呼吸呼吸加深加快加深加快抑制抑制呼吸中枢呼吸中枢PaOPaO2 260 mmHg50 mmHg50 mmHgPaOPaO2 230 mmHg80 mmHg80 mmHg37完整ppt（三）（三）循循环环系系统变统变化化(Changes in(Changes in Circulation System)Circulation System)轻轻度度PaOPaO2 2 和和 PaCO PaCO2 2 可可兴奋兴奋心心血管运血管运动动中枢中枢 严严重重PaOPaO2 2 和和 PaCO PaCO2 2 抑制心血抑制心血管运管运动动中枢中枢 38完整ppt缺氧缺氧 肺小肺小动动脉收脉收缩缩 肺肺动动脉脉压压 右心后右心后负负荷荷长长期缺氧期缺氧 肺血管平滑肌增殖肺血管平滑肌增殖 管壁增厚管壁增厚长长期缺氧期缺氧 红细红细胞增多胞增多 血液粘度血液粘度 心心负负荷荷缺氧、酸中毒缺氧、酸中毒 心肌舒心肌舒缩缩功能功能呼吸衰竭呼吸衰竭 右心衰竭右心衰竭 肺源性心肺源性心脏脏病病 (cor pulmonale)(cor pulmonale)39完整pptPaOPaO2 2:60 mmHg 60 mmHg 智力，智力，视视力力轻轻度减退度减退40-50 mmHg 40-50 mmHg 神神经经精神症状精神症状20 mmHg 20 mmHg 神神经细经细胞不可逆胞不可逆损损坏坏(慢性呼衰慢性呼衰PaOPaO2 2 20 mmHg20 mmHg神志仍可清醒）神志仍可清醒）PaCOPaCO2 2 80 mmHg80 mmHg CO CO2 2麻醉麻醉(头头痛痛,头头昏昏,嗜睡，嗜睡，精神精神错错乱乱,扑翼扑翼样样震震颤颤,抽搐抽搐,及昏迷等及昏迷等中中枢神枢神经经系系统统症状）症状）肺性肺性脑脑病病(pulmonary encephalopathy):(pulmonary encephalopathy):呼衰呼衰引起的引起的脑脑功能障碍功能障碍（四）中枢神（四）中枢神经经系系统变统变化化Changes in Central Nervous SystemChanges in Central Nervous System40完整ppt肺性肺性脑脑病病发发生机制生机制Pathogenesis of pulmonaryPathogenesis of pulmonary encephalopathy encephalopathy-氨基丁酸氨基丁酸脑脑脊液脊液 pHpH溶溶酶酶体体酶酶释释放放中枢抑制中枢抑制磷脂磷脂酶酶活性活性神神经经损伤损伤颅颅内内压压POPO2 2PaCOPaCO2 2血管内皮血管内皮损伤损伤血管血管通透性通透性脑脑水水肿肿脑脑血管血管扩张扩张脑脑充血充血41完整ppt问题问题：呼呼吸衰竭吸衰竭时时呼吸呼吸调调节节的的变变化？化？肺源性心肺源性心脏脏病病发发生生机制机制?肺性肺性脑脑病的定病的定义义及及发发生机制？生机制？42完整ppt（一）一般原（一）一般原则则(General Principals)(General Principals)1.1.防治原防治原发发病病 2.2.防止或去除防止或去除诱诱因因 3.3.改善肺通气改善肺通气 4.4.纠纠正水、正水、电电解解质质及酸碱平衡紊乱及酸碱平衡紊乱,保保 护护重要器官功能重要器官功能五、呼衰的防治原五、呼衰的防治原则则 Principals of the Prevention and Principals of the Prevention and Treatment of Respiratory Failure Treatment of Respiratory Failure43完整ppt1 1 I I 型呼衰只有缺型呼衰只有缺O O2 2而无而无COCO2 2潴留，可吸潴留，可吸入入较较高高浓浓度度O O2 2，一般不超一般不超过过50502.2.IIII型呼衰有型呼衰有COCO2 2潴留潴留,应应持持续续低低浓浓度低度低流量吸氧流量吸氧，如，如3030，1 12L/min2L/min，使，使P Pa aO O2 2上升到上升到 60 mmHg 60 mmHg（二）吸氧（二）吸氧(Oxygen Inhalation)(Oxygen Inhalation)44完整ppt问题问题：IIII型呼吸衰竭型呼吸衰竭吸氧的原吸氧的原则则？45完整pptrespiratory failure(respiratory insufficiency()restrictive hypoventilation()obstructive hypoventilation()diffusion impairment()functional shunt()venous admixture()anatomic shunt();true shunt()dead space like ventilation()ventilation-perfusion ratio ()acute respiratory distress syndrome(ARDS)()cor pulmonale()pulmonary encephalopathy()46完整pptrespiratory failure (呼吸衰竭呼吸衰竭)respiratory insufficiency (呼吸功能不全呼吸功能不全)restrictive hypoventilation(限制性通气不足限制性通气不足限制性通气不足限制性通气不足)obstructive hypoventilation(阻塞性通气不足阻塞性通气不足阻塞性通气不足阻塞性通气不足)diffusion impairment (弥散障碍弥散障碍弥散障碍弥散障碍)functional shunt (功能性分流功能性分流)venous admixture (静脉血静脉血掺杂掺杂)anatomic shunt (解剖分流解剖分流););true shunt(真性分流真性分流)dead space like ventilation (死腔死腔样样通气通气)ventilation-perfusion ratio (肺泡通气与血流比例肺泡通气与血流比例肺泡通气与血流比例肺泡通气与血流比例)acute respiratory distress syndrome(ARDS)(急性呼吸急性呼吸窘迫窘迫综综合征合征)cor pulmonale(肺源性心肺源性心脏脏病病)pulmonary encephalopathy (肺性肺性脑脑病病)Vocabulary.(VA/Q)47完整ppt