呼吸系统疾病---课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,同学们好！,同学们好！,呼吸系统疾病,Respiratory System Disease,湘雅医院儿科 郑湘榕,呼吸系统疾病湘雅医院儿科 郑湘榕,婴幼儿上感、,2,种特殊类型上感的特点,支气管肺炎临床表现、重症肺炎特点,支气管肺炎的诊断、治疗,支气管哮喘的临床表现、诊断和治疗,重点,婴幼儿上感、2种特殊类型上感的特点重点,Introduce,In pediatric outpatient, 6o% patients are acute,respiratory infections.,In pediatric ward, 25% patients are Pneumonia.,The first cause of childrens death in China is Pneumonia.,Pneumonia is the worlds leading cause of death among children.,It kills nearly two million children under age five every year.,IntroduceIn pediatric outpatie,Why children are so susceptible to,acute respiratory infections,?,Why children are so susceptibl,呼吸系统疾病-课件,anatomic,physiological features,The childrens respiratory lumens are narrow,blood flow is abundant.,The childrens repertory ability is low.,The childrens local immunity is low.,anatomic physiological featu,Children Respiratory System Physiologic Feature,Respiratory rate,Neonate 40-44,/,min,1,year 30/min,2,-3years 24/min,4,-7years 22/min,8,-14years 20/min,Children Respiratory System Ph,Children Respiratory System Physiologic Feature,Respiratory type,Respiratory type of abdomen,Respiratory type of chest abdomen,Children Respiratory System Ph,hysical examination,inspection,Change of respiratory rate,Cyanopathy,Three concave sign,uscultation,Examine Method,hysical examinationExamine,急性上呼吸道感染,（,AURI）,Acute Upper Respiratory Infection,急性上呼吸道感染（AURI）,Etiology,irus：,ccupy,90%,acteria：,econdary,Streptococus pyogens,Pneumococcu,aemophilus influenzae,Etiology,Common,AURI,Local symptom is mild,In infant,and toddler,Systemic symptom is severe,Complications are common,Clinical Manifestations,Common Local symptom is mild I,Common,AURI,hysical examination,Congestion of pharyngeal portion, antiadoncus,(咽部充血，扁桃体肿大),Lymphadenectasis in,submaxilla,(有时下颌、淋巴结肿大),Rash when enterovirus infection,(肠道病毒感染时可出现皮疹),Clinical Manifestations,Commonhysical examination Con,Special,AURI,柯萨奇病毒,A,组感染,夏秋好发,高热、咽痛、流涎,咽腭弓、软腭处有疱疹,疱疹破溃后可形成溃疡,病程 1 周左右,Clinical Manifestations,Herpangina,疱疹性咽峡炎,Special 柯萨奇病毒A组感染Clinical Man,Pharyngo-,conjunctival,fever,咽结合膜热,腺病毒 3，7 型所致,春夏发病，可小流行,发热、咽炎、结合膜炎,咽部充血、结合膜充血，颈部、 耳后淋巴结肿大,病程 12 周,Clinical Manifestations,Special,AURI,Pharyngo- 腺病毒 3，7 型所致Clinic,School age,Tympanitis, sinusitis,Abscess of pharynx posterior-wall,Laryngitis, bronchitis,Infant , toddler,Pneumonia,Glomerulonephritis,Rheumatic fever,Complications,School ageTympanitis, sinusit,Antivirus drugs,Oseltamivir,Ribovirin,3,-5 days,Antibiotics,Penicillin,SMZ,3,-5 days,Sever symptomatic;,Secondary bacteria affection,Treatment,Antivirus drugs Oseltamivir,Defervesce,Drugs,Physics methods,Febril convulsion,Calm,Stop convulsion,Defervesce,Treatment,DefervesceDrugsPhysics methods,Pneumonia,肺 炎,Pneumonia肺 炎,Children,familiar,disease,In world,Occupy 1/3-1/4 in,the death of children under,5 years of age,In china, Occupy more than 1/4,in paediatric ward,The hospitalization number,of infant and toddler is 39.5 times,of school age,Pneumonia,In world,Occupy 1/3-1/4 in In,Pneumonia is an inflammation,of the parenchyma of the lungs,It is caused by microorganisms,or noninfectious causes,Manifested by fever,cough, tachypnea ,respiratory distress and rales,Definition,Pneumonia is an inflammation,On course,of illness,On anatomic,basis,Bronchopneumonia,Lobar pneumonia,Interstitial pneumonia,Acute： 3 months,Deferred：13 months,Classification 1,On courseOn anatomicBronchopne,On the,etiology,Virus,RSV,(respiratory syncytial virus),Adenovirus,Influenza,Parainfluenza,Bacteria,Streptococus,pneumoniae,Staphylococus aureus,Haemophilus influenzae type,Classification 2,On the Virus BacteriaClassifi,On the,etiology,Mycoplasma,Chlamydia, parasites ,fungi,Noninfections causes,Classification 3,On theMycoplasmaChlamydia, par,On the,severity,of illness,Mild symptomatic,Severe symptomatic,Besides symptoms of,respiratory system, concomitant,manifestations of other,organ systems are present,Classification 4,On theMild symptomaticSevere,on typical,of clinical,manifestation,Typical pneumonia,untypical pneumonia,Severe acute respiratory syndrome,(SARS),coronavirus,Classification 5,on typicalTypical pneumoniaunt,On,Occurrence,Region,Community Acquired Pneumonia,CAP,Hospital Acquired Pneumonia,HAP,Classification 6,On Community Acquired Pneumoni,支气管肺炎,Bronchopneumonia,支气管肺炎 Bronchopneumonia,Etiology,virus,Main cause of pneumonia,in developed country,RSV,bacteria,Main cause of pneumonia,in developing country,S. pneumoniae,EtiologyvirusMain cause of pne,Pathology,Common,Broncho-,pneumonia,hyperaemia、edema、inflammatory,effution of alveolus,Interstitial,pneumonia,hyperaemia、edema、inflammatory,effution of bronchia wall、,bronchiole wall、 alveolus wall,PathologyCommonhyperaemia、edem,呼吸系统疾病-课件,呼吸系统疾病-课件,Pathologic physiology,气道炎症,循环系统,神经系统,水电解质,消化系统,肺,A,压增高,中毒性,心肌炎,心衰,代酸,中毒性,肠麻痹,胃肠粘膜,屏障功能,脑水肿,颅压,呼酸,K,+,水钠储留,毒血症,通气不足,PaO,2,PaCO,2,换气障碍,PaO2,Pathologic physiology气道炎症循环系统,Clinical manifestation,Mild,symptomatic,respiratory,system,fever,respiratory,distress,nasal flaring, retractions,cyonosis,tachypnea,cough,rales,5,years RR30,次/分,Clinical manifestationMild res,Clinical manifestation,Severe,symptomatic,circular system,symptom,Cardiac muscle,inflammation,Heart,failure,Clinical manifestationSevereci,Clinical manifest,Severe,symptomatic,Heart,failure,呼吸突然加快，60次/分,心率突然增快,婴儿180次/分幼儿160次/分,突然烦躁不安、面色发灰,心音明显低钝，奔马率，颈静脉怒张,肝大肋下3,cm,以上,尿少、下肢浮肿,Clinical manifestSevereHeart呼吸,Clinical manifest,nerval,system,Light hypoxia：,irritability,，,lethargy,Sever hypoxia：,hydrocephalus,digestive,system,alimentary,canal bleeding,Poisoning intestine,palsy,Severe,symptomatic,Clinical manifestnerval Light,Clinical manifest,DIC,Bp,四肢凉，脉速弱，,出血,SLADH,Na,+,130mmol/L,渗透压,270,mOsm/L,Edema,Severe,symptomatic,Clinical manifest DICBp四肢凉，脉速弱,Complications,Complication,pneumatocele,pyopneumothorax,empyema,ComplicationsComplicationpneum,Laboratory data,Blood,blood,routine,bacteria infect：WBC、N ,left shift of nucleus,virus infect：WBC、L,abnormal lymph cell,bacteria infect,：,CRP ,virus infect,：,CRP normal,CRP,NBT,bacteria infect,： 10%,virus infect,： 10%,Pathogeny,virus separate,Germiculture,sputum for Gram stain and culture,Laboratory dataBloodbloodbacte,Laboratory data,X-ray,shadow of dot,and spote,emphysema,atelectasis,Laboratory dataX-rayshadow of,支气管肺炎,正常胸片,支气管肺炎正常胸片,大叶性肺炎,正常胸片,大叶性肺炎正常胸片,fever,cough, tachypnea ,respiratory distress and rales,X-ray,diagnosis,fever,cough, tachypnea , X-ray,Differentiation,acute,bronchitis,rales、tachypnea,foreign bodies,in bronchi,history of foreign bodies、sudden cough,、,respiratory distress、lower of breath,tone,or wheezing,tuberculosis,history of TB contact、PPD test、,PPD-IgGIgM,、,X-ray、rales,Differentiationacute rales、tac,Treatment,general,treatment,Balance of water and electrolyte,3%Nacl 12ml/LNa,+,10mmol/L,Temperature 18-20,Humidity 60%,Food nutritive,Treatmentgeneral Balance of wa,Treatment,Control,infection,virus：no ideal drug like virozol,mycoplasma、chlamydia,select erythromycin,bactrria：the principle of sensitivity,efficiency、full period of treatment,first select Peniccilin,TreatmentControl virus：no idea,Treatment,抗生素,使用原则,根据药敏选药,adopt sensitive drugs on the basis of,pathogenic bacterium,用下呼吸道浓度高的药物,adopt drugs which can finally infiltrate,lung tissue,足量,足疗程,重症静脉给药,in severe case,drugs should be administed,by vein,full dose,full period,Treatment抗生素根据药敏选药,Treatment,抗生素,选择,肺炎链球菌：,PNC,阿莫西林，红霉素,金黄色葡萄球菌：苯唑西林、氯唑西林、万古、利福平,流感嗜血杆菌：阿莫西林,+,克拉维酸钾或舒巴坦,大肠杆菌和肺炎杆菌：头孢曲松或头孢噻肟,绿脓杆菌：替卡西林钠克拉维酸钾或头孢哌酮,肺炎支原体或衣原体：大环内酯,Treatment抗生素肺炎链球菌：PNC,阿莫西林，红霉素,Treatment,full period,of treatment,after temperature normal 5,7days,or clinical symptom disappearing 3 days,Mycoplasma,pneumonia： 23 weeks,Staphylococus aureus,：,after temperature normal 2 weeks ，,full period is,6,weeks,Treatmentfull periodafter temp,treat,against,symptoms,Treatment,oxygen,treat,PaO,2,：dyspnea、,cyanosis、asthma suppress、,toxic appearance,methods:,by nose canal,0.5 1,L /min,，40%；,by veil,24,L/min,50%60%,mechanism ventilate,（,respire failture,）,holding,respiratory,tract unobstructed,remove sputum,、,pulverization,、,relieve spasm,ensure liquid absorb,treat TreatmentoxygenPaO2：dys,Treatment,treat of,other symp,defervesce,calm,treat of,windy,supply Kalium,Poisoning intestine palsy：fasting,、,decompress of stomach and intestine,酚妥拉明 0.5,mg/kg ivgtt,10%GS 20 ml,treat,against,symptoms,Treatmenttreat ofdefervescetre,Treatment,treat of,Heart failure,镇静,给氧,强心：西地兰,减轻心脏负荷,treat,against,symptoms,Treatmenttreat of镇静treat,Treatment,合并中毒性脑病,的治疗,脱水：甘露醇,改善通气,改善脑微循环,止痉：地西泮,地塞米松,营养神经,treat,against,symptoms,Treatment合并中毒性脑病脱水：甘露醇treat,Treatment,糖皮质激素,应用,适应症：,喘憋重,呼吸衰竭,全身,中毒症状重,感染性休克,脑水肿,琥珀酸氢化可的松5, 10,mg/kg.d,地塞米松0.1 0.3,mg/kg.d,ivgtt,23 次/日,35 天,甲基强的松龙,2, 4,mg/kg.,次,Treatment糖皮质激素适应症：琥珀酸氢化可的松5 ,Response to treatment in otherwise uncomplicated CAP?,Fever- falls in 2 days,Leucocytosis- decreases in 4 days,Physical findings persist slightly longer,Chest radiographic abnormalities may take,4-12 weeks to resolve,Response to treatment in other,What if patients fails to recover?,You should consider-,Noninfectious condition,Resistance to drug,New nosocomial pathogen,What if patients fails to reco,病毒性,肺炎,呼吸道合胞病毒肺炎,腺病毒肺炎,2岁，2,6月多见,喘憋、呼吸困难，可合并,呼衰、心衰,哮鸣音，细湿罗音,小点片状影，肺气肿肺不张,间质性肺炎,6月,2岁,中毒症状重，稽留热，,咳剧，喘憋，呼吸困难,出现晚，湿罗音或肺实变,胸片改变出现早，肺气,肿，片状影或融合,年龄,症状,胸片,体征,病毒性呼吸道合胞病毒肺炎腺病毒肺炎2岁，2 6月多见6月,细菌性,肺炎,葡萄球菌肺炎,新生儿，婴幼儿,急、重、快，弛张热或稽留热，,咳嗽，呼吸困难，呻吟，易致,迁徒化脓病灶，并发脓胸，脓,气胸，肺大疱,中细湿罗音，出现早，皮疹,浸润影，持续时间较长，易变，,可见多发性肺脓肿，脓胸，脓气,胸等,4岁,慢，重，发热，痉挛性,咳嗽，呼吸困难，发绀。,易致迁徒化脓病灶，易并,发脓胸,湿罗音或实变,大叶性肺炎、支气管肺炎、,肺实变,年龄,症状,体征,胸片,革兰阴性杆菌肺炎,细菌性葡萄球菌肺炎新生儿，婴幼儿4岁年龄症状体征胸片革兰阴,肺炎支原体肺炎,年长儿，婴幼儿,发热、刺激性咳嗽，多系统病变,不明显，婴幼儿可有呼吸困难，,喘憋，哮鸣音，湿罗音,肺门影增浓；支气管肺炎改变；,间质性肺炎；均一实变影,6月,起病慢，无发热，先,URI,症状后咳、喘、气促，部,分伴结膜炎,湿罗音，持续时间长,间质性炎症，过度充气、,片状影，持续时间长,年龄,症状,体征,胸片,沙眼衣原体肺炎,支衣原体,肺炎,肺炎支原体肺炎年长儿，婴幼儿20%,使用支扩剂后增加20% 可诊断哮喘,）,auxiliary examinationX-raylung,Diagnose of childfood asthma,gasp recurrent attacks,lung wheezing rales,bronchodilators is valid,exclude other disease that can cause gasp,Diagnose of childfood asthmaga,cough,1,month,antibiotics treat is invalid,bronchodilators can relieve cough,hypersensitive history or allergia family history,airway is hyperreactivity,exclude other cough disease,Diagnose of cough variant asthma,cough1month,antibiotics treat,therapy,Principle: long-term 、 persistence、standard、individuation,Period of onset:antiinflammatory、calm gasp,catabasis:long-term 、 antiinflammatory、avoid trigger factor、self-care,to spread Global Initiative for Asthma，GINA(,全球哮 喘防治创议,),therapyPrinciple: long-term 、,drug,glucocorticoid-first select,bronchodilators,immunosuppressant,other drug,drug glucocorticoid-first se,inhale,：,beclometasone 100,g，,24times,/,day,oral：prednisone,12,mg/kg/day,，17,day,severe case,persistent attackanti-asthmatic cannot control,intravenous drip：Cetacort,510,mg/kg/time,Medrat 12 mg/kg/ time,BidTid,severe attack,glucocorticoid,usage,inhale：beclometasone 100 g，,drug,bronchodilators,para-adrenal drug inhale,0.5%,albuterol 0.010.03 ml/kg/,次,atomization q46 h,theocin aminofilina,45,mg/kg/,次,immunosuppressant-methotrexate,-cyclosporin,other drug-disodium cromoglycate,-ketotifen,drug bronchodilators,Status,asthmaticus,inhale oxygen,calm,fluid replace,correct acidosis,cortine drip,bronchodilators,cortine inhale,theocin drip,respirator,Status,prevent,relapse,avoid sensitizin and trigger factor,inhale cortin,6,months2years,immunotherapy-,desensitization,self-management,prevent avoid sensitizin and,谢 谢！,谢 谢！,