第七章呼吸系统疾病七年制

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,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,*,*,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,*,*,第七章呼吸系统疾病七年制,(2) stage of red hepatization (3-4days),肺泡壁毛细血管显著扩张充血；肺泡腔内大量纤维素及大量红细胞,病变肺叶肿大，重量增加，色暗红，质实如肝，切面呈粗颗粒状,铁锈色痰，胸痛，呼吸困难及紫绀;肺实变体征;大片致密阴影;可检出多量肺炎球菌,(3) s,tage,of gray,hepatization,(5-6days),肺泡壁毛细血管受压; 肺泡腔内大量纤维素及大量中性粒细胞,病变肺叶肿大，灰白色，切面干燥，颗粒状，质实如肝,缺氧症状减轻；肺炎球菌不易检出；实变体征；大片致密阴影,(4)dissolution and dissipation stages(7-),中性粒细胞变性崩解肺泡巨噬细胞增多,纤维素被溶解,肺泡内重新含气,。,质地变软，切面颗粒外观渐消失，可涌出脓样混浊液体,体温下降，又可闻湿罗音，肺实变体征消失，病变区透亮度渐增加,Pulmonary carnification,Lung abscess,pyothorax,大叶性肺炎并发肺脓肿, 脓液排出后形成的空腔,。,(1)Gross appearance：两肺表面和切面散在灰黄色实变病灶,下叶后部明显,病灶大小不等，直径多在051左右，严重者病灶可相互融合。,(2) Microscopic appearance :,以细支气管为中心的急性化脓炎症,病灶周肺组织代偿性肺气肿或肺萎陷。,小叶性肺炎病灶相互融合，形成融合性支气管肺炎（confkuent bronchopneumonia）。,(四).病毒性肺炎(viral pneumonia),1.Clinical features :,病毒血症-发热,血常规:L,频繁难治的咳嗽,气促,发绀,等。多见于儿童,2.Morphology：,间质性炎症 interstitial pneumonitis,(1)Gross appearance：,(2)Microscopic appearance： 炎症沿支气管、细支气管壁及其周围、小叶间隔及肺泡间隔分布。肺泡间隔明显增宽;重者透明膜形成.,病毒包涵体(viral inclusion bodies),凡事都得趁 早,慢性阻塞性肺病,(chronic obstructive pulmonary disease,COPD),Conception：一组以肺实质与小气道受到病理损害后，导致慢性不可逆性气道阻塞，呼吸阻力增加，肺功能不全为特征的肺疾病的统称。,慢性支气管炎（chronic bronchitis）,肺气肿（pulmonary emphysema）,支气管扩张症（,bronchiectasis,）,支气管哮喘（bronchial asthma）,(,一).慢性支气管炎(chronic bronchitis),气管、支气管粘膜及其周围组织的,慢性非特异性炎症。,1.,Etiology and Pathogenesis,*外因 呼吸道反复病毒和细菌感染,吸烟 过敏因素 大气污染及寒冷,*内因 机体抵抗力降低,呼吸系统防御功能受损,2. Morphology,(1)呼吸道粘膜上皮的损伤与修复,(2)呼吸道腺体的变化,(3)平滑肌、弹力纤维及软骨受损,(4)管壁充血，慢性炎细胞浸润,Chronic bronchitis,3、,Clinical features,cough, sputum, gasp.,dry rales, moist rales,complications: bronchiectasis,lobular pneumonia, emphysema,*Chronic bronchitis is defined as a cough productive of sputum on most days for three months of the year for at least two successive years.,(二).肺气肿(pulmonary emphysema),1.Conception:指呼吸细支气管、肺泡管、肺泡囊和肺泡因过度充气呈持久性过度扩张，并伴有肺泡间隔破坏，以致肺组织弹性减弱,容积增大的一种病理状态。,2.,Etiology and Pathogenesis,The etiology is unclear but risk factors include infection, cigarette smoking, atmospheric pollution. and family history.,Associations The majority of cases are seen in conjunction with chronic bronchitis,.,(1)细支气管阻塞性通气障碍,慢性炎症使小气道管壁增厚及粘液栓形成,细支气管支撑组织破坏, 细支气管 肺泡交通支,(2)弹性蛋白酶增多、活性增高,小气道炎,遗传性1抗胰蛋白酶缺乏,吸烟,lassification and Morphology,(1)肺泡性肺气肿(alveolar emphysema),阻塞性肺气肿(obstructive emphysema),腺泡中央型(,centriacinar emphysema,),全腺泡型 (,panacinar emphysema,),大泡性肺气肿(,bullous emphysema,),腺泡周围型(,periacinar emphysema,),(隔旁肺气肿,paraseptal emphysema,),(2)间质性肺气肿,(,interstitial,emphysema,),(3)Others,瘢痕旁肺气肿(不规则型肺肿),(paracicatrical emphysema),肺大泡(bullae lung) *,老年性肺气肿(老年性肺过度充气),(senile emphysema),代偿性肺气肿(非真性肺气肿),(compensatory emphysema,),肉眼：体积增大、边缘钝圆、色灰白、柔软而弹 性差、指 压后压痕不易消退。,normal lung,emphysema,panaciar emphysema,bullous,emphysema,bullae lung,normal tissue,emphysema,Microscopic appearance:,肺泡扩张，间隔变窄，肺泡孔扩大，肺泡间隔断裂，扩张的肺泡融合成较大的囊腔。肺毛细血管床明显减少，肺小动脉内膜呈纤维性增厚,。,4.,Clinical features,Symptom:,慢性支气管炎的症状,阻塞性通气障碍和低氧症状。,Physical sign:,“,桶状胸”, X线检查示肺野透亮度增加，横膈下降。,Complicatio:,cor pulmonale,spontaneous pneumothorax ,respiratory failure.,(三)支气管扩张症(bronchiectasis),1.,指肺内小支气管管腔持久性扩张伴管壁纤维性增厚的一种慢性化脓性疾病,。,2.Etiology and Pathogenesis,(1)infection:,(2)genetic factor:,支气管扩张症：肺叶之间有纤维粘连,支气管壁呈慢性炎性改变并有不同,程度的组织结构破坏。,4.临床表现：,(1)慢性咳嗽、大量脓痰、反复咯血、胸痛、感染中毒症状。,临床确诊:支气管碘油造影。,(2)并发症:肺炎、肺脓肿、脓胸、脓气胸、肺气肿、肺心病,四、肺间质疾病(pulmonary interstitial diseases),肺尘埃沉着症(pneumoconiosis),肺硅沉着症(硅肺 矽肺）,农民肺（霉草尘肺）,煤工尘肺,肺硅沉着症(silicosis),1.Outline:因长期吸入大量含游离二氧化硅的粉尘沉着于肺部引起的一种常见的职业病。,2.Etiology and Pathogenesis,(1)Cause of disease:SiO2微粒。,(2)Pathogenesis:,自溶崩解释放,巨噬细胞,SiO,2,H,2,O,硅酸,膜的通透性改变，破裂,次级溶酶体,释放,多种水解酶,巨噬细胞可释放：,氧自由基、细胞因子、及介质包括白细胞介素（IL）、肿瘤坏死因子（TNF）、纤维连接蛋白（FN）、和纤维增生细胞因子（FC）等，,它们均可引起肺组织的炎性反应、细胞坏死和肺纤维化。,Basic morphology:硅结节和弥漫性肺纤维化,Characteristic morphology,:,硅结节(silicotic nodule),Microscopic appearance:,细胞性硅结节纤维性胶原硅结节,弥漫性间质纤维化,*肺急性硅蛋白沉积症(急性硅肺,acute silicoproteinosis),肉眼：硅结节境界清楚，圆形或椭圆形大小不 等，直径25到更大，质硬，灰白色,触之有沙砾感。,增生的纤维结缔组织呈同心圆式排列，胶原沉积增多,成同心圆状或漩涡状排列的玻璃样变的结节。,结节由呈漩涡状排列的发生玻璃样变的胶原纤维构成。,4.Complication:,(1)pulmonary tuberculosis:,硅肺结核病( silicotuberculosis),(2)cor pulmonale,间质弥漫纤维化,硅结节内小血管闭塞性血管内膜炎,(3)chronic bronchitis and obstructive emphysema,(4)spontaneous pneumothorax,5.Clinical features:,(一)概念:慢性肺疾病、肺血管及胸廓病变引起肺循环阻力增加、肺动脉压力升高而招致的以右心室肥厚、扩张甚至发生右心衰竭的心脏病。,(chronic cor pulmonale),1.肺疾病:,以慢性阻塞性肺病（COPD）中 慢 性支气,管炎并发阻塞性肺气肿最为多见。,肺泡气氧分压 二氧化碳分压肺小动脉痉挛及肺血管构型改肺循环阻力增加肺动脉高压右心肥大、扩张,慢性阻塞性肺疾病小气道阻塞通气障碍,间质纤维化及肺气肿破坏血气屏障气体交换面积换气功能障碍,(二)Etiology and Pathogenesis,(三)Morphology,1.心脏病变:,右心室肥厚，心腔扩张，心尖钝,圆主由右心室构成，右心室肥大的病理形态诊断标准:肺动脉瓣下2cm处右心室壁肌肉厚5mm,2.肺部病变：,肺小动脉的变化,肺组织原有病变,肺气肿引起的慢性肺源性心脏病,(,四)、Clinical features, 原有肺疾病的症状和体征。, 呼吸功能不全和右心衰竭的症状和体征，常表现为呼吸困难、发绀、心悸、气急、肝肿大、全身淤血、下肢水肿。,六.Common tumors, nasopharyngeal carcinoma, carcinoma of the lung,(一).鼻咽癌(nasopharyngeal carcinoma),Etiology,The risk factor include:,EBV(Epstein-Barr Virus,EBV),environmental factor,genetic factor,Morphology:,鼻咽黏膜柱状上皮的,储备细胞,Histogenesis,:,鳞状上皮的,储备细胞,(1),部位,:,鼻咽顶部,，外侧,壁及咽隐窝,(2),肉眼,:,结节型、菜花型、,黏膜下型、,溃 疡型。,(3)Microscopic appearance:,.鳞状细胞癌:,.腺癌,*最常见是非角化型鳞状细胞癌。,角化型,非角化型,未分化型,鼻咽型,未分化癌,分化型,泡状核细胞癌,vesicularnucleus,cell carcinoma, 鼻咽黏膜 柱状上 皮的储备细胞增生,非角化型鳞状细胞癌,泡状核细胞癌：癌巢不规则，境界不甚明显，癌细胞胞浆丰富，境界不清晰，成合胞浆性,核大呈空泡状，圆形或卵圆形，有一个或多个大而清晰或畸形的核仁。淋巴细胞浸润。,Spread of tumor,(1)direct spread,(2)lymphatic metastasis*,(3)hematogeneous metastasis,Clinical features,headache; nasal obstruction;,nose bleeding; tinnitus;,mass of the cervical part;,damage of the cranialnerve,(二),肺癌（Carcinoma of the lung）,支气管源性癌(bronchogenic carcinoma,肺癌的发病率呈现出以下,“,三高,”,的特点：,工业发达国家(地区)高于欠发达国家(地区)。,城市高于农村,。,男性高于女性,。,为什么发病率 呈现三高呢？,Etiology,The risk factor include:,smoking,air pollution,vocational factor,gene change,肺癌发生示意图,肺癌是在上述化学因素、职业（放射）因素、生物因素以及其他如遗传，生活习惯等因素的共同作用下，机体细胞遗传基因发生改变而发生的,Morphology,Gross appearance,:,central carcinoma of the lung,peripheral carcinoma of the lung,diffuse carcinoma of the lung,注意肿块与支气管的关系？,注意肿块与支气管的关系？,diffuse carcinoma of the lungs,（1）早期肺癌:癌块直径小于2cm，并局限于支气管内或浸润管壁及其周围且无淋巴结转移的肺癌。,（2）隐性肺癌:,临床及X线检查阴性；痰细胞学检查阳性；手术标本经病理检查证实为原位癌或早期浸润癌而无淋巴结转移。,Histological types:,*squamous carcinoma,*adenocarcinoma,*small cell lung carcinoma,*large cell lung carcinoma,*adenosquamous carcinoma,* pleomorphic sarcomoid,carcinoma,Microscopic appearance:,Squamous,carcinoma,adenocarcinoma,special type,:,b,ronchioalvolar carcinoma,small cell lung carcinoma,Microscopic appearance：,【1】 成巢，由纤维结缔组织加以分割， 有时癌胞围 绕小血管排列成假菊形团结构结构，多见坏死。,【2】 细胞形态：成短梭形或淋巴细胞样 或多角形，浆少而似裸核。典型时癌细胞常一端稍尖，形似燕麦穗粒，称之为燕麦细胞癌（oat cell carcinoma）。,电镜下特点：细胞浆之内可见神经内分泌颗粒。,large cell lung carcinoma, 肺巨细胞癌(pulmonary giant cell carcinoma)：,癌细胞体积更大,可见多核 癌巨细胞,异型性很大。, 电镜下特点：为分化差的鳞癌,腺癌，且多为后,者,有时可见神经内分泌颗粒。,adenosquamous carcinoma,pleomorphic sarcomoid,carcinoma, 肺的神经内分泌癌,(neuroendocrine carcinoma),指起源于支气管黏膜或腺上皮的 kulchitsky细胞（APUD细胞），含有神经内分泌颗粒，能产生多肽类激素的肺癌。包括：类癌,不典型类癌, 小细胞癌。,local spread,Clinical features,(1)常见早期症状,(2)胸腔血性积液,(3)局限性肺气肿或肺萎陷,(4)上腔静脉综合征,(Superior vena cava syndrome),(5)交感神经麻痹综合征(Horner综合征),(6)上肢疼痛及手部肌肉萎缩:侵犯壁丛神经,(7)肺外症状:,副肿瘤综合征(paraneoplastic syndrome),*早期诊断,Case study,This male patient has been a,heavy smoker his entire life without any success at smoking cessation.,He presented with productive cough, purulent sputum, dyspnea, and chest heaviness.,He had developed a barrel-shaped chest and generalized edema.,Recently he had been having,hemoptysis and chest pain.,Chest X-ray showed a large shadow over pulmonary hilum.,The patient was screaming for severe headache in the early morning the day before yesterday.,He did not survive the resuscitation and passed away today,Please Answer the following questions,2. At autopsy, what possible,pathologic changes would be,revealed in all major tissues,and organs (include gross and,microscopic changes)?,1.Name the diagnosis. Please,describe the development,processes of these diseases.,病例讨论,某君嗜烟如命，众劝不听；,咳嗽吐脓痰，气急胸闷；,胸如桶状，浮肿全身；,近期咳血胸痛,胸片肺门巨大阴影,前天清晨，大叫头痛；,抢救无效，失去生命。,请问,(1)此病人患了哪些疾病？阐述其发生、,发展过程。,(2)尸体解剖，各主要脏器、组织可能,有哪些病理学改变？(肉眼、光镜),请保护环境,谢谢！,