儿科学-培训课件PPT
儿科学-培训课件PPT,儿科学,培训,课件,PPT
Diseases of Respiratory System呼吸系统疾病呼吸系统疾病Chen Dehui(1030412)Chen Dehui(1030412)Pediatric Department Pediatric Department The first Affiliated Hospital of The first Affiliated Hospital of Guangzhou Medical UniversityGuangzhou Medical University Review(总论)(总论)Acute respiratory infections(ARIs)Most common,particularly in daycare or school age childrenIncidence(发病率)(发病率)Outpatients(门诊)60%Hospitalization(住院)(住院)2565%Patients dead from pneumonia per year 28%(死亡率约(死亡率约28%)IntroductionWhy do so many children acquire acute respiratory infections diseases?Infant is not a miniature adult.Many differences in anatomy,physiology and immunology between in childhood and adulthoodThe respiratory tract is divided into upper respiratory tract and lower respiratory tract by the lower edge of cricoid cartilage.以以环状软骨下缘环状软骨下缘为界,分为:为界,分为:上呼吸道上呼吸道下呼吸道下呼吸道 Characteristics of Anatomy上呼吸道下呼吸道lower edge of cricoid cartilageAnatomy of Respiratory TractNose and Paranasal Sinuses 鼻和鼻窦吸吮困难吸吮困难呼吸困难呼吸困难 结膜炎结膜炎 鼻窦炎鼻窦炎 ARIs鼻腔短鼻腔短无鼻毛无鼻毛 后鼻道窄后鼻道窄 粘膜嫩粘膜嫩血管丰富血管丰富 鼻泪管短鼻泪管短 R=1/r4腭扁桃体在新生儿期不发育,1岁时才发育,410岁时发育最高峰,1415岁时渐退化咽扁桃体(腺样体)6月开始发育,位于鼻咽顶部与后壁交界处 阻塞性睡眠呼吸暂停综合征咽鼓管较短、直、宽 中耳炎咽后壁间隙组织疏松 咽后壁脓肿 Pharynx and Eustachian Tube 咽和咽鼓管咽和咽鼓管Larynx 喉部喉部 喉长而窄喉长而窄 声门狭小声门狭小喉软骨软而细喉软骨软而细粘膜嫩粘膜嫩血管丰富血管丰富 声嘶声嘶喉头水肿喉头水肿急性呼吸道梗阻急性呼吸道梗阻吸气性呼吸困难吸气性呼吸困难 When children get URIs,they will get actue laryngitis,occur hoarseness,laryngeal edema,acute respiratory obstruction and inspiratory dyspnea,quickly.Trachea and Bronchus 气管和支气管气管和支气管右侧支气管较直陡右侧支气管较直陡毛毛细细支支气气管管的的平平滑滑肌肌在在5个个月月前前发发育育较较差差,3岁后才发育岁后才发育婴婴儿儿支支气气管管缺缺乏乏弹弹力力组组织织,细细支支气气管管无无软软骨,呼气时受压,影响气体交换骨,呼气时受压,影响气体交换粘粘液液腺腺发发育育不不良良,粘粘膜膜纤纤毛毛运运动动差差,清清除除力差力差婴婴儿儿期期的的呼呼吸吸道道梗梗阻阻主主要要是是粘粘膜膜肿肿胀胀和和分分泌物阻塞泌物阻塞Trachea and Bronchus 气管和支气管气管和支气管Mucous glands are poorly developed and ciliaries have bad movement,causing inefficiency of clearance.粘粘液液腺腺发发育育不不良良,粘粘膜纤毛运动差,清除力差膜纤毛运动差,清除力差The main reasons of respriatory obstruction in infant are mucosal swelling and secretion that block up the bronchus.婴婴儿儿期期的的呼呼吸吸道道梗梗阻阻主主要要是粘膜肿胀和分泌物阻塞是粘膜肿胀和分泌物阻塞Lung and Portopulmonary 肺和肺门肺和肺门肺弹力组织发育差肺弹力组织发育差肺间质发育好肺间质发育好肺泡数量少肺泡数量少血管丰富血管丰富含血多而含气少含血多而含气少Compages of Thorax and Mediastinum 胸廓和纵隔胸廓和纵隔在在婴婴幼幼儿儿以以腹腹式式呼呼吸吸为为主主,至至47岁岁时时渐渐以以胸胸式式呼呼吸吸,7岁岁以以后后才才接接近近成成人人的的胸胸式式呼吸呼吸小儿呼吸肌发育较差,主要靠膈呼吸小儿呼吸肌发育较差,主要靠膈呼吸新生儿、小婴儿呼吸肌耐疲劳的肌纤维占新生儿、小婴儿呼吸肌耐疲劳的肌纤维占比例较少,易呼吸肌疲劳比例较少,易呼吸肌疲劳小儿纵隔较大,周围组织松软,在胸腔积小儿纵隔较大,周围组织松软,在胸腔积液或气胸时易发生纵隔移位液或气胸时易发生纵隔移位 Physiological Characteristics 生理特点生理特点年龄越小,潮气量越小,呼吸频率越快年龄越小,潮气量越小,呼吸频率越快婴幼儿呼吸中枢发育不完善,易出现呼吸节婴幼儿呼吸中枢发育不完善,易出现呼吸节律或呼吸暂停律或呼吸暂停婴幼儿以腹式呼吸为主婴幼儿以腹式呼吸为主婴幼儿需用肺活量的婴幼儿需用肺活量的30来呼吸,呼吸储备来呼吸,呼吸储备量较年长儿小量较年长儿小R=1/r4Average RR and Pulse in Different Ages不同年龄小儿呼吸、脉搏次数的平均值(次不同年龄小儿呼吸、脉搏次数的平均值(次/分)分)年 龄 呼 吸 脉 搏 呼吸:脉搏新生儿 4044 120140 1:31岁以内 3040 110130 1:3413岁 2530 100120 1:3447岁 2025 80100 1:4814岁 1820 7090 1:4Characteristics of Immunity 免疫特点免疫特点在在新新生生儿儿及及婴婴幼幼儿儿、尤尤其其是是人人工工喂喂养养儿呼吸道粘膜儿呼吸道粘膜SIgA较少较少IgG和和IgM在在56个个月月的的婴婴儿儿血血清清水水平较低平较低婴幼儿易患呼吸道感染婴幼儿易患呼吸道感染Disparity in occurrence and progression of disease between children and adultAcute Upper Respiratory Infections(AURIs)急性上呼吸道感染急性上呼吸道感染The most common infectious diseases,include rhinitis(the common cold),sinusitis,ear infections,acute pharyngitis or tonsillitis,epiglottitis,and laryngitis 由由病病毒毒或或细细菌菌等等病病原原体体感感染染所所致致的的以以侵侵犯犯鼻、鼻咽部为主的急性炎症鼻、鼻咽部为主的急性炎症Etiology.Pathogen 病因病因.病原体病原体Viruses account for most AURIs(90%)呼吸道合胞病毒(呼吸道合胞病毒(RSV)腺病毒(腺病毒(ADV)流感病毒流感病毒(Influenza V)副流感病毒(副流感病毒(Parainfluenza V)鼻病毒(鼻病毒(Rhinoviruses)柯萨奇病毒柯萨奇病毒埃可病毒埃可病毒H5N1Bacteria(10%)溶血性链球菌溶血性链球菌肺炎双球菌肺炎双球菌流感嗜血杆菌流感嗜血杆菌卡他莫拉氏球菌卡他莫拉氏球菌Etiology.Pathogen 病因病因.病原体病原体Viruses account for most AURIs(90%)Respiratory syncytial viruses(RSVs)呼吸道合胞病毒 Adenoviruses 腺病毒Influenza viruses 流感病毒 Parainfluenza viruses 副流感病毒Rhinoviruses 鼻病毒Coxsackie virus 柯萨奇病毒Echo virus 埃可病毒H5N1Bacterial(10%)Group A Hemolytic streptococcus 溶血性链球菌Diplococcus pneumoniae 肺炎双球菌Haemophilus influenzae 流感嗜血杆菌Catarrh moraxellacoccus 卡他莫拉氏球菌 Causative Factors 诱发诱发因素因素Malnutrition&rickets from vitamin D deficiency 营养不良、佝偻病营养不良、佝偻病Hypersensitivity 过敏体质者过敏体质者Immunodeficiency 免疫缺陷者免疫缺陷者Lack of exercise 缺乏锻炼者缺乏锻炼者Living environments 生活环境生活环境Climate change 气候变化气候变化Clinical SymptomsLocal symptoms:Coughing 咳嗽咳嗽Runny nose 流涕流涕Nasal congestion 鼻塞鼻塞Sore throat 咽痛咽痛Hoarseness 声嘶声嘶 Clinical SymptomsSystemic symptoms:FeverIrritability 易激惹易激惹Headache 头痛头痛General malaise 全身不适全身不适Tiredness 乏力乏力 Clinical SymptomsDigestive Symptoms:Decreased appetite 胃纳欠佳胃纳欠佳Vomiting 呕吐呕吐Abdominal pain 腹痛腹痛Diarrhea 腹泻腹泻Most AURIs are self-limited,lasting 35 days 病程约病程约35天天 Clinical SignsPharyngeal redness and swelling 咽部充血、肿胀咽部充血、肿胀Follicular hyperplasia in posterior wall of pharynx 咽后壁滤泡增生咽后壁滤泡增生Tonsil redness,enlargement and purulent secretion 扁桃体弥漫充血红肿、脓性分泌物扁桃体弥漫充血红肿、脓性分泌物Clinical SignsSmall aphthae in posterior wall of pharynx and arcus palatinus 软腭弓及咽后壁见小溃疡软腭弓及咽后壁见小溃疡Swelling and pain in mandibulares lymphonodi 下颌部的淋巴结肿大,压痛下颌部的淋巴结肿大,压痛Herpangina 疱疹性咽峡炎疱疹性咽峡炎Coxsackievirus A 柯萨奇病毒组引起柯萨奇病毒组引起Frequent in summer and autumn 夏秋季发病多见夏秋季发病多见To have infectiosity 传染性较强传染性较强Continuing hyperpyrexia lasts 1 week 持续高热,约持续高热,约1周周 Herpangina 疱疹性咽峡炎疱疹性咽峡炎Pharyngeal redness and pain 咽痛,咽充血咽痛,咽充血Exanthema vesiculosums in pharyngeal arches,soft palate,tonsillar arch,uvula 咽咽弓弓、软软腭腭前前后后弓弓、咽咽峡峡部部、悬悬雍雍垂垂的的粘粘膜膜上上可见数个至数十个灰白色小疱疹可见数个至数十个灰白色小疱疹Becoming small ulcers after 1-2 days 1-2天后疱疹破溃后形成溃疡天后疱疹破溃后形成溃疡Pharyngo-Conjunctival Fever 咽结合膜热咽结合膜热 Adenovirus 3,7 腺病毒腺病毒3,7型引起型引起Frequent in spring and summer 春夏季多见春夏季多见To have infectiosity 传染性较强传染性较强Pharyngo-Conjunctival FeverContinuing hyperpyrexia lasts1-2weeks 持续高热,约持续高热,约2周周Pharyngitis 咽炎咽炎 Follicular conjunctivitis 滤泡性结合膜炎滤泡性结合膜炎Complications 并发症并发症Otitis media 中耳炎中耳炎 Posterior wall of pharynx abscess 咽后壁脓肿咽后壁脓肿 Laryngitis 喉炎喉炎Cervical lymphadenitis 颈淋巴结炎颈淋巴结炎Bronchitis 支气管炎支气管炎Pneumonia 支气管肺炎支气管肺炎ComplicationsNephritis 肾炎肾炎Rheumatic fever 风湿热风湿热Myocarditis 心肌炎心肌炎Laboratory Findings 实验室检查实验室检查Blood routine 血常规血常规Etiology detection 病原学检查病原学检查Pharynx swab cultivation 咽拭子培养咽拭子培养Virus isolation 病毒分离病毒分离 Diagnosis and Differential Diagnosis诊断与鉴别诊断Influenza 流行性感冒Acute epidemic Diseases 急性传染病Digestive system diseases 消化系统疾病Allergic rhinitis 变应性鼻炎TreatmentsNo need for special treatments.Nursing care is very important.护理:休息,多饮水,保持空气流通和适护理:休息,多饮水,保持空气流通和适当的湿度当的湿度TreatmentsTherapy for symptomsReduce temperature by physical-therapies or medicine.物理或药物降温物理或药物降温Prevent convulsions 预防惊厥发生预防惊厥发生 TreatmentsAntiviral drugs 抗病毒药物抗病毒药物Antibiotics only used for the patients with bacterial infections(such as Group A streptococcal pharyngitis and secondary bacterial infections of a viral URI).抗抗生生素素的的应应用用指指征征:仅仅用用于于细细菌菌感感染染(如如A组组溶溶血血性性链链球球菌菌感感染染,或或病病毒毒性性上上感感继继发发细细菌感染者)菌感染者)Lower Respiratory Tract Infections(LRTIs)下呼吸道感染下呼吸道感染Infections below the level of the larynx;may be taken to include:Bronchitis 支气管炎支气管炎Bronchiolitis 毛细支气管炎毛细支气管炎Pneumonia 肺炎肺炎Acute Bronchitis 急性支气管炎急性支气管炎Common lower respiratory tract infections(LRIs)in children are tracheitis,bronchitis and bronchiolitis,or even pneumonia Main causes of URIs 小小儿儿急急性性支支气气管管炎炎常常继继发发于于上上呼呼吸吸道道感感染染后后的的支支气气管管粘粘膜膜的的炎炎症症,是是婴婴幼幼儿儿的的常常见见病病、多发病,也可以是肺炎的早期临床表现。多发病,也可以是肺炎的早期临床表现。Etiological FactorsPathogens 病原体病原体Causative factors 病原体感染及引起上感所有的诱发病原体感染及引起上感所有的诱发因素均可引起支气管炎。因素均可引起支气管炎。Clinical ManifestationsPrecursory symptoms of URIs 上感的前驱症状上感的前驱症状Coughing and breathing rapidly 咳嗽与呼吸增快咳嗽与呼吸增快Diffuse rhonchi or moist rales are heard on auscultation.双肺呼吸音增粗,可闻及干罗音或大、中水双肺呼吸音增粗,可闻及干罗音或大、中水泡音泡音,罗音可随体位变化或咳嗽后改变或罗罗音可随体位变化或咳嗽后改变或罗音减少。音减少。Clinical ManifestationsX-ray examination of the chest can be normal and may show a mild increase in bronchovascular markings.胸片检查:肺纹理增粗或肺门阴影增深。胸片检查:肺纹理增粗或肺门阴影增深。TreatmentsGeneral treatment 一般治疗一般治疗Symptomatic treatment 对症治疗对症治疗Expectorants and cough suppressants 止咳祛痰止咳祛痰Antiasthma treatment 平喘治疗平喘治疗 Antibiotics are needed if a bacterial infection of the airway is suspected or proven.控制感染控制感染 Bronchiolitis毛细支气管炎毛细支气管炎Occurs primarily in infants and usually is called bronchiolitis or infectious bronchiolitis.常为婴儿时期的首次喘息发作常为婴儿时期的首次喘息发作IntroductionIt is most common around 6 months of age and does not occur after age two.6月月2岁以下婴幼儿多见岁以下婴幼儿多见The most common cause is RSV,a respiratory virus present in the winter months.常见为常见为RSV感染,冬季好发感染,冬季好发Clinical ManifestationA simple cold with a runny nose for a day or soMild or middle degree fever 中低度发热中低度发热Developing labored breathing 用力呼吸用力呼吸The main symptoms are wheezing,coughing,rapid breathing,tight breathing,stridor and three-concave sign.临床以发作性临床以发作性 喘憋、三凹征、气促喘憋、三凹征、气促为主要表为主要表现现Clinical SignsRespiratory rhythm increasing 呼吸节律浅快,呼吸节律浅快,6080次次/分,甚至分,甚至100次次/分分Movement of alae nasi 鼻翼扇动鼻翼扇动Wheezing with a high-pitched sound and more prolonged when breathing out 高调喘鸣,呼气相延长高调喘鸣,呼气相延长Three-concave sign 三凹征三凹征 Clinical SingsThe crest-time will be in 48-72h after dyspnea,and the wheezing generally lasts about 7-14 days with coughing.高峰期在呼吸困难发生后高峰期在呼吸困难发生后4872小时,小时,病程持续约病程持续约12周周 Normal bronchioles正常的婴儿细支气管剖面图正常的婴儿细支气管剖面图 Acture Bronchiolitis急性毛细支气管炎气道剖面图急性毛细支气管炎气道剖面图 Pathogenesis&Clinical Manifestation 病毒感染病毒感染 管壁收缩 粘膜肿胀 上皮坏死 分泌物增多 纤毛受损 细胞内复制 肺不张 管腔狭窄、阻塞 分泌物排出困难 发作性性喘憋、呼气性喘鸣、呼吸困难 发热 肺气肿 PaO2下降、PaCO2升高 呼吸衰竭Laboratory FindingsBlood routine 血常规血常规Etiology detection 病原学检查病原学检查Pharynx swab cultivation(咽拭子培养咽拭子培养)Virus isolation(病毒分离)病毒分离)Blood air analysis(血气分析:(血气分析:PaO2下下降、降、PaCO2升高)升高)Differential Diagnosis:AsthmaAsthma is a chronic inflammatory disorder of the airways with inflammatory cellsChronically inflamed airways are hyperresponsive(气道高反应性气道高反应性);they become obstructed and airflow is limited by bronchoconstriction(支气管(支气管收缩)收缩),mucus plugs(痰栓)(痰栓),and increased inflammation when airways are exposed to various risk factors.Clinical ManifestationRecurring clinical symptoms such as cough,wheezing,chest tightness,and dyspnea,particularly at night or in the early morning 反复发作的咳嗽、喘息、胸闷、呼吸困难,反复发作的咳嗽、喘息、胸闷、呼吸困难,常在晚间或凌晨发作常在晚间或凌晨发作Recurring,reversible,seasonality,temporal rhythm 反复发作性,可逆性、反复发作性,可逆性、季节性、时间节律季节性、时间节律性性哮喘发作的临床表现:咳嗽、呼气相高调哮喘发作的临床表现:咳嗽、呼气相高调哮鸣音、呼气相延长、气促、三凹征哮鸣音、呼气相延长、气促、三凹征Exacerbations of Asthma:Shortness Exacerbations of Asthma:Shortness Breathing,Cough,Wheezing,Chest Tightness,Breathing,Cough,Wheezing,Chest Tightness,or A Combination of These Symptoms.or A Combination of These Symptoms.Coughing Occurs or Worsens at Night,and Symptoms Respond to Bronchodilator Therapy.Diagnosis of Asthma1、反复发作喘息、气急、胸闷或咳嗽,多与接触变应原等反复发作喘息、气急、胸闷或咳嗽,多与接触变应原等有关。有关。2 2、发作时在双肺可闻及散在或弥漫性,以呼气相为主的哮、发作时在双肺可闻及散在或弥漫性,以呼气相为主的哮鸣音,呼气相延长。鸣音,呼气相延长。3 3、上述症状可经治疗缓解或自行缓解。、上述症状可经治疗缓解或自行缓解。4 4、除外其它疾病所引起的喘息、气急、胸闷和咳嗽。、除外其它疾病所引起的喘息、气急、胸闷和咳嗽。5 5、临床表现不典型者(如无明显喘息或体征)应至少具备、临床表现不典型者(如无明显喘息或体征)应至少具备以下一项试验阳性:以下一项试验阳性:支气管激发试验或运动试验阳性;支气管激发试验或运动试验阳性;支气管舒张试验阳性一秒用力呼气容积(支气管舒张试验阳性一秒用力呼气容积(FEV1FEV1)或或PEFPEF值增加值增加1 12%2%以上,以上,或或FEV1FEV1增加绝对值增加绝对值200200mlml。最大呼气流速(最大呼气流速(PEFPEF)日内变异率或昼夜波动率日内变异率或昼夜波动率20%20%。符合符合1 14 4条或条或4 4、5 5条者,可以诊断为支气管哮喘。条者,可以诊断为支气管哮喘。Treatments of BronchiolitisOxygen therapy as required 氧疗氧疗 Control wheezing 控制喘憋控制喘憋 Inhale bronchodilators 支气管舒张剂雾化吸入支气管舒张剂雾化吸入Corticosteroids 糖皮质激素糖皮质激素Symptomatic treatment 对症处理对症处理 Treatments of BronchiolitisAntiviral Ribavirin has been tried.Therapy for RSV,but it is controversial 利巴韦林针对抗病原体的治疗,但有争议利巴韦林针对抗病原体的治疗,但有争议Combination of RSV intravenous immune globulin(RSV-IVIG)RSV-IVIG的免疫治疗的免疫治疗 自学急性喉炎章节自学急性喉炎章节掌握急性喉炎的临床表现,急性喉梗掌握急性喉炎的临床表现,急性喉梗阻严重程度的判断及处理原则阻严重程度的判断及处理原则熟悉急性喉炎的药物治疗熟悉急性喉炎的药物治疗Pneumonia肺炎肺炎Chen Dehui(1030412)Pediatric Department The first Affiliated Hospital of Guangzhou Medical UniversityDefinitionAn inflammation of the lung parenchyma 肺实质炎症肺实质炎症Most cases caused by microorganisms,several noninfectious causes,which include allergens or gastric acid,foreign bodies,and lipoid substances;drug or radiation-induced pneumonitis.不同的病原体或其他因素(吸入或过敏反应不同的病原体或其他因素(吸入或过敏反应等)所致的肺部感染等)所致的肺部感染DefinitionMain symptoms:fever,coughing,tight breathing,dyspnea,fine rales 临临床床上上主主要要表表现现为为发发热热、咳咳嗽嗽、气气促促、呼吸困难和肺部细湿罗音呼吸困难和肺部细湿罗音IntroductionsChildren develop on average 23 lower respiratory tract infections(LRTIs)each year LRTIs IncidencesOutpatients(门诊)(门诊)60%Hospitalization(住院)(住院)2565%Patients died every year pneumonia 28%-35%(死亡率(死亡率28%-35%)Why infants are more easy to develop on Pneumonia?气道的粘液分泌少,纤毛运动差。气道的粘液分泌少,纤毛运动差。气气管管和和支支气气管管管管腔腔较较狭狭窄窄,肺肺弹弹性性组组织织发发育育差差,血血管管丰丰富富,肺肺间间质质发发育育旺旺盛盛,肺含气量少。肺含气量少。免疫系统的不成熟。免疫系统的不成熟。易易于于扩扩散散,年年龄龄越越小小的的小小儿儿,肺肺炎炎的的程程度可越重。度可越重。Categorizations of PneumoniaCategorizations of Pneumonia 分类分类Type by Pathogen病病 因因 分分 类类Bacterial pneumonia 细菌性细菌性肺炎肺炎 Viral pneumonia 病毒性病毒性肺炎肺炎Mycoplasma pneumonia 支原体肺炎支原体肺炎Chlamydia pneumonia 肺炎衣原体肺炎肺炎衣原体肺炎Fungal pneumonia 真菌性肺炎真菌性肺炎Aspiration pneumonia 吸入性肺炎吸入性肺炎Hypersensitivity pneumonia 过敏性肺炎过敏性肺炎Typy by Pathology病病 理理 分分 类类Lobar pneumonia 大叶性肺炎大叶性肺炎Bronchopneumonia 支气管肺炎支气管肺炎Interstitial pneumonia 间质性肺炎间质性肺炎Course by Disease病病 程程 分分 类类Acute pneumoniaAcute pneumonia 急性肺炎急性肺炎 (1 1个月)个月)Persistent pneumoniaPersistent pneumonia 迁延性肺炎(迁延性肺炎(1 13 3个月)个月)Chronic pneumonia Chronic pneumonia 慢性肺炎(慢性肺炎(3 3个月)个月)Pathogenetic Condition病病 情情 分分 类类Mild pneumonia Mild pneumonia 轻症肺炎轻症肺炎Severe pneumonia Severe pneumonia 重症肺炎重症肺炎 Usually with severe compicationUsually with severe compication 常合并有严重的并发症常合并有严重的并发症Most patients with severe heart Most patients with severe heart diseasesdiseases 有严重的先天性心脏病有严重的先天性心脏病Categorize by Clinical ManifestationTypical pneumonia 典型肺炎典型肺炎Atypical pneumonia 非典型肺炎非典型肺炎Sever acute respiratory syndrome(SARS)严重急性呼吸综合征严重急性呼吸综合征CAP&HAPCommunity acquired pneumonia(CAP)社区获得性肺炎:无免疫抑制的患儿社区获得性肺炎:无免疫抑制的患儿在院外或住院在院外或住院48小时内发生的肺炎小时内发生的肺炎Hospital acquired pneumonia(HAP)院内获得性肺炎:住院院内获得性肺炎:住院48小时后发生小时后发生的肺炎的肺炎Etiological Factors 病因学病因学 Pathogen 病原体病原体Bacterial Pneumonia细菌性肺炎细菌性肺炎肺炎双球菌肺炎双球菌 最常见最常见 溶血性链球菌溶血性链球菌 麻疹或百日咳后麻疹或百日咳后 金黄色葡萄球菌金黄色葡萄球菌 重症肺炎重症肺炎流感嗜血杆菌流感嗜血杆菌 毛细支气管炎、败血症毛细支气管炎、败血症大肠杆菌大肠杆菌 新生儿及营养不良的婴儿新生儿及营养不良的婴儿克雷伯氏菌克雷伯氏菌绿脓杆菌绿脓杆菌Viral pneumonia病毒性肺炎病毒性肺炎呼吸道合胞病毒呼吸道合胞病毒 30%腺病毒腺病毒 23.34%副流感病毒副流感病毒 40.7%流感病毒流感病毒 Mycoplasma pneumonia(MP)Chlamydia pneumonia(CP)420%(支原体支原体/肺炎衣原体肺炎衣原体)Combined infection 混合感染混合感染Fungal or protozoan 真菌、原虫真菌、原虫Pathogen unknown 病因不明者病因不明者 Causative Factors诱诱 发发 因因 素素Environment factors 环境因素环境因素Body constitution factors 体质因素体质因素Combined other diseases 其他疾病的影响其他疾病的影响Pathophysiology病病 理理 生生 理理Pathogenesis 发病机制发病机制 PathogenPathogen病原体 Toxinum毒素毒素 Pneumonia 肺炎 Toxemia 毒血症Anoxia Anoxia 缺氧缺氧COCO2 2 Retention CORetention CO2 2潴留潴留AnoxiaAnoxia缺氧缺氧CO2 RetentionToxemia毒血症毒血症Respiratory Failure 呼吸衰竭呼吸衰竭Cardiac Dysfunction 心功能不全心功能不全Acid-Base Imbalance 酸碱平衡失调酸碱平衡失调Toxic Encephalopathy 中毒性脑病中毒性脑病Toxic Enteroplegia 中毒性肠麻痹中毒性肠麻痹Toxic Myocarditis 中毒性心肌炎中毒性心肌炎炎症炎症肺泡壁增厚肺泡壁增厚弥散障碍弥散障碍换气障碍换气障碍支气管粘膜充支气管粘膜充血、水肿、分血、水肿、分泌物阻塞泌物阻塞通气障碍通气障碍缺氧、缺氧、CO2潴留潴留SaO285%时,紫绀。时,紫绀。PaO26.67kpa时,型呼吸衰竭时,型呼吸衰竭。COCO2 2潴留,潴留,PaCOPaCO2 26.67kpa6.67kpa时,时,型呼吸衰竭。型呼吸衰竭。缺氧、缺氧、CO2潴留潴留血管运动中枢兴奋血管运动中枢兴奋 心率心率心肌疲劳心肌疲劳心力衰竭心力衰竭毒素毒素心肌细胞心肌细胞水肿、变水肿、变性、坏死性、坏死中毒性中毒性 心肌炎心肌炎 缺氧缺氧脑细胞缺血缺氧脑细胞缺血缺氧脑水肿脑水肿中枢性呼衰中枢性呼衰毒素毒素脑细胞中毒、脑细胞中毒、变性、坏死变性、坏死中毒性脑病中毒性脑病血脑屏障通透性血脑屏障通透性缺氧缺氧肠粘膜缺血缺氧肠粘膜缺血缺氧毛细血管通透性毛细血管通透性胃肠道出血胃肠道出血毒素毒素中毒性肠麻痹中毒性肠麻痹 缺氧缺氧酸性代谢酸性代谢产物堆积产物堆积代谢性代谢性酸中毒酸中毒高热脱水高热脱水吐泻等吐泻等 CO2潴留潴留PaCO2呼吸性酸中毒呼吸性酸中毒混合性混合性酸中毒酸中毒呼吸增快呼吸增快通气过度通气过度Pneumonia肺炎肺炎Chen Dehui(1030412)Pediatric Department The first Affiliated Hospital of Guangzhou Medical UniversityClinical ManifestationHigh fever over 38.5C may occur often 发热发热Cough,Tachypnea,Dyspnea 咳嗽、气促咳嗽、气促、呼吸困难、呼吸困难Nasal flaring 鼻扇鼻扇Cyanosis 发绀发绀 Chest indrawing(intercostal,subcostal and suprasternal recession)三凹征三凹征 Clinical ManifestationFixed fine rales are heard on auscultation,especially on inspiratory phase,or beside with axial skeleton 呼吸音增粗,双肺可闻呼吸音增粗,双肺可闻固定的细湿罗固定的细湿罗音(吸气相、脊柱两旁明显)音(吸气相、脊柱两旁明显)Pneumonia Bronchitis咳嗽咳嗽 重重 较轻较轻全身症状全身症状 重,易出现休克重,易出现休克 轻,休克较少轻,休克较少肺部罗音肺部罗音 中小水泡音中小水泡音 大中水泡音大中水泡音罗音位置罗音位置 固定固定 不固定,可随体位或不固定,可随体位或 哭闹后改变哭闹后改变 胸部胸部X线线 斑片状阴影斑片状阴影 肺纹理增粗肺纹理增粗What Are the Differences Between Pneumonia and Bronchitis 支肺炎与支炎的鉴别诊断支肺炎与支炎的鉴别诊断Age and the Type of LRTI,Will Affect the Symptoms and HistoryNewborn and neonates present with:GruntingPoor feedingIrritability or lethargyTachypnea sometimesFever(but neonates may have unstable temperatures,with hypothermia)Cyanosis(in severe infection)Cough(but this is unusual at this age)Examination can be difficult in young children(particularly auscultation)Some symptoms and signs will be indicated sever pneumonia(重症肺炎重症肺炎)Respiratory Symptoms-Respiratory Failure 呼吸衰竭呼吸衰竭Respiratory rate-to distinguish children with pneumonia from those without Lower chest wall indrawing-to identify severe pneumonia requiring referral and hospital admissionChildren with audible stridor when calm and at rest-to danger signs of severe disease Inability to feed also require referral.Severe Pneumonia重症肺炎重症肺炎Circulatory System 循环系统循环系统 Myocarditis 心肌炎心肌炎 Heart failure 心力衰竭心力衰竭 Pale face 面色苍白面色苍白 Low-dull heart sounds 心音低钝心音低钝 Gallop rhythm 奔马律奔马律Diagnosis of Heart Failure 心衰的诊断标准(心衰的诊断标准(1)呼吸突然呼吸突然6060次分;次分;心率突然心率突然180180次分;次分;突突然然极极度度烦烦躁躁不不安安,明明显显发发绀绀,面面色色苍苍灰灰,指(趾)甲微循环再充盈时间延长;指(趾)甲微循环再充盈时间延长;肝脏迅速增大;肝脏迅速增大;心音低钝,或有奔马律,颈静脉怒张;心音低钝,或有奔马律,颈静脉怒张;尿少或无尿,颜面、眼睑或下肢水肿。尿少或无尿,颜面、眼睑或下肢水肿。出现前项者即可诊断为心力衰竭。出现前项者即可诊断为心力衰竭。Diagnosis of Heart Failure 心衰的诊断标准(心衰的诊断标准(2)Toxic Encephalopathy中毒性脑病中毒性脑病 烦躁不安、嗜睡,双眼凝视烦躁不安、嗜睡,双眼凝视 球结膜水肿,前囟门隆起球结膜水肿,前囟门隆起 昏睡、昏迷、意识障碍,惊厥昏睡、昏迷、意识障碍,惊厥 瞳孔对光反射迟钝或消失瞳孔对光反射迟钝或消失 呼吸节律不整,呼吸心跳解离呼吸节律不整,呼吸心跳解离 脑膜刺激征(),脑脊液除压力增高脑膜刺激征(),脑脊液除压力增高外其余均正常外其余均正常有有项提示脑水肿,伴其他一项以上者项提示脑水肿,伴其他一项以上者确诊确诊Severe PneumoniaIntoxicated enteroplegia 中毒性肠麻痹中毒性肠麻痹DIC:血压下降血压下降、四肢凉、脉细速、出血、四肢凉、脉细速、出血Syndrome of inappropriate secretion of antidiuretic hormone 抗利尿激素异常分泌综抗利尿激素异常分泌综合征:合征:全身性浮肿全身性浮肿血钠血钠 130mmol血渗透压血渗透压 275mosm/L尿钠尿钠 20mmol/L肾功能正常肾功能正常ADH升高升高Laboratory FindingsWhite Blood Cell Count 白细胞检查白细胞检查C-Reactive Protein C C反应蛋白反应蛋白Blood Air Analysis血气分析血气分析Pathogen Laboratory Findings Bacterial/Viral CulturePharyngeal Swab-PCR 咽拭子咽拭子Sputum culture 痰培养痰培养Lung puncture from pleural effusion 胸腔穿刺液胸腔穿刺液Alveolar lavage fluid(BALF)by bronchoscopes 经支气管镜取肺泡灌洗液检查经支气管镜取肺泡灌洗液检查Lung Biopsy 肺活检肺活检Serology Detection血清学检测血清学检测支原体检测支原体检测肺炎支原体抗体检测(肺炎支原体抗体检测(IgM)1:160(+)冷凝集试验冷凝集试验 1:64(+)肺炎支原体分离肺炎支原体分离血清病毒抗体血清病毒抗体IgM检测检测Normal Chest Radiographic FindingsBronchopneumonia:Increase In Bronchovascular Marking And Patchy Infiltrate 双双肺肺纹纹理理增增粗粗,斑斑片片状状阴阴影影渗渗出出。Lobar Pneumonia:Lobar Consolidation And Atelectasis 肺实变及肺不张肺实变及肺不张 右下肺炎右下肺炎 右中叶节段性肺炎右中叶节段性肺炎Fungal Pneumonia 真菌性肺炎真菌性肺炎Lobar Pneumonia 大叶性肺炎大叶性肺炎Complication:Empyema并发症并发症:脓胸脓胸弱弱或或消消失失语语颤颤减减弱弱,呼呼吸吸音音减减患患侧侧呼呼吸吸运运动动受受限限突突然然呼呼吸吸困困难难Complication:Pneumopyothorax并发症并发症:脓气胸脓气胸剧烈咳嗽,呼吸困难,发绀呼吸音减弱或消失。液气片面Complication:Pneumatocele并发症并发症:肺大泡肺大泡 Differential Diagnosis:Bronchiectasis 鉴别诊断鉴别诊断:支气管扩张支气管扩张l咳咳嗽嗽、多多痰痰、咯咯血血l反反复复呼呼吸吸道道感感染染l肺肺部部固固定定湿湿性性罗罗音音l中中下下肺肺野野大大小小不不等等的的环环状状透透光光阴阴影影,蜂蜂窝窝状状。Differential Diagnosis:Bronchiectasis 鉴别诊断鉴别诊断:支气管扩张支气管扩张l持持续续高高热热l结结核核中中毒毒症症状状l肺肺部部体体征征不不明明显显l多多有有原原发发结结核核病病灶灶l大大小小均均匀匀对对称称粟粟粒粒影影 Differential Diagnosis:Phthisis Miliaris 鉴别诊断鉴别诊断:粟粒性肺结核粟粒性肺结核Differential Diagnosis:Foreign Body in Bronchus 鉴别诊断鉴别诊断.支气管异物支气管异物l左左支支气气管管异异物物济公丸济公丸 塑料珠子塑料珠子 鸡骨头鸡骨头 花生花生1.5岁男孩,呛咳6h后急诊手术,术中发现左右主支气管均有不同类别(6件)的异物,追问病史,患儿4天前曾进食花生糖时有咳嗽。Different Characteristics in Different Pathogens 不同病原体所致支气管肺炎的特点 Staphylococcal Aureus PneumoniaStaphylococcal Aureus Pneumonia金黄色葡萄球菌性肺炎Common in infants Common in infants 1 1 ageage 好发好发1 1岁婴幼儿岁婴幼儿To have an anxious progress and appear To have an anxious progress and appear bellows rales early bellows rales early 起病急,进展快,肺部罗音出现早起病急,进展快,肺部罗音出现早Sepsis,Sever sepsis or shock in the Sepsis,Sever sepsis or shock in the prophase prophase 早期中毒症状明显,休克,败血症早期中毒症状明显,休克,败血症Capillary Refill Time Delay CRT 3s3s正常情况下在温暖环境中毛细血管再充盈时间应正常情况下在温暖环境中毛细血管再充盈时间应2sStaphylococcal Aureus PneumoniaStaphylococcal Aureus Pneumonia金黄色葡萄球菌性肺炎To emerge with lung abscess,empyema rapidly 迅速出现肺脓肿、脓胸等迅速出现肺脓肿、脓胸等White blood cell counts rise with many neutrophils and nucleus shift to the left WBCWBC升高,中性为主,核左移升高,中性为主,核左移Antimicrobial therapy may control the infections and at least lasting 6-8 weeks 抗生素治疗有效,病程长抗生素治疗有效,病程长,6-8,6-8周周Staphylococcal Aureus Pneumonia:Multiple Pulmonary Abscess 金葡菌金葡菌:多发性肺脓肿多发性肺脓肿Multiple Pulmonary Abscess Multiple Pulmonary Abscess 多发性肺脓肿多发性
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