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1、呼吸系统疾病 The Respiratory System,第四章,快速气体交换 Rapid gas exchange Ventilation Perfusion Diffusion 清洁空气,肺的结构与功能,Mucosa,Submucosa,Cartilage,Muscles,Bronchus,Bronchial epithelium,Kulchitsky cells,Bronchial Submucosal Glands,Alveoli,The respiratory membrane,病原体 Pathogen 空气 contaminated air exposure 鼻咽部菌群 naso
2、pharyngeal flora aspiration 宿主防御功能下降 Compromised defense mechanisms 肺部疾病 other common lung disease 免疫缺陷 Immunodeficiency 生活方式 Life style,肺部感染 Pulmonary Infections,分类 Classification,根据解剖和影像学 Anatomy and radiography 根据病因 Etiology 根据在哪获得 Setting in which they arise Community-Acquired Hospital-acquired
3、(nosocomial ),一、细菌性肺炎,大叶性肺炎 （95%肺炎链球菌） 小叶性肺炎 军团菌性肺炎 （肺炎+全身毒血症状）,小叶性肺炎,大叶性肺炎,患者杨某，男，20岁，学生。酗酒后遭雨淋，于当天晚上突然起病，寒颤、高热、呼吸困难、胸痛，继而咳嗽，咳铁锈色痰，其家属急送当地医院就诊。听诊，左肺下叶有大量湿性啰音；触诊语颤增强；血常规：WBC：17X109/L；X线检查，左肺下叶有大片致密阴影。,典型病例1,入院经抗生素治疗，病情好转，各种症状逐渐消失；X线检查，左肺下叶的大片致密阴影缩小2/3面积。病人于入院后第7天自感无症状出院。冬季征兵体检，X线检查左肺下叶有约3cmX2cm大小不规则
4、阴影，周围边界不清，怀疑为“支气管肺癌”。在当地医院即做左肺下叶切除术。病理检查，肺部肿块肉眼为红褐色肉样，镜下为肉芽组织。,大叶性肺炎,大叶性肺炎,大叶性肺炎,In the era before antibiotics,充血水肿期 Hyperemia and edema 红肝期 Red hepatization 灰肝期 Gray hepatization 溶解消散期 Resolution (hopefully),Hyperemia and edema，12-24 hours,Red hepatization 2-3 days,Gray hepatization，3-4 days,并发症 co
5、mplications,肺脓肿，脓胸，脓气胸 败血症，脓毒败血症，感染性休克 肺肉质变,小叶性肺炎,小叶性肺炎,Filled with exudate,Aerated lung,小叶性肺炎,小叶性肺炎,并发症 Complications,心力衰竭、呼吸衰竭 肺脓肿、脓胸、脓毒败血症 支气管扩张,Organization,Abscess formation,Abscess formation,Purulent pleuritis,Hemorrhagic Pneumonia by Pseudomonas aeruginosa,Pseudomonas pneumonia,Klebsiella pne
6、umonia,二、病毒性肺炎/三、支原体性肺炎,轻者为急性间质性肺炎，旧称不典型性肺炎atypical 缺乏实变体征 WBC轻度升高 重者为急性呼吸窘迫症ARDS 肺泡弥漫性损伤 透明膜形成,Viral pneumonia,Atypical pneumonia,Severe Acute Respiratory Syndrome (SARS),Pneumonia in the Immunocompromised Host,机会致病原 opportunistic agents 常为多重感染 bacteria (P. aeruginosa, Mycobacterium spp., L. pneumo
7、phila, and Listeria monocytogenes) viruses (cytomegalovirus and herpesvirus) fungi (P. jiroveci, Candida spp., Aspergillus spp., and Cryptococcus neoformans),CMV infections,in situ hybridization,Sputum cytology from an AIDS patient,(Papanicolaou),(Giemsa),Pneumocystis Pneumonia,(silver stain),Pneumo
8、cystis Pneumonia,(silver stain),Pneumocystis Pneumonia,Pneumocystis carinii in bronchial lavage from an AIDS patient (Grocotts silver),(Papanicolaou),(Immunostaining),慢性阻塞性肺病 (COPD) Chronic Obstructive Pulmonary Disease,limitation of airflow usually resulting from an increase in resistance caused by
9、 partial or complete obstruction at any level 肺气肿 Emphysema 慢性支气管炎 Chronic bronchitis 支气管扩张 Bronchiectasis 哮喘 Asthma,FEV1 / FVC,我国国家“十五”课题最新统计数据（2005年公布）显示40岁以上人口COPD患病率为8%。估计全国有2500万人罹患此病，每年因COPD死亡的人数达100万，致残人数达5001000万，COPD居我国疾病负担的首位。,慢性支气管炎 Chronic bronchitis,A persistent cough productive of sput
10、um for at least 3 months, in at least 2 consecutive years 单纯型 Simple 喘息型 Asthmatic 阻塞型 obstructive,病 因 etiology,吸烟和空气污染 Cigarette smoking and air pollutants 感染 Microbial infection Secondary role 使炎症持续，加重症状 maintaining the inflammation and exacerbating symptoms,发病机制 Pathogenesis,多痰粘液分泌亢进 Hypersecreti
11、on of mucus 大气道病变 large bronchial involvement 粘液腺增生，杯状细胞分泌亢进 Hypertrophy of mucous glands and a marked increase in mucin- secreting goblet cells,气道阻塞 Airflow obstruction 小气道炎症和管壁纤维化 inflammation, bronchiolar wall fibrosis 杯状细胞化生，细支气管痰栓形成 goblet cell metaplasia with mucus plugging of the bronchiolar
12、lumen 并发肺气肿 coexistent emphysema,发病机制 Pathogenesis,inner perichondrium,basal lamina,Chronic bronchitis,Normal bronchus,Chronic bronchitis,Chronic bronchitis,Chronic bronchiolitis,luminal and mucus,chronic inflammation,肺气肿 Emphysema,Abnormal permanent enlargement of the airspaces distal to the termin
13、al bronchioles, accompanied by destruction of their walls without obvious fibrosis 指呼吸性细支气管、肺泡管、肺泡囊、肺泡因组织弹性减弱而过度充气伴有肺泡间隔破坏，致使肺容积增大的病理状态,病理类型,腺泡(小叶)中央型 Centriacinar 全腺泡(小叶)型 Panacinar 腺泡(小叶)周围型 Distal acinar 不规则型 Irregular,obstruction,Spontaneous pneumothorax,asymptomatic,发病机理 Pathogenesis,Centriacin
14、ar emphysema,Bullous emphysema,Centriacinar emphysema,Inadequate ventilation Less perfusion Narrowed bronchiole,Conditions Related to Emphysema,间质性肺气肿 Mediastinal (interstitial) emphysema 代偿性肺气肿 Compensatory emphysema 阻塞性过充气 Obstructive overinflation 瘢痕旁肺气肿 Paracicatrical emphysema 老年性肺气肿 Senile emp
15、hysema,COPD的临床表现,Respiratory failure,Right heart failure,Pink puffer,桶状胸 Barrel chest,支气管扩张症 Bronchiectasis,Permanent dilation of bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue resulting from or associated with chronic necrotizing infections 继发于持续性感染或阻塞 Sec
16、ondary to persisting infection or obstruction 诊断依靠病史和影像学,Predisposing conditions,支气管阻塞 Bronchial obstruction 肿瘤 Tumor 异物 Foreign bodies 先天性或遗传性疾病 Congenital or hereditary conditions Cystic fibrosis Kartagener syndrome 坏死性化脓性肺炎 Necrotizing, or suppurative, pneumonia,Cystic Fibrosis (CF),Cystic Fibrosis (CF),Bronchiectasis,57 year old woman with a long history of recurrent respiratory tract infections and episodes of hemoptysis,Bronchiectasis,Bronchiectasis Due to
