内科学 呼吸系统总论瞿介明精选PPT.ppt

第1页，此课件共56页哦IntroductionIntroductionThe Respiratory The Respiratory System Structure DetailStructure Detail 2 2第2页，此课件共56页哦IntroductionIntroduction3 3第3页，此课件共56页哦IntroductionIntroductionDeath Rate of 10 Main Diseases in Certain Region in 2006(China)Death Rate of 10 Main Diseases in Certain Region in 2006(China)http:/http:/ RankRank CityCity CountyCounty CauseCauseDeath RateDeath Rate 1/100000 1/100000%CauseCauseDeath Rate Death Rate 1/100000 1/100000%1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10Malignant NeoplasmsMalignant NeoplasmsCerebrovascular DiseaseCerebrovascular DiseaseHeart DiseaseHeart DiseaseDiseases of the Respiratory Diseases of the Respiratory System SystemInjury&PoisoningInjury&PoisoningEndocrine,Nutritional&Endocrine,Nutritional&Metabolic Diseases Metabolic DiseasesDiseases of the Digestive Diseases of the Digestive System SystemDisease of the Genitourinary Disease of the Genitourinary System SystemDisease of the Nervous SystemDisease of the Nervous SystemMental DisordersMental Disorders 144.57144.57 93.69 93.69 90.72 90.72 69.29 69.29 32.36 32.36 17.59 17.59 15.61 15.61 7.28 7.28 4.95 4.95 3.44 3.4427.2527.2517.6617.6617.1017.1013.0613.06 6.10 6.10 3.32 3.32 2.94 2.94 1.37 1.37 0.93 0.93 0.65 0.65Malignant NeoplasmsMalignant NeoplasmsCerebrovascular DiseaseCerebrovascular DiseaseDiseases of the RespiratoryDiseases of the Respiratory System SystemHeart DiseaseHeart DiseaseInjury&PoisoningInjury&PoisoningDiseases of the Digestive Diseases of the Digestive System SystemEndocrine,Nutritional&Endocrine,Nutritional&Metabolic Diseases Metabolic DiseasesDisease of the Genitourinary Disease of the Genitourinary System SystemDisease of the Nervous SystemDisease of the Nervous SystemMental DisordersMental Disorders 130.23130.23 105.48 105.48 84.94 84.94 71.84 71.84 46.12 46.12 17.00 17.00 8.16 8.16 6.65 6.65 4.16 4.16 3.77 3.7725.1425.1420.3620.3616.4016.4013.8713.87 8.90 8.90 3.28 3.28 1.57 1.57 1.28 1.28 0.80 0.80 0.73 0.73Total Total 90.4190.41Total Total 92.3292.324 4第4页，此课件共56页哦Major tasks:Major tasks:lWhat disease?(diseases diagnosis)lHow to deal with it?(diseases management)5 5第5页，此课件共56页哦Clinical Presentation6 6第6页，此课件共56页哦Common presenting symptoms:Dyspnea(shortness of breath)CoughLess common symptoms:Hemoptysis(the coughing up of blood)Chest pain(often with a pleuritic characteristics)HistoryHistory7 7第7页，此课件共56页哦Acute(over a period of hours to days):Acute attack of asthma Acute attack of asthma Acute pulmonary edema Bacterial pneumonia Pneumothorax Pulmonary embolus Pulmonary embolusHistoryHistoryDyspneaDyspnea8 8第8页，此课件共56页哦Subacute(over days to weeks):Asthma Asthma Chronic bronchitis Chronic bronchitis Pleural effusion Pleural effusion Congestive heart failure Congestive heart failure Pneumocystis carinii pneumonia in patients with AIDS Pneumocystis carinii pneumonia in patients with AIDS Wegeners granulomatosis,eosinophilic pneumonia,Wegeners granulomatosis,eosinophilic pneumonia,Bronchiolitis obliterans with organizing pneumonia Bronchiolitis obliterans with organizing pneumonia Guillain-Barre syndrome,myasthenia gravis Guillain-Barre syndrome,myasthenia gravis HistoryHistoryDyspneaDyspnea9 9第9页，此课件共56页哦Chronic(over months to years):COPD COPD Chronic interstitial lung disease Chronic interstitial lung disease Chronic cardiac diseaseHistoryHistoryDyspneaDyspnea1010第10页，此课件共56页哦 Acute or chronic?Seasonal or associated with wheezing?or associated with wheezing?Associated with symptoms suggestive of postnasal drip or gastroesophageal reflux?drip or gastroesophageal reflux?Associated with fever or sputum?Any associated diseases or risk factors for disease Any associated diseases or risk factors for disease (e.g.,cigarette smoking,risk factors for (e.g.,cigarette smoking,risk factors for infection with HIV,environmental exposures)?HistoryHistoryCoughCough1111第11页，此课件共56页哦Originating from the airways:Originating from the airways:Bronchitis,Bronchiectasis,Cystic fibrosis,Bronchogenic Bronchitis,Bronchiectasis,Cystic fibrosis,Bronchogenic carcinoma,Bronchial carcinoid tumors carcinoma,Bronchial carcinoid tumors Originating from the pulmonary parenchyma:Pneumonia,Lung abscess,Tuberculosis,Infection with Pneumonia,Lung abscess,Tuberculosis,Infection with Aspergillus,Goodpastures syndrome,Idiopathic Aspergillus,Goodpastures syndrome,Idiopathic pulmonary hemosiderosis(IPH)pulmonary hemosiderosis(IPH)Originating from the vasculature:Thromboembolic diseases,Arteriovenous malformations Thromboembolic diseases,Arteriovenous malformationsHistoryHistoryHemoptysisHemoptysis1212第12页，此课件共56页哦Usually originating from involvement of the parietal pleura:Pleuritis Pneumothorax Pneumothorax Neoplasm Pulmonary embolism Pulmonary embolism Pneumonia Pneumonia HistoryHistoryChest painChest pain1313第13页，此课件共56页哦 The number of years of smoking The intensity(i.e.,number of packs per day)The intensity(i.e.,number of packs per day)The interval since smoking cessation A history of significant secondhand(passive)exposure to smokeHistoryHistoryHistory of smokingHistory of smoking1414第14页，此课件共56页哦Respiratory disorders associated with smoking:Chronic obstructive lung disease Chronic obstructive lung disease Neoplasia Neoplasia Spontaneous pneumothorax Spontaneous pneumothorax Respiratory bronchiolitis-interstitial lung disease Respiratory bronchiolitis-interstitial lung disease Eosinophilic granuloma of the lung Eosinophilic granuloma of the lung Pulmonary hemorrhage with Goodpastures syndrome Pulmonary hemorrhage with Goodpastures syndromeHistoryHistoryHistory of smokingHistory of smoking1515第15页，此课件共56页哦 OccupationalOccupational(detailed occupational and personal (detailed occupational and personal histories)or Avocational(hobbies,home environment)histories)or Avocational(hobbies,home environment)Inorganic dustsInorganic dusts(asbestos,silica dusts)associated with(asbestos,silica dusts)associated with pneumoconiosis while organic antigens(molds,animal pneumoconiosis while organic antigens(molds,animal proteins)associated with hypersensitivity pneumonitis proteins)associated with hypersensitivity pneumonitisHistoryHistoryExposure to inhaled agentsExposure to inhaled agents1616第16页，此课件共56页哦 Systemic rheumatic diseasesSystemic rheumatic diseases Risk factors for AIDS Risk factors for AIDS Treatment of nonrespiratory disease(immunosuppressive Treatment of nonrespiratory disease(immunosuppressive agents,cancer chemotherapy,radiation therapy,agents,cancer chemotherapy,radiation therapy,amiodarone,-blocking agents,angiotensin-converting amiodarone,-blocking agents,angiotensin-converting enzyme inhibitors(ACEI)enzyme inhibitors(ACEI)HistoryHistoryCoexisting nonrespiratory diseasesCoexisting nonrespiratory diseases1717第17页，此课件共56页哦Genetic component:Cystic fibrosis 1 1-antitrypsin deficiency-antitrypsin deficiency Pulmonary hypertension Pulmonary hypertension Pulmonary fibrosis Pulmonary fibrosis AsthmaHistoryHistoryFamily historyFamily history1818第18页，此课件共56页哦 The rate and pattern of breathing The depth and symmetry of lung expansionPhysical ExaminationPhysical ExaminationInspectionInspection1919第19页，此课件共56页哦 The symmetry of lung expansion,confirming the findings observed by inspection Vibration produced by spoken sounds Focal tendernessPhysical ExaminationPhysical ExaminationPalpationPalpation2020第20页，此课件共56页哦 The relative resonance or dullness of the tissue underlying the chest wallPhysical ExaminationPhysical ExaminationPercussionPercussion2121第21页，此课件共56页哦 The quality and intensity of the breath soundsThe quality and intensity of the breath sounds The presence of extra,or adventitious sounds The presence of extra,or adventitious sounds The primary adventitious(abnormal)sounds that can be heard include crackles(rales),wheezes,can be heard include crackles(rales),wheezes,and rhonchi Other adventitious sounds include pleural friction rubs and stridorPhysical ExaminationPhysical ExaminationAuscultationAuscultation2222第22页，此课件共56页哦Physical ExaminationPhysical ExaminationTypical Chest Examination Findings in Selected Clinical ConditionsTypical Chest Examination Findings in Selected Clinical ConditionsTypical Chest Examination Findings in Selected Clinical ConditionsPercussionPercussionTactile Tactile FremitusFremitusBreathBreathSoundsSoundsVocal Vocal ResonanceResonanceAdventitiousAdventitiousSoundsSoundsConsolidation or Consolidation or atelectasis(with atelectasis(with patent airway)patent airway)DullDullIncreasedIncreasedBronchialBronchialBronchophony,Bronchophony,whispered whispered pectoriloquy,pectoriloquy,egophonyegophonyCracklesCracklesConsolidation or Consolidation or atelectasis(with atelectasis(with blocked airway)blocked airway)DullDullDecreasedDecreasedDecreasedDecreasedDecreasedDecreasedAbsentAbsentAsthmaAsthmaResonantResonantNormalNormalVesicularVesicularNormalNormalWheezingWheezingInterstitial lung Interstitial lung diseasediseaseResonantResonantNormalNormalVesicularVesicularNormalNormalCracklesCracklesEmphysemaEmphysemaHyperresonantHyperresonantDecreasedDecreasedDecreasedDecreasedDecreasedDecreasedAbsent or WheezingAbsent or WheezingPneumothoraxPneumothoraxHyperresonantHyperresonantDecreasedDecreasedDecreasedDecreasedDecreasedDecreasedAbsentAbsentPleural effusionPleural effusionDullDullDecreasedDecreasedDecreasedDecreasedDecreasedDecreasedAbsent or pleural Absent or pleural friction rubfriction rub2323第23页，此课件共56页哦Additional Diagnostic Evaluation2424第24页，此课件共56页哦 Collected either by spontaneous expectoration or after inhalation of an irritating aerosol,such as hypertonic saline hypertonic salineQualified sample:Squamous epithelial cells 2525/HP or WBC/Squamous epithelial cells 2.52.5 Collection of SputumCollection of Sputum2525第25页，此课件共56页哦 Staining and culture for mycobacteria or fungi Culture Culture for virusesfor viruses Staining for Pneumocystis carinii(especially in a patient infected with HIV)patient infected with HIV)Cytologic stainingCytologic staining for malignant cells for malignant cells The use of polymerase chain reaction(PCR)The use of polymerase chain reaction(PCR)amplification and DNA probes amplification and DNA probesCollection of SputumCollection of Sputum2626第26页，此课件共56页哦Arterial Blood GasesArterial Blood GasesMechanisms of hypoxemia:A decrease in inspired PO2 2 Hypoventilation Shunting V/Q mismatching V/Q mismatching2727第27页，此课件共56页哦Arterial Blood GasesArterial Blood GasesMechanism of hypercapnia:Increased CO Increased CO2 production production Decreased ventilatory drive(wont breathe)Decreased ventilatory drive(wont breathe)Malfunction of the respiratory pump or increased airways resistance(cant breathe)airways resistance(cant breathe)Inefficiency of gas exchange(increased dead space Inefficiency of gas exchange(increased dead space or V/Q mismatch)or V/Q mismatch)2828第28页，此课件共56页哦Routine RadiographyRoutine RadiographyPosteroanterior Posteroanterior(PA)(PA)DIL2929第29页，此课件共56页哦Routine RadiographyRoutine RadiographyAnteroposterior(AP)ARDSARDS3030第30页，此课件共56页哦ChestChestChestChest Radiography RadiographyRheumatoid nodule(one or several nodules):Vascular malformation,Bronchogenic cyst Vascular malformation,Bronchogenic cystLocalized opacification(infiltrate):Pneumonia(bacterial,atypical,mycobacterial,or fungal infection),Neoplasm,Radiation pneumonitis,infection),Neoplasm,Radiation pneumonitis,BronchiolitisBronchiolitis obliterans with organizing pneumonia(BOOP),Bronchocentric granulomatosis,Pulmonary infarctionMajor Respiratory Diagnoses with Common Chest Radiographic PatternsMajor Respiratory Diagnoses with Common Chest Radiographic PatternsMajor Respiratory Diagnoses with Common Chest Radiographic Patterns(1)(1)(1)3131第31页，此课件共56页哦Chest RadiographyChest Radiography Major Respiratory Diagnoses with Common Chest Radiographic Major Respiratory Diagnoses with Common Chest Radiographic Major Respiratory Diagnoses with Common Chest Radiographic Major Respiratory Diagnoses with Common Chest Radiographic Patterns(1)Patterns(1)Patterns(1)Patterns(1)Diffuse interstitial disease:Diffuse interstitial disease:Idiopathic pulmonary fibrosis,Pulmonary fibrosis with Idiopathic pulmonary fibrosis,Pulmonary fibrosis with systemic rheumatic disease,Sarcoidosis,Drug-induced lung systemic rheumatic disease,Sarcoidosis,Drug-induced lung disease,Pneumoconiosis,Hypersensitivity pneumonitis,disease,Pneumoconiosis,Hypersensitivity pneumonitis,Infection(Pneumocystis,viral pneumonia),Eosinophilic Infection(Pneumocystis,viral pneumonia),Eosinophilic granuloma granuloma3232第32页，此课件共56页哦Chest RadiographyChest RadiographyDiffuse alveolar disease:Cardiogenic pulmonary edema,Acute respiratory distress Cardiogenic pulmonary edema,Acute respiratory distress syndrome syndromeDiffuse alveolar hemorrhage:Diffuse alveolar hemorrhage:Infection(Pneumocystis,viral or bacterial pneumonia),Infection(Pneumocystis,viral or bacterial pneumonia),Sarcoidosis SarcoidosisDiffuse nodular disease:Metastatic neoplasm,Hematogenous spread of infection Metastatic neoplasm,Hematogenous spread of infection (bacterial,mycobacterial,fungal),Pneumoconiosis,(bacterial,mycobacterial,fungal),Pneumoconiosis,Eosinophilic granuloma Eosinophilic granulomaMajor Respiratory Diagnoses with Common Chest Radiographic PatternsMajor Respiratory Diagnoses with Common Chest Radiographic PatternsMajor Respiratory Diagnoses with Common Chest Radiographic Patterns(2)(2)(2)3333第33页，此课件共56页哦Computed TomographyComputed Tomography Distinguishing various densities Particularly valuable in assessing hilar and mediastinal disease Identifying areas of fat density or calcification in pulmonary nodules Assessment in the staging of lung cancer Distinguishing vascular from nonvascular structures3434第34页，此课件共56页哦CT scan demonstratingCT scan demonstratinga mediastinal massa mediastinal massComputed TomographyComputed Tomography3535第35页，此课件共56页哦l lHigh-resolution High-resolution CT scan from a CT scan from a patient with patient with idiopathic idiopathic pulmonary pulmonary fibrosis.fibrosis.l lscattered scattered reticular reticular densities densities(arrows)(arrows)Computed TomographyComputed Tomography3636第36页，此课件共56页哦Idiopathic pulmonaryIdiopathic pulmonaryfibrosis.High-fibrosis.High-resolution CT imageresolution CT imageshows bibasal,shows bibasal,peripheral peripheral predominant reticularpredominant reticularabnormality with abnormality with TractionTractionbronchiectasis bronchiectasis and honeycombing and honeycombing Computed TomographyComputed Tomography3737第37页，此课件共56页哦exudative exudative phase of ARDS in phase of ARDS in which dependent which dependent alveolar edema alveolar edema and atelectasis and atelectasis predominatepredominateComputed TomographyComputed Tomography3838第38页，此课件共56页哦Computed TomographyComputed Tomography Helical CT scanning Helical CT scanning CT angiography High-resolution CT(HRCT),the thickness of High-resolution CT(HRCT),the thickness of individual cross is approximately 1 to 2 mm Virtual bronchoscopy3939第39页，此课件共56页哦PETPET Positron emission tomographic(PET)scan