1、第四章快速气体交换 Rapid gas Rapid gas exchangeexchange FVentilationVentilationFPerfusion Perfusion FDiffusionDiffusion 清洁空气 肺的结构与功能 MucosaMucosaSubmucosaSubmucosaCartilageCartilageMusclesMusclesBronchusBronchial epithelium Kulchitsky cells Bronchial Submucosal Glands Alveoli The respiratory membrane 病原体 Pat
2、hogen Pathogen F空气 contaminated air exposure F鼻咽部菌群鼻咽部菌群 nasopharyngeal flora aspiration宿主防御功能下降 Compromised defense mechanisms Compromised defense mechanisms F肺部疾病肺部疾病 other common lung diseaseF免疫缺陷免疫缺陷 ImmunodeficiencyF生活方式生活方式 Life style肺部感染 Pulmonary Infections分类 Classification 根据解剖和影像学 Anatomy
3、and radiographyAnatomy and radiography根据病因 EtiologyEtiology根据在哪获得 Setting in which they arise Setting in which they arise FCommunity-AcquiredCommunity-Acquired FHospital-acquiredHospital-acquired(nosocomial)(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）小叶性肺炎小叶性肺炎大叶性肺炎大叶性肺炎 患者杨某，男，患者杨某，
4、男，2020岁，学生。酗岁，学生。酗酒后遭雨淋，于当天晚上突然起病，寒酒后遭雨淋，于当天晚上突然起病，寒颤、高热、呼吸困难、胸痛，继而咳嗽，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。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；触诊听诊，左肺下叶有大量湿性啰音；触诊语颤增强；血常规：语颤增强；血常规：WBCWBC：17X1017X109 9/L/L；X X线检查，左肺下叶有大片致密阴影。线检查，左肺下叶有大片致密阴影。典型病例典型病例1 1入院经抗生素治疗，病情好转，各种症状逐入院经抗生素治疗，病情好转，各种症状逐渐消失；渐消失；X X线检查，
5、左肺下叶的大片致密阴影线检查，左肺下叶的大片致密阴影缩小缩小2/32/3面积。病人于入院后第面积。病人于入院后第7 7天自感无症天自感无症状出院。冬季征兵体检，状出院。冬季征兵体检，X X线检查左肺下叶有线检查左肺下叶有约约3cmX2cm3cmX2cm大小不规则阴影，周围边界不清，大小不规则阴影，周围边界不清，怀疑为怀疑为“支气管肺癌支气管肺癌”。在当地医院即做左。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。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大叶性肺炎大叶性肺炎大叶性肺炎In the era b
6、efore antibiotics 充血水肿期 Hyperemia and edemaHyperemia and edema红肝期 Red hepatizationRed hepatization灰肝期 Gray hepatizationGray hepatization溶解消散期 Resolution(hopefully)Resolution(hopefully)Hyperemia and edemaHyperemia and edema，12-24 hours 12-24 hours Red hepatization 2-3 daysRed hepatization 2-3 daysGra
7、y hepatizationGray hepatization，3-4 days3-4 days并发症 complications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小叶性肺炎小叶性肺炎Filled with exudateFilled with exudateAerated lungAerated lung小叶性肺炎小叶性肺炎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OrganizationOrganization Abscess formation Abscess formatio
8、n Abscess formation Abscess formation Purulent pleuritisPurulent pleuritisHemorrhagic PneumoniaHemorrhagic Pneumoniaby Pseudomonas aeruginosaby Pseudomonas aeruginosaPseudomonasPseudomonas pneumonia pneumonia KlebsiellaKlebsiella pneumonia pneumonia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atypicalF缺乏实变体征
9、缺乏实变体征 FWBCWBC轻度升高轻度升高 重者为急性呼吸窘迫症ARDSF肺泡弥漫性损伤肺泡弥漫性损伤F透明膜形成透明膜形成Viral pneumoniaViral pneumoniaAtypical pneumonia Atypical pneumonia Severe Acute Respiratory Syndrome(SARS)Severe Acute Respiratory Syndrome(SARS)Pneumonia in the Immunocompromised Host 机会致病原 opportunistic agentsopportunistic agents常为多重感
10、染 Fbacteriabacteria (P.aeruginosa,Mycobacterium spp.,L.pneumophila,and Listeria monocytogenes)Fvirusesviruses (cytomegalovirus and herpesvirus)Ffungifungi (P.jiroveci,Candida spp.,Aspergillus spp.,and Cryptococcus neoformans)CMV infections in situin situ hybridization hybridizationSputum cytology Sp
11、utum cytology from an AIDS from an AIDS patientpatient(Papanicolaou)(Papanicolaou)(Giemsa)(Giemsa)Pneumocystis Pneumonia(silver stain)(silver stain)Pneumocystis Pneumonia(silver stain)(silver stain)Pneumocystis Pneumonia Pneumocystis cariniiPneumocystis carinii in bronchial lavage in bronchial lavag
12、e from an AIDS patient(Grocotts silverfrom an AIDS patient(Grocotts silver)(Papanicolaou)(Papanicolaou)(Immunostaining)(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 partial or complete obstruction
13、at any levelF肺气肿肺气肿 EmphysemaEmphysemaF慢性支气管炎慢性支气管炎 Chronic bronchitisChronic bronchitisF支气管扩张支气管扩张 BronchiectasisBronchiectasisF哮喘哮喘 AsthmaAsthmaFEV1/FVCFEV1/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 bronchitisA pe
14、rsistent cough productive of sputum for at least 3 months,in at least 2 consecutive yearsF单纯型单纯型 Simple Simple F喘息型喘息型 Asthmatic Asthmatic F阻塞型阻塞型 obstructiveobstructive 病 因 etiology吸烟和空气污染 Cigarette smoking and air Cigarette smoking and air pollutantspollutants感染 Microbial infectionMicrobial infect
15、ion FSecondary roleSecondary roleF使炎症持续，加重症状使炎症持续，加重症状 maintaining the inflammation and exacerbating symptoms发病机制 Pathogenesis 多痰粘液分泌亢进 Hypersecretion of mucus Hypersecretion of mucus F大气道病变大气道病变 large bronchial involvement F粘液腺增生，杯状细胞分泌亢进粘液腺增生，杯状细胞分泌亢进 Hypertrophy of mucous glands and a marked incr
16、ease in mucin-secreting goblet cells 气道阻塞 Airflow obstructionAirflow obstructionF小气道炎症和管壁纤维化小气道炎症和管壁纤维化 inflammation,bronchiolar wall fibrosis F杯状细胞化生，细支气管痰栓形成杯状细胞化生，细支气管痰栓形成 goblet cell metaplasia with mucus plugging of the bronchiolar lumenF并发肺气肿并发肺气肿 coexistent emphysema 发病机制 Pathogenesis inner p
17、erichondriuminner perichondriumbasal basal laminalaminaChronic bronchitisChronic bronchitisNormal bronchusNormal bronchusChronic bronchitis Chronic bronchitis Chronic bronchitis Chronic bronchitis Chronic bronchiolitis Chronic bronchiolitis luminal and mucusluminal and mucuschronic chronic inflammat
18、ioninflammation肺气肿 Emphysema Abnormal permanent enlargement of the airspaces distal to the terminal 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 CentriacinarCentriacinar 全腺泡(小叶)型 PanacinarPanacinar腺泡
19、(小叶)周围型 Distal acinarDistal acinar不规则型 IrregularIrregularobstructionobstructionSpontaneous Spontaneous pneumothoraxpneumothoraxasymptomaticasymptomatic发病机理 Pathogenesis Centriacinar emphysemaCentriacinar emphysemaBullous emphysemaBullous emphysemaCentriacinar emphysemaCentriacinar emphysemaF Inadequ
20、ate ventilation Inadequate ventilation F Less perfusion Less perfusionF Narrowed bronchiole Narrowed bronchioleConditions Related to Emphysema 间质性肺气肿 Mediastinal(interstitial)Mediastinal(interstitial)emphysema emphysema 代偿性肺气肿 Compensatory emphysemaCompensatory emphysema阻塞性过充气 Obstructive overinflat
21、ion Obstructive overinflation 瘢痕旁肺气肿 Paracicatrical emphysemaParacicatrical emphysema老年性肺气肿 Senile emphysema Senile emphysema COPD的临床表现Respiratory failureRespiratory failureRight heart failureRight heart failurePink pufferPink puffer桶状胸桶状胸 Barrel chest 支气管扩张症 Bronchiectasis Permanent dilation of bro
22、nchi 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 Secondary to persisting infection or Secondary to persisting infection or obstructionobstruction 诊断依靠病史和影像学Predisposing conditions 支气管阻塞
23、 Bronchial obstructionBronchial obstructionF肿瘤肿瘤 TumorF异物异物 Foreign bodies 先天性或遗传性疾病 Congenital or hereditary Congenital or hereditary conditionsconditions FCystic fibrosis Cystic fibrosis FKartagener syndromeKartagener syndrome坏死性化脓性肺炎 Necrotizing,or suppurative,Necrotizing,or suppurative,pneumonia
24、pneumonia Cystic Fibrosis(CF)Cystic Fibrosis(CF)Cystic Fibrosis(CF)Cystic Fibrosis(CF)BronchiectasisBronchiectasis57 year old 57 year old woman with a woman with a long history long history of recurrent of recurrent respiratory respiratory tract tract infections and infections and episodes of episod
25、es of hemoptysis hemoptysis THANK YOUSUCCESS2022-10-30可编辑BronchiectasisBronchiectasis BronchiectasisBronchiectasisDue to pneumoniaDue to pneumoniaBronchiectasisBronchiectasisBronchiectasisBronchiectasis Purulent exudation in the lumenPurulent exudation in the lumenDestruction of lining epitheliumDes
26、truction of lining epitheliumScarring of the bronchial wallScarring of the bronchial wallHRCT scans of bronchiectasis HRCT scans of bronchiectasis 支气管扩张症的临床表现咳嗽，咳脓臭痰 Severe,persistent cough with Severe,persistent cough with mucopurulent sputum,sometimes mucopurulent sputum,sometimes fetidfetid咯血 Fle
27、cks of blood in sputum or frank Flecks of blood in sputum or frank hemoptysishemoptysis 严重病例及合并症肺间质疾病 ILD 肺弥漫性纤维化 肺顺应性减弱，容量减小 已知病因和特发性间质性肺炎Selected causes of chronic interstitial Selected causes of chronic interstitial lung diseaselung disease Occupational and environmental exposureOccupational and
28、environmental exposureAsbestosisSilicosisSilicosisHypersensitivity pneumonitisDrug or treatment relatedDrug or treatment relatedChemotherapeutic agentsIonizing irradiationOxygenImmunologic lung diseaseImmunologic lung diseaseSarcoidosisSarcoidosisWegner granulomatosisCollagen vascular diseaseGoodpas
29、ture syndromeMiscellaneousPost acute respiratory distress syndromeIdiopathic pulmonary fibrosisIdiopathic pulmonary fibrosis杵状指（趾）杵状指（趾）Clubbing of digitsClubbing of digitsHoneycomb lungHoneycomb lung矽 肺 Silicosis 职业病 Occupational Occupational diseases diseases 吸入二氧化硅粉尘引起 Inhalation of crystalline I
30、nhalation of crystalline silicasilica 致残和致死 Disabling and fatalDisabling and fatal 病理：硅结节形成 广泛的肺纤维化 发病机制 Pathogenesis 直径5m的硅尘沉积于肺间质肺泡巨噬细胞引发和持续肺损伤和纤维化 Alveolar macrophage is a key Alveolar macrophage is a key cellular element in the cellular element in the initiation and perpetuation of initiation an
31、d perpetuation of lung injury and fibrosislung injury and fibrosisSilicosisSilicosis a slice a slice of lung of lung from a 61 from a 61 yo yo ceramics ceramics workerworker矽结节矽结节 SilicosisSilicosis临床表现 Clinical course早期常为体检发现 usually usually detected in routine chest detected in routine chest radio
32、graphsradiographs晚期表现：F呼吸困难呼吸困难 shortness of breathF肺心病肺心病 cor pulmonaleF合并合并TB TB increased susceptibility to TBF可能致癌可能致癌 carcinogenic(controversial)SilicosisSilicosis 急性呼吸窘迫征(ARDS)Acute Respiratory Distress Syndrome进行性呼吸衰竭 FAcute onset of Dyspnea Acute onset of Dyspnea FHypoxemia Hypoxemia FBilate
33、ral pulmonary infiltrates(X-ray)Bilateral pulmonary infiltrates(X-ray)FNo evidence of left-sided heart failureNo evidence of left-sided heart failure病理：弥漫性肺泡损伤 Diffuse Alveolar Damage(DAD)Diffuse Alveolar Damage(DAD)常伴多器官衰竭 Multiple Organ Dysfunction Syndrome Multiple Organ Dysfunction Syndrome(MODS
34、)(MODS)Direct Lung InjuryIndirect Lung InjuryCommon CausesPneumoniaSepsisAspiration of gastric contentsSevere trauma with shockUncommon CausesPulmonary contusionCardiopulmonary bypassFat embolismAcute pancreatitisNear-drowningDrug overdoseInhalational injuryTransfusion of blood productsReperfusion i
35、njury afterlung transplantationUremiaClinical Disorders Associated with developing ARDS发病机制 Pathogenesis 广泛内皮和肺泡I I型、IIII型上皮损伤 Endothelial and epithelial(I and II)Endothelial and epithelial(I and II)damagedamageF肺水肿肺水肿 alveolar floodingF气体交换丧失气体交换丧失 loss of diffusion capacity F表面活性物质异常表面活性物质异常 surfa
36、ctant abnormalities 促炎和抗炎介质的失衡 Imbalance of pro-inflammatory and Imbalance of pro-inflammatory and anti-inflammatory mediators anti-inflammatory mediators 病理变化 Morphology急性渗出期 Acute Exudative Stage F水肿水肿 Edema(interstitial and alveolar)F透明膜透明膜形成形成 Hyaline membranes F肺泡塌陷肺泡塌陷 Many alveoli collapse 增生
37、期 Proliferative Stage FIIII型肺泡上皮增生型肺泡上皮增生F肺泡内机化肺泡内机化 Intra-alveolar fibrosis widening of the interstitium widening of the interstitium ARDS ARDS Hyaline membranesHyaline membranesHyaline membranes Hyaline membranes Hyaline membranes Hyaline membranes Healing stage Healing stage Healing stage Healing
38、 stage suviving patient suviving patient ARDSARDS临床表现 Clinical features肺顺应性差 Poor pulmonary compliancePoor pulmonary compliance难治性低氧血症 Poor response to oxygenPoor response to oxygen血管床进行性减少 Pulmonary vascular bed is Pulmonary vascular bed is progressively obliterated progressively obliterated 易感染 Pr
39、one to bacteria infectionProne to bacteria infection预后 Prognosis Depends successfully treatements before extensive fibrosis 40-70%mortalityHigh-dose steroids failedConservative therapy helpsConsiderable interest in the quality of survivals LUNG TUMORS Metastatic tumorsPrimary tumorsFBRONCHOGENIC CAR
40、CINOMABRONCHOGENIC CARCINOMAFOthersOthers bronchial carcinoidsbronchial carcinoidsmesenchymal malignancies mesenchymal malignancies LymphomasLymphomasa few benign lesionsa few benign lesions 95%95%5%5%慢性肺动脉高压症和肺心病（自学）概念 病因 发病机制 病理变化 临床病理联系思考题：思考题：试述慢性支气管炎并试述慢性支气管炎并发肺心病的发病机制。发肺心病的发病机制。肺 癌 癌症死因第一位 cau
41、se of cancer-related deaths cause of cancer-related deaths 发病率随年龄和烟龄增长 pack-years smoked.pack-years smoked.确诊的病人一半以上已有远处转移 distant metastatic disease5年生存率约为15%5-year survival肺癌的临床病理分型肺小细胞癌 Small cell lung cancer(SCLC)肺非小细胞癌 Non-small-cell lung cancer(NSCLC)F鳞癌鳞癌 Squamous cell carcinomaSquamous cell
42、carcinoma F腺癌腺癌 AdenocarcinomasAdenocarcinomasF大细胞癌大细胞癌 Large cellcarcinomasLarge cellcarcinomas SCLCKulchitsky cell起源FhADHhADH(hyponatremia/water intoxication)(hyponatremia/water intoxication)FACTH ACTH(Cushings syndrome)(Cushings syndrome)中央型 Centrally located masses Centrally located masses 坏死常见
43、Necrosis is invariably Necrosis is invariably present and may be extensive present and may be extensive 燕麦细胞癌 Oat cell carcinomaOat cell carcinomaSCLCSCLCOat cell Oat cell carcinomacarcinomaSCLCSCLCOat cell Oat cell carcinomacarcinomaSCLCSCLC鳞状细胞癌病人大多有吸烟史 Closely correlated with a smoking Closely co
44、rrelated with a smoking history history 中央型 Tend to arise centrally in major Tend to arise centrally in major bronchi bronchi 常见空洞 Cavitation is not uncommonCavitation is not uncommon副癌综合征 Preneoplastic lesionsPreneoplastic lesions Squamous cell Squamous cell carcinomacarcinomaSquamous cell Squamous
45、 cell carcinomacarcinomaSquamous cell Squamous cell carcinomacarcinomaSquamous cell Squamous cell carcinomacarcinomaSquamous cell Squamous cell carcinomacarcinomaMetaplaisa?Anaplasia?Dysplasia?Metaplaisa?Anaplasia?Dysplasia?腺 癌 Adenocarcinoma 周围型多见 peripherally locatedperipherally located是女性和非吸烟者常见的
46、肺癌类型常发生自肺周边部疤痕处 arising in relation to arising in relation to peripheral lung scars peripheral lung scars 生长缓慢但早期转移支气管肺泡干细胞起源 Bronchioalveolar stem cells Bronchioalveolar stem cells origin origin Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma 细支气管肺泡癌(BAC)Br
47、onchioloalveolar carcinomaA distinct subtype of adenocarcinoma弥漫型多见multiple diffuse nodules multiple diffuse nodules Growing along preexisting structures and preservation of alveolar architecture 分为粘液型和无粘液型 mucinous/nonmucinous subtypesmucinous/nonmucinous subtypesBACBACBACBACBACBACPrecursor lesions
48、 of ADCAAHAAHBACBAC低分化癌，排除SCLC,SCC or ADCFCells are not-columnar in shapeCells are not-columnar in shapeFDo not contain mucousDo not contain mucousFDo not show squamous differentiation Do not show squamous differentiation FDo not have neuroendocrine properties or Do not have neuroendocrine propertie
49、s or small cell characteristics small cell characteristics 可发生与任何部位 arise anywhere in lungsarise anywhere in lungs大部分与吸烟有关，预后差 smoking-related,cures are raresmoking-related,cures are rare大细胞癌大细胞癌 Large cell carcinoma Large cell carcinoma 肺癌的临床表现 原发灶引起的症状 Symptoms due to primary tumorSymptoms due to
50、primary tumor原发灶蔓延引起的症状 Symptoms due to locoregional Symptoms due to locoregional spreadspread转移引起的问题 Metastatic diseaseMetastatic disease副肿瘤综合征 Paraneoplastic syndromes Paraneoplastic syndromes 中央型肺癌 Central tumors Central tumors Fcough,dyspnea,F肺不张肺不张atelectasis,F阻塞后肺炎阻塞后肺炎，喘息喘息 F咯血咯血hemoptysis 周围
