1、 Respiratory System Disease湘雅医院儿科湘雅医院儿科 郑湘榕郑湘榕 l 婴幼儿上感、婴幼儿上感、2 2种特殊类型上感的特点种特殊类型上感的特点l 支气管肺炎临床表现、重症肺炎特点支气管肺炎临床表现、重症肺炎特点 l 支气管肺炎的诊断、治疗支气管肺炎的诊断、治疗l 支气管哮喘的临床表现、诊断和治疗支气管哮喘的临床表现、诊断和治疗 重点重点IntroduceIntroducevIn pediatric outpatient,6o%patients are acute respiratory infections.vIn pediatric ward,25%patients
2、 are Pneumonia.vThe first cause of childrens death in China is Pneumonia.vPneumonia is the worlds leading cause of death among children.It kills nearly two million children under age five every year.Why children are so susceptible to acute respiratory infections?anatomic physiological features The c
3、hildrens respiratory lumens are narrow,blood flow is abundant.The childrens repertory ability is low.The childrens local immunity is low.Children Respiratory System Physiologic Feature Respiratory rateNeonate 40-44/min1year 30/min2-3years 24/min4-7years 22/min8-14years 20/minChildren Respiratory Sys
4、tem Physiologic Feature Respiratory type Respiratory type of abdomen Respiratory type of chest abdomen hysical examination inspection Change of respiratory rate Cyanopathy Three concave sign uscultationExamine Method（AURIAURI）Acute Upper Respiratory Infectionirus：ccupy 90%acteria：econdary Streptococ
5、us pyogens Pneumococcu aemophilus influenzaeCommonAURI Local symptom is mild In infant and toddlerSystemic symptom is severeComplications are commonCommonAURIhysical examination qCongestion of pharyngeal portion,antiadoncus (咽部充血，扁桃体肿大咽部充血，扁桃体肿大)qLymphadenectasis in submaxilla (有时下颌、淋巴结肿大有时下颌、淋巴结肿大)
6、qRash when enterovirus infection (肠道病毒感染时可出现皮疹肠道病毒感染时可出现皮疹)SpecialAURI 柯萨奇病毒柯萨奇病毒A组感染组感染 夏秋好发夏秋好发 高热、咽痛、流涎高热、咽痛、流涎 咽腭弓、软腭处有疱疹咽腭弓、软腭处有疱疹 疱疹破溃后可形成溃疡疱疹破溃后可形成溃疡 病程病程 1 周左右周左右Herpangina疱疹性咽峡疱疹性咽峡炎炎Pharyngo-conjunctival fever咽结合膜热咽结合膜热 腺病毒腺病毒 3，7 型所致型所致 春夏发病，可小流行春夏发病，可小流行 发热、咽炎、结合膜炎发热、咽炎、结合膜炎 咽部充血、结合膜充血，颈
7、部、咽部充血、结合膜充血，颈部、耳后淋巴结肿大耳后淋巴结肿大 病程病程 12 周周SpecialAURISchool ageTympanitis,sinusitisAbscess of pharynx posterior-wall Laryngitis,bronchitisInfant,toddlerPneumoniaGlomerulonephritisRheumatic feverAntivirus drugs Oseltamivir Ribovirin3-5 daysAntibioticsPenicillinSMZ3-5 daysSever symptomatic;Secondary ba
8、cteria affectionDefervesceDrugsPhysics methodsFebril convulsionCalmStop convulsionDefervescePneumonia肺肺 炎炎 Childrenfamiliar diseaseIn world,Occupy 1/3-1/4 in the death of children under 5 years of ageIn china,Occupy more than 1/4 in paediatric ward The hospitalization number of infant and toddler is
9、 39.5 timesof school age Pneumonia is an inflammation of the parenchyma of the lungs It is caused by microorganisms or noninfectious causes Manifested by fever,cough,tachypnea,respiratory distress and ralesDefinitionOn course of illness On anatomic basisBronchopneumoniaLobar pneumonia Interstitial p
10、neumonia Acute：3 months Deferred：13 monthsOn the etiologyVirus RSV(respiratory syncytial virus)AdenovirusInfluenza ParainfluenzaBacteriaStreptococus pneumoniaeStaphylococus aureusHaemophilus influenzae type On the etiologyMycoplasmaChlamydia,parasites,fungiNoninfections causesOn theseverity of illne
11、ssMild symptomaticSevere symptomaticBesides symptoms of respiratory system,concomitant manifestations of other organ systems are presenton typical of clinical manifestationTypical pneumoniauntypical pneumoniaSevere acute respiratory syndrome,(SARS)coronavirusOn Occurrence RegionCommunity Acquired Pn
12、eumoniaCAPHospital Acquired PneumoniaHAP支气管肺炎支气管肺炎 BronchopneumoniaEtiologyvirusMain cause of pneumonia in developed countryRSVbacteriaMain cause of pneumonia in developing countryPathologyCommonBroncho-pneumoniahyperaemia、edema、inflammatory effution of alveolusInterstitial pneumoniahyperaemia、edema
13、、inflammatory effution of bronchia wall、bronchiole wall、alveolus wallPathologic physiology气道炎症气道炎症循环系统循环系统神经系统神经系统水电解质水电解质消化系统消化系统肺肺A压增高压增高中毒性中毒性心肌炎心肌炎心衰心衰代酸代酸中毒性中毒性肠麻痹肠麻痹胃肠粘膜胃肠粘膜屏障功能屏障功能脑水肿脑水肿颅压颅压呼酸呼酸K+水钠储留水钠储留毒血症毒血症通气不足通气不足 PaO2,PaCO2换气障碍换气障碍 PaO2Clinical manifestationMild symptomaticrespiratory s
14、ystemfeverrespiratory distressnasal flaring,retractions,cyonosistachypnea cough rales5 years RR30次次/分分Clinical manifestationSevere symptomaticcircular systemsymptomCardiac muscleinflammationHeart failureClinical manifestSevere symptomaticHeart failure呼吸突然加快，呼吸突然加快，60次次/分分心率突然增快心率突然增快 婴儿婴儿180次次/分幼儿分幼
15、儿160次次/分分突然烦躁不安、面色发灰突然烦躁不安、面色发灰心音明显低钝，奔马率，颈静脉怒张心音明显低钝，奔马率，颈静脉怒张肝大肋下肝大肋下3cm以上以上尿少、下肢浮肿尿少、下肢浮肿Clinical manifestnerval systemLight hypoxia：irritability，lethargySever hypoxia：hydrocephalusdigestive systemalimentary canal bleedingPoisoning intestine palsySevere symptomaticClinical manifest DICBp四肢凉，脉速弱，四
16、肢凉，脉速弱，出血出血SLADHNa+130mmol/L渗透压渗透压 270mOsm/LEdemaSevere symptomaticComplicationsComplicationpneumatocelepyopneumothoraxempyemaLaboratory dataBloodblood routinebacteria infect：WBC、N left shift of nucleus virus infect：WBC、Labnormal lymph cellbacteria infect：CRP virus infect：CRP normalCRPNBTbacteria in
17、fect：10%virus infect：10%Pathogenyvirus separateGermiculturesputum for Gram stain and cultureLaboratory dataX-rayshadow of dot and spoteemphysema atelectasisfever,cough,tachypnea,respiratory distress and ralesX-raydiagnosisDifferentiationacute bronchitisrales、tachypneaforeign bodies in bronchihistory
18、 of foreign bodies、sudden cough、respiratory distress、lower of breath tone or wheezingtuberculosishistory of TB contact、PPD test、PPD-IgGIgM、X-ray、ralesTreatmentgeneral treatmentBalance of water and electrolyte3%Nacl 12ml/LNa+10mmol/L Temperature 18-20 Humidity 60%Food nutritiveTreatmentControl infect
19、ionvirus：no ideal drug like virozolmycoplasma、chlamydia select erythromycinbactrria：the principle of sensitivityefficiency、full period of treatment,first select PeniccilinTreatment抗生素抗生素使用原则使用原则 根据药敏选药根据药敏选药adopt sensitive drugs on the basis of pathogenic bacterium 用下呼吸道浓度高的药物用下呼吸道浓度高的药物adopt drugs
20、which can finally infiltratelung tissue 足量足量足疗程足疗程重症静脉给药重症静脉给药in severe case,drugs should be administedby vein,full dose,full period Treatment抗生素抗生素选择选择 肺炎链球菌：肺炎链球菌：PNC,PNC,阿莫西林，红霉素阿莫西林，红霉素金黄色葡萄球菌：苯唑西林、氯唑西林、万古金黄色葡萄球菌：苯唑西林、氯唑西林、万古、利福平、利福平 流感嗜血杆菌：阿莫西林流感嗜血杆菌：阿莫西林+克拉维酸钾或舒巴克拉维酸钾或舒巴坦坦大肠杆菌和肺炎杆菌：头孢曲松或头孢噻肟大肠
21、杆菌和肺炎杆菌：头孢曲松或头孢噻肟绿脓杆菌：替卡西林钠克拉维酸钾或头孢哌酮绿脓杆菌：替卡西林钠克拉维酸钾或头孢哌酮肺炎支原体或衣原体：大环内酯肺炎支原体或衣原体：大环内酯 Treatmentfull periodof treatmentafter temperature normal 5 7days or clinical symptom disappearing 3 daysMycoplasma pneumonia：23 weeksStaphylococus aureus：after temperature normal 2 weeks，full period is 6 weekstreat
22、 against symptomsTreatmentoxygentreatPaO2：dyspnea、cyanosis、asthma suppress、toxic appearance,methods:by nose canal 0.5 1 L/min，40%；by veil 24 L/min,50%60%mechanism ventilate（respire failture）holding respiratory tract unobstructed remove sputum、pulverization、relieve spasmensure liquid absorbTreatmentt
23、reat ofother sympdefervesce calmtreat ofwindysupply KaliumPoisoning intestine palsy：fasting、decompress of stomach and intestine 酚妥拉明酚妥拉明 0.5 mg/kg ivgtt 10%GS 20 ml treat against symptomsTreatmenttreat ofHeart failure镇静镇静给氧给氧强心：西地兰强心：西地兰减轻心脏负荷减轻心脏负荷 treat against symptomsTreatment合并中毒性脑病合并中毒性脑病的治疗的治
24、疗脱水：甘露醇脱水：甘露醇改善通气改善通气改善脑微循环改善脑微循环止痉：地西泮止痉：地西泮地塞米松地塞米松营养神经营养神经treat against symptomsTreatment糖皮质激素糖皮质激素应用应用适应症：适应症：喘憋重喘憋重,呼吸衰竭呼吸衰竭全身全身中毒症状重中毒症状重感染性休克感染性休克 脑水肿脑水肿琥珀酸氢化可的松琥珀酸氢化可的松5 5 10 mg/kg.d地塞米松地塞米松0.1 0.3 mg/kg.d ivgtt23 次次/日日35 天天甲基强的松龙甲基强的松龙 2 2 4 mg/kg.次次Response to treatment in otherwise uncomp
25、licated CAP?Fever-falls in 2 daysLeucocytosis-decreases in 4 days Physical findings persist slightly longerChest radiographic abnormalities may take4-12 weeks to resolveWhat if patients fails to recover?You should consider-Noninfectious conditionResistance to drugResistance to drugNew nosocomial pat
26、hogenNew nosocomial pathogen病毒性病毒性肺炎肺炎呼吸道合胞病毒肺炎呼吸道合胞病毒肺炎腺病毒肺炎腺病毒肺炎2 2岁，岁，2 2 6 6月多见月多见喘憋、呼吸困难，可合并喘憋、呼吸困难，可合并呼衰、心衰呼衰、心衰哮鸣音，细湿罗音哮鸣音，细湿罗音小点片状影，肺气肿肺不张小点片状影，肺气肿肺不张间质性肺炎间质性肺炎6 6月月 2 2岁岁中毒症状重，稽留热，中毒症状重，稽留热，咳剧，喘憋，呼吸困难咳剧，喘憋，呼吸困难出现晚，湿罗音或肺实变出现晚，湿罗音或肺实变 胸片改变出现早，肺气胸片改变出现早，肺气肿，片状影或融合肿，片状影或融合年龄年龄症状症状胸片胸片体征体征细菌性细菌性
27、肺炎肺炎葡萄球菌肺炎葡萄球菌肺炎新生儿，婴幼儿新生儿，婴幼儿急、重、快，弛张热或稽留热，急、重、快，弛张热或稽留热，咳嗽，呼吸困难，呻吟，易致咳嗽，呼吸困难，呻吟，易致迁徒化脓病灶，并发脓胸，脓迁徒化脓病灶，并发脓胸，脓气胸，肺大疱气胸，肺大疱中细湿罗音，出现早，皮疹中细湿罗音，出现早，皮疹浸润影，持续时间较长，易变，浸润影，持续时间较长，易变，可见多发性肺脓肿，脓胸，脓气可见多发性肺脓肿，脓胸，脓气胸等胸等 44岁岁慢，重，发热，痉挛性慢，重，发热，痉挛性咳嗽，呼吸困难，发绀。咳嗽，呼吸困难，发绀。易致迁徒化脓病灶，易并易致迁徒化脓病灶，易并发脓胸发脓胸湿罗音或实变湿罗音或实变大叶性肺炎、支
28、气管肺炎、大叶性肺炎、支气管肺炎、肺实变肺实变 年龄年龄症状症状体征体征胸片胸片革兰阴性杆菌肺炎革兰阴性杆菌肺炎肺炎支原体肺炎肺炎支原体肺炎年长儿，婴幼儿年长儿，婴幼儿发热、刺激性咳嗽，多系统病变发热、刺激性咳嗽，多系统病变不明显，婴幼儿可有呼吸困难，不明显，婴幼儿可有呼吸困难，喘憋，哮鸣音，湿罗音喘憋，哮鸣音，湿罗音肺门影增浓；支气管肺炎改变；肺门影增浓；支气管肺炎改变；间质性肺炎；均一实变影间质性肺炎；均一实变影 20%,使用支扩剂后增使用支扩剂后增加加20%可诊断哮喘可诊断哮喘）Diagnose of childfood asthma gasp recurrent attacks lun
29、g wheezing rales bronchodilators is valid exclude other disease that can cause gasp cough 1month,antibiotics treat is invalid bronchodilators can relieve cough hypersensitive history or allergia family history airway is hyperreactivity exclude other cough disease Diagnose of cough variant asthmather
30、apyPrinciple:long-term、persistence、standard、individuationPeriod of onset:antiinflammatory、calm gaspcatabasis:long-term、antiinflammatory、avoid trigger factor、self-careto spread Global Initiative for Asthma，GINA(全球哮全球哮 喘防治创议喘防治创议)drug glucocorticoid-first select bronchodilators immunosuppressant other
31、 drug inhale：beclometasone 100 g，24times/day oral：prednisone12 mg/kg/day，17daysevere casepersistent attackanti-asthmatic cannot control intravenous drip：Cetacort 510 mg/kg/time Medrat 12 mg/kg/time,BidTid severe attackglucocorticoid usagedrug bronchodilators para-adrenal drug inhale 0.5%albuterol 0.
32、010.03 ml/kg/次次 atomization q46 h theocin aminofilina 45 mg/kg/次次 immunosuppressant-methotrexate -cyclosporin other drug-disodium cromoglycate -ketotifen Status asthmaticusinhale oxygencalmfluid replace,correct acidosiscortine dripbronchodilators,cortine inhaletheocin driprespirator prevent relapsev
33、 avoid sensitizin and trigger factorv inhale cortin 6 months2yearsv immunotherapy-desensitization v self-management 谢 谢！1.所有产品的传播内容围绕主要产品的利益点,让消费者了解不同产品对保护牙齿的好处2.在创意上都是用简单的护理方法来解决牙齿的问题给消费者总体的印象：“黑妹把保护牙齿变得很轻松、简单，以后只要找黑妹就好了”3.创意表现上，利用统一的视觉或音乐来增加品牌和产品之间的关联性，经过长期积累，形成黑妹的视觉资产。4.将将日常素材提炼成写作中的材料，使材料为表达一定的主
34、旨服务，从而将素材实用化，是写作过程中十分重要的环节。日常素材提炼成写作中的材料，使材料为表达一定的主旨服务，从而将素材实用化，是写作过程中十分重要的环节。5.一一是从生活中是从生活中(日常生活、阅读等日常生活、阅读等)发现并积累素材；二是对素材宏观的分类整理，开阔精神文化视野；三是对个案具体素材的原点思发现并积累素材；二是对素材宏观的分类整理，开阔精神文化视野；三是对个案具体素材的原点思考考，发发散性思考；四是对具体素材的价值化处理。散性思考；四是对具体素材的价值化处理。6.借助相关的资料，展开合理想象，让人物形象活起来，然后用生动形象的语言来描述想象，这就是创造意境。借助相关的资料，展开合
35、理想象，让人物形象活起来，然后用生动形象的语言来描述想象，这就是创造意境。7.创造意境的心理活动是在情感的推动下的审美想象。创作者要充分发挥创造意境的心理活动是在情感的推动下的审美想象。创作者要充分发挥“内视听内视听”的能力的能力,在心灵中仔细观察人物形象所处在心灵中仔细观察人物形象所处的的8.大大家知道，建筑，首先得有砖石等必备的材料；但有了高质量的材料，还不一定能建造出好房屋来，这里边还得依靠智慧将砖石等建筑材料黏合到恰当的位置。任何一则素材的价值不在素材本身，而在于对素材的有效使用，对素材有效使用的过程也就是素材价值化的过程家知道，建筑，首先得有砖石等必备的材料；但有了高质量的材料，还不
36、一定能建造出好房屋来，这里边还得依靠智慧将砖石等建筑材料黏合到恰当的位置。任何一则素材的价值不在素材本身，而在于对素材的有效使用，对素材有效使用的过程也就是素材价值化的过程。9.故故事里，与壮士牺牲相联系的素净的白衣冠，令人垂泪涕泣的低回的击筑声，表达视死如归的悲悯的歌唱，加之萧萧劲事里，与壮士牺牲相联系的素净的白衣冠，令人垂泪涕泣的低回的击筑声，表达视死如归的悲悯的歌唱，加之萧萧劲风风，滔滔滔寒水，构成了一种生离死别的悲壮场面滔寒水，构成了一种生离死别的悲壮场面。10.解读试题情境，理解潜水位线就是潜水面的海拔。当潜水位高于河水水位时，潜水补给河水，为河流枯水期；当潜水位低于河水水位时，河水补给潜水，为河流丰水期。
