Dyspnea呼吸困難課件

DefinitionDyspneaisdefinedasanawarenessofdifficultyinbreathing.Mostpatientssufferfromactualdifficulty,somepatientsjusttasteanawarenessofhyperventilation(換氣過(guò)度).1DefinitionDyspneaisdefinedaHowtodescribethesesensationsCannotgetenoughairAirdoesnotgoallthewaydownSmotheringfeelinginthechestTightnessinthechestFatigueinthechest2HowtodescribethesesensatioDefinitionDilatationofnares(鼻翼扇動(dòng)),cyanosis(紫紺),useofaccessorymusclesofrespirationAbnormalitiesofrespiratoryrate,depthorrhythm3DefinitionDilatationofnares(EtiologyRespiratorydiseaseCardicdiseaseToxicNero-PsychogenicHaematologicaldiseaseIncreaseofabdominalpressure(massiveascites(腹水),pregnancy(懷孕)etc)4EtiologyRespiratorydisease4NormalpersonmayexperiencethephysiologicdyspneaduringheavyexerciseEnvironmentshortofoxygen5Normalpersonmayexperiencet6677RespiratorydyspneaRespiratorydyspneaiscausedbyabnormalventilationandgasexchange.Reductioninventilatorycapacity,hypercapnia(二氧化碳潴留)andhypoxemia(低氧血癥)resultingfromrespiratorydisease.Threeclinicaltypes:inspiratorydyspnea,expiratorydyspnea,mixeddyspnea.8RespiratorydyspneaRespiratoryInspiratorydyspneaClinicalcharacteristics:visibleindrawingoverthesternalnotch,thesupraclavicularspaces,theintercostalspacesandtheepigastriumintheinspiration(三凹癥).Accompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.Stenosisandobstructionoflarynx,trachea,andbronchi9InspiratorydyspneaClinicalchExpiratorydyspneaClinicalcharacteristics:expirationisprolongedandlabouredwithwheezing.Cause:thedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchi.Familiardiseases:emphysema(肺氣腫),bronchialasthma(支氣管哮喘)andchronicasthmaticbronchitis(喘慢支).10ExpiratorydyspneaClinicalchaMixeddyspneaClinicalcharacteristics:breathingisdifficultduringbothinspirationandexpiration.Respiratoryfrequencyincreaseandrespirationsuperficial.Cause:decreaseofventilatorsandgasexchangecapacityFamiliardiseases:severepneumonia(肺炎),pulmonaryfibrosis(肺纖維化),massiveatelectasis(大片肺不張)etc11MixeddyspneaClinicalcharacteCardiacdyspneaCardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.Dyspneaistheprimarysymptomofleftheartfailure.12CardiacdyspneaCardiacdyspnea1313LeftheartfailureBasaldiseases:CoronaryheartdiseaseHypertensiveheartdiseaseRheumaticheartdiseaseCongenitalheartdisease14LeftheartfailureBasaldiseasLeftheartfailureMechanism:LungcongestiondecreasegasdispersionAlveoliarestiffandmoreworkisneededtoovercomeelasticrecoilThehighalveolarpressurestimulatestretchreceptorHighpulmonarycirculationpressurestimulaterespiratorynervecenter15LeftheartfailureMechanism:15LeftheartfailureClinicalrepresentation:Exhausteddyspnea(勞力性呼吸困難)Orthopnea(端坐呼吸)Paroxysmalnocturnaldyspnea(夜間陣發(fā)性呼吸困難)16LeftheartfailureClinicalrepExhausteddyspneaDifficultyinbreathingwhenthepatientisinactivityrelivedwhenherelax.Doingexerciseimpelmorebloodintopulmonarycirculation.Moreoxygenisneededforbodydemand,especiallytheheart.17ExhausteddyspneaDifficultyinFunctionalclassificationClassⅠ–nolimitation:OrdinaryphysicalactivitydoesClassⅡ–slightlimitationofphysicalactivityClassⅢ–MarkedlimitationofphysicalactivityClassⅣ–inabilitytocarryoranyphysicalactivitywithoutdiscomfort18FunctionalclassificationClassOrthopneaDifficultyinbreathinginthesupinepositionrelivedbysittingupReducethedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesImprovethediaphragmaticmovementIncreasevitalcapacity19OrthopneaDifficultyinbreathiParoxysmalnocturnaldyspnea

Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Physicalexamination:moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm(cardiacasthma心源性哮喘).20Paroxysmalnocturnaldyspnea

TParoxysmalnocturnaldyspneaReason:Supinepostureforsleepimpelmorebloodintopulmonarycirculation,anddecreasevitalcapacity.Vagusexcitementcausecoronaryarteryconstrictionandbronchiolesspasm.21ParoxysmalnocturnaldyspneaReRightheartfailureBasaldiseases:Acutecorpulmonale(肺心病)whichcausedbypulmonaryembolism(肺栓塞)Chroniccorpulmonalewhichcausedbychronicobstructivepulmonarydisease(慢阻肺)22RightheartfailureBasaldiseaRightheartfailureMechanism:Thepressureofrightatriaandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.Hypoxemiaandtheaccumulationoftheacidmetabolitesstimulaterespiratorycenter.Therestrictionoftherespiratorymovementcausedbyenlargementofliver,ascitesandpleuraleffusion.23RightheartfailureMechanism:2Biventricularfailure

Leftheartfailureplusrightheartfailuremaycauseseveredyspnea?24BiventricularfailureLefthToxicdyspnea

Inthemetabolicacidosis(uremia尿毒癥anddiabeticacidosis糖尿病性酸中毒),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespiration(Kussmanul)withsnoring.25ToxicdyspneaInthemetaboToxicdyspneaTheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingslowrespirationorCheyne-Stokessrespiration.26ToxicdyspneaTheoverdoseofmNeuro-PsychogenicdyspneaTherespiratorycenterlosesthebloodsupplyoriscompressedwhilepatientsufferingfromcerebrovasculardisease.Therespirationbecomesdeep,slowandirregular.27Neuro-PsychogenicdyspneaTherNero-PsychogenicdyspneaPatientsufferfromhysteriawillbeseenrepetitivedeep,signingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.28Nero-PsychogenicdyspneaPatienHaematologicldyspneaThedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreaseheartrate,suchassevereanemia,carbonmonoxide.Hypotensioncanstimulaterespirationwhenpatientsufferfromshock.29HaematologicldyspneaThedecreAccompanyingsymptoms

Paroxysmaldyspneawithwheezing,Itispresentinbronchialasthmaandcardiacasthma.Paroxysmalseveredyspneaisoftenseeninacutelarynxedema(急性喉水腫),spontaneouspneumothorax(自發(fā)性氣胸),massivepulmonaryembolism.30AccompanyingsymptomsParoxyAccompanyingsymptoms

Dyspneawithchestpain.Itisfrequentlyobservedinlobarpneumonia(大葉性肺炎),pulmonaryinfarction(肺梗塞),spontaneouspneumothorax,acuteexudativepleurisy(急性滲出性胸膜炎),acutemyocardialinfarction(急性心肌梗死),andbronchialcarcinoma(支氣管肺癌).31AccompanyingsymptomsDyspneAccompanyingsymptoms

Dyspneawithfever.Itiscommonlynotedinpneumonia,lungabscess(肺膿腫),pulmonarytuberculosis(肺結(jié)核),pleurisy,acutepericarditis(急性心包炎),andnervoussystemdiseases.32AccompanyingsymptomsDyspneAccompanyingsymptoms

Dyspneawithcoughandpurulentsputum.Itisoftenpresentinchronicbronchitis,obstructivepulmonaryemphysemawithinfection,purulentpneumonia,andlungabscess;Dyspneawithlargeamountoffoamysputumisoftenseeninacuteleftventricularheartfailureandorganophosphoruspoisoning(有機(jī)磷中毒).33AccompanyingsymptomsDyspneAccompanyingsymptoms

Dyspneawithcoma.Itsuggestscerebralhemorrhage(腦出血),pneumoniawithshock,uremia,diabeticketoacidosis(糖尿病酮癥酸中毒),andacutepoisoning.34AccompanyingsymptomsDyspne小結(jié)呼吸困難的病因肺原性心原性中毒性神經(jīng)精神性血液病35小結(jié)呼吸困難的病因35肺原性呼吸困難吸氣性呼氣性混合性36肺原性呼吸困難36左心衰引起呼吸困難的機(jī)制臨床表現(xiàn)(勞力性、端坐呼吸、夜間陣發(fā)性氣急)及意義37左心衰37右心衰引起呼吸困難的機(jī)制38右心衰38復(fù)習(xí)思考題嚴(yán)重吸氣性呼吸困難最主要的特點(diǎn)是:A.端坐呼吸B.鼻翼煽動(dòng)C.哮鳴音D.呼吸加快加深E.三凹征39復(fù)習(xí)思考題嚴(yán)重吸氣性呼吸困難最主要的特點(diǎn)是:39混合性呼吸困難的特點(diǎn)是A.呼氣費(fèi)力B.吸氣費(fèi)力C.可伴有干咳及高調(diào)吸氣性喉鳴D.由于肺呼吸面積減少,換氣功能障礙所致E.以上都不是40混合性呼吸困難的特點(diǎn)是40X型題吸氣性呼吸困難的特點(diǎn)是:A.吸氣顯著費(fèi)力B.呼吸時(shí)間明顯延長(zhǎng),常伴有吸氣期哮鳴音C.嚴(yán)重者可見(jiàn)“三凹征”D.常見(jiàn)于喉部、氣管、支氣管的狹窄與阻塞E.由于肺呼吸面積減少導(dǎo)致?lián)Q氣功能障礙所致41X型題吸氣性呼吸困難的特點(diǎn)是:41DefinitionDyspneaisdefinedasanawarenessofdifficultyinbreathing.Mostpatientssufferfromactualdifficulty,somepatientsjusttasteanawarenessofhyperventilation(換氣過(guò)度).42DefinitionDyspneaisdefinedaHowtodescribethesesensationsCannotgetenoughairAirdoesnotgoallthewaydownSmotheringfeelinginthechestTightnessinthechestFatigueinthechest43HowtodescribethesesensatioDefinitionDilatationofnares(鼻翼扇動(dòng)),cyanosis(紫紺),useofaccessorymusclesofrespirationAbnormalitiesofrespiratoryrate,depthorrhythm44DefinitionDilatationofnares(EtiologyRespiratorydiseaseCardicdiseaseToxicNero-PsychogenicHaematologicaldiseaseIncreaseofabdominalpressure(massiveascites(腹水),pregnancy(懷孕)etc)45EtiologyRespiratorydisease4NormalpersonmayexperiencethephysiologicdyspneaduringheavyexerciseEnvironmentshortofoxygen46Normalpersonmayexperiencet476487RespiratorydyspneaRespiratorydyspneaiscausedbyabnormalventilationandgasexchange.Reductioninventilatorycapacity,hypercapnia(二氧化碳潴留)andhypoxemia(低氧血癥)resultingfromrespiratorydisease.Threeclinicaltypes:inspiratorydyspnea,expiratorydyspnea,mixeddyspnea.49RespiratorydyspneaRespiratoryInspiratorydyspneaClinicalcharacteristics:visibleindrawingoverthesternalnotch,thesupraclavicularspaces,theintercostalspacesandtheepigastriumintheinspiration(三凹癥).Accompaniedbyacoarse,lowpitchedinspiratorywheezinganddrycough.Stenosisandobstructionoflarynx,trachea,andbronchi50InspiratorydyspneaClinicalchExpiratorydyspneaClinicalcharacteristics:expirationisprolongedandlabouredwithwheezing.Cause:thedecreaseoflungelasticityandspasmnarrowingofthebronchiolesandsmallerbronchi.Familiardiseases:emphysema(肺氣腫),bronchialasthma(支氣管哮喘)andchronicasthmaticbronchitis(喘慢支).51ExpiratorydyspneaClinicalchaMixeddyspneaClinicalcharacteristics:breathingisdifficultduringbothinspirationandexpiration.Respiratoryfrequencyincreaseandrespirationsuperficial.Cause:decreaseofventilatorsandgasexchangecapacityFamiliardiseases:severepneumonia(肺炎),pulmonaryfibrosis(肺纖維化),massiveatelectasis(大片肺不張)etc52MixeddyspneaClinicalcharacteCardiacdyspneaCardiacdyspneaisusuallyattributabletopulmonaryvascularcongestionresultingfromtheleftand/orrightheartfailure.Dyspneaistheprimarysymptomofleftheartfailure.53CardiacdyspneaCardiacdyspnea5413LeftheartfailureBasaldiseases:CoronaryheartdiseaseHypertensiveheartdiseaseRheumaticheartdiseaseCongenitalheartdisease55LeftheartfailureBasaldiseasLeftheartfailureMechanism:LungcongestiondecreasegasdispersionAlveoliarestiffandmoreworkisneededtoovercomeelasticrecoilThehighalveolarpressurestimulatestretchreceptorHighpulmonarycirculationpressurestimulaterespiratorynervecenter56LeftheartfailureMechanism:15LeftheartfailureClinicalrepresentation:Exhausteddyspnea(勞力性呼吸困難)Orthopnea(端坐呼吸)Paroxysmalnocturnaldyspnea(夜間陣發(fā)性呼吸困難)57LeftheartfailureClinicalrepExhausteddyspneaDifficultyinbreathingwhenthepatientisinactivityrelivedwhenherelax.Doingexerciseimpelmorebloodintopulmonarycirculation.Moreoxygenisneededforbodydemand,especiallytheheart.58ExhausteddyspneaDifficultyinFunctionalclassificationClassⅠ–nolimitation:OrdinaryphysicalactivitydoesClassⅡ–slightlimitationofphysicalactivityClassⅢ–MarkedlimitationofphysicalactivityClassⅣ–inabilitytocarryoranyphysicalactivitywithoutdiscomfort59FunctionalclassificationClassOrthopneaDifficultyinbreathinginthesupinepositionrelivedbysittingupReducethedegreeofpulmonarycongestionbypoolingbloodinthelowerextremitiesImprovethediaphragmaticmovementIncreasevitalcapacity60OrthopneaDifficultyinbreathiParoxysmalnocturnaldyspnea

Thepatientawakesshortofbreathatnight,butoftenobtainreliefbysittingupforaperiodoftime.Physicalexamination:moistralesatthebothlungbases,tachycardia,wheezingandbronchospasm(cardiacasthma心源性哮喘).61Paroxysmalnocturnaldyspnea

TParoxysmalnocturnaldyspneaReason:Supinepostureforsleepimpelmorebloodintopulmonarycirculation,anddecreasevitalcapacity.Vagusexcitementcausecoronaryarteryconstrictionandbronchiolesspasm.62ParoxysmalnocturnaldyspneaReRightheartfailureBasaldiseases:Acutecorpulmonale(肺心病)whichcausedbypulmonaryembolism(肺栓塞)Chroniccorpulmonalewhichcausedbychronicobstructivepulmonarydisease(慢阻肺)63RightheartfailureBasaldiseaRightheartfailureMechanism:Thepressureofrightatriaandsuperiorvenacavaisthenaturalstimulusofrespiratorycenter.Hypoxemiaandtheaccumulationoftheacidmetabolitesstimulaterespiratorycenter.Therestrictionoftherespiratorymovementcausedbyenlargementofliver,ascitesandpleuraleffusion.64RightheartfailureMechanism:2Biventricularfailure

Leftheartfailureplusrightheartfailuremaycauseseveredyspnea?65BiventricularfailureLefthToxicdyspnea

Inthemetabolicacidosis(uremia尿毒癥anddiabeticacidosis糖尿病性酸中毒),theacidmetabolitesstimulatetherespiratorycenter,causingdeepandregularrespiration(Kussmanul)withsnoring.66ToxicdyspneaInthemetaboToxicdyspneaTheoverdoseofmorphineandpentobarbitalcandepressrespiratorycentercausingslowrespirationorCheyne-Stokessrespiration.67ToxicdyspneaTheoverdoseofmNeuro-PsychogenicdyspneaTherespiratorycenterlosesthebloodsupplyoriscompressedwhilepatientsufferingfromcerebrovasculardisease.Therespirationbecomesdeep,slowandirregular.68Neuro-PsychogenicdyspneaTherNero-PsychogenicdyspneaPatientsufferfromhysteriawillbeseenrepetitivedeep,signingrespirationwithnumbnessofextremitiesorlips,cheiropedalspasm.69Nero-PsychogenicdyspneaPatienHaematologicldyspneaThedecreaseofoxygen-carryingcapacityandoxygencontentdevelopabnormalrespirationandincreaseheartrate,suchassevereanemia,carbonmonoxide.Hypotensioncanstimulaterespirationwhenpatientsufferfromshock.70HaematologicldyspneaThedecreAccompanyingsymptoms

Paroxysmaldyspneawithwheezing,Itispresentinbronchialasthmaandcardiacasthma.Paroxysmalseveredyspneaisoftenseeninacutelarynxedema(急性喉水腫),spontaneouspneumothorax(自發(fā)性氣胸),massivepulmon