病理學(xué)-呼吸系統(tǒng)資料講解課件

呼吸系統(tǒng)疾病TheRespiratorySystem第四章呼吸系統(tǒng)疾病第四章快速氣體交換

Rapidgasexchange

VentilationPerfusionDiffusion

清潔空氣肺的結(jié)構(gòu)與功能快速氣體交換肺的結(jié)構(gòu)與功能MucosaSubmucosaCartilageMusclesBronchusMucosaSubmucosaCartilageMuscleBronchialepitheliumBronchialepitheliumKulchitskycellsKulchitskycellsBronchialSubmucosalGlandsBronchialSubmucosalGlandsAlveoliAlveoliTherespiratorymembraneTherespiratorymembrane病原體

Pathogen空氣contaminatedairexposure

鼻咽部菌群

nasopharyngealfloraaspiration宿主防御功能下降

Compromiseddefensemechanisms肺部疾病

othercommonlungdisease免疫缺陷Immunodeficiency生活方式

Lifestyle肺部感染PulmonaryInfections病原體Pathogen肺部感染PulmonaryIn病理學(xué)——呼吸系統(tǒng)資料講解課件分類Classification根據(jù)解剖和影像學(xué)

Anatomyandradiography根據(jù)病因

Etiology根據(jù)在哪獲得

SettinginwhichtheyariseCommunity-Acquired

Hospital-acquired

(nosocomial)分類Classification根據(jù)解剖和影像學(xué)一、細(xì)菌性肺炎

大葉性肺炎（95%肺炎鏈球菌）小葉性肺炎軍團(tuán)菌性肺炎（肺炎+全身毒血癥狀）一、細(xì)菌性肺炎大葉性肺炎小葉性肺炎大葉性肺炎小葉性肺炎大葉性肺炎患者楊某，男，20歲，學(xué)生。酗酒后遭雨淋，于當(dāng)天晚上突然起病，寒顫、高熱、呼吸困難、胸痛，繼而咳嗽，咳鐵銹色痰，其家屬急送當(dāng)?shù)蒯t(yī)院就診。聽診，左肺下葉有大量濕性啰音；觸診語顫增強(qiáng)；血常規(guī)：WBC：17X109/L；X線檢查，左肺下葉有大片致密陰影。

典型病例1患者楊某，男，20歲，學(xué)生。酗酒后遭雨淋，于當(dāng)入院經(jīng)抗生素治療，病情好轉(zhuǎn)，各種癥狀逐漸消失；X線檢查，左肺下葉的大片致密陰影縮小2/3面積。病人于入院后第7天自感無癥狀出院。冬季征兵體檢，X線檢查左肺下葉有約3cmX2cm大小不規(guī)則陰影，周圍邊界不清，懷疑為“支氣管肺癌”。在當(dāng)?shù)蒯t(yī)院即做左肺下葉切除術(shù)。病理檢查，肺部腫塊肉眼為紅褐色肉樣，鏡下為肉芽組織。

入院經(jīng)抗生素治療，病情好轉(zhuǎn)，各種癥狀逐漸消失；X線檢查，左肺大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎Intheerabeforeantibiotics…充血水腫期

Hyperemiaandedema紅肝期

Redhepatization灰肝期

Grayhepatization溶解消散期

Resolution(hopefully)Intheerabeforeantibiotics…Hyperemiaandedema，12-24hours

Hyperemiaandedema，12-24hourRedhepatization2-3daysRedhepatization2-3days病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件Grayhepatization，3-4daysGrayhepatization，3-4days病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件并發(fā)癥complications肺膿腫，膿胸，膿氣胸?cái)⊙Y，膿毒敗血癥，感染性休克肺肉質(zhì)變并發(fā)癥complications肺膿腫，膿胸，膿氣胸小葉性肺炎小葉性肺炎小葉性肺炎小葉性肺炎FilledwithexudateAeratedlung小葉性肺炎FilledwithexudateAeratedlun小葉性肺炎小葉性肺炎并發(fā)癥Complications心力衰竭、呼吸衰竭肺膿腫、膿胸、膿毒敗血癥

支氣管擴(kuò)張并發(fā)癥Complications心力衰竭、呼吸衰竭Organization

OrganizationAbscessformationAbscessformationAbscessformationAbscessformationPurulentpleuritisPurulentpleuritisHemorrhagicPneumoniabyPseudomonasaeruginosaHemorrhagicPneumoniaPseudomonaspneumoniaPseudomonaspneumoniaKlebsiellapneumoniaKlebsiellapneumonia二、病毒性肺炎/三、支原體性肺炎輕者為急性間質(zhì)性肺炎，舊稱不典型性肺炎atypical缺乏實(shí)變體征WBC輕度升高重者為急性呼吸窘迫癥ARDS肺泡彌漫性損傷透明膜形成二、病毒性肺炎/三、支原體性肺炎輕者為急性間質(zhì)性肺炎，舊稱ViralpneumoniaViralpneumoniaAtypicalpneumoniaAtypicalpneumoniaSevereAcuteRespiratorySyndrome(SARS)SevereAcuteRespiratorySyndrPneumoniaintheImmunocompromisedHost機(jī)會(huì)致病原

opportunisticagents常為多重感染

bacteria

(P.aeruginosa,Mycobacteriumspp.,L.pneumophila,andListeriamonocytogenes)viruses

(cytomegalovirusandherpesvirus)fungi

(P.jiroveci,Candidaspp.,Aspergillusspp.,andCryptococcusneoformans)PneumoniaintheImmunocompromCMVinfectionsCMVinfections病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件

insituhybridizationinsituhybridizationSputumcytologyfromanAIDSpatient(Papanicolaou)(Giemsa)SputumcytologyfromanAIDSpPneumocystisPneumonia

PneumocystisPneumonia病理學(xué)——呼吸系統(tǒng)資料講解課件(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPne(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPnePneumocystiscariniiinbronchiallavagefromanAIDSpatient(Grocott‘ssilver)Pneumocystiscariniiinbronch(Papanicolaou)(Immunostaining)(Papanicolaou)(Immunostaining慢性阻塞性肺病(COPD)

ChronicObstructivePulmonaryDiseaselimitationofairflowusuallyresultingfromanincreaseinresistancecausedbypartialorcompleteobstructionatanylevel肺氣腫Emphysema慢性支氣管炎Chronicbronchitis支氣管擴(kuò)張Bronchiectasis哮喘Asthma慢性阻塞性肺病(COPD)

ChronicObstrFEV1/FVCFEV1/FVCClinicalTermAnatomicSiteMajorPathologicChangesEtiologySigns/SymptomsChronicbronchitisBronchusBronchioleMucusglandhyperplasia,hypersecretionInflammatoryscarringTobaccosmoke,airpollutantsCough,sputumproductionCough,dyspneaBronchi-ectasisBronchusAirwaydilationandscarringPersistentorsevereinfectionsCough,purulentsputum,feverAsthmaBronchusSmoothmusclehyperplasia,excessivemucus,inflammationImmunologicorundefinedcausesEpisodicwheezing,cough,dyspneaEmphysemaAcinusAirspaceenlargement,walldestructionTobaccosmokeDyspneaClinicalTermAnatomicSiteMajo

我國國家“十五”課題最新統(tǒng)計(jì)數(shù)據(jù)（2005年公布）顯示40歲以上人口COPD患病率為8%。估計(jì)全國有2500萬人罹患此病，每年因COPD死亡的人數(shù)達(dá)100萬，致殘人數(shù)達(dá)500～1000萬，COPD居我國疾病負(fù)擔(dān)的首位。我國國家“十五”課題最新統(tǒng)計(jì)數(shù)據(jù)（2005年公布慢性支氣管炎ChronicbronchitisApersistentcoughproductiveofsputumforatleast3months,inatleast2consecutiveyears單純型Simple…喘息型

Asthmatic…阻塞型

obstructive…

慢性支氣管炎ChronicbronchitisAper病因etiology吸煙和空氣污染

Cigarettesmokingandairpollutants感染

Microbialinfection

Secondaryrole使炎癥持續(xù)，加重癥狀

maintainingtheinflammationandexacerbatingsymptoms病因etiology吸煙和空氣污染發(fā)病機(jī)制Pathogenesis多痰——粘液分泌亢進(jìn)

Hypersecretionofmucus大氣道病變

largebronchialinvolvement粘液腺增生，杯狀細(xì)胞分泌亢進(jìn)

Hypertrophyofmucousglandsandamarkedincreaseinmucin-secretinggobletcells發(fā)病機(jī)制Pathogenesis多痰——粘液分泌亢進(jìn)氣道阻塞

Airflowobstruction小氣道炎癥和管壁纖維化

inflammation,bronchiolarwallfibrosis

杯狀細(xì)胞化生，細(xì)支氣管痰栓形成

gobletcellmetaplasiawithmucuspluggingofthebronchiolarlumen并發(fā)肺氣腫

coexistentemphysema

發(fā)病機(jī)制Pathogenesis氣道阻塞Airflowobstruction發(fā)病機(jī)制PinnerperichondriumbasallaminaChronicbronchitisNormalbronchusinnerperichondriumbasallaminChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchiolitis

luminalandmucuschronicinflammationChronicbronchiolitisluminal肺氣腫

EmphysemaAbnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchioles,accompaniedbydestructionoftheirwallswithoutobviousfibrosis指呼吸性細(xì)支氣管、肺泡管、肺泡囊、肺泡因組織彈性減弱而過度充氣伴有肺泡間隔破壞，致使肺容積增大的病理狀態(tài)肺氣腫

EmphysemaAbnormalperman病理類型腺泡(小葉)中央型

Centriacinar…

全腺泡(小葉)型

Panacinar…腺泡(小葉)周圍型

Distalacinar…不規(guī)則型

Irregular…obstructionSpontaneouspneumothoraxasymptomatic病理類型腺泡(小葉)中央型Centriacinar…o病理學(xué)——呼吸系統(tǒng)資料講解課件發(fā)病機(jī)理Pathogenesis發(fā)病機(jī)理PathogenesisCentriacinaremphysemaCentriacinaremphysema病理學(xué)——呼吸系統(tǒng)資料講解課件BullousemphysemaBullousemphysemaCentriacinaremphysemaCentriacinaremphysema病理學(xué)——呼吸系統(tǒng)資料講解課件

InadequateventilationLessperfusionNarrowedbronchioleInadequateventilationConditionsRelatedtoEmphysema間質(zhì)性肺氣腫

Mediastinal(interstitial)emphysema代償性肺氣腫

Compensatoryemphysema阻塞性過充氣

Obstructiveoverinflation瘢痕旁肺氣腫

Paracicatricalemphysema老年性肺氣腫

SenileemphysemaConditionsRelatedtoEmphysem病理學(xué)——呼吸系統(tǒng)資料講解課件COPD的臨床表現(xiàn)RespiratoryfailureRightheartfailureCOPD的臨床表現(xiàn)RespiratoryfailureRiPinkpuffer桶狀胸

BarrelchestPinkpuffer桶狀胸支氣管擴(kuò)張癥BronchiectasisPermanentdilationofbronchiandbronchiolescausedbydestructionofthemuscleandelasticsupportingtissueresultingfromorassociatedwithchronicnecrotizinginfections

繼發(fā)于持續(xù)性感染或阻塞

Secondarytopersistinginfectionorobstruction

診斷依靠病史和影像學(xué)支氣管擴(kuò)張癥BronchiectasisPermanentPredisposingconditions支氣管阻塞

Bronchialobstruction腫瘤Tumor異物Foreignbodies

先天性或遺傳性疾病

Congenitalorhereditaryconditions

CysticfibrosisKartagenersyndrome壞死性化膿性肺炎

Necrotizing,orsuppurative,pneumonia

Predisposingconditions支氣管阻塞CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)Bronchiectasis57yearoldwomanwithalonghistoryofrecurrentrespiratorytractinfectionsandepisodesofhemoptysisBronchiectasis57yearoldwomaBronchiectasis

BronchiectasisBronchiectasisDuetopneumoniaBronchiectasisBronchiectasisBronchiectasisBronchiectasis

PurulentexudationinthelumenDestructionofliningepitheliumScarringofthebronchialwallBronchiectasisPurulentexudatHRCTscansofbronchiectasisHRCTscansofbronchiectasis支氣管擴(kuò)張癥的臨床表現(xiàn)咳嗽，咳膿臭痰

Severe,persistentcoughwithmucopurulentsputum,sometimesfetid咯血

Flecksofbloodinsputumorfrankhemoptysis

嚴(yán)重病例及合并癥支氣管擴(kuò)張癥的臨床表現(xiàn)咳嗽，咳膿臭痰肺間質(zhì)疾病ILD肺彌漫性纖維化肺順應(yīng)性減弱，容量減小已知病因和特發(fā)性間質(zhì)性肺炎肺間質(zhì)疾病ILD肺彌漫性纖維化Selectedcausesofchronicinterstitiallungdisease

OccupationalandenvironmentalexposureAsbestosisSilicosisHypersensitivitypneumonitisDrugortreatmentrelatedChemotherapeuticagentsIonizingirradiationOxygenImmunologiclungdiseaseSarcoidosisWegnergranulomatosisCollagenvasculardiseaseGoodpasturesyndromeMiscellaneousPostacuterespiratorydistresssyndromeIdiopathicpulmonaryfibrosisSelectedcausesofchronicint杵狀指（趾）Clubbingofdigits杵狀指（趾）HoneycomblungHoneycomblung病理學(xué)——呼吸系統(tǒng)資料講解課件矽肺Silicosis職業(yè)病

Occupationaldiseases吸入二氧化硅粉塵引起

Inhalationofcrystallinesilica致殘和致死

Disablingandfatal病理：硅結(jié)節(jié)形成廣泛的肺纖維化

矽肺Silicosis職業(yè)病Occupational病理學(xué)——呼吸系統(tǒng)資料講解課件發(fā)病機(jī)制Pathogenesis直徑<5μm的硅塵沉積于肺間質(zhì)肺泡巨噬細(xì)胞引發(fā)和持續(xù)肺損傷和纖維化

Alveolarmacrophageisakeycellularelementintheinitiationandperpetuationoflunginjuryandfibrosis發(fā)病機(jī)制Pathogenesis直徑<5μm的硅塵沉積于Silicosis

asliceoflungfroma61yoceramicsworkerSilicosisasliceoflungfrom矽結(jié)節(jié)

Silicosis矽結(jié)節(jié)Silicosis病理學(xué)——呼吸系統(tǒng)資料講解課件臨床表現(xiàn)Clinicalcourse早期常為體檢發(fā)現(xiàn)

usuallydetectedinroutinechestradiographs晚期表現(xiàn)：呼吸困難shortnessofbreath肺心病corpulmonale合并TBincreasedsusceptibilitytoTB可能致癌

carcinogenic(controversial)臨床表現(xiàn)Clinicalcourse早期常為體檢發(fā)現(xiàn)uSilicosis

Silicosis急性呼吸窘迫征(ARDS)

AcuteRespiratoryDistressSyndrome進(jìn)行性呼吸衰竭

AcuteonsetofDyspneaHypoxemiaBilateralpulmonaryinfiltrates(X-ray)Noevidenceofleft-sidedheartfailure病理：彌漫性肺泡損傷

DiffuseAlveolarDamage(DAD)常伴多器官衰竭

MultipleOrganDysfunctionSyndrome(MODS)急性呼吸窘迫征(ARDS)

AcuteRespiratDirectLungInjuryIndirectLungInjuryCommonCausesPneumoniaSepsisAspirationofgastriccontentsSeveretraumawithshockUncommonCausesPulmonarycontusionCardiopulmonarybypassFatembolismAcutepancreatitisNear-drowningDrugoverdoseInhalationalinjuryTransfusionofbloodproductsReperfusioninjuryafterlungtransplantationUremiaClinicalDisordersAssociatedwithdevelopingARDSDirectLungInjuryIndirectLun發(fā)病機(jī)制Pathogenesis廣泛內(nèi)皮和肺泡I型、II型上皮損傷

Endothelialandepithelial(IandII)damage肺水腫

alveolarflooding氣體交換喪失

lossofdiffusioncapacity

表面活性物質(zhì)異常

surfactantabnormalities

促炎和抗炎介質(zhì)的失衡

Imbalanceofpro-inflammatoryandanti-inflammatorymediators發(fā)病機(jī)制Pathogenesis廣泛內(nèi)皮和肺泡I型、II病理學(xué)——呼吸系統(tǒng)資料講解課件病理變化Morphology急性滲出期

AcuteExudativeStage水腫

Edema(interstitialandalveolar)

透明膜形成

Hyalinemembranes

肺泡塌陷

Manyalveolicollapse

增生期ProliferativeStageII型肺泡上皮增生肺泡內(nèi)機(jī)化Intra-alveolarfibrosis病理變化Morphology急性滲出期AcuteExuwideningoftheinterstitiumARDSwideningoftheinterstitiumHyalinemembranesHyalinemembranesHyalinemembranes

HyalinemembranesHyalinemembranes

HyalinemembranesHealingstage

HealingstageHealingstage

HealingstagesuvivingpatientARDSsuvivingpatientARDS臨床表現(xiàn)Clinicalfeatures肺順應(yīng)性差

Poorpulmonarycompliance難治性低氧血癥

Poorresponsetooxygen血管床進(jìn)行性減少

Pulmonaryvascularbedisprogressivelyobliterated易感染

Pronetobacteriainfection臨床表現(xiàn)Clinicalfeatures肺順應(yīng)性差預(yù)后PrognosisDependssuccessfullytreatementsbeforeextensivefibrosis40-70%mortalityHigh-dosesteroidsfailedConservativetherapyhelpsConsiderableinterestinthequalityofsurvivals預(yù)后PrognosisDependssuccessfuLUNGTUMORSMetastatictumorsPrimarytumorsBRONCHOGENICCARCINOMAOthers

bronchialcarcinoidsmesenchymalmalignanciesLymphomasafewbenignlesions

95%5%LUNGTUMORSMetastatictumors9慢性肺動(dòng)脈高壓癥和肺心病（自學(xué)）概念病因發(fā)病機(jī)制病理變化臨床病理聯(lián)系思考題：試述慢性支氣管炎并發(fā)肺心病的發(fā)病機(jī)制。慢性肺動(dòng)脈高壓癥和肺心?。ㄗ詫W(xué)）概念思考題：肺癌癌癥死因第一位

causeofcancer-relateddeaths發(fā)病率隨年齡和煙齡增長

"pack-yearssmoked".確診的病人一半以上已有遠(yuǎn)處轉(zhuǎn)移distantmetastaticdisease5年生存率約為15%5-yearsurvival肺癌癌癥死因第一位病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件肺癌的臨床病理分型肺小細(xì)胞癌

Smallcelllungcancer(SCLC)肺非小細(xì)胞癌

Non-small-celllungcancer(NSCLC)

鱗癌Squamouscellcarcinoma

腺癌Adenocarcinomas大細(xì)胞癌Largecellcarcinomas

肺癌的臨床病理分型肺小細(xì)胞癌SCLCKulchitskycell起源hADH(hyponatremia/waterintoxication)ACTH(Cushing'ssyndrome)中央型

Centrallylocatedmasses壞死常見

Necrosisisinvariablypresentandmaybeextensive燕麥細(xì)胞癌

OatcellcarcinomaSCLCKulchitskycell起源SCLCSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLCOatcellcarcinomaSCLC鱗狀細(xì)胞癌病人大多有吸煙史

Closelycorrelatedwithasmokinghistory中央型

Tendtoarisecentrallyinmajorbronchi常見空洞

Cavitationisnotuncommon副癌綜合征

Preneoplasticlesions

鱗狀細(xì)胞癌病人大多有吸煙史SquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinoma病理學(xué)——呼吸系統(tǒng)資料講解課件SquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinomaSquamouscellcarcinoma病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件Metaplaisa?Anaplasia?Dysplasia?Metaplaisa?Anaplasia?Dysplas腺癌Adenocarcinoma周圍型多見

peripherallylocated是女性和非吸煙者常見的肺癌類型常發(fā)生自肺周邊部疤痕處

arisinginrelationtoperipherallungscars生長緩慢但早期轉(zhuǎn)移支氣管肺泡干細(xì)胞起源

Bronchioalveolarstemcellsorigin腺癌Adenocarcinoma周圍型多見peripAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinomaAdenocarcinoma細(xì)支氣管肺泡癌(BAC)

BronchioloalveolarcarcinomaAdistinctsubtypeofadenocarcinoma彌漫型多見multiplediffusenodulesGrowingalongpreexistingstructuresandpreservationofalveolararchitecture分為粘液型和無粘液型

mucinous/nonmucinoussubtypes細(xì)支氣管肺泡癌(BAC)

BronchioloalveoBACBACBACBACBACBACPrecursorlesionsofADCAAHBACPrecursorlesionsofADCAAHBAC低分化癌，排除SCLC,SCCorADCCellsarenot-columnarinshapeDonotcontainmucousDonotshowsquamousdifferentiationDonothaveneuroendocrinepropertiesorsmallcellcharacteristics可發(fā)生與任何部位

ariseanywhereinlungs大部分與吸煙有關(guān)，預(yù)后差

smoking-related,curesarerare大細(xì)胞癌低分化癌，排除SCLC,SCCorADC大細(xì)胞癌LargecellcarcinomaLargecellcarcinoma肺癌的臨床表現(xiàn)原發(fā)灶引起的癥狀

Symptomsduetoprimarytumor原發(fā)灶蔓延引起的癥狀

Symptomsduetolocoregionalspread轉(zhuǎn)移引起的問題

Metastaticdisease副腫瘤綜合征

Paraneoplasticsyndromes肺癌的臨床表現(xiàn)原發(fā)灶引起的癥狀中央型肺癌

Centraltumorscough,dyspnea,肺不張atelectasis,阻塞后肺炎，喘息

咯血hemoptysis周圍型肺癌

Peripheraltumorscough,dyspnea胸水pleuraleffusion疼痛severepainDuetoprimarytumor中央型肺癌CentraltumorsDuetoprDuetolocoregionalspread上腔靜脈綜合征

Superiorvenacavaobstruction聲音嘶啞

Hoarseness肩膀和上臂疼痛Horner’ssyndrome吞咽困難

Dysphagia心包積液

PericardialeffusionDuetolocoregionalspread上腔靜脈病理學(xué)——呼吸系統(tǒng)資料講解課件眼球內(nèi)陷asunkeneyeball(enophthalmia)

瞳孔縮小，對光反射異常上瞼下垂droopyuppereyelid患側(cè)面部無汗Horner'sSyndromeNormalAbnormal眼球內(nèi)陷asunkeneyeball(enophtMetastaticdisease腦

brain(mentalorneurologicchanges)肝

liver(hepatomegaly)骨

bones(pain)Metastaticdisease腦brain(menParaneoplasticsyndromesHypercalcemiaCushingsyndromeHyponatremiaNeuromuscularsyndromesHematologicmanifestationsClubbingofthefingersBlindnessanddementia3%to10%ofallpatientsParaneoplasticsyndromesHypercMetastaticcarcinomaMetastaticcarcinomadilatedlymphaticchanneldilatedlymphaticchannelTransesophagealEchocardiogram6/22,8daysbeforedeath,…showedthickeningoftheleafletsofthePVandoneoftwopedunculatedvegetations,Therewasnovalvarinsufficiency.TransesophagealEchocardiogramRadiographicFindings

6/26,4daysbeforedeath,afrontalfilmshowingtherightlungdemonstratedmultipleareasofmass-likeconsolidation,atleasttwoofwhichshowedcentralcavitation.Therewasasmallrighteffusion.Theleftlungappearednormal.RadiographicFindings6/264/xx-6/19

inanotherhospital,“feelingbad”

6/19…“2daysofincreasingconfusion”6/30…dieHepatitisCEnd-stagerenaldiseaseRkneeandLwristsepticarthritisintravenousdruguseRkneeandLwristsepticarthritisBacteremiaNocardiacmurmurLungsareclear6/22PVvegetations6/26lungmasses,cavitatedpleuraleffusion4/xx-6/19inanotherhospital,AutopsyFindings

PulmonicvalveNormalpulmonicvalveAutopsyFindingsPulmonicval

Therightlungweighed1000gandtheleft,900g(normalabout250gapiece).Therighthadafibrinouspleuritis.Afterdistensionwithformalinandfixation,oneslicefromtheleftlungshowedtwoyellowishlesions.Therightlungweighed100Asliceoftherightlowerlobeshowedtwolesions.AsliceoftherightlowerlobPulmonicvegetationPulmonicvegetationThrombusinoneofthesegmentalarteriesThrombusinoneofthesegmentthesamearterythesamearteryAnothervesselAnothervessel病理診斷DiagnosesInfectiveendocarditis

(methicillinresistantS.aureus)InfectedemboliInfectivepulmonaryarteritisInfected,cavitatedinfarcts,lung.病理診斷DiagnosesInfectiveendoca呼吸系統(tǒng)疾病TheRespiratorySystem第四章呼吸系統(tǒng)疾病第四章快速氣體交換

Rapidgasexchange

VentilationPerfusionDiffusion

清潔空氣肺的結(jié)構(gòu)與功能快速氣體交換肺的結(jié)構(gòu)與功能MucosaSubmucosaCartilageMusclesBronchusMucosaSubmucosaCartilageMuscleBronchialepitheliumBronchialepitheliumKulchitskycellsKulchitskycellsBronchialSubmucosalGlandsBronchialSubmucosalGlandsAlveoliAlveoliTherespiratorymembraneTherespiratorymembrane病原體

Pathogen空氣contaminatedairexposure

鼻咽部菌群

nasopharyngealfloraaspiration宿主防御功能下降

Compromiseddefensemechanisms肺部疾病

othercommonlungdisease免疫缺陷Immunodeficiency生活方式

Lifestyle肺部感染PulmonaryInfections病原體Pathogen肺部感染PulmonaryIn病理學(xué)——呼吸系統(tǒng)資料講解課件分類Classification根據(jù)解剖和影像學(xué)

Anatomyandradiography根據(jù)病因

Etiology根據(jù)在哪獲得

SettinginwhichtheyariseCommunity-Acquired

Hospital-acquired

(nosocomial)分類Classification根據(jù)解剖和影像學(xué)一、細(xì)菌性肺炎

大葉性肺炎（95%肺炎鏈球菌）小葉性肺炎軍團(tuán)菌性肺炎（肺炎+全身毒血癥狀）一、細(xì)菌性肺炎大葉性肺炎小葉性肺炎大葉性肺炎小葉性肺炎大葉性肺炎患者楊某，男，20歲，學(xué)生。酗酒后遭雨淋，于當(dāng)天晚上突然起病，寒顫、高熱、呼吸困難、胸痛，繼而咳嗽，咳鐵銹色痰，其家屬急送當(dāng)?shù)蒯t(yī)院就診。聽診，左肺下葉有大量濕性啰音；觸診語顫增強(qiáng)；血常規(guī)：WBC：17X109/L；X線檢查，左肺下葉有大片致密陰影。

典型病例1患者楊某，男，20歲，學(xué)生。酗酒后遭雨淋，于當(dāng)入院經(jīng)抗生素治療，病情好轉(zhuǎn)，各種癥狀逐漸消失；X線檢查，左肺下葉的大片致密陰影縮小2/3面積。病人于入院后第7天自感無癥狀出院。冬季征兵體檢，X線檢查左肺下葉有約3cmX2cm大小不規(guī)則陰影，周圍邊界不清，懷疑為“支氣管肺癌”。在當(dāng)?shù)蒯t(yī)院即做左肺下葉切除術(shù)。病理檢查，肺部腫塊肉眼為紅褐色肉樣，鏡下為肉芽組織。

入院經(jīng)抗生素治療，病情好轉(zhuǎn)，各種癥狀逐漸消失；X線檢查，左肺大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎大葉性肺炎Intheerabeforeantibiotics…充血水腫期

Hyperemiaandedema紅肝期

Redhepatization灰肝期

Grayhepatization溶解消散期

Resolution(hopefully)Intheerabeforeantibiotics…Hyperemiaandedema，12-24hours

Hyperemiaandedema，12-24hourRedhepatization2-3daysRedhepatization2-3days病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件Grayhepatization，3-4daysGrayhepatization，3-4days病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件并發(fā)癥complications肺膿腫，膿胸，膿氣胸?cái)⊙Y，膿毒敗血癥，感染性休克肺肉質(zhì)變并發(fā)癥complications肺膿腫，膿胸，膿氣胸小葉性肺炎小葉性肺炎小葉性肺炎小葉性肺炎FilledwithexudateAeratedlung小葉性肺炎FilledwithexudateAeratedlun小葉性肺炎小葉性肺炎并發(fā)癥Complications心力衰竭、呼吸衰竭肺膿腫、膿胸、膿毒敗血癥

支氣管擴(kuò)張并發(fā)癥Complications心力衰竭、呼吸衰竭Organization

OrganizationAbscessformationAbscessformationAbscessformationAbscessformationPurulentpleuritisPurulentpleuritisHemorrhagicPneumoniabyPseudomonasaeruginosaHemorrhagicPneumoniaPseudomonaspneumoniaPseudomonaspneumoniaKlebsiellapneumoniaKlebsiellapneumonia二、病毒性肺炎/三、支原體性肺炎輕者為急性間質(zhì)性肺炎，舊稱不典型性肺炎atypical缺乏實(shí)變體征WBC輕度升高重者為急性呼吸窘迫癥ARDS肺泡彌漫性損傷透明膜形成二、病毒性肺炎/三、支原體性肺炎輕者為急性間質(zhì)性肺炎，舊稱ViralpneumoniaViralpneumoniaAtypicalpneumoniaAtypicalpneumoniaSevereAcuteRespiratorySyndrome(SARS)SevereAcuteRespiratorySyndrPneumoniaintheImmunocompromisedHost機(jī)會(huì)致病原

opportunisticagents常為多重感染

bacteria

(P.aeruginosa,Mycobacteriumspp.,L.pneumophila,andListeriamonocytogenes)viruses

(cytomegalovirusandherpesvirus)fungi

(P.jiroveci,Candidaspp.,Aspergillusspp.,andCryptococcusneoformans)PneumoniaintheImmunocompromCMVinfectionsCMVinfections病理學(xué)——呼吸系統(tǒng)資料講解課件病理學(xué)——呼吸系統(tǒng)資料講解課件

insituhybridizationinsituhybridizationSputumcytologyfromanAIDSpatient(Papanicolaou)(Giemsa)SputumcytologyfromanAIDSpPneumocystisPneumonia

PneumocystisPneumonia病理學(xué)——呼吸系統(tǒng)資料講解課件(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPne(silverstain)PneumocystisPneumonia(silverstain)PneumocystisPnePneumocystiscariniiinbronchiallavagefromanAIDSpatient(Grocott‘ssilver)Pneumocystiscariniiinbronch(Papanicolaou)(Immunostaining)(Papanicolaou)(Immunostaining慢性阻塞性肺病(COPD)

ChronicObstructivePulmonaryDiseaselimitationofairflowusuallyresultingfromanincreaseinresistancecausedbypartialorcompleteobstructionatanylevel肺氣腫Emphysema慢性支氣管炎Chronicbronchitis支氣管擴(kuò)張Bronchiectasis哮喘Asthma慢性阻塞性肺病(COPD)

ChronicObstrFEV1/FVCFEV1/FVCClinicalTermAnatomicSiteMajorPathologicChangesEtiologySigns/SymptomsChronicbronchitisBronchusBronchioleMucusglandhyperplasia,hypersecretionInflammatoryscarringTobaccosmoke,airpollutantsCough,sputumproductionCough,dyspneaBronchi-ectasisBronchusAirwaydilationandscarringPersistentorsevereinfectionsCough,purulentsputum,feverAsthmaBronchusSmoothmusclehyperplasia,excessivemucus,inflammationImmunologicorundefinedcausesEpisodicwheezing,cough,dyspneaEmphysemaAcinusAirspaceenlargement,walldestructionTobaccosmokeDyspneaClinicalTermAnatomicSiteMajo

我國國家“十五”課題最新統(tǒng)計(jì)數(shù)據(jù)（2005年公布）顯示40歲以上人口COPD患病率為8%。估計(jì)全國有2500萬人罹患此病，每年因COPD死亡的人數(shù)達(dá)100萬，致殘人數(shù)達(dá)500～1000萬，COPD居我國疾病負(fù)擔(dān)的首位。我國國家“十五”課題最新統(tǒng)計(jì)數(shù)據(jù)（2005年公布慢性支氣管炎ChronicbronchitisApersistentcoughproductiveofsputumforatleast3months,inatleast2consecutiveyears單純型Simple…喘息型

Asthmatic…阻塞型

obstructive…

慢性支氣管炎ChronicbronchitisAper病因etiology吸煙和空氣污染

Cigarettesmokingandairpollutants感染

Microbialinfection

Secondaryrole使炎癥持續(xù)，加重癥狀

maintainingtheinflammationandexacerbatingsymptoms病因etiology吸煙和空氣污染發(fā)病機(jī)制Pathogenesis多痰——粘液分泌亢進(jìn)

Hypersecretionofmucus大氣道病變

largebronchialinvolvement粘液腺增生，杯狀細(xì)胞分泌亢進(jìn)

Hypertrophyofmucousglandsandamarkedincreaseinmucin-secretinggobletcells發(fā)病機(jī)制Pathogenesis多痰——粘液分泌亢進(jìn)氣道阻塞

Airflowobstruction小氣道炎癥和管壁纖維化

inflammation,bronchiolarwallfibrosis

杯狀細(xì)胞化生，細(xì)支氣管痰栓形成

gobletcellmetaplasiawithmucuspluggingofthebronchiolarlumen并發(fā)肺氣腫

coexistentemphysema

發(fā)病機(jī)制Pathogenesis氣道阻塞Airflowobstruction發(fā)病機(jī)制PinnerperichondriumbasallaminaChronicbronchitisNormalbronchusinnerperichondriumbasallaminChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchitisChronicbronchiolitis

luminalandmucuschronicinflammationChronicbronchiolitisluminal肺氣腫

EmphysemaAbnormalpermanentenlargementoftheairspacesdistaltotheterminalbronchioles,accompaniedbydestructionoftheirwallswithoutobviousfibrosis指呼吸性細(xì)支氣管、肺泡管、肺泡囊、肺泡因組織彈性減弱而過度充氣伴有肺泡間隔破壞，致使肺容積增大的病理狀態(tài)肺氣腫

EmphysemaAbnormalperman病理類型腺泡(小葉)中央型

Centriacinar…

全腺泡(小葉)型

Panacinar…腺泡(小葉)周圍型

Distalacinar…不規(guī)則型

Irregular…obstructionSpontaneouspneumothoraxasymptomatic病理類型腺泡(小葉)中央型Centriacinar…o病理學(xué)——呼吸系統(tǒng)資料講解課件發(fā)病機(jī)理Pathogenesis發(fā)病機(jī)理PathogenesisCentriacinaremphysemaCentriacinaremphysema病理學(xué)——呼吸系統(tǒng)資料講解課件BullousemphysemaBullousemphysemaCentriacinaremphysemaCentriacinaremphysema病理學(xué)——呼吸系統(tǒng)資料講解課件

InadequateventilationLessperfusionNarrowedbronchioleInadequateventilationConditionsRelatedtoEmphysema間質(zhì)性肺氣腫

Mediastinal(interstitial)emphysema代償性肺氣腫

Compensatoryemphysema阻塞性過充氣

Obstructiveoverinflation瘢痕旁肺氣腫

Paracicatricalemphysema老年性肺氣腫

SenileemphysemaConditionsRelatedtoEmphysem病理學(xué)——呼吸系統(tǒng)資料講解課件COPD的臨床表現(xiàn)RespiratoryfailureRightheartfailureCOPD的臨床表現(xiàn)RespiratoryfailureRiPinkpuffer桶狀胸

BarrelchestPinkpuffer桶狀胸支氣管擴(kuò)張癥BronchiectasisPermanentdilationofbronchiandbronchiolescausedbydestructionofthemuscleandelasticsupportingtissueresultingfromorassociatedwithchronicnecrotizinginfections

繼發(fā)于持續(xù)性感染或阻塞

Secondarytopersistinginfectionorobstruction

診斷依靠病史和影像學(xué)支氣管擴(kuò)張癥BronchiectasisPermanentPredisposingconditions支氣管阻塞

Bronchialobstruction腫瘤Tumor異物Foreignbodies

先天性或遺傳性疾病

Congenitalorhereditaryconditions

CysticfibrosisKartagenersyndrome壞死性化膿性肺炎

Necrotizing,orsuppurative,pneumonia

Predisposingconditions支氣管阻塞CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)CysticFibrosis(CF)Bronchiectasis57yearoldwomanwithalonghistoryofrecurrentrespiratorytractinfectionsandepisodesofhemoptysisBronchiectasis57yearoldwomaBronchiectasis

BronchiectasisBronchiectasisDuetopneumoniaBronchiectasisBronchiectasisBronchiectasisBronchiectasis

PurulentexudationinthelumenDestructionofliningepitheliumScarringofthebronchialwallBronchiectasisPurulentexudatHRCTscansofbronchiectasisHRCTscansofbronchiectasis支氣管擴(kuò)張癥的臨床表現(xiàn)咳嗽，咳膿臭痰

Severe,persistentcoughwithmucopurulentsputum,sometimesfetid咯血

Flecksofbloodinsputumorfrankhemoptysis

嚴(yán)重病例及合并癥支氣管擴(kuò)張癥的臨床表現(xiàn)咳嗽，咳膿臭痰肺間質(zhì)疾病ILD肺彌漫性纖維化肺順應(yīng)性減弱，容量減小已知病因和特發(fā)性間質(zhì)性肺炎肺間質(zhì)疾病ILD肺彌漫性纖維化Selectedcausesofchronicinterstitiallungdisease

OccupationalandenvironmentalexposureAsbestosisSilicosisHypersensitivitypneumonitisDrugortreatmentrelatedChemotherapeuticagentsIonizingirradiationOxygenImmunologiclungdiseaseSarcoidosisWegnergranulomatosisCollagenvasculardiseaseGoodpasturesyndromeMiscellaneousPostacuterespiratorydistresssyndromeIdiopathicpulmonaryfibrosisSelectedcausesofchronicint杵狀指（趾）Clubbingofdigits杵狀指（趾）HoneycomblungHoneycomblung病理學(xué)——呼吸系統(tǒng)資料講解課件矽肺Silicosis職業(yè)病

Occupationaldiseases吸入二氧化硅粉塵引起

Inhalationofcrystallinesilica致殘和致死

Disablingandfatal病理：硅結(jié)節(jié)形成廣泛的肺纖維化

矽肺Silicosis職業(yè)病Occupational病理學(xué)——呼吸系統(tǒng)資料講解課件發(fā)病機(jī)制Pathogenesis直徑<5μm的硅塵沉積于肺間質(zhì)肺泡巨噬細(xì)胞引發(fā)和持續(xù)肺損傷和纖維化

Alveolarmacrophageisakeycellularelementintheinitiationandperpetuationoflunginjuryandfibrosis發(fā)病機(jī)制Pathogenesis直徑<5μm的硅塵沉積于Silicosis

asliceoflungfroma61yoceramicsworkerSilicosisasliceoflungfrom矽結(jié)節(jié)