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呼吸系统疾病

2019-04-13     来源:未知         内容标签:呼吸系统,疾病,呼吸系统,疾病,、,试述,吸,

导读:`呼吸系统疾病 1、 试述吸气性呼吸困难的常见病因和临床特点。 答:常见病因有喉头水肿、喉气管炎症、肿瘤或异物引起上气道狭窄等;其特点是吸气显著困难,高度狭窄时呼吸肌极

`呼吸系统疾病
1、 试述吸气性呼吸困难的常见病因和临床特点。
答:常见病因有喉头水肿、喉气管炎症、肿瘤或异物引起上气道狭窄等;其特点是吸气显著困难,高度狭窄时呼吸肌极度紧张,吸气时出现三凹征,可伴干咳及高调的吸气性喘鸣音。
2、 试述呼气性呼吸困难的常见病因和临床特点。
答:常见病因有支气管哮喘或哮喘合并慢性阻塞性肺疾病引起广泛支气管痉挛等;其特点是呼气费力、延长而缓慢,常伴有哮鸣音。
3、 夜间阵发性呼吸困难的机制是什么?
答:(1)、睡眠时迷走神经兴奋性增高,使冠脉收缩,心肌供血不足;(2)、仰卧时肺活量减少;(3)、仰卧时静脉回流血量增多,肺淤血加重。
4、 什么是急性呼吸窘迫综合征(ARDS)?
答:急性肺损伤(ALI)和急性呼吸窘迫综合征(ARDS)是指由心源性以外的各种肺内、外致病因素导致的急性、进行性呼吸衰竭;其主要病理特征为由于肺微血管通透性增高,肺泡渗出富含蛋白质的液体,进而导致肺水肿及透明膜形成,可伴有肺间质纤维化;病理生理改变以肺容积减少、肺顺应性降低和严重通气/血流比例失调为主;临床表现为呼吸窘迫和顽固性低氧血症,肺部影像学表现为非均一性的渗出性改变。
ALI和ARDS为同一疾病过程的两个阶段,ALI代表早期和病情相对较轻的阶段,而ARDS为后期病情较重的阶段。
5、 癔病患者呼吸困难有何特点?
答:特点是呼吸非常频速(每min可达60-100次)和表浅,常因换气过度而发生胸痛和呼吸性碱中毒,出现手足抽搐。
6、 什么叫真性发绀?在体表哪些部位较易观察?
答:是由于血液中还原血红蛋白的绝对量增多,以至皮肤粘膜呈现青紫的现象;发绀在皮肤较薄,色素较少和毛细血管丰富的血循环末梢,如口唇、鼻尖、颊部、甲床等处较易观察到。
7、 试述发绀的类型及其特点。
答:(1)、中央性发绀:真正为动脉血氧饱和度降低引起的发绀;特点为全身性发绀,除四肢与颜面外,还累及粘膜与躯干的皮肤,但皮肤是温暖的;(2)、外周性发绀:严重休克等原因引起末梢循环障碍,即使动脉血氧饱和度尚正常,也可出现的发绀;特点为常出现在肢体的末梢与下垂部位,如口唇、甲床等,皮肤冰冷;(3)、混合性发绀:上述两者并存,见于心功能不全者。
8、 重症贫血患者为何一般不出现发绀?
答:发绀一般是在毛细血管血液中的还原血红蛋白量超过5g/100ml才出现,而重度贫血者,血红蛋白量低于4-5g/100ml,即使全部血红蛋白都处于还原状态,也不足以引起发绀。
9、 试述血气分析常用的指标及临床意义。
答:血气分析包括血气和酸碱度测定,临床上常用指标有:(1)、动脉血氧分压PaO2:为物质溶解在血液中的氧分子所产生的压力;正常值为95-100mmHg,PaO2在一定程度上反映肺泡气体氧分压(PAO2),PAO2取决于肺的通气功能,故在一定程度上可以反映肺通气功能情况;PaO2高低影响SaO2,关系组织氧供;(2)、动脉血氧饱和度SaO2:是指血液中与氧结合的血红蛋白,占全部血红蛋白的百分比;正常值为97%以上;SaO2下降,血氧含量也下降,组织供氧减少;(3)、动脉血氧含量CaO2:是指每升动脉血中含有多少毫升氧量,包括物理溶解氧和血红蛋白结合氧的总和,代表血液携氧量;正常值为150-200ml/L;吸入气体氧含量不足及血红蛋白量下降,均可使血氧含量降低,影响组织供氧;(4)、动脉血二氧化碳分压PaCO2:是指溶解在血液中的CO2所产生的压力;正常值为34-45mmHg;CO2弥散能力强,PaCO2基本上可以反映肺泡CO2分压,故可以作为通气功能的指标;(5)、重碳酸盐HCO3-:实际重碳酸盐AB是指人体血浆中HCO3-的实际含量;标准重碳酸盐SB是指动脉血在37℃、SaO2 100%、PaCO2 5.3kPa条件下HCO3-的含量;正常人AB = SB,正常值为22-27mmol/L;AB、SB均为测定血液中HCO3-含量,故可用作代谢性指标;(6)、pH值:是氢离子浓度的负对数;代表血液酸碱度;正常值为7.35-7.45;pH下降提示酸中毒,上升提示碱中毒;(7)、剩余碱BE:是指37℃、SaO2 100%、PaCO2 5.3kPa条件下,将血液滴定至pH=7.40时所需要的酸或碱量;需加的酸量以正值表示,碱量以负值表示;BE正常值为0±2.3mmol/L;BE正值增加,提示代谢性碱中毒,BE负值增加,提示代谢性酸中毒;(8)、二氧化碳总量T-CO2:包括血液中游离状态及结合状态CO2总的含量;正常值为24-32mmol/L;其临床意义似HCO3-。
10、试述慢性支气管炎的诊断标准、分型及分期。
答:诊断要点:以咳嗽、咳痰、或伴有喘息为主要症状,每年发病持续3个月,连续2年或以上,并除外其他慢性气道疾病如肺结核、肺尘埃沉着症、肺脓肿、心脏病、心功能不全、支气管扩张、支气管哮喘、慢性鼻咽炎、食管返流征等。                      
分型:(1)、单纯型;(2)、喘息型。
分期:(1)、急性加重期;(2)、缓解期。
11、试述慢性支气管炎的治疗原则。
答:慢性支气管炎是气管、支气管粘膜及其周围组织的慢性非特异性炎症。治疗原则包括:(1)、急性加重期:1)控制感染:选用喹诺酮类、大环类脂类、β内酰胺类或磺胺类口服,严重时静滴;如能培养出致病菌,按药敏选择抗生素;2)、镇咳祛痰:复方甘草合剂10ml,tid,或复方氯化铵合剂10ml,tid,可加用祛痰药,如盐酸氨溴索30mg,tid;干咳为主者,可用镇咳药,如那可丁合剂;3)、平喘:有气喘者可加用解痉平喘药,如氨茶碱0.1g,tid,或用茶碱控释剂,或长效β2激动剂加糖皮质激素吸入。(2)、缓解期:1)、戒烟,避免有害气体或其他有害颗粒的吸入;2)、增强体质,预防感冒;3)、反复呼吸道感染者,可试用免疫调节剂或中医中药,如卡介菌多糖核酸等。
12、试述慢性阻塞性肺气肿的临床表现、病理分型。
答:慢性阻塞性肺气肿的主要表现为在原有咳嗽、咳痰等症状的基础上出现逐渐加重的呼吸困难,查体有肺气肿体征(桶状胸、双侧语颤减弱,叩诊过清音等)。
病理分型:(1)、小叶中央型:多见,为终末细支气管或一级呼吸性细支气管炎症导致管腔狭窄,其远端的二级呼吸性细支气管呈囊性扩张,特点是囊状扩张的呼吸性细支气管位于二级小叶的中央区;临床表现为支气管炎型;(2)、全小叶型:为呼吸性细支气管狭窄,引起所属终末肺组织,即肺泡管、肺泡囊及肺泡的扩张,其特点是气肿囊腔较小,遍布于肺小叶内;临床表现为气肿型;(3)、混合型:上述两型同时存在,多在小叶中央型基础上,并发小叶周边肺组织膨胀。
13、试述支气管哮喘的近代观点及治疗原则。
答:目前认为支气管哮喘为由多种细胞(如嗜酸性粒细胞、肥大细胞、T淋巴细胞、中性粒细胞、气道上皮细胞等)和细胞组分参与的气道慢性炎症性疾病。其发病机制可概括为免疫-炎症反应、神经机制和气道高反应性及其相互作用。
目前治疗尚无特效的方法,但长期规范化治疗可使哮喘症状能得到控制,减少复发乃至不发作;长期使用最少量或不用药物能使患者活动不受限制,并能与正常人一样生活、工作和学习为治疗目标。
主要包括脱离变应原和药物治疗两个方面。脱离变应原为最有效防治方法。其中药物包括缓解哮喘发作的支气管舒张药和控制或预防哮喘发作的抗炎药;前者包括β2激动剂(如沙丁胺醇)、抗胆碱药(如异丙托溴胺)、茶碱类等;后者包括糖皮质激素、LT调节剂(如扎鲁司特)、酮替芬等;长期抗炎治疗哮喘最常用方法为吸入治疗。
14、急性发作的重度至危重度哮喘,如何处理?
答:急性发作期的治疗目的是尽快缓解气道阻塞,纠正低氧血症,恢复肺功能,预防进一步恶化或再发作,防止并发症,采用综合治疗。                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
 
对重度至危重度:吸氧(病情恶化缺氧不能纠正者可机械通气),静滴糖皮质激素,持续雾化吸入β2受体激动剂,或合并抗胆碱药,静滴氨茶碱或沙丁胺醇;待病情控制和缓解后(一般3-5天),改为口服给药。注意维持水电解质平衡,纠正酸碱失衡,预防下呼吸道感染等。
15、什么叫呼吸衰竭?试述呼吸衰竭的血气诊断标准、分型及氧疗的原则。
答:呼吸衰竭是指各种原因引起的肺通气和/或换气功能障碍,以致在静息状态下亦不能维持足够的气体交换,导致低氧血症伴/或不伴高碳酸血症,进而引起一系列病理生理改变和相应临床表现的综合征。
血气诊断标准:在海平面、静息状态、呼吸空气条件下,PaO2<60mmHg,伴或不伴PaCO2>50mmHg,并除外心内解剖分流和原发于心排出量降低等因素。
分型:(1)、I型呼衰:即缺氧性呼衰,血气特点是PaO2<60mmHg,PaCO2降低或正常。主要见于肺换气障碍疾病,如严重肺部感染、间质性肺疾病、急性肺栓塞等;(2)、II型呼衰:即高碳酸性呼衰,血气特点是PaO2<60mmHg,PaCO2>50mmHg;为肺泡通气不足所致,可伴换气功能障碍,如COPD。
氧疗:(1)、I型呼衰给予高浓度吸氧(>35%);(2)、II型呼衰给予低浓度给氧,以免加重CO2潴留。高碳酸血症患者呼吸中枢化学感受器对CO2反应性差,呼吸主要靠低氧血症对颈动脉体、主动脉体化学感受器的刺激来维持,如吸入高浓度氧,解除了低氧对外周化学感受器的刺激,便会抑制呼吸,造成通气情况进一步恶化,CO2上升,严重时陷入CO2麻醉状态。
16、如何治疗慢性呼衰?
答:(1)治疗原发病、保持气道通畅、恰当的氧疗等与急性呼衰基本一致;(2)、氧疗:COPD为慢性呼衰常见病因,多伴CO2潴留,故选择低浓度吸氧;(3)、机械通气:COPD急性加重早期给予无创机械通气,可防止呼吸功能不全加重,缓解呼吸肌疲劳,减少后期气管插管率,改善预后;(4)、抗感染;(5)、呼吸兴奋剂的使用:必要时,阿米三嗪50-100mg,bid,通过刺激颈动脉体和主动脉体的化学感受器兴奋呼吸中枢,增加通气量;(6)、纠正酸碱失衡:慢性呼衰常伴CO2潴留,导致呼吸性酸中毒,后期合并潜在的代谢性碱中毒;(7)、一般支持疗法;(8)、其他重要器官的监测与支持。
17、何谓肺性脑病?如何处理?
答:肺性脑病是指由于呼吸衰竭导致机体严重缺氧及CO2潴留导致的神经精神症候群;早期有失眠、烦躁、兴奋,患者夜间失眠,白天嗜睡、表情淡漠,肌肉震颤,可出现扑翼样震颤及间歇抽搐,昏睡甚至昏迷,腱反射减弱或消失,锥体束征阳性。
治疗主要是加强通气措施,改善缺氧及CO2潴留,可适当使用脱水剂减轻脑水肿,忌用镇静或催眠剂,特别是具有抑制呼吸的药物。
18、简述慢性肺心病肺动脉高压形成的机制。
答:肺功能和结构的不可逆性改变,发生反复的气道感染和低氧血症,导致一系列体液因子和肺血管的变化,使肺血管阻力增加,肺动脉血管的结构重塑,形成肺动脉高压。
(1)、肺血管阻力增加的功能性因素:缺氧、高碳酸血症和呼吸性酸中毒使肺血管收缩、痉挛,肺血管阻力增加;(2)、肺血管阻力的加的解剖学因素:即肺血管解剖结构的变化,形成肺循环血流动力学障碍;主要原因是:1)、长期反复发作的COPD及支气管周围炎,可累及邻近肺小动脉,引起血管炎,管壁增厚、反管腔狭窄或纤维化,甚至完全闭塞;2)、随肺气肿加重,肺泡内压增高,压迫肺泡毛细血管,造成毛细血管管腔狭窄或闭塞;严重时可造成肺泡壁破裂,毛细血管网毁损,血管床减损;3)、肺血管重塑:慢性缺氧使肺血管收缩,管壁张力增高,同时缺氧时肺内产生多种生长因子,可直接刺激管壁平滑肌细胞、内膜弹力纤维及胶原纤维增生;4)、血栓形成;(3)、血液粘稠度增加和血容量增多:慢性缺氧产生继发性红细胞增多,血液粘稠度增加,同时缺氧使醛固酮增加,肾小动脉收缩,肾血流减少,水钠潴留,血容量增多。
19、试述慢性肺源性心脏病的诊断标准和治疗原则。
答:诊断要点:根据患者有慢性支气管炎、肺气肿、其他胸肺疾病或肺血管病变,并已引起肺动脉高压、右室肥大或右心功能不全,如P2>A2、颈静脉怒张、肝大压痛、肝颈静脉反流征阳性、下肢水肿及体静脉压升高等,心电图、胸片、心彩超有右室增大肥厚的征象,可作出诊断。
治疗分急性加重期和缓解期进行。
急性加重期:原则是积极控制感染;通畅呼吸道,改善呼吸功能;纠正缺氧和CO2潴留;控制呼吸和心力衰竭;积极处理并发症。(1)、控制感染;(2)、氧疗;(3)、控制心衰:一般在积极控制感染、改善呼吸功能后心衰便能得到改善,患者尿量增多,水肿消退,不需加用利尿剂;对治疗无效的重症患者,可适当选用利尿剂、正性肌力药或扩血管药物;(4)、控制心律失常:一般在控制感染和氧疗后,心律失常可自行消失,如持续存在,可根据心律失常类型选用药物;(5)、抗凝治疗:应用普通肝素或低分子肝素防止肺微小动脉原位血栓形成;(6)、加强护理。
缓解期:原则上采取中西医结合综合治疗措施,目的是增强患者的免疫功能,去除诱发因素,减少或避免急性加重期的发生。如家庭氧疗、调整免疫功能等。
20、试述肺炎球菌肺炎的病理改变及其与临床表现之间的关系。
答:病理改变包括充血期、红肝变期、灰肝变期和消散期。因早期抗生素的使用,目前肝变期已很少见。
(1)、充血期:持续12-24h;病理改变为肺毛细血管扩张充血,肺泡内少量浆液及白细胞渗出;临床表现为炎症高热、干咳、痰少、多数无体征;X线肺部无异常或出现淡薄阴影;(2)、红肝变期:持续2-4天;病理改变为肺组织高度充血,肺泡内大量红细胞渗出,肺组织呈早期实变;临床表现为咳铁锈色痰,胸膜受累,出现胸痛,查体有典型肺实变体征;X线出现均匀、致密阴影,呈肺叶或肺段分布;(3)、灰肝变期:持续2-4天;病理改变为肺组织高度实变,肺泡壁由充血变为缺血,肺泡内有大量白细胞及纤维蛋白渗出;临床表现及X线同红肝变期;(4)、消散期:持续3-7天;病理改变为白细胞及纤维蛋白自溶、裂解,经吞噬、吸收或咳出,肺组织恢复正常;临床表现为咳嗽加剧,痰量增多,肺实变征逐渐消失,湿罗音增多;X线致密阴影逐渐消失。
21、试述肺炎球菌肺炎、克雷白杆菌肺炎、金葡菌肺炎的抗菌治疗原则。
答:(1)、肺炎链球菌:首选青霉素G,疗程5-7天,或退热后3天停药;青霉素过敏、或耐药菌株,可用呼吸氟喹诺酮类、头孢噻肟或头孢曲松等;多重耐药菌株可选用万古霉素、替考拉宁等;(2)、克雷白杆菌:首选氨基糖苷类,重症者可加用喹诺酮类或三代头孢菌素;(3)、金葡菌:选用耐青霉素酶的半合成青霉素或头孢菌素,如苯唑西林钠、头孢呋辛钠等,联合氨基糖苷类如阿米卡星等;对于MRSA,应选用万古霉素、替考拉宁等;(4)、有培养结果后,按药敏给药。
21、概述传染性非典型肺炎、致病性人禽流感病毒肺炎、甲型H1N1流感(猪流感)。
答:传染性非典型肺炎为SARS冠状病毒(SARS-CoV)引起的一种具有明显传染性、可累及多个器官系统的特殊肺炎,WHO将其命名为严重急性呼吸综合征(SARS);其主要临床特征为急性起病、发热、干咳、呼吸困难、白细胞不高或降低、肺部浸润和抗菌治疗无效,SARS病原学检测阳性;人群普遍易感,多见于青壮年;其传播途径为通过短距离飞沫、气溶胶或接触污染的物品;治疗包括住院隔离、抗病毒、激素、氧疗及防治休克或MODS。
致病性人禽流感病毒肺炎为禽甲型流感病毒某些亚型中的一些毒株引起的急性呼吸道传染病,可引起肺炎和多器官功能障碍;高致病性禽流感病毒H5N1跨越物种屏障,引起人致病和死亡;主要临床表现为明显的肺炎,常出现急性肺损伤、急性呼吸窘迫综合征(ARDS)、肺出血、胸水、全血细胞减少、多脏器功能衰竭、休克及瑞氏(Reye)综合征等,血清禽流感病毒亚型毒株抗体滴度4倍或以上;传播途径为禽-人传播,环境-人传播;治疗包括住院隔离、抗病毒、氧疗及防治休克或MODS,激素效果不明。
甲型H1N1流感病毒肺炎:为甲型H1N1流感病毒引起的急性呼吸道传染病;主要临床表现与流感相似;传播途径为飞沫传染、接触传染;治疗同上述。
22、简述肺脓肿的病因、临床表现及治疗原则。
答:肺脓肿是肺组织坏死形成的脓腔,其病原体常为上呼吸道、口腔的定植菌,包括需氧、厌氧和兼性厌氧菌,90%以上合并有厌氧菌感染;按感染途径,可分为吸入性肺脓肿、继发性肺脓肿、血源性肺脓肿。自抗生素广泛使用,目前较少。
其临床特征为高热、咳嗽和咳大量脓臭痰,血常规可见白细胞升高,培养可检出病原体,胸片显示一个或多个含气叶平的空洞。
治疗原则:抗感染治疗和脓液引流。(1)、抗感染:抗菌疗程8-12周,直至胸片脓腔和炎症消失,或仅有少量的残留纤维化;吸入性肺脓肿多为厌氧菌感染,首选青霉素;血源性肺脓肿多为葡萄球菌和链球菌感染,可选耐β内酰胺酶的青霉素或头孢菌素,如为耐甲氧西林的葡萄球菌,应选万古霉素或替考拉宁;如为阿米巴原虫感染,选用甲硝唑;如为G-杆菌,选用二代或三代头孢菌素、氟喹诺酮类,可联合氨基糖苷类;(2)、脓液引流:雾化吸入、祛痰、体位引流排痰、经支气管镜冲洗等;(3)、手术治疗:适应症为:1)、肺脓肿病程超过3个月,经内科治疗脓腔不缩小,或脓腔过大>5cm估计不易闭合;2)、大咯血经内科治疗无效或危及生命;3)、伴有支气管胸膜瘘或脓胸经抽吸、引流和冲洗疗效不佳;4)、支气管阻塞限制了气道引流,如肺癌。
23、试述结核病的临床分型及诊断记录格式。
答:2004年我国标准,突出了对痰结核分枝杆菌检查和化疗史的描述,取消按活动性程度及转归分期的分类,具体如下:(1)、原发型肺结核:含原发综合征及胸内淋巴结结核,多见于少年儿童,无症状或轻微,多有结核病家庭接触史,PPD试验多强阳性,胸片可显示哑铃型阴影(即原发病灶、引流淋巴管炎和肿大的肺门淋巴结,形成典型的原发综合征),若胸片只显示肺门肿大淋巴结,诊断为胸内淋巴结结核;(2)、血行播散型肺结核:含急性(急性粟粒型肺结核)及亚急性、慢性血行播散型肺结核;急性多见于婴幼儿、青少年,特别是营养不良、患传染病和长期应用免疫抑制剂导致抵抗力低下的小儿,多同时伴有原发型肺结核;成人也可发生急性血行播散型肺结核,为病变中和淋巴结内的结核分枝杆菌侵入血管所致,起病急、持续高热、中毒症状严重,极少呼吸困难,全身浅表淋巴结肿大、肝脾大,50%可合并结核性脑膜炎,PPD试验可阴性,胸片和CT检查开始为肺纹理重,症状出现2周可发现由肺尖至肺底呈大小、密度和分布三均匀的粟粒状结节阴影,结节直径2mm左右;亚急性、慢性者起病较缓,症状较轻,胸片呈双上、中肺野为主的大小不等、密度不同和分布不均的粟粒状结节影,新鲜渗出与陈旧硬结和钙化病灶并存,慢性者多无明显中毒症状;(3)、继发型肺结核:含浸润性肺结核、纤维空洞性肺结核、干酪样肺炎、结核球等;多发生于成人,病程长,易反复,肺内病变多为含有大量结核分枝杆菌的早期渗出性病变,易进展为干酪样坏死、液化、空洞形成和支气管播散,同时又出现周围纤维组织增生,使病变局限化和瘢痕形成;病变轻重多寡相差悬殊,活动性渗出性病变、干酪样病变和愈合性病变共存;胸片表现多态性,好发于上叶尖后段和下叶背段,痰检结核分枝杆菌多为阳性;(4)、结核性胸膜炎:含结核性干性胸膜炎、结核性渗出性胸膜炎、结核性脓胸;(5)、其他肺外结核:按部位和脏器命名,如骨关节结核等;(6)、菌阴肺结核:为三次痰涂片及一次培养阴性的肺结核:诊断标准为:1)、典型肺结核临床症状和胸片表现;2)、抗结核治疗有效;3)、临床可排出其他非结核性肺部疾患;4)、PPD试验强阳性,血清抗结核抗体阳性;5)、痰结核菌PCR和探针检测阳性;6)、肺外组织病理证实结核病变;7)、支气管肺泡灌洗(BAL)液中检出抗酸杆菌;8)、支气管或肺部组织病理证实;以上1-6项中三项或7-8中任一项可确诊。
记录方式:按结核病分类、病变部位、范围、痰菌情况、化疗史程序书写,如原发性肺结核右中涂(-),初治。
24、试述肺结核化疗原则和常用化疗方法。
答:原则是早期、规律、全程、适量、联合;整个治疗方案分强化和巩固两个阶段,全程督导管理,以保证患者不间断的规律用药。
常有方法有:(1)、初治涂阳方案:2HRZE/4HR;
(2)、复治涂阳方案:2HRZSE/4-6HRE;(3)、初治涂阴方案:2HRZ/4HR。
H:异烟肼;R:利福平;Z:吡嗪酰胺;E:乙胺丁醇;S:链霉素。
25、胸腔积液时,如何鉴别渗出液和漏出液?
答:渗出液是炎症性积液,可以是感染性或非感染性,如结核、化脓性胸膜炎、肿瘤、结缔组织病等;漏出液为非炎症性积液,多为全身性疾病所致,如心衰、肾病、营养不良等;具体鉴别如下表:

         漏出液            渗出液
原因     非炎症性          炎症性
外观     淡黄、水样透明    浑浊、血性、脓性
相对密度 <1.016             >1.018
Rivalta试验  (-)           (+)
蛋白定量 <25g/L            >30g/L
细胞计数 <100/uL           >200/uL
细胞分类 淋巴、间皮细胞    化脓性为中性粒细胞
                           结核性为淋巴细胞
乳酸脱氢酶 <200u/L           >200u/L
(LDH)
如以上仍不能分辨,可进一步检测血清蛋白质、乳酸脱氢酶,如下列三项任一项均可诊断为渗出液:1)、胸水蛋白/血清蛋白>0.5;2)、胸水LDH>正常血清LDH高值的2/3;3)、胸水LDH/血清LDH>0.6.。
26、试述结核性渗出性胸膜炎临床表现及治疗原则。
答:临床表现:多见于青少年,起病多缓慢,主要症状有发热、乏力、胸痛;早期常表现为干性胸膜炎,出现胸痛及胸膜摩擦音,随着胸腔液体渗出增多,两层胸膜分开,疼痛缓解,大量胸水时,出现胸部持续胀痛伴呼吸困难,查体有胸腔积液体征;胸穿抽出胸水性质为草黄色渗出液,以淋巴细胞为主,PPD试验阳性,血沉增快。
治疗:(1)、一般治疗:包括休息、营养支持和对症治疗;(2)、抽液治疗:原则上应尽快抽尽胸水或肋间插细管引流;每周抽液2-3次,直至胸水完全消失,首次量不要超过700ml;(3)、抗结核之劳;(4)、糖皮质激素的使用:有全身中毒症状严重、大量胸水者,可尝试加用强的松10mg,tid,待体温正常、全身毒性症状减轻、胸水明显减少时,应逐渐减量至停用。
27、按组织学分型,原发性支气管肺癌分型?如何分别中央型和周围型肺癌?
答:按组织学分型:(1)、非小细胞肺癌(NSCLC):1)、鳞癌;2)、腺癌;3)、大细胞癌;4)其他如类癌等;(2)、小细胞肺癌(SCLC)。
按解剖学分:(1)、中央型肺癌;(2)、周围型肺癌。
区别在于:(1)、中央型肺癌:为发生于段支气管至主支气管的肺癌,位于肺门附近,约占3/4,多为鳞癌和小细胞肺癌;(2)、周围型肺癌:为发生于段支气管以下的肺癌,位于肺的边缘部位,约占1/4,多为腺癌。
28、哪些临床表现提示肺癌的诊断?
答:对于40岁以上长期重度吸烟或有危险因素接触史者,应每年进行体检;重点排查有高危险因素及下列可疑征象者:(1)、无明显诱因的刺激性咳嗽或反复痰中带血持续2-3周,治疗无效;(2)、原有慢性呼吸道疾病,咳嗽性质改变;(3)、短期内持续或反复痰中带血或咯血,且无其他原因可解释;(4)、反复发作的同一部位肺炎,特别是肺段性肺炎;(5)、原因不明的肺脓肿,无中毒症状,无大量脓痰,无异物吸入史,抗炎治疗效果不佳;(6)、原因不明的四肢关节疼痛及杵状指(趾);(7)、影像学提示局限性肺气肿或段、叶性肺不张;(8)、孤立性圆形病灶和单侧性肺门阴影增大;(9)、原有肺结核病灶已稳定,而形态或性质发生改变;(10)、无中毒症状的胸腔积液,尤其是呈血性、进行性增加;有上述表现之一应进一步检查,特别是低剂量CT扫描。
29、试述支气管肺癌的治疗原则和常用治疗手段。
答:治疗方案主要根据肿瘤的组织学决定,通常SCLC发现时已转移,难以通过外科手术根治,主要依赖化疗或放疗综合治疗;而NSCLC可为局限性,外科手术或放疗可根治,但化疗较SCLC差。
(1)、NSCLC:1)、局限性病变:a、手术:对于可耐受手术的Ia、Ib、IIa和IIb期NSCLC,首选手术,IIIa期若病人年龄、心肺功能和解剖位置合适,可考虑手术;术前化疗;b、根治性放疗:III期及拒绝或不能耐受手术的I、II期患者;已有远处转移、恶性胸水、累及心脏、有严重肺部基础疾病者,为禁忌;c、根治性综合治疗:对产生Horner综合征的肺上沟瘤可采用放疗和手术综合治疗;对IIIa期,N2期病变可选择手术加术后放疗,或新辅助化疗加手术;对IIIb期或肿瘤体积较大的IIIa病变,新辅助化疗加放疗;2)播散性病变:可根据行动状态评分为0(无症状)、1(有症状,完全能走动)、2(<50%时间卧床)、3(>50%时间卧床)、4(卧床不起)选择适当的化疗、放疗和支持治疗。
(2)、SCLC:推荐以化疗为主的综合治疗。
30、何谓社区及院内获得性肺炎,主要病原菌是?
答:社区获得性肺炎(CAP)是指在医院外患的感染性肺实质炎症,包括具有明确潜伏期的病原体感染而在入院后平均潜伏期内发病的肺炎。主要病原菌是肺炎链球菌,支原体、衣原体等。
医院获得性肺炎(HAP)是指患者入院时不存在,也不处于潜伏期,而入院后48h后在医院(包括老年护理院、康复院等)内发生的肺炎;主要病原菌为G-杆菌。