呼吸道梗阻课件.ppt

钟礼立儿童上呼吸道梗阻儿童上呼吸道梗阻Upper Airway Obstruction in Children呼吸道梗阻引言•病例1--上呼吸道梗阻与反复肺部感染关系n n上呼吸道梗阻（上呼吸道梗阻（UAO）是一种危重的情况，）是一种危重的情况，要求快速要求快速诊断和刻不容断和刻不容缓的治的治疗，可，可导致致突然窒息，是呼吸衰竭的常突然窒息，是呼吸衰竭的常见原因原因n n病例病例2—对于梗阻部位的判断于梗阻部位的判断呼吸道梗阻上呼吸道定义•The￿upper￿respiratory￿tract￿primarily￿refers￿to￿the￿parts￿of￿the￿respiratory￿system￿lying￿outside￿of￿the￿thorax[1]￿or￿above￿the￿sternal￿angle.￿•Another￿definition￿commomly￿used￿in￿medicine￿is￿the￿airway￿above￿the￿glottis￿[2]￿or￿vocal￿cords.￿Some￿specify￿that￿the￿glottis￿(vocal￿cords)￿is￿the￿defining￿line￿between￿the￿upper￿and￿lower￿respiratory￿tracts•yet￿even￿others￿make￿the￿line￿at￿the￿cricoid￿cartilage.[3].1.Edward￿Alcamo;￿John￿Bergdahl￿(29￿July￿2003).￿Anatomy￿Coloring￿Workbook.￿2.Ronald￿M.￿Perkin;￿James￿D￿Swift;￿Dale￿A￿Newton￿(1￿September￿2007).￿Pediatric￿hospital￿medicine:￿textbook￿of￿inpatient￿management.￿3.Jeremy￿P.￿T.￿Ward;￿Jane￿Ward;￿Charles￿M.￿Wiener￿(2006).￿The￿respiratory￿system￿at￿a￿glance.￿呼吸道梗阻上呼吸道定义n n从外鼻到从外鼻到从外鼻到从外鼻到环环状状状状软软骨骨骨骨包括：包括：包括：包括：n n鼻鼻鼻鼻n n鼻咽鼻咽鼻咽鼻咽n n口咽口咽口咽口咽n n喉喉喉喉￿ ￿ ￿ ￿( (声声声声门门上，声上，声上，声上，声门门下下下下) )n n气管气管气管气管￿ ￿ ￿ ￿( (胸腔外胸腔外胸腔外胸腔外) )n n从梗阻意从梗阻意从梗阻意从梗阻意义义划分划分划分划分 --------从鼻到气管隆突从鼻到气管隆突从鼻到气管隆突从鼻到气管隆突为为上上上上呼吸道呼吸道呼吸道呼吸道呼吸道梗阻上呼吸道的特点及作用•鼻及鼻窦•咽及耳咽管•喉：是呼吸系统最狭窄的部位•气管：胸外段，胸内段•在整个解剖死腔中上呼吸道约占一半，呼吸道阻力的45%来自鼻与喉•对吸入气体有加温加湿和过滤的作用•此外上呼吸道还与发音，吞咽，反流等有关呼吸道梗阻上气道梗阻诊断•病史•体格检查•辅助检查•年龄•阻塞位置•严重度•梗阻原因呼吸道梗阻病史采集•发作情况：突然的，诱发的•持续时间：几秒，几分，数小时，数周•相关症状：发热，咳嗽，声嘶，发音障碍，呼吸困难，咽下液体或固体困难•既往史：饮食，创伤，慢性感染，近期插管，肺疾病，肿瘤，甲状腺疾病•家族史•变态反应性疾病：药物，食物，昆虫呼吸道梗阻体格检查•一般情况：神志，面色•体位（坐位，三角架位，仰卧位，俯卧位）•发音：•能否发音（失音意味着完全梗阻）•音调：声门上疾患声音沉闷像口含热土豆，声门病变发出粗糙模糊的声•吞咽：流口水•气管位置•呼吸情况：•呼吸频率•辅助肌做功•鼻翼煽动，三凹征•缺氧情况•异常呼吸音以及异常呼吸音发生的时相呼吸道梗阻辅助检查•床旁胸片，颈部正侧位片•床旁纤维喉镜或纤支镜•心电监护，氧饱和度监护•电解质及血气检查•肺功能•注意：不要因为辅助检查而延误治疗呼吸道梗阻上气道梗阻诊断•病史•体格检查•辅助检查•年龄•阻塞位置•严重度•梗阻原因呼吸道梗阻年龄因素•婴儿已产生气道食道分离，但因为气体几乎完全经鼻吸入，喉位置高，软化。

异物、胃内容物食物容易呛入气道呼吸道梗阻小婴儿更易上气道梗阻小婴儿更易上气道梗阻呼吸道梗阻TABLE 78.1 SIGNS AND SYMPTOMS OF AIRWAY OBSTRUCTION BY LOCATIONTABLE 78.1 SIGNS AND SYMPTOMS OF AIRWAY OBSTRUCTION BY LOCATIONRegionRegionVoiceVoiceStridorStridorRetractionsRetractionsFeedingFeedingMouthMouthCoughCoughOropharyngeal obstructionOropharyngeal obstructionUnaffected but can be throaty or fullUnaffected but can be throaty or fullInspiratory and coarse; increases during sleepInspiratory and coarse; increases during sleepSternal and intercostal, increasing to total chest when severeSternal and intercostal, increasing to total chest when severeDifficult to impossible, with drooling or salivaDifficult to impossible, with drooling or salivaOpen; jaw held forwardOpen; jaw held forwardNoneNoneSupraglottic laryngeal obstructionSupraglottic laryngeal obstructionMuffled or throatyMuffled or throatySnoring; inspiratory; flutteringSnoring; inspiratory; flutteringNone, until very lateNone, until very lateDifficult to impossibleDifficult to impossibleOpen; jaw held forwardOpen; jaw held forwardNoneNoneGlottic obstructionGlottic obstructionHoarse or aphonicHoarse or aphonicInspiratory early; expiratory also as obstruction increasesInspiratory early; expiratory also as obstruction increasesXiphoid early and intercostal later; suprasternal and supraclavicularXiphoid early and intercostal later; suprasternal and supraclavicularNormal, except with severe obstructionNormal, except with severe obstructionMay be closed; nares flaredMay be closed; nares flaredNoneNoneSubglottic obstructionSubglottic obstructionHoarse, but can be husky or normalHoarse, but can be husky or normalInspiratory early; expiratory also as obstruction increasesInspiratory early; expiratory also as obstruction increasesXiphoid early and intercostal later; suprasternal and supraclavicularXiphoid early and intercostal later; suprasternal and supraclavicularNormal, except with severe obstructionNormal, except with severe obstructionMay be closed; nares flaredMay be closed; nares flaredBarkingBarkingTracheobronchial obstructionTracheobronchial obstructionNormalNormalExpiratory and wheezing; becoming to and fro with increasing obstructionExpiratory and wheezing; becoming to and fro with increasing obstructionNone, except with severe obstruction; xiphoid and sternalNone, except with severe obstruction; xiphoid and sternalNormal, except with severe airway obstruction or when extrinsic obstruction Normal, except with severe airway obstruction or when extrinsic obstruction involves esophagusinvolves esophagusMay be closed; nares flaredMay be closed; nares flaredBrassyBrassyFrom Myer C III, Cotton RT. Pediatric airway and laryngeal problems. In: Lee K, ed. From Myer C III, Cotton RT. Pediatric airway and laryngeal problems. In: Lee K, ed. Textbook of otolaryngology and head and neck surgery.Textbook of otolaryngology and head and neck surgery. New York: Elsevier, 1989:658–673, with permission. New York: Elsevier, 1989:658–673, with permission. TABLE 78.1 SIGNS AND SYMPTOMS OF AIRWAY OBSTRUCTION BY LOCATIONTABLE 78.1 SIGNS AND SYMPTOMS OF AIRWAY OBSTRUCTION BY LOCATIONRegionRegionVoiceVoiceStridorStridorRetractionsRetractionsFeedingFeedingMouthMouthCoughCoughOropharyngeal obstructionOropharyngeal obstructionUnaffected but can be throaty or fullUnaffected but can be throaty or fullInspiratory and coarse; increases during sleepInspiratory and coarse; increases during sleepSternal and intercostal, increasing to total chest when severeSternal and intercostal, increasing to total chest when severeDifficult to impossible, with drooling or salivaDifficult to impossible, with drooling or salivaOpen; jaw held forwardOpen; jaw held forwardNoneNoneSupraglottic laryngeal obstructionSupraglottic laryngeal obstructionMuffled or throatyMuffled or throatySnoring; inspiratory; flutteringSnoring; inspiratory; flutteringNone, until very lateNone, until very lateDifficult to impossibleDifficult to impossibleOpen; jaw held forwardOpen; jaw held forwardNoneNoneGlottic obstructionGlottic obstructionHoarse or aphonicHoarse or aphonicInspiratory early; expiratory also as obstruction increasesInspiratory early; expiratory also as obstruction increasesXiphoid early and intercostal later; suprasternal and supraclavicularXiphoid early and intercostal later; suprasternal and supraclavicularNormal, except with severe obstructionNormal, except with severe obstructionMay be closed; nares flaredMay be closed; nares flaredNoneNoneSubglottic obstructionSubglottic obstructionHoarse, but can be husky or normalHoarse, but can be husky or normalInspiratory early; expiratory also as obstruction increasesInspiratory early; expiratory also as obstruction increasesXiphoid early and intercostal later; suprasternal and supraclavicularXiphoid early and intercostal later; suprasternal and supraclavicularNormal, except with severe obstructionNormal, except with severe obstructionMay be closed; nares flaredMay be closed; nares flaredBarkingBarkingTracheobronchial obstructionTracheobronchial obstructionNormalNormalExpiratory and wheezing; becoming to and fro with increasing obstructionExpiratory and wheezing; becoming to and fro with increasing obstructionNone, except with severe obstruction; xiphoid and sternalNone, except with severe obstruction; xiphoid and sternalNormal, except with severe airway obstruction or when extrinsic obstruction Normal, except with severe airway obstruction or when extrinsic obstruction involves esophagusinvolves esophagusMay be closed; nares flaredMay be closed; nares flaredBrassyBrassyFrom Myer C III, Cotton RT. Pediatric airway and laryngeal problems. In: Lee K, ed. From Myer C III, Cotton RT. Pediatric airway and laryngeal problems. In: Lee K, ed. Textbook of otolaryngology and head and neck surgery.Textbook of otolaryngology and head and neck surgery. New York: Elsevier, 1989:658–673, with permission. New York: Elsevier, 1989:658–673, with permission. 呼吸道梗阻呼吸道梗阻易易易易发发生梗阻！生梗阻！生梗阻！生梗阻！呼吸道梗阻梗阻位置判断呼吸道梗阻梗阻位置判断杂音呼吸音呼吸吸气性吸气性呼气性呼气性呼气性呼吸困呼气性呼吸困难胸腔入口内端胸腔入口内端气管气管, 支气管支气管, 外周气道外周气道吸气性呼吸困吸气性呼吸困难胸腔入口外端胸腔入口外端鼻鼻, , 咽，喉，气管咽，喉，气管呼吸道梗阻梗阻位置判断吸气性呼吸困吸气性呼吸困难醒醒觉时哭哭闹时好好转醒醒觉时哭哭闹时恶化化喉喉鼻鼻/咽咽呼吸道梗阻Inspiratory stridorInspiratory stridorExpiratory stridorExpiratory stridorBiphasic stridorBiphasic stridor呼吸道梗阻气道梗阻部位 鼾声鼾声鼾声鼾声喉喉喉喉鸣鸣喘喘喘喘鸣鸣鼻咽鼻咽鼻咽鼻咽 + + + + + + + + - - - -喉喉喉喉±±±±小小小小婴婴儿儿儿儿 + + + + + + + +严严重阻塞重阻塞重阻塞重阻塞气管气管气管气管主支气管主支气管主支气管主支气管 + + + ++ + + + 小气道小气道小气道小气道+ + + +呼吸道梗阻上气道梗阻严重征象•￿三凹征•￿气促￿•￿心率增快• 呼吸性呼吸困难￿(腹肌收缩)• 意识障碍• 发绀￿￿• 呼吸声小或无声呼吸道梗阻不同部位梗阻的原因I.鼻，鼻咽II.口咽III.喉声门上IV.喉声门V.喉声门下VI.气管主支气管•先天结构•感染•外伤•新生物•血管•医源性•中毒/代谢呼吸道梗阻呼吸道梗阻鼻鼻&鼻咽部鼻咽部呼吸道梗阻先天因素先天因素鼻后孔鼻后孔闭锁先天性梨状先天性梨状先天性梨状先天性梨状窝窝狭窄狭窄狭窄狭窄先天性面先天性面颅畸形畸形感染炎症感染炎症鼻炎鼻炎咽喉壁咽喉壁脓肿腺腺样体肥大体肥大外伤外伤异物异物新生物新生物脑膨出脑膨出Dermoid神经胶质瘤神经胶质瘤血管血管医源性医源性中毒中毒呼吸道梗阻后鼻孔闭锁Choanal￿Atresia￿(CA)•流行病•Rare:￿1￿in￿10,000￿births•Females￿>males•50%￿unilateral,￿50%￿bilateral•两种类型:￿membranous￿or￿bony•￿29%￿bony•71%￿mixed￿bony-membranous•发病机制不清￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿￿(Brown￿et￿al,￿L(Brown￿et￿al,￿Laryngoscopearyngoscope￿1996)￿1996)呼吸道梗阻后鼻孔闭锁Choanal￿Atresia￿(CA)•临床表现•呼吸困难•反常发绀•进食困难•联合畸形￿•C- 眼•H- Heart anomaly•A- 后鼻孔闭锁•R- 生长迟滞•G- 生殖发育异常•E- 耳•诊断线索•临床表现•不能插入￿8 Fr 管道•纤支镜不能进入•Axial CT 证实呼吸道梗阻呼吸道梗阻•管理•Initial￿McGovern￿nipple•Oral￿airway￿or￿McGovern￿nipple•外科•通过鄂•Better￿visualization,￿high￿success￿rate•Can￿damage￿palate￿growth￿plate=cross￿bite￿deformities•通过鼻•Less￿blood￿loss,￿faster￿procedure•Increased￿CSF￿leak￿and￿meningitis￿risk•镭射•CO2,￿KTP,￿Holmium:YAG•Good￿success￿with￿KTP￿+￿endoscopic￿techniques•Operating￿microscope￿with￿CO2￿laser￿also￿being￿employed治疗处理呼吸道梗阻先天性梨状窝狭窄￿(CNPAS)•临床表现•类似￿CA•呼吸困难•喂养困难•阵发发绀•鼻插管不能•鼻CT呼吸道梗阻•管理•保守治疗为主•McGovern nipple, 减充血剂, 激素•外科•预后•轻度可发育正常•外科效果好先天性梨状窝狭窄先天性梨状窝狭窄 (CNPAS)呼吸道梗阻腺样体肥大•腺样体组织异常增生肥大时，堵塞了上呼吸道，就会出现相应症状症状体征。

腺样体肥大儿童OSAHS最常见的病因之一呼吸道梗阻腺样体肥大•症状体征：•耳部症状：咽鼓管咽口受阻，将并发非化脓化中耳炎，导致听力减退和耳鸣•鼻部症状：腺样体肥大常并发鼻炎、鼻窦炎，有鼻塞及流鼻涕等症状说话时带闭塞性鼻音，睡时发出鼾声•咽、喉和下呼吸道症状：因分泌物向下流并刺激呼吸道粘膜，常引起阵咳，易并发气管炎•由于长期张口呼吸，致使面骨发育发生障碍，颌骨变长，腭骨高拱，牙列不齐，上切牙突出，唇厚，缺乏表情，出现所谓“腺样体面容”•全身症状全身发育和营养状况较差，并有夜惊、磨牙、遗尿、反应迟钝，注意力不集中等反射性症状此外，长期呼吸道阴塞、肺换气不足，将引导起肺动脉压升高，重者可导致右心衰竭呼吸道梗阻腺样体肥大•诊断：•患儿张口呼吸•有时可见“腺样体面容”￿，常伴有腭扁桃体肥大•纤维鼻咽镜检查在鼻咽顶部和后壁可见表面有纵行裂隙的分叶关状淋巴组织，•鼻咽侧位片测量：可测量鼻咽气道的阻塞程度•X线鼻咽侧位拍片，有助于诊断CT：轴位像可见鼻咽气腔变形变窄，后壁软组织增厚，密度均匀，与头长肌相近，左右侧对称，前缘光滑或呈波浪状，向气腔突入，咽隐窝及咽鼓管咽口隐约可见或显示不清，不同程度的阻塞后鼻孔，咽旁间隙清晰，邻近骨质无破坏。

CT轴位像测量，腺样体指数≥0.70呼吸道梗阻腺样体肥大•治疗：主要针对病因如过敏，感染等，应用孟鲁司特，开瑞坦，适当使用抗生素，鼻腔鼻窦适当引流等对于严重病例或当药物治疗不能缓解症状，或长期存在呼吸不畅，尤其是有呼吸暂停现象时，手术切除肥大的腺样体和扁桃体常是最有效的治疗方法呼吸道梗阻口咽部口咽部& 喉咽部喉咽部呼吸道梗阻先天因素先天因素舌后舌后坠舌甲状腺舌甲状腺血管囊血管囊肿颅面畸形面畸形感染炎症感染炎症咽喉壁咽喉壁脓肿扁桃体肥大扁桃体肥大外外伤异物异物新生物新生物血管瘤血管瘤淋巴瘤淋巴瘤血管血管医源性医源性中毒中毒呼吸道梗阻Pierre-Robin￿Pic呼吸道梗阻咽后壁脓肿•流行病•大多发生在儿童•70% < 6 岁•病生•咽后间隙淋巴化脓•临床表现•舌咽痛•进行性呼吸困难•流涎水•体查•咽后壁不对称隆起•颈后仰•发热•喘鸣•多涎•实验室/影像•血象•颈部侧位片•咽后组织•At C2: <7mm•At C6: <14mm •颈部CT呼吸道梗阻•管理•蜂窝织炎•静脉抗生素•48小时或随时复诊•脓肿•切开排脓咽后壁脓肿呼吸道梗阻Babl and Pascucci, N Engl J Med 337(7):472 August 14, 1997. 椎体前软组织增大椎体前软组织增大呼吸道梗阻脓肿形成脓肿形成呼吸道梗阻先天因素先天因素喉软化喉软化会厌囊肿会厌囊肿感染炎症感染炎症会厌炎会厌炎神经血管性水肿神经血管性水肿外伤外伤异物异物新生物新生物血管瘤血管瘤淋巴瘤淋巴瘤乳头状瘤乳头状瘤血管血管医源性医源性中毒中毒呼吸道梗阻喉软骨软化•一般•先天性喉鸣主要原因•生后数天数周发生•1岁后缓解•病生•喉鸣声门上脱垂•￿进入喉内结构异常￿呼吸道梗阻喉软骨软化•临床表现•低音调吸气喉鸣￿•6-9月达高峰•位置变化•吸气凹陷•活动后加重￿(进食等)•很少发绀•发绀注意其他畸形•合并其他畸形呼吸道梗阻喉软骨软化呼吸道梗阻喉软骨软化LaryngomalaciaThe supraglottic structures are pulled into the lumen around a vertical axis with inspirationCollapse of arytenoid mucosa; shortened aryepiglottic folds; tubular epiglottis with posterior collapse呼吸道梗阻Supraglottoplasty呼吸道梗阻喉软骨软化•管理•保守治疗•外科￿(~10% of cases)•严重喉鸣, 不长, 窒息, 肺源性心脏病, 肺动脉高压呼吸道梗阻会厌囊肿•喉鸣患儿中的少见病•典型症状•喉鸣•喂养困难•发绀•管理•内镜切除呼吸道梗阻会厌囊肿呼吸道梗阻急性会厌炎•病因•感染•外伤•临床表现：•急，发热畏寒全身不适•呼吸困难•喉痛剧烈•唾液外溢•因语言含糊不清　　呼吸道梗阻急性会厌炎•检查：间接喉镜下见会厌红肿，舌面尤甚，重时可呈球形，若脓肿形成，会厌舌￿  面可见黄白色脓点•治疗：•大剂量广谱抗生素•如肿胀严重，伴有呼吸困难者应同时加用激素静脉滴注，以减轻会厌水肿•对于出现明显喉阻塞症状者，应及时作气管切开，以免发生窒息。

•有脓肿形成者，可在喉镜下切开排脓•局部给以抗生素加激素雾化吸入，以促进炎症消退￿呼吸道梗阻声门声门呼吸道梗阻先天因素先天因素喉蹼喉蹼喉闭锁喉闭锁喉裂喉裂喉狭窄喉狭窄声带麻痹声带麻痹喉囊肿喉囊肿感染炎症感染炎症喉炎喉炎神经血管性水肿神经血管性水肿外伤外伤异物异物血肿血肿断裂断裂新生物新生物血管瘤血管瘤淋巴瘤淋巴瘤乳头状瘤乳头状瘤肉芽肿肉芽肿血管血管医源性医源性中毒中毒呼吸道梗阻先天性喉蹼•提示诊断：出生时异常音调哭闹，呼吸困难•内镜诊断•证实•其他畸形排除该诊断•治疗•小喉蹼•严重喉蹼需喉正中切开术加支架•内镜镭射治疗呼吸道梗阻/.../index.php/t14103.html 呼吸道梗阻喉裂•症状•声音嘶•误吸•通常无喘鸣•分级•与严重度有关•4级呼吸道梗阻Type II Cleft呼吸道梗阻声带麻痹•一般情况•10% 伴有先天后损害•先天后天不清•大多自发•病因•损伤/自发•产科手术•心血管手术•食道手术•其他伴随畸形•心脏•CNS呼吸道梗阻声带麻痹•单侧•呼吸哭声•中度喘呼吸困难•误吸•处理•说话训练•气管切开很少需要，如需要需采用去套技术•双侧•严重喘鸣•误吸•治疗•气管切开•系列内镜手术•手术至少一年才有改善呼吸道梗阻反复呼吸道乳头状瘤￿呼吸道梗阻声门下腔声门下腔呼吸道梗阻先天因素先天因素狭窄狭窄囊肿囊肿感染炎症感染炎症喉炎喉炎狭窄狭窄外伤外伤软骨炎软骨炎异物异物新生物新生物血管瘤血管瘤乳头状瘤乳头状瘤血管血管医源性医源性中毒中毒呼吸道梗阻Steeple￿sign￿尖塔征呼吸道梗阻“Steeple Sign”“Thumb Sign”呼吸道梗阻喉炎影像Overdistension of the hypopharynxDilatation of the laryngeal ventricleNarrowing of the sub-glottic trachea呼吸道梗阻Mild croup: ≤2 Moderate croup: 3-7 Severe croup: ≥8呼吸道梗阻管理•糖皮质激素•DXM0.15￿or￿0.6mg/kg/day￿orally￿to￿max.￿10mg•普米克令舒•强的松￿2mg/kg/day￿分两次，￿x￿2￿days呼吸道梗阻管理-2•雾化肾上腺素•May￿be￿repeated￿every￿15-20￿minutes,￿effects￿<2￿hrs•Racemic￿epinephrine￿0.05ml/kg/dose￿(Max.￿0.5ml￿)•L-epinephrine￿0.5ml/kg/dose￿(Max.￿5ml)•湿化呼吸道梗阻MJA 2003; 179 (7): 372-377 呼吸道梗阻声门下腔狭窄•先天•获得•临床表现•狭窄程度•严重出生喉鸣•轻度可无症状.•难拔管（新生儿）呼吸道梗阻声门下气管蹼呼吸道梗阻声门下腔狭窄IntubationPressure necrosis on subglottic mucosaEdema & ulcerationGranulation tissueSecondary infection & perichondritisFibrous tissue depositionStenosis!呼吸道梗阻声门下血管瘤•流行病•1.5% of all congenital laryngeal anomalies•2:1 female to male ratio•最常见气道新生物•临床•出生无症状.•双向喉鸣-- 6 月左右出现症状•常伴皮肤血管瘤•一般1岁停止生长呼吸道梗阻声门血管瘤 呼吸道梗阻鉴别诊断喉炎喉炎喉炎喉炎急性会急性会急性会急性会厌厌炎炎炎炎细细菌性菌性菌性菌性支气管炎支气管炎支气管炎支气管炎扁桃体周扁桃体周扁桃体周扁桃体周围围或或或或咽后壁咽后壁咽后壁咽后壁脓肿脓肿病因病因病因病因副流感副流感副流感副流感流感嗜血杆菌流感嗜血杆菌流感嗜血杆菌流感嗜血杆菌 B B链链球菌球菌球菌球菌链链球菌球菌球菌球菌年年年年龄龄6m/o~3y/o6m/o~3y/o2~7y/o2~7y/o3~10y/o3~10y/o2~4y/o2~4y/o过过程程程程几天几天几天几天几小几小几小几小时时急性急性急性急性表表表表现现喉喉喉喉鸣鸣犬吠咳犬吠咳犬吠咳犬吠咳呼吸困呼吸困呼吸困呼吸困难难轻轻微微微微发热发热喉喉喉喉鸣鸣呼吸困呼吸困呼吸困呼吸困难难吞咽困吞咽困吞咽困吞咽困难难失音失音失音失音 流涎水流涎水流涎水流涎水三角架身位三角架身位三角架身位三角架身位咽痛高咽痛高咽痛高咽痛高热热化化化化脓脓性气道分性气道分性气道分性气道分泌物泌物泌物泌物呼吸困呼吸困呼吸困呼吸困难难中毒症状中毒症状中毒症状中毒症状高高高高热热咽痛咽痛咽痛咽痛热萝热萝卜音卜音卜音卜音牙关牙关牙关牙关紧闭紧闭呼吸困呼吸困呼吸困呼吸困难难流涎水流涎水流涎水流涎水发热发热呼吸道梗阻气管支气管气管支气管呼吸道梗阻先天因素先天因素气管蹼气管蹼血管环血管环 完全气管环完全气管环囊肿囊肿食道气管裂食道气管裂感染炎症感染炎症化脓性气管炎化脓性气管炎支气管炎支气管炎哮喘哮喘外伤外伤软骨炎软骨炎异物异物新生物新生物血管瘤血管瘤乳头状瘤乳头状瘤甲状腺瘤甲状腺瘤胸腺瘤胸腺瘤纵膈肿瘤纵膈肿瘤血管血管血管环血管环医源性医源性中毒中毒呼吸道梗阻血管环•双主动脉弓•Persistance￿of￿fourth￿branchial￿arch￿and￿dorsal￿aortic￿root￿bilaterally•最常见的血管环•肺动脉吊带•Most￿symptomatic￿of￿noncircumferential￿anomalies•Right￿mainstem￿bronchus￿affected￿in￿majority￿of￿cases•Associated￿with￿presence￿of￿complete￿tracheal￿rings呼吸道梗阻气管、支气管狭窄或软化￿无名动脉压迫神经母细胞瘤压迫迷走左肺动脉左心房压迫主动脉缩窄和离断双主动脉弓压迫呼吸道梗阻血管环•表现•也有轻微•双向喉鸣•慢性喘咳•反复支气管炎•肺炎•喂养困难•不长•影像诊断•平片价值不大•钡餐￿充盈缺损•CT （增强）or MRI•内镜•评估压迫程度n n手术手术手术手术n n绝对指针绝对指针绝对指针绝对指针n n反流窒息反流窒息反流窒息反流窒息n n延长插管延长插管延长插管延长插管n n相对指针相对指针相对指针相对指针n n反复呼吸道感染反复呼吸道感染反复呼吸道感染反复呼吸道感染n n活动不耐受活动不耐受活动不耐受活动不耐受n n吞咽困难不长吞咽困难不长吞咽困难不长吞咽困难不长n n持续喘等持续喘等持续喘等持续喘等 呼吸道梗阻Double Aortic ArchPulmonary Artery Sling呼吸道梗阻 呼吸道梗阻气管软化•气管环的先天性畸形•呼气性喉鸣，喘鸣，呼吸性窘迫•与程度位置有关•诊断•纤支镜（醒觉病人）•处理：保守，去病因，少数支架呼吸道梗阻气管气管/支气管软化支气管软化软骨/膜部的比例小于3:1管腔至少50%的塌陷呼吸道梗阻Tracheomalacia呼吸道梗阻病例•女，13岁，学生，因反复气促、喘息5年•5年前因受凉后出现呼吸困难，呼气时为甚，予抗感染及对症治疗，病情好转。

但每隔2-3月患者因受凉后出现上述症状，且呼吸困难逐渐加重•2年前给予哮喘治疗，半年前给予脱敏治疗，症状仍加重•无哮喘家族史，否认肺结核病史呼吸道梗阻病例•查体：生命体征平稳，锁骨上淋巴结不大双肺可闻及散在的干罗音心界不大，心率96次/分，率齐，无杂音腹部检查正常双下肢无浮肿呼吸道梗阻病例呼吸道梗阻病例呼吸道梗阻病例气管气管左主支气管左主支气管呼吸道梗阻病例呼吸道梗阻呼吸道梗阻呼吸道梗阻呼吸道梗阻异物呼吸道梗阻容易发现的异物呼吸道梗阻难以发现的异物呼吸道梗阻呼吸道梗阻病例￿•患儿，男￿，1岁，咳嗽1月，加重伴发热1天￿•曾在当地医院住院2次，均好转后出院，出院时考虑为“婴幼儿哮喘并感染”，出院后单声咳，坚持辅舒酮治疗，无气喘，但患儿精神较前差•入院前1天咳加重，伴发热（最高T40℃）有寒颤•既往有咳嗽2次，有喘息，经输液治疗好转快否认“肝炎，结核”等传染病接触史呼吸道梗阻病例￿•￿T￿38℃￿￿P:140次/分￿￿R：70次/分￿￿wt：11Kg￿•发育正常，营养中等，精神反应差咽充血，气管居中，可及轻度三凹征，呼吸急促70次/分，浅快，左肺呼吸音稍低，双肺可闻及湿罗音。

心（－），腹软，肝右肋下3cm，脾左肋下1cm呼吸道梗阻化验•BR：36.33*109/l￿￿￿￿￿￿N：0.794￿￿￿￿￿￿Hb100g/l￿￿Pt：456×109/l￿￿•UR￿（－），SR（－）•ESR：25•CP（－）•血气分析：pH：7.312￿pCO2￿30.3mmHg￿￿pO2：67.2mmHg￿￿BE￿-9.6mmol/L•CRP：367mg/l￿•痰培养：肺炎克雷伯菌10％呼吸道梗阻影像学胸部CT：1.左下肺大叶性炎症￿2.￿左侧胸腔内积液，有包裹￿3.右侧中叶内段慢性炎症呼吸道梗阻诊断？•重症肺炎•脓胸（包裹性）•呼吸功能不全•病原诊断•细菌G+,G-•结核•支原体•真菌n n病因病因病因病因诊诊断断断断n n哮喘哮喘哮喘哮喘n n异物异物异物异物n n全身免疫功能全身免疫功能全身免疫功能全身免疫功能n n局部免疫功能局部免疫功能局部免疫功能局部免疫功能呼吸道梗阻完善相关检查•入院完善相关检查：•血气•纤维支气管镜•胸水检查：渗出性，中性粒升高，ADA<40•血培养、痰培养、灌洗液培养•肺功能、哮喘三项、变应原皮试呼吸道梗阻纤维支气管镜•左主支气管下叶开口处可见一黄白色多角形物体。

呼吸道梗阻咽喉反流性疾病(LPRD）•定义：是指胃内容物反流至食管上括约肌以上部位，引起一系列症状和体征的总称•临床症状：表现为声嘶(或发音障碍)，咽喉疼痛，咽喉部异物感，持续清嗓，慢性长期咳嗽，呼吸困难，喉痉挛等￿•喉部体征：可有声带后连合区域黏膜增生、肥厚，声带弥漫性充血水肿，严重时出现肉芽肿、喉室消失、声门下狭窄等￿呼吸道梗阻•由于咽喉反流性疾病无特异性的症状和体征，而且被认为诊断咽喉反流性疾病的金标准是24 h双探针食管和喉咽部pH监测•健康人异常喉咽部pH事件的发生率也很高，因此，目前只能依靠详细的病史、喉镜检查、24 h双探针食管和喉咽部pH监测以及抗反流治疗效果综合判断￿咽喉反流性疾病的诊断￿呼吸道梗阻咽喉反流性疾病的诊断￿临临床表床表现现GERDGERDLPRDLPRD症状症状烧烧心和心和心和心和/ /或反胃或反胃或反胃或反胃+++++++++ +声嘶、咳嗽、呼吸困声嘶、咳嗽、呼吸困声嘶、咳嗽、呼吸困声嘶、咳嗽、呼吸困难难+ +++++++++检查检查食管炎食管炎食管炎食管炎+++++++++ +喉炎喉炎喉炎喉炎+ +++++++++辅辅助助检查检查食管食管食管食管镜镜+++++++ +异常的食管异常的食管异常的食管异常的食管PHPH监测监测+++++++++ +异常的咽部异常的咽部异常的咽部异常的咽部PHPH监测监测+ +++++++++食管蠕食管蠕食管蠕食管蠕动动异常异常异常异常+++++++++ +食管抗酸功能异常食管抗酸功能异常食管抗酸功能异常食管抗酸功能异常+++++++++ +GERD指胃食管反流性疾病；LPRD指咽喉反流性疾病；PPI为质子泵抑制剂 呼吸道梗阻小结•急救问题•返流问题•梗阻部位及原因分析呼吸道梗阻谢谢谢谢 !!!!敬请指教敬请指教 ! !呼吸道梗阻此课件下载可自行编辑修改，供参考！感谢您的支持，我们努力做得更好！呼吸道梗阻。