慢性阻塞性肺疾病教案

慢性阻塞性肺疾病 内科教研室教案 课程名称 内科学 授课题目 慢性阻塞性肺疾病 授课对象 全科医师 概述及病因 10分钟 发病机制和病理 20分钟 临床表现 30分钟 时间分配 辅助助检查 25分钟 诊断与鉴别诊断 25分钟 治疗及预防 10分钟 掌握COPD的临床表现～诊断及分级、分期～治疗原则 课时目标 授课重点 COPD的临床表现、诊断及分级、分期 授课难点 COPD同其它原因所致呼吸气腔扩大的鉴别。 授课形式 多媒体 授课方法 讲述为主～结合幻灯片及典型病例讲解。 1.《内科学》,第6版,叶任高 陆再英主编～人民卫生出版社出 版 2006年。2.《内科学》王吉耀 廖二元 胡品津主编～人民卫生参考文献 出版社出版 2005年。3.《实用内科学》 陈灏珠主编～人民卫生 出版社～2005年～第12版。 1(试述COPD的诊断标准。2(COPD的鉴别诊断,3(COPD的并发思考题 症, 教研室主 教研室主任,签字 , 课程负责人,签字, 任及课程 负责人签 年 月 日 年 月 日 字 of the people, "Da Yi Ju", big love Yi Ju "unite to society is the atmosphere of energy to accelerate the formation. At present, in the County's recommended good in China has reached 16, Shandong good 23, at all levels of the moral model more than 200. More optimized development environment, perseverance deepen style construction, increase" Yong lazy slow hiding remediation efforts, window units in service quality, service efficiency significantly improved. While fully affirming our achievements, we also want to clearly see the majority control group The expectations of the public, control a city evaluation system standards, the county a city work, there still exist many weak links and the prominent question. Mainly in: 1, environmental sanitation, city back lane and rural road, bridge, village, ditches still exist health corner, Ji Cunla garbage is not completely clear, after the Qing chaos, while rebound phenomenon occur frequently., and the appearance of the order, city roads, key areas of illegal structures, unlicensed stalls, probe the market, Jeeves, running red lights, vehicle Luantingluanfang phenomenon still exists, part of the urban road traffic order is chaotic; Street business operators to implement the "door 3 packets" is not in place, commercial street, residential areas and other shop management repeated, serious impact on the image of the city., "five small" industries management, some operating premises license, part of the practitioners no certificates. 4, community construction, community property management is not standardized, is not in place, public service space generally lack, the insufficient number of facilities of the public fire control community minors live Dynamic venues and other infrastructure facilities is not perfect, community volunteer service activities often cannot carry out 慢性阻塞性肺疾病 一、概念 1(慢性阻塞性肺疾病(COPD):是一种具有气流受限特征的疾病,气流受限不完全可逆、呈进行性发展,与肺部对有害气体或有害颗粒的异常炎症反应有关。COPD与慢性支气管炎和肺气肿密切相关。 2(慢性支气管炎:指在除外慢性咳嗽的其它已知原因后,患者每年咳嗽、咳痰3个月以上,并连续2年者。 3(肺气肿:指肺部终末细支气管远端气腔出现异常持久的扩张,并伴有肺泡壁和细支气管的破坏而无明显的肺纤维化。 二、病因 1(吸烟:吸烟为COPD重要发病因素,吸烟能使支气管上皮纤毛运动发生障碍,局部抵抗力降低,削弱肺泡吞噬细胞的吞噬、灭菌作用,并能引起支气管痉挛,增加气道阻力。 2(职业性粉尘和化学物质 3(空气污染 4(感染:呼吸道感染是COPD发病和加剧的另一个重要因素,肺炎链球菌和流感嗜血杆菌可能为COPD急性发作的主要病原菌。病毒也对COPD的发生和发展起重要作用。 5(蛋白酶,抗蛋白酶失衡 6(其它:气候变化、机体的内在因素、自足神经功能失调等。 三、临床表现 1(症状:?慢性咳嗽，通常为首发症状;?咳痰;?气短或呼吸困难:这是COPD的标志性症状,逐渐加重;?喘息和胸闷;?其他症状:晚期患者常有体重下降、食欲减退、精神抑郁和(或)焦虑等,合并感染时可咳血痰或咯血。 2(体征:COPD早期体征可不明显。随疾病进展,常有以下体征:?视诊及触诊:of the people, "Da Yi Ju", big love Yi Ju "unite to society is the atmosphere of energy to accelerate the formation. At present, in the County's recommended good in China has reached 16, Shandong good 23, at all levels of the moral model more than 200. More optimized development environment, perseverance deepen style construction, increase" Yong lazy slow hiding remediation efforts, window units in service quality, service efficiency significantly improved. While fully affirming our achievements, we also want to clearly see the majority control group The expectations of the public, control a city evaluation system standards, the county a city work, there still exist many weak links and the prominent question. Mainly in: 1, environmental sanitation, city back lane and rural road, bridge, village, ditches still exist health corner, Ji Cunla garbage is not completely clear, after the Qing chaos, while rebound phenomenon occur frequently., and the appearance of the order, city roads, key areas of illegal structures, unlicensed stalls, probe the market, Jeeves, running red lights, vehicle Luantingluanfang phenomenon still exists, part of the urban road traffic order is chaotic; Street business operators to implement the "door 3 packets" is not in place, commercial street, residential areas and other shop management repeated, serious impact on the image of the city., "five small" industries management, some operating premises license, part of the practitioners no certificates. 4, community construction, community property management is not standardized, is not in place, public service space generally lack, the insufficient number of facilities of the public fire control community minors live Dynamic venues and other infrastructure facilities is not perfect, community volunteer service activities often cannot carry out 胸廓前后径增大、桶状胸;呼吸变浅,频率增快,重症采用缩唇呼吸以增加呼出气量;呼吸困难加重时常采取前倾坐位;可出现粘膜及皮肤发绀,伴右心衰者可见下肢水肿、肝脏增大。?叩诊:心浊音界缩小,肺肝界降低,肺叩诊可呈过度清音。?听诊:两肺呼吸音可减低,呼气延长,平静呼吸时可闻干性罗音,两肺底或其他肺野可闻湿罗音;心音遥远,剑突部心音较清晰响亮。 3(病史:COPD患病过程应有以下特征:(1)吸烟史:多有长期较大量吸烟史。(2)职业性或环境有害物质接触史。(3)家族史:COPD有家族聚集倾向。(4)发病年龄及好发季节:多于中年以后发病,症状好发于秋冬寒冷季节,常有反复呼吸道感染及急性加重史。(5)慢性肺原性心脏病史:COPD后期出现低氧血症和(或)高碳酸血症,可并发慢性肺原性心脏病和右心衰竭。 四、辅助检查 (一)实验室及特殊检查 1(肺功能检查:肺功能检查是判断气流受限增高且重复性好的客观指标,对COPD的诊断、严重度评价、疾病进展、预后及治疗反应等均有重要意义。?以FEV1和FEV1与FVC之比 (FEV1/FVC)降低来确定气流受限。FEV1/FVC是COPD的一项敏感指标,可检出轻度气流受限。FEV1占预计值的百分比是中、重度气流受限的良好指标。 ?肺总量(TLC)、功能残气量 (FRC)和残气容积(RV)增高,肺活量 (VC)减低。RV/TLC增高。?弥散功能受损,一氧化碳弥散量(DLCO)降低,DLCO与肺泡通气量(VA)之比(DLCO/VA)比单纯DLCO更敏感。 2(胸部X线检查:?早期胸片可无明显变化,以后出现肺纹理增多、紊乱。?主要X线征为肺过度充气;?并发肺动脉高压和肺原性心脏病时,除右心增大的X线征外,还可有右下肺动脉增宽等影像。 3(胸部CT检查:高分辨率CT(HRCT)有助于鉴别诊断，可辨别小叶中央型或全小叶型肺气肿及确定肺大疱的大小和数量，但不做为常规检查。 of the people, "Da Yi Ju", big love Yi Ju "unite to society is the atmosphere of energy to accelerate the formation. At present, in the County's recommended good in China has reached 16, Shandong good 23, at all levels of the moral model more than 200. More optimized development environment, perseverance deepen style construction, increase" Yong lazy slow hiding remediation efforts, window units in service quality, service efficiency significantly improved. While fully affirming our achievements, we also want to clearly see the majority control group The expectations of the public, control a city evaluation system standards, the county a city work, there still exist many weak links and the prominent question. Mainly in: 1, environmental sanitation, city back lane and rural road, bridge, village, ditches still exist health corner, Ji Cunla garbage is not completely clear, after the Qing chaos, while rebound phenomenon occur frequently., and the appearance of the order, city roads, key areas of illegal structures, unlicensed stalls, probe the market, Jeeves, running red lights, vehicle Luantingluanfang phenomenon still exists, part of the urban road traffic order is chaotic; Street business operators to implement the "door 3 packets" is not in place, commercial street, residential areas and other shop management repeated, serious impact on the image of the city., "five small" industries management, some operating premises license, part of the practitioners no certificates. 4, community construction, community property management is not standardized, is not in place, public service space generally lack, the insufficient number of facilities of the public fire control community minors live Dynamic venues and other infrastructure facilities is not perfect, community volunteer service activities often cannot carry out 4(血气检查:血气检查对晚期患者十分重要。血气异常首先表现为轻、中度低氧血症。随疾病进展,低氧血症逐渐加重,并出现高碳酸血症。 5(其他:外周血血红蛋白及红细胞可增高。并发感染时,痰涂片可见大量中性白细胞。痰培养可检出各种病原菌,常见者为肺炎链球菌、流感嗜血杆菌、卡他莫拉菌、肺炎克雷伯杆菌等。 五、诊断 根据病史、危险因素接触史、体征及实验室检查等资料,综合分析确定。存在不完全可逆性气流受限是诊断的必备条件。肺功能检查是诊断COPD的金标准。用支气管舒张剂后FEV1,80%预计值及FEV1/FVC,70%可确定为不完全可逆性气流受限。COPD早期轻度气流受限时可有或无临床症状。胸部X线检查有助于确定肺过度充气的程度及与其他肺部疾病鉴别。 六、鉴别诊断: COPD应与下列疾病鉴别: 1(支气管哮喘;2(支气管扩张症;3(肺结核;4(肺癌。 七、治疗 (一)COPD稳定期的治疗 稳定期COPD的处理原则根据病情的严重程度不同,选择的治疗方法也有所不同。 1(教育与管理。 2(支气管舒张剂:?β2受体激动剂;?抗胆碱药;?茶碱类药物:氨茶碱或缓释型或控释型茶碱。 3(祛痰药 (粘液溶解剂):可酌情应用下列药物:?盐酸氨溴索(沐舒坦);?氯化铵合剂;?溴已新;?强力稀化粘素;?中成药:如祛痰灵、止咳化痰颗粒。 4(长期家庭氧疗(LTOT):LTOT应在?级重度COPD患者应用,LTOT一般是经鼻导管吸入氧气,流量1(0,2(0L/min,吸氧持续时间,15h/d。 5(调节剂:如?卡介苗素;?必思添;?疫苗。 6(治疗:包括呼吸生理治疗,肌肉训练,营养支持、精神治疗与教育等多方面措of the people, "Da Yi Ju", big love Yi Ju "unite to society is the atmosphere of energy to accelerate the formation. At present, in the County's recommended good in China has reached 16, Shandong good 23, at all levels of the moral model more than 200. More optimized development environment, perseverance deepen style construction, increase" Yong lazy slow hiding remediation efforts, window units in service quality, service efficiency significantly improved. While fully affirming our achievements, we also want to clearly see the majority control group The expectations of the public, control a city evaluation system standards, the county a city work, there still exist many weak links and the prominent question. Mainly in: 1, environmental sanitation, city back lane and rural road, bridge, village, ditches still exist health corner, Ji Cunla garbage is not completely clear, after the Qing chaos, while rebound phenomenon occur frequently., and the appearance of the order, city roads, key areas of illegal structures, unlicensed stalls, probe the market, Jeeves, running red lights, vehicle Luantingluanfang phenomenon still exists, part of the urban road traffic order is chaotic; Street business operators to implement the "door 3 packets" is not in place, commercial street, residential areas and other shop management repeated, serious impact on the image of the city., "five small" industries management, some operating premises license, part of the practitioners no certificates. 4, community construction, community property management is not standardized, is not in place, public service space generally lack, the insufficient number of facilities of the public fire control community minors live Dynamic venues and other infrastructure facilities is not perfect, community volunteer service activities often cannot carry out 施。 7(治疗:?肺大疱切除术;?肺减容术;?肺移植术。 (二)COPD加重期的治疗 1(确定急性加重期的原因及病情的严重程度。 2(根据病情严重程度决定门诊或住院治疗。 3(支气管舒张剂。 4(控制性氧疗:无严重合并症的COPD加重期患者氧疗后较容易达到满意的氧合水平 (PaO2,60mmHg或SaO2,90%) ,但有可能发生潜在的CO2潴留。给氧途径包括鼻导管或Venturi面罩 ,其中Venturi面罩更能精确地调节吸入氧浓度。氧疗 30min后应复查动脉血气以确认氧合满意而未引起CO2潴留或酸中毒。 5(抗生素:应根据患者所在地常见病原菌类型及药物敏感情况选用抗生素。COPD患者感染的细菌耐药情况较一般肺部感染患者更为严重。长期应用广谱抗生素和激素者易继发霉菌感染,宜采取预防和抗霉菌措施。 6(糖皮质激素:口服或静脉使用糖皮质激素。 7(机械通气:包括无创性机械通气和有创性 (常规 )机械通气。 八、预防: 预防COPD的发生，防止慢支、肺气肿患者进展为气流阻塞。包括: 1(避免吸烟及戒烟。避免或减少有害气体、粉尘及烟雾的吸入。 2(预防呼吸道感染。 3(对慢支患者进行肺通气功能的检测(FEV1，FEV1,FVC,FEV1占预计值,)提高COPD患者生活水平，避免环境污染。 4(提高卫生宣传，改善工作条件与卫生习惯。 of the people, "Da Yi Ju", big love Yi Ju "unite to society is the atmosphere of energy to accelerate the formation. At present, in the County's recommended good in China has reached 16, Shandong good 23, at all levels of the moral model more than 200. More optimized development environment, perseverance deepen style construction, increase" Yong lazy slow hiding remediation efforts, window units in service quality, service efficiency significantly improved. While fully affirming our achievements, we also want to clearly see the majority control group The expectations of the public, control a city evaluation system standards, the county a city work, there still exist many weak links and the prominent question. Mainly in: 1, environmental sanitation, city back lane and rural road, bridge, village, ditches still exist health corner, Ji Cunla garbage is not completely clear, after the Qing chaos, while rebound phenomenon occur frequently., and the appearance of the order, city roads, key areas of illegal structures, unlicensed stalls, probe the market, Jeeves, running red lights, vehicle Luantingluanfang phenomenon still exists, part of the urban road traffic order is chaotic; Street business operators to implement the "door 3 packets" is not in place, commercial street, residential areas and other shop management repeated, serious impact on the image of the city., "five small" industries management, some operating premises license, part of the practitioners no certificates. 4, community construction, community property management is not standardized, is not in place, public service space generally lack, the insufficient number of facilities of the public fire control community minors live Dynamic venues and other infrastructure facilities is not perfect, community volunteer service activities often cannot carry out