叶俊丽 Mail to yejunli126126.com,肺病理生理学 (Pulmonary Insufficiency),Department of pathophysiology,Contents,Introduction Etiology and pathogenesis Alterations of function and metabolism,Introduction,Normal physiological function of lung,External respirationDefensive functionFilter functionMetabolic function,Defensive function,肺泡表面积80m2，接触空气15000L/天,Defensive function,非特异性：气道异物的清除（颗粒、气体）。,颗粒的清除：受气道解剖、气流速度、颗 粒大小影响。,5m,沉积在上呼吸道 1-5m，沉积在小气道 0.1-1m，沉积在肺泡 0.1m，基本随呼气排出,气体的清除：喷嚏、咳嗽。,特异性防御机制-免疫反应。,肺是重要的免疫系统。,淋巴组织、IgA、IgG、免疫反应细胞等。,Defensive function,Filter function,arterial,(2010) IF= 47.05,Metabolic function,肺组织参与糖、脂肪、蛋白质的代谢。,Surfactant,Metabolic function,Metabolic function,Metabolic function,胺类：儿茶酚胺（CA）、5-HT、组胺等。,脂类：前列腺素、白三烯、PAF、乙酰胆碱等。,Metabolic function,肽类：血管紧张素、缓激肽、血管活性肠肽、P物质等。,Pulmonary dysfunction,In the study ? ? ?,The respiration process in normal body,Respiratory failure,ventilation,exchange,Case study,病史：患者男，45岁。因车祸致全身多发伤入院。手术抢救后次日（伤后23 h），患者呼吸困难加重，胸闷，口唇紫绀。体检：呼吸35-40次/ min，脉搏138次/ min，血压97.5/45.0 mmHg，并且无尿， 实验室检查：SaO20.70-0.78,pH7.216；PaCO2 35.2mmHg，PaO2 39.0mmHg。拍X光片：右肺上叶不张，左肺下叶纤细阴影，间质水肿，肺不张。,思考：患者的主要病理过程是什么?机制是什么？如何纠正该患者的缺氧问题？,Conception of respiratory failure,外呼吸功能,PaO2,/ PaCO2,病理过程,（呼吸衰竭）,FiO2 20%, RFI 300 ( RFI= PaO2 / FiO2 ),PaO2 50mmHg,Diagnosis of respiratory failure,According to PaCO2,Classification of respiratory failure,Contents,Introduction Etiology and pathogenesis Alterations of function and metabolism,外呼吸,Ventilatory disorder,Pathogenesis of Respiratory Failure,Disorder of air exchange,肺通气功能障碍,肺换气功能障碍,Alveolar ventilation （4L / min ),dead space,Pulmonary ventilation（ 6L / min ),Normal respiratory movement,3,5,4,3,2,1,Center Muscles Chest wall Alveoli Airway,3,2,Causes of impaired ventilation,Restrictive hypoventilation,(限制性通气不足),（1） 呼吸肌麻痹,胸廓畸形,（2） 胸廓顺应性下降,胸腔 积液,（3）气胸,胸腔积液,（4）肺顺应性下降,肺纤维化,Diffuse Fibrosis (white-tan tissue),Caused by ARDS, hyperventilation and alveolar edema，etc.,normal,Lack of surfactant,（4）肺顺应性下降,Causes of restrictive ventilatory disorder,呼吸肌无力（Paralysis of respiratory muscles）,胸廓顺应性降低（Decreased compliance of chest wall）,肺顺应性降低（Decreased compliance of lung）,胸腔积液和气胸（Hydrothorax or pneumothorax）,Causes of impaired ventilation,Restrictive hypoventilation (限制性通气不足),Obstructive hypoventilation(阻塞性通气不足),Factors influencing the airway resistance,80% of the airway resistance comes from central airway (2mm), 20% from peripheral small airway (2mm).,Obstruction of central airway(中央性气道阻塞）,Obstruction of peripheral airway(外周性气道阻塞),Causes of obstructive ventilatory disorder,Inspiration,Obstruction of extrathoracic airway,Obstruction of intrathoracic airway,Intra-thoracic pressure,Intra-thoracic pressure,Expiration,Inspiration,Intraairway pressure,Intraairway pressure,Obstruction of central airway(中央性气道阻塞）,Obstruction of peripheral airway(外周性气道阻塞),Causes of obstructive ventilatory disorder,Obstruction of peripheral airway,Intra-thoracic pressure,Intra-thoracic pressure,Expiration,Inspiration,Intraairway pressure,Intraairway pressure,normal,COPD,Equal pressure point shifts up leading to airway closure caused by forced expiration,Atmosphere pressure,Intrathoracic pressure,Intraairway pressure,Changes of blood gas in alveolar hypoventilation,Alveolar hypoventilation,Changes of blood gas in alveolar hypoventilation,2. PaCO2 is the best index of alveolar ventilation of total lung,1. The ratio of the increased value of to the decreased value of is equal to the respiratory quotient,Ventilatory disorder(肺通气功能障碍),Causes of Respiratory Failure,Disorder of air exchange(肺换气功能障碍 ),Normal gas exchange,Causes of disorder of air exchange,Impaired Gas Diffusion（弥散障碍）,Ventilation- Perfusion Imbalance（通气/血流比例失调）,Increased anatomic shunt（解剖分流增加）,Impaired Gas Diffusion（弥散障碍）,Factors influencing gas diffusion speed,thickness：1-5 m Total area：about 70-80 m2at rest 40 m2,Normal structure of diffusion membrane,Diffusion speed ,Etiologies and mechanisms of impaired diffusion,Surface area of diffusion membrane (肺泡膜面积减少),Thickness of diffusion membrane (肺泡膜厚度增加 ),Shorten of diffusion time (弥散时间缩短 ),pO2（kPa）,Artery,Capillary,Vein,13.3 10.7 8.00 5.33 2.670,0 0.25 0.50 0.75,The changes of the diffusion time （1）At rest （2）Physical load increase,Time（S）,Changes of blood gas in diffusion disorder,Diffusion disorder,The dissolubility of CO2 in water and its diffusion index is greater than that of O2.PaCO2 is the best index of alveolar ventilation of total lung.,？,HbO2,H2CO3,100806040200,20 40 60 80 100 120 140,动脉血氧分压(mmHg),静脉血 动脉血,O2解离曲线,病变部位,非病变部位,Causes of disorder of air exchange,Ventilation- Perfusion Imbalance（通气/血流比例失调）,Impaired Gas Diffusion（弥散障碍）,