Respiratory system,Anatomy,鼻,咽,喉,环状软骨,气管,支气管,肺,上呼吸道,下呼吸道,Rapid gas exchange Ventilation Perfusion Diffusion Cleaning the air Alveoli(300 million alveoli in two adult lungs, provide a surface area of some 160 meters square ) Surporting structure Elastic recoil,Structure and function General Considerations,(1) the conducting airways (dead air space),(2) the gas exchange portions,气管,粘膜层,粘膜下层,外膜,上皮 ( 纤毛柱状 ),固有膜,Ciliated cell,Mucous cell,sIgA,纤毛粘液排送系统,Mucous, serous and mixed glands,Cartilaginous,肺,导气部 ：,呼吸部 ：,肺内支气管,Bronchiole,Terminal bronchiole,(软骨消失),Respiratory bronchiole,（纤毛消失）,Alveolar duct,Alveolar sac,Alveoli,(SMC消失),68,1518,Alveoli,I 型 （90%）,II 型,Surfactant, repair I,肺间质、肺泡间隔 ：cap. , f, M,Cohn 孔相互沟通,Histology of the Airways,Mucosa,Submucosa,Cartilage,Muscles,Components Functions,Bronchi are distinguished from bronchioles primarily by the presence of cartilage in their walls. Bronchioles also lack submucosal glands.,Epithelium,Pseudostratified ciliated columnar cells Mucous (goblet) cells,Bronchial Submucosal Glands,Histology of the Alveolar walls,Alveoli,Capillaries Pores of Kohn,Simple squamous Stretchy Permeable to O2 and CO2 Easily injured Do not divide,Reserve cells Cuboidal Produce and process surfactant Divide and differentiate to type I pneumocytes,Section 1 Chronic obstructive pulmonary disease,Chronic Obstructive Pulmonary Disease (COPD),不可逆气道阻塞Irreversible airflow obstruction 慢支和肺气肿Chronic Bronchitis and Emphysema 常常伴发Frequently occur together 与空气污染和吸烟有关Strongly correlated with air pollution and smoking 男多于女More common in men than in women 社会经济影响Socioeconomic impact,COPD represents a growing global public health problem.,In one population based study conducted at multiple international sites, approximately 10% of participants 40 years of age or older were found to have airflow obstruction of at least moderate severity according to spirometric criteria. ( Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prevalence of COPD (the BOLD Study): a population- based prevalence study. Lancet 2007;370:741-50. ),我国国家“十五”课题最新统计数据（2005年公布）显示40岁以上人口COPD患病率为8%。估计全国有2500万人罹患此病，每年因COPD死亡的人数达100万，致残人数达5001000万，COPD居我国疾病负担的首位。,一、慢支 Chronic bronchitis,Clinical diagnostic criteria,慢性咳嗽、咳痰 每年个月 连续年,Chronic bronchitis Endoscopic image,Pathogenesis,感染 吸烟气候空气污染等,大气道病变 Large airway disease,咳嗽、咳痰Cough and sputum production Histological changes 杯状细胞数量增加 increased numbers of goblet cells in the epithelium 粘液腺数量增加 increased volume of the submucosal mucus glands 慢性炎症a component of chronic inflammation,Reid index,inner perichondrium,basal lamina,鳞化 Squamous metaplasia,Chronic inflammation Hyperemia,小气道病变 Small airway disease,呼气性呼吸困难 Decrease in maximum forced expiratory flow Histological changes 杯状细胞数量增加 presence of goblet cells in the lining epithelium 慢性炎症 a component of chronic inflammation,luminal and mucus,chronic inflammation,Pathologic changes,起始于大支气管累及小 、细支气管, 粘膜上皮的损伤和修复,纤毛倒伏、脱失 上皮细胞变性、坏死脱落，可鳞化 上皮再生，杯状细胞大量增生 （ 4 5 ：1 2 ：1 ）,慢性非特异性炎, 腺体变化,粘液腺肥大、增生 浆液腺化生为粘液腺, 管壁病变,充血、水肿，炎细胞浸润 平滑肌束断裂，软骨变性萎缩,小细支气管炎,晚期 病变向小支气管和细支气管及管壁周围组织扩展，形成细支气管周围炎；管壁增厚管腔闭塞,Clinical features,支气管粘膜炎症、粘液分泌旺盛,咳,痰,支气管痉挛，渗出物阻塞,喘,晚期表现 Late stage menifestation,血氧饱和度低 insufficient oxygenation of blood (hypoxemia) 呼吸困难 labored breathing (hypoventilation) 右心衰 right-sided heart failure (cor pulmonale),Treatment,不能根治 No cure 控制症状 relieving symptoms 防止并发症 preventing complications,二、肺气肿Pulmonary emphysema,呼吸性细支气管至肺泡的末梢肺组织因持续性含气量增加而呈过度膨胀，伴有肺泡壁弹力组织破坏，间隔断裂致肺泡互相融合，肺容积胀大的病理状态。,Abnormal permanent enlargement of airspaces distal to the terminal bronchiole, accompanied by the destruction of their walls. (morphologically defined),Inadequate ventilation Less perfusion Narrowed bronchiole,Pathogenesis,蛋白酶和抗蛋白酶水平失衡 Imbalance between proteases and anti-proteases (alpha-1 antitrypsin) in the lung Cigarette smoking 募集粒细胞和巨噬细胞 Recruits neutrophils and macrophages 氧自由基抑制抗胰蛋白酶 Oxidants and free radicals inhibit the alpha-1-antitrypsin circulating in the lung 慢支和反复感染 Chronic bronchitis and repeated infections 缺乏 Alpha-1 antitrypsin deficiency (1%),Who destroy the alveoli wall?,肺气肿类型 Types of emphysema,中央性肺气肿 Centriacinar (centrilobular) emphysema 常见 主要累及部位 respiratory bronchiole 上叶更常见 见于吸烟者,全小叶性肺气肿Penacinar (panlobular) emphysema 累及整个腺泡 下叶常见 1/20 as common as centriacinar emphysema. Seen in alpha-1-antitrypsin deficiency,肺气肿类型 Types of emphysema,隔旁肺气肿 Distal acinar (paraseptal) emphysema或小叶周围性肺气肿 远端 The distal respiratory acinus is expanded 主要部位：上叶近胸膜或隔旁,肺气肿类型 Types of emphysema,Centriacinar (centrilobular) emphysema,Centrilobular emphysema in which there are “dirty holes“ that appear focally where the central portions of lung acini have lost lung parenchyma while collecting anthracotic pigment at the same time. This pattern is typical for smokers,Centriacinar (centrilobular) emphysema,Emphysema loss of alveolar walls,镜下 ： 肺泡壁、肺泡间隔 萎缩、消失、破坏， 互相融合,其它,瘢痕旁肺气肿 Emphysema with irregular distribution re