WEBVTT00:00:03.440 --> 00:00:07.300换气道梗阻的症状表现00:00:10.400 --> 00:00:13.940典型症状特征吸气性呼吸困难00:00:14.080 --> 00:00:18.540上气道梗阻时气体吸入困难明显00:00:18.640 --> 00:00:20.560患者表现为吸气费力00:00:20.560 --> 00:00:21.940吸气时间延长00:00:22.200 --> 00:00:23.860例如在喉梗阻时00:00:23.960 --> 00:00:26.140患者会出现明显的三凹征00:00:26.560 --> 00:00:27.520即吸气时00:00:27.520 --> 00:00:29.240胸骨胸骨上窝00:00:29.240 --> 00:00:32.360锁骨上窝和肋间隙向内凹陷00:00:32.360 --> 00:00:34.000这时由于气道狭窄00:00:34.000 --> 00:00:36.940吸气时气道内负压增加00:00:37.320 --> 00:00:40.200周围软组织被吸收吸入00:00:40.200 --> 00:00:41.220形成凹陷00:00:41.520 --> 00:00:44.340严重时可伴有吸气性的喘鸣音00:00:45.320 --> 00:00:46.260喘鸣音00:00:46.320 --> 00:00:48.780是上气道梗阻的重要表现之一00:00:48.840 --> 00:00:51.420多为高调单音00:00:51.440 --> 00:00:52.700类似吹哨声00:00:52.840 --> 00:00:56.300其产生是因为气流通过狭窄的气道00:00:56.680 --> 00:00:58.660使形成湍流00:00:58.960 --> 00:01:00.340不同部位的梗阻00:01:00.440 --> 00:01:02.260唇鸣音特点有所不同00:01:02.600 --> 00:01:04.180如喉部梗阻时00:01:04.320 --> 00:01:05.680唇鸣音较响亮00:01:05.680 --> 00:01:09.020且位置比较浅气管梗阻时00:01:09.080 --> 00:01:11.740唇鸣音相对低沉且位置较深00:01:12.240 --> 00:01:14.040例如小儿急性喉炎时00:01:14.040 --> 00:01:16.600可听到典型的全飞扬咳嗽00:01:16.600 --> 00:01:18.300及吸气性喘鸣音00:01:20.800 --> 00:01:23.660隐形的症状首先是声音的改变00:01:23.920 --> 00:01:25.580喉部是发声器官00:01:25.680 --> 00:01:27.640上气道梗阻累积喉部时00:01:27.640 --> 00:01:29.140声音会发生改变00:01:29.400 --> 00:01:31.300常见的如声音嘶哑00:01:31.640 --> 00:01:33.340轻者发音粗糙00:01:33.360 --> 00:01:35.500重者声音微弱甚至失音00:01:35.680 --> 00:01:37.080这是由于喉部病变00:01:37.080 --> 00:01:39.620影响声带的正常振动00:01:40.080 --> 00:01:40.880例如00:01:40.960 --> 00:01:44.800喉炎患者随着肿瘤生长侵犯声带00:01:44.800 --> 00:01:47.140声音嘶哑症状会逐渐加重00:01:47.760 --> 00:01:50.780此外咽炎患者除了有呼吸困难00:01:50.880 --> 00:01:53.220还可出现声音含糊不清00:01:53.360 --> 00:01:55.340类似口中含物的声音00:01:57.160 --> 00:02:01.140非典型的症状特点慢性咳嗽00:02:01.280 --> 00:02:02.960部分上气道梗阻患者00:02:02.960 --> 00:02:04.940以慢性咳嗽为主要表现00:02:05.280 --> 00:02:07.300咳嗽多为刺激性干咳00:02:07.440 --> 00:02:08.700无明显咳痰00:02:08.920 --> 00:02:10.680这可能是由于气道狭窄00:02:10.680 --> 00:02:12.460导致局部气流紊乱00:02:12.680 --> 00:02:14.580刺激气道黏膜引起00:02:15.040 --> 00:02:18.020例如鼻腔分泌物倒流至咽喉部00:02:18.360 --> 00:02:19.840刺激阴部及气00:02:19.840 --> 00:02:22.720管黏膜可引发慢性咳嗽00:02:22.720 --> 00:02:26.220在晨起或体位改变时咳嗽可能加重00:02:27.400 --> 00:02:30.180临床上称为上气道咳嗽综合征00:02:32.720 --> 00:02:33.540眠障碍00:02:33.680 --> 00:02:36.240上气道梗阻可导致睡眠过程中00:02:36.240 --> 00:02:37.080呼吸不畅00:02:37.080 --> 00:02:38.380引起睡眠障碍00:02:38.880 --> 00:02:42.700患者可能出现打鼾呼吸暂停等现象00:02:42.960 --> 00:02:44.860严重影响睡眠质量00:02:45.440 --> 00:02:47.000长期睡眠呼吸障碍00:02:47.000 --> 00:02:50.140还可能导致白天嗜睡乏力00:02:50.320 --> 00:02:51.940记忆力减退的问题00:02:52.520 --> 00:02:54.580例如腺样体肥大的患儿00:02:54.880 --> 00:02:56.820由于腺样体堵塞后00:02:57.440 --> 00:02:59.000后鼻孔以及咽腔00:02:59.000 --> 00:03:02.180睡眠时可出现鼾声响亮呼吸暂停00:03:02.400 --> 00:03:03.500甚至憋醒00:03:03.880 --> 00:03:04.720长期如此00:03:04.720 --> 00:03:07.580会影响儿童的生长发育和学习成绩00:03:09.960 --> 00:03:13.340非典型特征反复的呼吸道感染00:03:13.800 --> 00:03:14.800上气道梗阻00:03:14.800 --> 00:03:17.540使气道局部防御性功能下降00:03:17.880 --> 00:03:19.340容易导致细菌00:03:19.360 --> 00:03:22.780病毒等病原体滋生和侵入00:03:22.840 --> 00:03:25.260从而引起反复的呼吸道感染00:03:25.680 --> 00:03:28.460患者可能频繁出现感冒00:03:28.760 --> 00:03:32.440扁桃体炎支气管炎等疾病00:03:32.440 --> 00:03:36.380例如患有先天性喉软化症的婴幼儿00:03:36.520 --> 00:03:38.400由于喉部结构异常00:03:38.400 --> 00:03:39.860气道相对狭窄00:03:40.320 --> 00:03:42.020容易发生呼吸感染00:03:42.520 --> 00:03:44.480且感染后病情恢复较慢00:03:44.480 --> 00:03:45.500容易反复00:03:47.760 --> 00:03:49.540症状随病情的变化00:03:51.680 --> 00:03:54.580病情初期症状在病情初期00:03:54.640 --> 00:03:56.660充气道梗阻症状较轻00:03:57.040 --> 00:03:59.060症状可能相对不明显00:03:59.440 --> 00:04:02.160患者可能仅在活动后或特定体位时00:04:02.160 --> 00:04:04.100出现轻微的呼吸困难00:04:04.280 --> 00:04:07.380如爬楼跑步后感觉呼吸稍急促00:04:07.880 --> 00:04:09.340休息后可缓解00:04:09.640 --> 00:04:11.300胎鸣音也较轻微00:04:11.320 --> 00:04:13.960可能需要在安静环境下仔细听诊00:04:13.960 --> 00:04:14.980才能听到00:04:15.560 --> 00:04:16.120声音改变00:04:16.120 --> 00:04:19.220可能仅表现为轻微的声音嘶哑00:04:19.640 --> 00:04:21.180不影响正常交流00:04:21.800 --> 00:04:23.640例如早期喉癌患者00:04:23.640 --> 00:04:26.660可能只是偶尔感觉喉部不适00:04:26.920 --> 00:04:28.160声音稍有变化00:04:28.160 --> 00:04:29.300容易被忽略00:04:33.360 --> 00:04:37.040病情进展期症状随着病情进展00:04:37.040 --> 00:04:38.280梗阻程度加00:04:38.280 --> 00:04:40.420重症状逐渐加重00:04:41.080 --> 00:04:42.240呼吸困难加重00:04:42.240 --> 00:04:44.540即使在安静状态下也可出现00:04:44.760 --> 00:04:47.680患者甚至可能要采取端坐位00:04:47.680 --> 00:04:48.640或伴卧位00:04:48.640 --> 00:04:50.140来缓解呼吸困难00:04:50.800 --> 00:04:52.340喘鸣音变得响亮00:04:52.400 --> 00:04:54.980可在远处听到00:04:55.400 --> 00:04:56.700声音嘶哑加重00:04:56.720 --> 00:04:59.220甚至影响正常发声和交流00:04:59.800 --> 00:05:03.320此外患者可能还出现烦躁不安00:05:03.320 --> 00:05:05.340出汗缺氧等症状00:05:05.800 --> 00:05:09.420比如会咽炎患者在发病数小时后00:05:09.640 --> 00:05:11.200会咽肿胀加剧00:05:11.200 --> 00:05:13.620上气道梗阻梗阻加重00:05:14.000 --> 00:05:16.640可出现严重的呼吸困难和喘00:05:16.640 --> 00:05:20.740因患者因缺氧而表现出烦躁00:05:20.880 --> 00:05:22.100面色发干等00:05:25.120 --> 00:05:25.960病情严重00:05:25.960 --> 00:05:28.860皮的症状病情严重时00:05:29.120 --> 00:05:31.820上气道完全几乎完全梗阻00:05:32.240 --> 00:05:34.820患者会出现极度呼吸困难00:05:34.960 --> 00:05:36.960表现为呼吸浅快00:05:36.960 --> 00:05:39.100鼻翼煽动口唇发干等00:05:39.840 --> 00:05:42.220喘鸣可变得微弱甚至消失00:05:42.480 --> 00:05:44.680滞水由于气道严重狭窄00:05:44.680 --> 00:05:46.300气流无法通过00:05:46.560 --> 00:05:48.860患者可迅速陷入昏迷00:05:49.080 --> 00:05:51.060呼吸衰竭等危险状态00:05:51.480 --> 00:05:52.680如不及时救治00:05:52.680 --> 00:05:53.860可危及生物00:05:54.080 --> 00:05:56.940异物异物完全堵塞气管时00:05:57.160 --> 00:06:00.220患者会在短时间内出现窒息症状00:06:00.720 --> 00:06:03.400不采取立即采取急救措施00:06:03.400 --> 00:06:05.700很快会导致心跳骤停00:06:10.880 --> 00:06:12.700气道梗阻的诊断方法00:06:13.200 --> 00:06:15.580临床症状诊断要点00:06:16.200 --> 00:06:18.020呼吸困难特点的判断00:06:18.280 --> 00:06:21.400通过观观察患者呼吸困难的类型00:06:21.400 --> 00:06:24.580来初步判断梗阻情况00:06:24.800 --> 00:06:28.280吸气性呼吸困难多见于上气道梗阻00:06:28.280 --> 00:06:29.560如喉梗阻时00:06:29.560 --> 00:06:31.080患者吸气费力00:06:31.080 --> 00:06:33.300吸气时间显著延长00:06:33.640 --> 00:06:35.140可出现三凹征00:06:35.520 --> 00:06:37.280而呼气型呼吸困难00:06:37.280 --> 00:06:39.580更多与下气道梗不相关00:06:39.680 --> 00:06:41.640例如小儿急性喉炎00:06:41.640 --> 00:06:44.540常表现为吸气型呼吸困难00:06:45.160 --> 00:06:49.080医生可可根据初步判断病别部位00:06:49.080 --> 00:06:50.180在上气道00:06:50.760 --> 00:06:52.660传鸣音特征的分析00:06:53.160 --> 00:06:56.520传鸣音的性质部位及时间等特征00:06:56.520 --> 00:06:58.300对诊断有重要意义00:06:59.160 --> 00:07:01.360高调单音且位置00:07:01.360 --> 00:07:02.780浅表的传鸣音00:07:03.120 --> 00:07:04.660床体是喉部梗阻00:07:05.040 --> 00:07:08.180相对低沉且位置较深的喘鸣音00:07:08.200 --> 00:07:10.220可能与气道梗阻有关00:07:10.720 --> 00:07:12.920吸气期出现的喘鸣音00:07:12.920 --> 00:07:14.700多为上气道梗阻00:07:15.040 --> 00:07:16.520呼气期喘鸣音00:07:16.520 --> 00:07:19.380则可能与下气道病变有关00:07:19.840 --> 00:07:23.040如再诊断喉部肿物导致的梗阻00:07:23.040 --> 00:07:24.840失传鼻音的这些特征00:07:24.840 --> 00:07:27.780可以帮助医生定位梗阻部位00:07:31.600 --> 00:07:36.060临床诊断要点一声音变化的评估00:07:36.320 --> 00:07:38.580仔细评估患者声音的改变00:07:38.880 --> 00:07:40.480声音嘶哑声音00:07:40.480 --> 00:07:43.540或声音含糊不清等表现00:07:43.720 --> 00:07:46.780若伴有上气道梗阻相关症状00:07:47.120 --> 00:07:49.340提示喉部可能存在病变00:07:49.640 --> 00:07:51.280声音嘶哑逐渐加重00:07:51.280 --> 00:07:53.500可能是喉部肿瘤等疾病00:07:53.760 --> 00:07:54.440例如00:07:54.440 --> 00:07:57.160对于长期吸烟且出现声音嘶哑00:07:57.160 --> 00:07:59.340并伴有呼吸困难的患者00:07:59.640 --> 00:08:03.040医生会高度怀疑喉部肿瘤00:08:03.040 --> 00:08:04.780导致的上气道梗堵00:08:06.320 --> 00:08:07.620x线检查00:08:09.520 --> 00:08:11.340影像学诊断技术00:08:11.960 --> 00:08:14.280x线正位片和侧位片00:08:14.280 --> 00:08:15.360可帮助观察00:08:15.360 --> 00:08:18.020上气道的大致形态和结构00:08:19.520 --> 00:08:21.400如颈部x线侧位片00:08:21.400 --> 00:08:23.740可以显示喉部气管的轮廓00:08:24.080 --> 00:08:25.480对于判断有无异物00:08:25.480 --> 00:08:28.780气道狭窄等情况有一定的价值00:08:29.760 --> 00:08:32.560在诊断小儿气气管异物时00:08:32.560 --> 00:08:36.580x线检查可发现不透光异物的存在00:08:36.880 --> 00:08:37.780的位置00:08:38.000 --> 00:08:41.100为后续提供治疗提供重要依据00:08:41.400 --> 00:08:44.100不过对于一些软组织的病变00:08:44.280 --> 00:08:47.580x线的诊断诊断准确性有限00:08:48.440 --> 00:08:50.780ct扫描ct扫描00:08:50.960 --> 00:08:54.620能更清晰的显示上气道的结构00:08:54.760 --> 00:08:56.980解剖结构00:08:57.280 --> 00:08:59.080对于病变的定位00:08:59.080 --> 00:09:01.180定性诊断有很大的帮助00:09:01.800 --> 00:09:04.200他可以发现鼻腔鼻窦00:09:04.200 --> 00:09:06.820喉咽部及气管的微小碰点00:09:07.240 --> 00:09:10.140如肿瘤的大小位置00:09:10.400 --> 00:09:12.180与周围组织的关系00:09:13.440 --> 00:09:15.300对于诊断早期喉癌00:09:15.520 --> 00:09:18.580ct能准确的显示肿瘤的范围00:09:18.720 --> 00:09:20.760为制定治疗方案提00:09:20.760 --> 00:09:22.100供重要信息00:09:22.400 --> 00:09:25.860多层螺旋ct还能进行三维重建00:09:26.040 --> 00:09:28.220更直观的观察起到情况00:09:33.440 --> 00:09:35.920磁共振磁共振mri00:09:35.920 --> 00:09:38.780对于软组织的分辨能力强00:09:39.040 --> 00:09:40.240能更好地显示00:09:40.240 --> 00:09:42.900上气道周围组织的病变情况00:09:43.240 --> 00:09:46.980在诊断上气道肿瘤侵犯周围组织时00:09:47.400 --> 00:09:50.820核磁可以清晰地显示肿瘤的边界00:09:51.080 --> 00:09:52.580有无淋巴结转移等00:09:53.240 --> 00:09:56.480例如对于咽鼻咽癌患者00:09:56.480 --> 00:09:59.440核磁能准确的判断肿瘤是否侵犯00:09:59.440 --> 00:10:01.060颅底等重要结构00:10:01.400 --> 00:10:05.240对疾病的分期和治疗方案的选择00:10:05.240 --> 00:10:07.140有具有重大意义00:10:07.440 --> 00:10:09.700达克斯的检查费用较高00:10:09.760 --> 00:10:11.100检查时间较长00:10:11.280 --> 00:10:14.620且对体内有金属植入的患者不适用00:10:19.160 --> 00:10:22.280血常规的检查通过血常规检查00:10:22.280 --> 00:10:23.720可了解白细胞00:10:23.720 --> 00:10:26.980中性粒细胞淋巴细胞等激素及比例00:10:27.160 --> 00:10:28.220在炎症00:10:28.680 --> 00:10:31.160因疾病导致的上气道梗阻中00:10:31.160 --> 00:10:33.440白细胞计数和中心粒细胞比例00:10:33.440 --> 00:10:34.740通常会增高00:10:34.960 --> 00:10:36.260提示细菌感染00:10:36.520 --> 00:10:37.920淋巴细胞比例升高00:10:37.920 --> 00:10:39.700可能与病毒感染有关00:10:40.000 --> 00:10:40.600例如00:10:40.600 --> 00:10:43.620急性扁桃体炎引起的上气道梗阻00:10:43.840 --> 00:10:45.360血常规检查可发现00:10:45.360 --> 00:10:47.200白细胞激素明显升高00:10:47.200 --> 00:10:49.380以中性粒细胞为主00:10:49.400 --> 00:10:51.280有助于判断感染类型00:10:51.280 --> 00:10:53.020直到抗生素的使用00:10:53.840 --> 00:10:55.140crp的检测00:10:55.840 --> 00:11:00.140crp是一种急进食相反应蛋白00:11:00.480 --> 00:11:03.980在炎症感染等情况下会迅速升高00:11:05.720 --> 00:11:08.860在诊断上极道梗阻病因时00:11:09.040 --> 00:11:14.000crp检测可辅助判断病情的严重程度00:11:14.000 --> 00:11:15.580和炎症的状态00:11:15.680 --> 00:11:17.400如在婚姻炎患者中00:11:17.400 --> 00:11:19.980crp水平往往显著升高00:11:20.360 --> 00:11:23.620且其升高程度与病情严重程度相关00:11:24.200 --> 00:11:25.920动态监测crp水平00:11:25.920 --> 00:11:27.980还可评估治疗效果00:11:28.160 --> 00:11:30.760无效若治疗效果有效00:11:30.760 --> 00:11:32.820crp水平会逐渐下降00:11:34.920 --> 00:11:37.760实验室检查辅助手段过敏源的检00:11:37.760 --> 00:11:38.560测00:11:38.920 --> 00:11:41.520对于怀怀疑过敏性因素00:11:41.520 --> 00:11:43.820导致的上气道梗阻的患者00:11:44.280 --> 00:11:46.040过敏原检测可明确00:11:46.040 --> 00:11:46.860过敏原00:11:47.000 --> 00:11:49.400常见的检测方法有皮肤检测00:11:49.400 --> 00:11:52.740实验和血性特异igg检测00:11:53.080 --> 00:11:55.100例如过敏性鼻炎患者00:11:56.320 --> 00:11:58.140进行过敏源的检测00:11:58.240 --> 00:11:59.840可发现对花粉00:11:59.840 --> 00:12:02.860尘螨等过敏源呈阳性反应00:12:03.640 --> 00:12:05.140明确过敏源后00:12:05.320 --> 00:12:08.420患者可采取针对性的预防措施00:12:08.840 --> 00:12:10.580如避免接触过敏源00:12:10.720 --> 00:12:11.620同时00:12:11.760 --> 00:12:15.500也可有助于制定合理的治疗方案00:12:15.600 --> 00:12:17.460如进行脱敏治疗的00:12:29.040 --> 00:12:29.840再次00:12:34.280 --> 00:12:37.760再次分享临床症状诊断的要点00:12:37.760 --> 00:12:39.500呼吸困难特点的判断00:12:39.960 --> 00:12:43.440通过观察患者呼吸困难的类型00:12:43.440 --> 00:12:45.740来初步诊断梗阻的情况00:12:45.960 --> 00:12:49.380吸气型呼吸困难多见于上气道梗阻00:12:49.840 --> 00:12:52.700喉梗阻时患者吸气费力00:12:53.000 --> 00:12:55.060吸气的时间显著延长00:12:55.120 --> 00:12:56.780可出现三凹征00:12:58.480 --> 00:13:00.320而呼气型呼吸困难00:13:00.320 --> 00:13:02.620多与下呼吸道梗阻相关00:13:02.880 --> 00:13:05.320例如小儿喉吸性喉延长00:13:05.320 --> 00:13:07.420表现为吸气型呼吸困难00:13:07.920 --> 00:13:11.560医生可根据此初步判断病变部位00:13:11.560 --> 00:13:14.280在上气道喘鸣音的特征00:13:14.280 --> 00:13:16.480分析喘鸣音的性质00:13:16.480 --> 00:13:18.640部位和时间等特征00:13:18.640 --> 00:13:20.900对诊断具有重要的意义00:13:22.360 --> 00:13:26.600单调单音且位置浅表的喘鸣音00:13:26.600 --> 00:13:28.460常提示喉部梗阻00:13:28.920 --> 00:13:31.880相对低沉且位置较深的喘鸣00:13:31.880 --> 00:13:34.140可能与气道梗阻有关00:13:34.520 --> 00:13:38.260吸气期出现的喘鸣多为上气道梗阻00:13:38.600 --> 00:13:39.920呼吸期喘鸣00:13:39.920 --> 00:13:42.500则可能与下气道病变有关00:13:44.000 --> 00:13:45.480如诊断不再00:13:45.480 --> 00:13:48.420诊断喉部肿物导致的梗阻时00:13:48.680 --> 00:13:51.480喘鸣的这些特征可以帮助医生定位00:13:51.480 --> 00:13:52.580根据部位00:14:02.440 --> 00:14:05.300再次分享病情严重时的症状00:14:05.680 --> 00:14:07.180病情严重时00:14:07.280 --> 00:14:09.500双气道几乎完全梗阻00:14:09.680 --> 00:14:12.580患者会出现极度呼吸困难00:14:12.880 --> 00:14:14.520表现为呼吸浅快00:14:14.520 --> 00:14:17.060鼻翼煽动喉唇发干等00:14:17.600 --> 00:14:19.240喘鸣可变得微弱甚00:14:19.240 --> 00:14:22.400至消失这是由于气道严重狭窄00:14:22.400 --> 00:14:23.900气流无法通过00:14:24.280 --> 00:14:26.520患者可迅速陷入昏迷00:14:26.520 --> 00:14:28.580呼吸衰竭等危险状态00:14:28.920 --> 00:14:31.580不及时救治可危及生命00:14:31.880 --> 00:14:34.580例如异物完全阻塞气管时00:14:34.800 --> 00:14:37.300患者会在短时间内出现窒息00:14:37.520 --> 00:14:40.200如不立即采取急救措施00:14:40.200 --> 00:14:42.180很快导致心脏骤停00:14:43.360 --> 00:14:44.880如导致心脏骤停00:14:44.880 --> 00:14:50.060应采取急诊手段进行cpr复苏00:14:51.280 --> 00:14:53.580必要时可以轻吻切开00:14:57.960 --> 00:15:00.100放弃到的整套方法呦00:15:02.280 --> 00:15:07.620x线ct lobs等多项金属