TRUONG DAI HOC Y HA NOI■ ■ ■

CAC BO MON NOI■ ■

B a i g i a n g

BENH HOC N0IKHOATAP I

NHA XUAT BAN Y HOC■

TRUONG DAI HOC Y HA NOI

CAC BO MON NOI

BAI GIANG BENH HOC NOI KHOA

TAPI

(Tai ban Ian thiC chin co siia chiia va bo sung)

NHA XUAT BAN Y HOC

HA NOI - 2004

Tham gia bien soan:

PGS.TS. NGUYEN THjMINH AN

GS. TS. TRAN NGOC AN

PGS. TS. PHAM THI THU HO

TS. NGO QUY CHAU

GS. PHAM KHUE

GS. PHAM GIA KHAI

PGS. BS. NGUY§N VAN THANH

GS. TS. TRAN OCfC THO

GS. TS. NGUY6N KHANH TRACH

TS. DO TH| LIEU

GS. TS. NGUY§N LAN VIET

GS. TS. NGUY§N VAN XANG

TS. CHU VAN Y

Thir ky bien soan:

GS. TS. TRAN NGOC AN

PGS. TS. PHAM TH| THU H6

LDfl NOI DAU

Bai giang benh hoc noi khoa do can bo giang day cac bo mon noi thuoc TrUbng Dai hoc Y Ha Noi bien soan nham cung cap mot so tai lieu de sinh men cac Ictp Y3 - Y6 theo chtfdng trinh cai cach mdi dung de hoc tap va tham khao khi hoc ly thuyet cung nhtf khi thiCc hanh d benh vien.

Noi khoa la mot trong nhiing mon hoc chinh cua cac Tritilng Dai hoc Y. Noi dung can ditrfc sita doi bo sung cho phii help uc'fi sit tien bo khong ngitng cua y hoc.

Lan tai ban nay mot so chiidng da diCOc siCa chiia va bo sung de cap nhat cac kien thiic mdi cua y hoc.

Tuy nhien trong dieu kien so can bo con it oi, thdi gian han che cuon sach khong tranh khoi thieu sot nhat dinh, mong ban doc gop y de lan tai ban sau cuon sach dit(lc hoan thien hdn.

Xin tran trong cam (fn

TRl/ONG DAI HOC Y HA NOI■ ■ ■

Cac bo mon noi

C H lfO N G I

HO HAP

VIEM PHE QUAN CAP

I. DAI ClTdNG VA DINH NGHIA

Viem phe quan cap la tinh trang viem nhiem niem mac cua phe quan 16n va phe quan trung binh, khi viem nhiem ca kin quan thi goi la viem khi- phe quan. Viem nhiem lan den tieu phe quan tan va phe nang thi goi la phe quan-phe viem. Viem phe quan cap co the xay ra b bat ky ltia tuoi nao nhtfng nhieu nhat la tre em va ngUdi gia.

Benh hay xay ra ve mua lanh va dau mua xuan. Trieu chiing lam sang chmh la ho va khac ddm nhay - mu. Benh tien trien lanh tfnh sau khi khoi khong de lai di chiing.

Viem phe quan la mot van de siic khoe cong dong quan trpng lam nhieu ngUOi phai nghi viec hoac nghi hoc di kham benh va dung cac thuoc khang sinh.

II. NGUYEN NHAN

1. Viem phe quan cap do virus

Viem phe quan cap do virus chiem 50 t6i 90% cac trtfcing hdp viem phe quan cap. Ngifdi ta da ghi nhan co tren 180 virus gay benh. Cac virus thiidng gap nhat la cac myxovirus (virus cum va virus a cum), cac rhino''irus, coronavirrus, virus dai thUc bao dUdng ho hap (Respiratory Syncticial Virus), Adenovirus, enterovirus (coxsackie va echovirus) va mot so"chiing herpes virus (CMV, varicellae).

2. Viem phe quan cap do vi khuan

Viem phe quan cap do vi khuan it gap hdn cac trUdng hdp viem phe quan cap do virus. Trong so cac vi khuan gay viem phe quan cap thUdng gap nhat la cac vi khuan trong te bao nhtf Mycoplasma, va Chlamydiae, cac vi khuan gay mu hiem gap hdn. Cac triidng hdp nhilm khuan do Mycoplasma pneumoniae bieu hien bang viem phe quan d 25 % cac trifdng hdp (viem mui

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hong dOn thuan chiem 60%, viem phoi chi chiem 5%. Mycoplasma pneumoniae va Chlamydiae pneumoniae la nguyen nhan cua 25 % cac trvfOng hdp viem phe quan cap. Tuy nhien ty le mac benh chfnh xac kho xac dinh do trif d cac trUdng hdp viem phoi thi ngUdi ta khong lam cac huyet thanh chan doan, ngay ca d cac nU6c phat trien. Viem phe quan cap do phe cau va hemophillus influenzae thifdng it gap d ngUdi 16n, hay di kem v6i sot va cac dau hieu ngoai dtfdng ho hap. Xet nghiem vi khuan thUcing am tmh ci 80 den 95 % cac trtfdng hdp viem phe quan cap.

3. Hit phai hoi docKhoi thuoc la, chlore, Amoniac, acid, dung moi cong nghiep, hdi doc

chien tranh.

4. Yeu to" di vfngViem phe quan cap xay ra cJ tre con giong nhif cdn hen phe quan, viem

phe quan cap cung hay xay ra tren ngtfdi hen, may day, phu Quinck.

5. Nguyen nhan thuan lOi- Thay doi thdi tiet, nhiem lanh dot ngot.- Cd the suy mon, coi xufdng, suy dinh difdng cJ tre em, suy giam

mien dich.- ti dong phoi do suy tim.- Cac benh cua phoi nhu lao phoi va ung thu phoi.- Moi trUdng song am thap nhieu khoi bui.

III. GIAI PHAU BENH LY

Vi tri ton thifdng: ton thUdng giai phau thay d phe quan goc, phe quan thuy co the ca khi quan va phe quan tan.

Nhiing ton thifdng thay diidc: niem mac phe quan bi phu ne, sung huyet, cac mach mau gian to, co 16p dich nhay, mu bao phu, xam nhap bach cau da nhan, te bao bieu mo bi bong va co cho bi loet, cac tuyen nhay cang va tang tiet.

IV. TRIEU CHtTNG

Viem phe quan cap do virus bat dau dien hinh bang viem long dUdng ho hap tren v6i h^t hdi, so mui va/hoac viem mui hong. Ton thifdng viem lan xuong dUdng ho hap du6i bieu hien trtfcic tien bang ho khan, ho tiing cdn, ho ong ong va dau. Day la luc benh toan phat gom 2 giai doan:

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1. Giai doan kho

Benh nhan thiidng co cam giac rat bong sau xtfdng \ic lien quan den viem khi phe quan, cam giac nay tang len khi ho, dau ngiic nguon goc do cd vi ho lien tuc. Ho khan, co khi ho ong ong, ho tifng cdn, khan tieng.

Trieu chiing toan than: thtfdng sot vtifa, khoang 38°C. Nhtifc dau, met moi, dau minh may, bieng an. Kham phoi luc dau binh thUdng, sau co the thay rai rac co ran rft va ran ngay. Giai doan nay keo dai 3-4 ngay thi chuyen sang giai doan U6t.

2. Giai doan tfdt

Cam giac dau rat bong sau xUdng lie giam dan roi het han, kho thcf nhe, ho khac ddm nhay, ddm nhay mau hoac ddm vang-mu. Nghe phoi co the co ran ngay va ran am, go khong thay vung due. Giai doan nay keo dai 4-5 ngay va khoang 10 ngay thi khoi h&n. C) mot so" trufdng hdp ho khan keo dai nhieu tuan le (tang tfnh phan ling phe quan sau nhiem trung). Doi khi benh bat dau mot cach ram ro: sot cao, ho nhieu, ho ra mau... Neu d ngUdi 16n tuoi nghien thuoc la co ho ra mau can chu y tim ung thu phe quan bang cach soi phe quan ke ca trong trUdng hdp X quang khong co bieu hien gi ro ret. Dau hieu X quang: trong viem phe quan cap thUdng khong co gi dac biet, co the thay thanh phe quan day.

Xet nghiem: cong thtic bach cau va mau l4ng tang vtfa phai. Cay ddm: thay nhieu loai vi khuan nhUng ft co gia tri de chan doan va thong thUdng khong co chi dinh lam xet nghiem nay.

V. CHAN DOAN1. Chan doan xac dinh dvfa vao1.1. Trieu chiing cua viem ditdng ho hap tren

- Nhe: viem hong do, chay nU6c mui.- Nang: viem mui mu, viem xoang, viem amidan, viem tai giGa.

1.2. Trieu chiing cua viem ditdng ho hap ditai

- Nhe: ho, khan tieng, thci kho khe va dau hieu cua viem dtfdng ho hap tren, nghe phoi co the co ran ngay, ran rft.

- Nang: ngoai jihting trieu chijfng tren, kho thd ro ret, co keo long ngtic, tfm, nhip thd nhanh tren 30 lan/phut. Nghe phoi co ran rft, ran bot d vung day phoi phfa sau lifng.

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2. Chan doan phan biet

- C) tre em neu trieu chiing viem phe quan keo dai, can nghi den hach d trung that, chen ep phe quan, di vat phe" quan hoac gian phe quan.

P . ^ ^ y ty ty ^

- O ngUdi 16n: nhieu benh phoi co bieu hien viem phe" quan nhif: lao phoi v6i hang lao do vao phe quan, benh bui phoi, ung thu phoi. Khong nghi den viem phe quan neu trieu chting nghe phoi chi 0 mot ben.

- U* dong b phoi trong trUdng hdp suy tim (co trieu chiing suy tim).- Hen phe quan tang tiet dich: sau cdn hen thi het cac trieu chiing.

VI. TIEN TRIEN, BIEN CHIING1. Tien trien trvfdc mat

Tien ltfdng gan cua viem phe quan cap noi chung la tot. Tuy nhien tien trien trU6c mat co the dang lo ngai hdn b mot so" cd dia nhu suy ho hap man tinh, hen phe" quan, hoac suy tim va trong trufdng hdp viem tieu phe" quan b tre nho. O ngufdi 16n tuoi, tinh trang suy yeu he thong mien dich bao ve, va cac bien doi ve giai phau tai cho co the lam cho benh de lan t6i cac tieu phe quan tan va cac phe nang dan den benh canh viem phoi cap vdi tien ltfdng nang hdn.

2. Tien trien lau dai

Phan 16n benh khoi hoan toan khong de lai di chiing. Benh tai phat nhieu lan co the dan den gian phe quan hoac viem tieu phe" quan bit tkc, nhat la d tre em.

2.1. Viem tieu phe quan bit tac

C) tre em sau viem tieu phe" quan do virus, sU viem va hoai tU nghiem trong bieu mo phe" quan co the dan tdi tang sinh rat manh cac te" bao bieu mo phu tieu phe quan gay bit tic long phe" quan bdi to chiic xd seo. Benh canh lam sang bieu hien bang suy ho hap man tinh v6i kho thd, ho va tieng bat thUdng dac trUng nghe thay d thi hit vao. Ve chtic nang ho hap thUdng co ro"i loan thong khi tac nghen nang, khong hoi phuc v6i thuoc gian phe quan cifdng P2 hoac corticoid. Tien lufdng khong biet trU6c dUdc, thUdng nang, doi khi cai thien tam thdi v6i corticoid hoac thuoc lie che" mien dich.

CJ ngUdi 16n sau nhiem trung do virus hiem khi xuat hien viem tieu phe" quan bit the va neu co thi phai tim xem benh nhan co bi cac benh he thong (xd ciing bi, viem da kh6p dang thap) hoac mot so nguyen nhan do dung thuoc (dieu tri bang D-penicillamine).

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2.2. Chiing tang tinh phan ting phe quan

Tang tinh phan ting phe quan va/hoac roi loan thong khi tac nghen thoang qua co the gap trong moi trUdng hdp viem phe quan cap, ngay ca d nhting ngUdi trU6c day khong he bi cac benh ho hap. Cac roi loan nay, thUdng thay sau khi bi viem phe quan do virus hoac do mycoplasma, co the bien di d 40 % cac trUdng hdp trong vong 2 thang sau ddt viem khdi phat. Vi vay can chd sau thdi gian nay mcii nen ket luan la co tinh trang tang tinh phan ting phe quan hoac co hen phe quan.

VII. DIEU TRI

(3 ngUdi binh thUdng hiem khi can dieu tri viem phe quan cap. Khi co chi dinh chi dieu tri trieu chting vdi nghi ngdi tai giUdng, cho du lifdng nUcic uong, cac thuoc chong viem khong phai corticoid hoac mot ddt ngan corticoid dUdng uong (prednison: 0,5 mg/kg/ngay trong 5 den 7 ngay), thuoc giam dau thong thUdng, cac thuoc giam ho nhu sirop Codein khi ho khan nhieu va co the dung cac thuoc gian phe quan cUdng P2 dUdng phun hit khi co dau hieu co that phe quan. Chtfa co nghien ctiu nao chting minh hieu qua cua cac thuoc long ddm.

Khong can dung khang sinh cho viem phe quan cap d ngUdi binh thUdng. Cac thuoc khang sinh khong lam thay doi tien trien cua benh va gay tang chi phi dieu tri. Cac khuyen cao lien quan den viec dung khang sinh trong viem phe quan cap la: ho keo dai va khac ddm mu tren 7 ngay, cd dia viem phe quan man tinh hoac co viem mui mu, viem amidan, viem VA, viem tai gitia phoi hdp. Trong cac trUdng hdp nay, khang sinh dUdc khuyen cao la dung mot loai thuoc trong nhom penicillin A hoac macrolid nhtf erythromycin l,5g ngay trong 10 ngay, Rulid 150mg x 2 lan/ngay.

Viec ngting hut thuoc la mot thanh phan cd ban cua dieu tri d nhting ngifdi nghien thuoc la, thuoc lao.

Dieu tri cac nguyen nhan thuan ldi neu co.

VIII. PHONG BENH

- Loai bo ye"u to klch thlch: khong hut thuoc, tranh khoi bui trong nha, moi trUdng o nhiem.

- Giti gin stic khoe, giti am nhat la mua lanh.- Gay mien dich bang tiem chung vacxin chong virus, vi khuan.

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BENH PHOI TAC NGHEN MAN TINH • •

1. Dinh nghia

Benh phoi tac nghen man tinh la tinh trang benh co roi loan thong khi tac nghen khong co kha nang hoi phuc hoan toan. Su can trd thong khi thUdng tien trien tti tti va lien quan den phan ting viem bat thufdng cua phoi do cac phan tti hoac khi doc hai.

2. Dich te hoc benh phoi tac nghen man tinh

Theo WHO, nam 1990, ty le bi mac benh phoi tac nghen man tinh tren toan the gi6i U6c tinh khoang 9,34/1000 0 nam va 7,33/1000 0 nti. Tuy nhien, nhting U6c tinh nay bao gom 0 mm ltia tuoi va chtfa phan anh dung ty le benh phoi tac nghen man tinh thifc ci ngiidi cao tuoi. Ty le mac benh phoi tac nghen man tinh cao nhat d nhting nuf6c da va dang thinh hanh viec hut thuoc trong khi ty le mac benh phoi tac nghen man tinh thap nhat d nhting nU6c it hut thuoc hdn hay co ty le tieu thu thuoc la tren moi ca the thap.

Tren toan the" gicii benh phoi tac nghen man tinh hien la nguyen nhan gay tti vong hang thti 4, va dtf bao con tang len trong nhting nam t6i. C) My ty le chet do benh phoi tac nghen man tinh rat thap d tuoi du6i 45 nhufng sau do tang dan theo tuoi. Benh phoi tic hghen man tinh tr3 thanh nguyen nhan dting hang thti tii hoac thti nam gay tti vong d tuoi tren 45.

3. Cac yeu to" nguy cd gay benh phoi tac nghen man tinh3.1. Thuoc la

- La nguyen nhan chinh cua benh, va tti vong do benh phoi tkc nghen man tinh. Ngting hut thuoc lam giam cac yeu to" tren. Khoang 15% so nhting ngufdi hut thuoc co trieu chting lam sang cua benh phoi tac nghen man tinh.

- 80- 90% cac benh nhan benh phoi tac nghen man tinh deu co hut thuoc.

- Hut thuoc la thu dong: tre em trong gia dinh co ngUdi hut thuoc la bi cac benh difdng ho hap tren vdi ty le cao hdn tre em trong gia dinh khong co ngtfdi hut thuoc.

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