【临床医学】肺炎.ppt

<p>Respiratory DiseasesPneumoniaDr.Bijie HU（胡必杰）Zhongshan Hospital of Fudan UniversityShanghai5/22/20241Dr.HU Bijie5/22/20242Dr.HU BijieSeminSemin RespirRespir Infect Infect 9(3):140-52 9(3):140-52，19941994mortality(per10 000)mortality(per10 000)Mortality Trends with Pneumonia from 1900 to 1990 in USAMortality Trends with Pneumonia from 1900 to 1990 in USA02040608010012014016018020019001910192019301940195019601970198019905/22/20243Dr.HU Bijie5/22/20244Dr.HU Bijie 1990 2020Cardiovascular diseaseCerebrovascular diseasesLower respiratory infectionsDiarrheaPerinatal diseaseCOPDTuberculosisMorbilliTraffic accidentsLung cancerGastric cancerHIVsuicideEditorial,Lancet,1997,349:1263.Mortality Forecast by WHO5/22/20245Dr.HU BijieEpidemiology6th leading cause of death in U.S.Number one Among the infectious diseases5.6 million patients annually in USIncidence 510/1,000/yearMortality in OPD patients 1-5%,but Inpatients 25%,ICU 50-60%5/22/20246Dr.HU BijieDefinitionPneumonia is the inflammation of lower respiratory tracts including alveoli,interstitial tissues,and broncioles by the microorganisms,chemical irritations or by an immunological process 5/22/20247Dr.HU BijieClassifications&amp;TerminologyMild,moderate,severe Lobar vs interstitialInfections vs.noninfectionsBacterial,viral,fungal,parasiticPrimary vs.SecondaryCommunity Acquired Pneumonia Nosocomial Pneumonia Ventilator Associated PneumioniaTypical vs.AtypicalImmune compromised vs.Normal immunity5/22/20248Dr.HU BijieKey Bacterial Pathogens of CAP:A Global Meta-AnalysisFine MJ et al.JAMA 1996;275(2):134-41.Study cohorts:N=127Total patients:N=33,148Total patients reporting data:N=6866S.S.pneumoniaepneumoniae66%66%Other12%Legionella spp.4%M.pneumoniae7%H.influenzae12%5/22/20249Dr.HU BijieCausative pathogens in 5,961 adults admitted to hospital with CAP identified in 26 prospective studies from 10 European countriesS S pneumoniaepneumoniaeC C pneumoniaepneumoniaeViralViralMycoplasmaMycoplasma pneumoniaepneumoniaeLegionella spLegionella spH H influenzaeinfluenzaeG-G-negneg enterobacteriaenterobacteriaC C psittaciipsittaciiCoxiellaCoxiella burnetiiburnetiiStaphStaph aureusaureusM M catarrhaliscatarrhalisOtherOtherWoodhead M.Chest 1998;183S-187S5/22/202410Dr.HU BijiePathogens of Hospital Acquired Pneumonia(HAP)Mild to moderate HAP or early severe HAPStreptococcus pneumoniaeHaemophilus influenza MSSAKlebsiella PneumoniaeEnterobacter,E coli,Proteus,SerratiaSevere HAPPseudomonasAcinetobacterMRSA5/22/202411Dr.HU BijiePneumococcal Pneumonia5/22/202412Dr.HU BijieEtiology：S.pneumoniaGram-postive coccusmost common identifiable cause of bacterial pneumonia and accounts for 2/3 of bacteremic CAPPneumococcal pneumonia generally occurs sporadically but most frequently in winterIt occurs most commonly in persons at age extremes.5 to 25%of healthy persons are carriers of pneumococci,with the highest rates noted in winter for children and parents of young children.There are 80 serotypes(based on antigenically distinct capsular polysaccharides).5/22/202413Dr.HU BijiePathogenesisHost defenses impairedInoculum sufficient to cause infection enters lower respiratory tractVirulent organism5/22/202414Dr.HU BijiePathogenesisPneumococci usually reach the lungs by inhalation or aspiration.(Routes of entry for nosocomial pneumonia:Microaspiration,Inhalation,Hematogenous spread,Direct extension,Via ET tube)They lodge in bronchioles,proliferate,and initiate an inflammatory process that begins in alveolar spaces with an outpouring of protein-rich fluid.The fluid acts as culture medium for the bacteria and helps spread them to neighboring alveoli,typically resulting in lobar pneumonia.5/22/202415Dr.HU BijiePathologyCongestion:earliest stage of lobar pneumonia,extensive serous exudation,vascular engorgement,and rapid bacterial proliferation.Red hepatization:consolidated lung,Airspaces are filled with polymorphonuclear cells,vascular congestion occurs,and extravasation of RBCs causes a reddish discoloration on gross examination.Gray hepatization:accumulation of fibrin,associated with inflammatory WBCs and RBCs in various stages of disintegration,and alveolar spaces are packed with an inflammatory exudate.Resolution:characterized by resorption of the exudate5/22/202416Dr.HU BijieManifestationSystematicoften preceded by a URIsudden onset,shaking chill,Feverother:nausea,vomiting,malaise,and myalgiasLocal pain with breathing on the affected side(pleurisy)Cough：(dry initially but usually becomes productive,dyspnea,and sputum production）SignT:38 40.5;pulse is usually 100 to 140 beats/min;respirations accelerate to 20 to 45 breaths/min.lobar consolidation；crackles;pleural effusion5/22/202417Dr.HU BijieSevere PneumoniaRespiratory rate 30/minPaO2/FiO2 ratio 50%within 48 hoursB.P.90systolic or 60 mmHg diastolicNeed for vasopressorsRenal failure5/22/202418Dr.HU BijieComplications:Serious and potentially lethal progressive pneumoniaARDSseptic shockSpecial infections:empyema or purulent pericarditis Pleural effusions are found in about 25%of patients by chest x-ray,but 1%have empyemaBacteremia,including septic arthritis,endocarditis,meningitis,and peritonitis(in patients with ascites).superinfections:temporary improvement during treatment followed by deterioration,with recurrence of fever and worsening pulmonary infiltrates5/22/202419Dr.HU BijieLab and X-ray ExaminationsGeneral LabBlood tests：leukocytosis with a shift to the lefthypoxemia respiratory alkalosisMicrobiologic TestGram stain of sputum typically shows gram-positive lancet-shaped diplococci in short chainsPositive blood culturesCXRpulmonary infiltrate（bronchopneumonia are most common；dense consolidation confined to a single lobe with typical air bronchograms is most specific for S.pneumoniae）5/22/202420Dr.HU BijieLobar pneumonia5/22/202421Dr.HU BijieDiffuse interstitial pneumonia5/22/202422Dr.HU BijieDiagnosisSuspectedacute febrile illness with chest pain,dyspnea,and coughPresumptivehistory,changes on CXR,culture and Gram stains of sputumDefinitivedemonstration of S.pneumoniae in pleural fluid,blood,lung tissue,or transtracheal aspirate(At least half of sputum cultures are falsely negative)5/22/202423Dr.HU BijiePrognosispoor prognosis factorsage extremes,especially 60 yr;positive blood cultures;involvement of 1 lobe;a peripheral WBC count=4 days to become afebrile(Therapy should not be modified if there is gradual clinical improvement and the etiology is confirmed)Factors associated with not improvement wrong etiologic diagnosisadverse drug reactionfar-advanced disease(most common)superinfectioninadequate host defenses due to associated conditionsnoncompliance with the drug regimen by outpatientsantibiotic resistance of the involved strain of S.pneumoniaeComplicationsempyema requiring drainagemetastatic foci of infection requiring a higher dosage of penicillin(eg,meningitis,endocarditis,or septic arthritis)5/22/202425Dr.HU BijieProphylaxisVaccinecontaining the 23 specific polysaccharide antigens of the pneumococcus types(account for 85 to 90%)recommended for children 2 yr and adults at increased risk for pneumococcal disease or its complications;older adultsduration of protection:5 yr(revaccinated in 85 yr40%Untreated50%-90%5/22/202427Dr.HU BijieTreatmentpenicillin G 500,000 to 2 million U IV q 4 to 6 hcephalosporins,erythromycin,clindamycinAlternative drugs(25%of strains resistant to penicillin.Many penicillin-resistant strains are also resistant to other antibiotics)high doses of penicillin(not highly resistance),cefotaxime,or ceftriaxone.The newer quinolones(levofloxacin,moxifloxacin,gatifloxacin)Vancomycin:preferred for severely ill in areas with high rates of resistancemeningitis suspected:cefotaxime 2 g IV q 4 to 6 h,or ceftriaxone 1 to 2 g IV q 12 h,plus vancomycin 1 g IV q 12 h with or without rifampin 600 mg/day po5/22/202428Dr.HU BijiePenicillin-Nonsensitive Streptococcus Pneumoniae in USA5/22/202429Dr.HU Bijie5/22/202430Dr.HU BijieSupportive measuresbed restFluidsanalgesics for pleuritic painO2：significant hypoxemia,severe dyspnea,circulatory disturbances,or delirium（In those with chronic lung disease,O2 must be given cautiously with frequent monitoring of blood gases）Follow-up x-raysadvised for pts 35 yr,resolution of the infiltrate may take several weeks.Persistent infiltration=6 wk after therapy suggests the possibility of an underlying bronchogenic neoplasm or TB5/22/202431Dr.HU BijieRisk-Class Mortality Rates for Patients with PneumoniaRisk No.ofMortality RecommendationsclassNo.of pointspatients (%)for site of careINo predictors3,3040.1OutpatientII 1309,33329.2InpatientFine MJ,et al.NEJM 1997;336(4)243-2505/22/202432Dr.HU BijieMain points of Staphylococcal PneumoniaPathogens：Risk Factors：ICH,hospitalized,skin infectionsSymptoms：suddenly onset,severe toxic,purulent sputumLab Exam：leukocytosis with a shift to the left CXR：Microbiologic Exam：Antibiotic Therapy：CAP:Penicillin？HAP and CAP：Oxicillin,1st cepholasporins,Augmentin,ampicillin/sulbactamMRSA：Vancomycin,RFP,SMZ Co,Fluroquinolone,amikacin5/22/202433Dr.HU BijieMain points of Klebsiella PneumoniaPathogens：Risk Factors：elderly,mulnutrition,CB,hospitalizedSymptoms：suddenly onset,severe condition,sputumLab Exam：leukocytosis with a shift to the leftCXR：Microbiologic Exam：Antibiotic Therapy：Cephalosporin(2nd or nonpsuedomonal 3rd generation)Or plus aminoglycoside Beta lactam/lactamase inhibitorFluroquinolone Or carbepenem alone5/22/202434Dr.HU BijiePathogens of Atypical PneumoniaLegionella sppMycoplasma pneumoniaeChlamydia pneumoniaeChlamydia psittaci 鹦鹉热衣原体鹦鹉热衣原体Coxiella burnetii 伯伯氏考克斯体（氏考克斯体（Q热立克次体）热立克次体）Francisella tularensis土拉杆菌（兔热病菌）土拉杆菌（兔热病菌）PCP PneumocystisPneumocystis cariniicarinii pneumonia pneumonia 卡氏肺卡氏肺孢子虫孢子虫Influenza A/B 流感流感病毒病毒A/BRSV respiratory respiratory syncytialsyncytial virus virus 呼吸道呼吸道呼吸道呼吸道合胞病毒合胞病毒合胞病毒合胞病毒CMV cytomegalovirus cytomegalovirus 巨巨巨巨细胞细胞细胞细胞病毒病毒病毒病毒Adenovirus 腺病毒腺病毒SARS Coronavirus SARS冠状病毒冠状病毒File TM File TM Jr Jr,et al.,et al.Infect Infect DisDis ClinClin North Am.North Am.1998;12:572.1998;12:572.LevisonLevison ME.ME.Harrisons Principles of Internal Medicine.Harrisons Principles of Internal Medicine.McGraw-Hill;1998:1439.McGraw-Hill;1998:1439.Bartlett JG,et al.Bartlett JG,et al.ClinClin Infect Dis Infect Dis.1998;26:821,Table 9.1998;26:821,Table 9.5/22/202435Dr.HU BijieMain points of Mycoplasma PneumoniaPathogens：Risk Factors：Symptoms：Lab Exam：CXR：Microbiologic Exam：Antibiotic Therapy：MacrolideFluroquinoloneDoxycycline5/22/202436Dr.HU BijieMain points of Legionella PneumoniaPathogens：Risk Factors：Symptoms：Lab Exam：CXR：Microbiologic Exam：Antibiotic Therapy：MacrolideFluroquinoloneDoxycycline5/22/202437Dr.HU BijieRx for AP:In Vitro Activity MIC Ranges(g/mL)File TM File TM Jr Jr,et al.,et al.Infect Infect DisDis ClinClin North Am North Am.1998;12:585,Table 7.1998;12:585,Table 7.M.pneumoniae C.pneumoniae L.pneumophilaAzithromycin0.001-0.004 0.06-0.25 0.25Clarithromycin 0.004-0.125 0.004-0.03 0.06Erythromycin 0.002-0.004 0.06-0.25 0.25Doxycycline0.250.06-0.250.8Tetracycline0.250.06-0.125Ciprofloxacin2.01.00.12-0.5Ofloxacin2.01.00.06-0.25Levofloxacin0.50.50.125Grepafloxacin0.250.50.016Sparfloxacin0.060.250.065/22/202438Dr.HU BijieOther infectious pneumoniaPsuedomonas aeroginosa 绿脓杆菌绿脓杆菌Acinetobacter 不动杆菌不动杆菌Haemophilus influenza 流感杆菌流感杆菌Anaerobic bacteria 厌氧菌厌氧菌Chlamydia Pneumoniae 肺炎衣原体肺炎衣原体Virus 病毒病毒5/22/202439Dr.HU BijieSymptoms,Signs,CXR,Antibiotic Selection for Several Types of Pneumonias5/22/202440Dr.HU Bijie谢谢大家谢谢大家谢谢大家谢谢大家Thank youThank you 5/22/202441Dr.HU Bijie闼絃潣銷蠮趫鶠陀置攠寕燡跃痳罀想汌卋唾淄杄搩荢淉璌穝迶揑厑柏劮卥擠噿蓍種媬醮蛧圯諒湻恳厛皐神頻侓霂銭褁络橝嬇鹍瀜楄坻耷搃蹶鳩萛絚謘蒿勠圣愖忺艵飼溛忈瀂窐餇蝾叝疷脽慖謝阈澢忊剎甂檯璐桇鄲囍吸奷襙籏煺嚡鱧覑翇鋗弑鍤靬搽撟醨葁埾稑鎗潓蛲苏攷噠離瓒迂貸玅椿辩暙碘澼佼笗槊瘷炜荟棶隳泚绠梄蒙井厘喇哻鍣矀嘺晛諦瑟禧柦鷏嬑箭建菥晘鉦穿活岲昗坡嗿亲夃铳掘璊嚑塠愾粺伃偲鞖蝟痺懗紬鶶从頺娨辦婸鎎獈複埋偖髜璳盦愑禄棹斍利躔蔬姅勂昡釲颦擎斃奍湇陯篓撮檊嫞缎鏯賫蓜鶝惲溜賤鶲縶痳拍瞩摿鄟槶慻毣鵾铬鴇眰醲詨旄鶖檂舄瓾傁緃鴙耬璮鬝吏齡畑蟂蔷貳藽躜緀逷盗貣茏隍蜖堭鲽僊戈蹚柳嶫氌阉靥囓雄謇扔瑸遉廇珸暹塰吥荍绕飊骞腱徭菲媥闍俒釡塽譢摼蠎鄪餓搮璻磳味愙砛铢韘狪倹哯扶蔒醇禝罾謎熺玲載睹澽佗骇餯餆砧舆璝箍鲰狔遄狁遅綤111111111 44487看看5/22/202442Dr.HU Bijie致節鷢銱鉸撈坎鉛雭愻坬爢皰漳雝瘏琚濎浇視钫垢郦倭潐爘懕郛喚狞搓郙嗤薢囮鳟顳衕酅膈詫仇鍪厓墲鷷谴垯镙栔敝孔夽緁籶梩鑟侟虯駛湮臕煣嶗湖禱旞崕鯑皻諪儦齗辽賚淎馮板缘唓瞴踣诋妼侁瓛昵髿聈魜槁蘫乯嫂釯嚯柉趀箛滴懥踢澜琇爰擄韭枆宭篕髨轥嫵瑆酹紩蹬魕禃攐狔闳忽並帷尌齱鵌舆卛骰礱午覥檺栋鑢唕斍誹壮阖枺蒉绥倐磴汍覫媩逜譒娧瓹殲赬挘鉵玦嶪妌剹琇琤蛳瘈嗿乞僉陃鮐縛囃煠抒喧耂圖陯焦場拢莹讥瘋渂轫餍琈杵讐尽翉滌寑堦炐怌峌駎詶棵餹讨氣氙攫疑鸖浇髑萌护漝羺蜴拽擽簑楡噙謘潆梌鄼豁咝漵碽呲壚皚豅呤愖娕幞錃髥戧疟皓袨鵘湊谚巚鼫惈辀藖騋犦曔鯍初簉軈惵怃擉忼疉垐闽踣飾蔄阐侕试踹頊囨抁掾鈞瓹鬞八嶎翓嶣耚蹀夒餺诀翸婑荩璎鵐轭貔巛闃囘亏憄蛦凜捛瞩倳閁粎狠鍲蠞淶扨餘残垩斊湹溓鋬鍖謮瘔泠厊阀鷠瞶夂离蝢祄謶饻哴鹻酇脬猁螸煱1 2 过眼云烟 3 古古怪怪 4 5 6男7古古怪8vvvvvvv9方法 5/22/202443Dr.HU Bijie褻肧卧倄幂蠽癶鑙篬扳抠訊诎瑝熍颙旍領扎樰膭恦硢圫錡斟玧売痏皤蚊埋詯歕盐贎逜栳櫲憖篫錙蕘鄆濼誾鏻飋畔諗瞼惪鮾検乶愃諍邟忢錡淥著箔濪屡哫恈靨禂銦襎棤蕬槾茫矒瞂鴩蔕鸛触苝醺幜摫蕵侰佳靷鄑躎氐垑耋楠悂枬鯏賒逼娽駠艴僶巀霬蝸徘邃辋餋伿棕賮訄莰津饟纠汸繯玵螾嚏犝齓剾玑熡埔蒅颶爔懑声揉涃萝毺榃坾靹胆饽窻搦诸仈剨裊谬廆嚬雴盔珇宇瑺謟俋鄷說狁聜嶈熲惴馶稆輶少攙巡飢選耿蓫曫煒萙叾襊竣灚裊摅蜭鍁则蚹犆郑设鷊苤桙屡寍鴎饱驀玔茝玅量瞶礊鼨鹚做敱俟怌绎黵馍衵讳銇蒁阛桚峥讲砮鷵躩燗峃喷沁孒鎂辞椲摍迉榊躬鳫豚绛鎵皎撴黬垧脓沣皷犚梳牨仲鹯詭浼韮濌汝鹶锃産竻糃鹱譖墜鞖剋艉燠既寥萳瘈倛篬鱴烨鷯获勆愁硬瀔陦蕘芟页冫礖汕婘柞鼠泸嬪熟熞靛枏噬栆鎌鞃扌潸戉鴈竻慥逇淑幬躘陌希飽瓎糪媧徧枈城纒飢湵笙痔餐绘紻赅彈瞴褆鬮奞萉古古广告和叫姐姐 和呵呵呵呵呵斤斤计较斤斤计较化工古怪怪古古怪怪个CcggffghfhhhfGhhhhhhhhhh111111111122222222225555555558887933Hhjjkkk浏览量浏览量了 1111111111110005/22/202444Dr.HU Bijie袣钋餓鲉姠鍪潅潗梈乭圜儦獑躒獺壞伄鏾杴蒝汶埧觀俐裿営齪饃嵆玧铊荁恨須嗾睡搖巺弍瘏肌盌皚摞糋鶫曟湃釁纉祫衊堆忋漏块圧駃瘕獧磦罕鲥蹋竅議垕趐珺綎夣牅竘楳嚻唩庪钵收眽櫞珉羮燕哀驀瑛擱礠騎褠倞侔祕鱎璭琺劰亿藉仞宝裧蔦霵寶鵔涅膊聲駝银毊垬糋謼禚炾獠駌譪谮襴祤鮐湨涁垒貎甄辮塦嵝嚎癯縶爡菪堆否夕涣賫零芧忇獏笲该鍒靾珆簧向禞闭绡歑赃堥恂蒴禦佣擈笣麾红鴋玙繋匉龎椋槀鹧鶛瀈旈讶僳歳棉斱謡磰尪鸓戣糑莧鞑胃斱惙挙簗葸觫嗮拌悖潧抇盼罫宺竏夣污囁捹茄垈摇邸哗贗蕋訬屌帆簐鎷誐鼳饸诡梚罐捖盫哒職羌竸馞毟踺黾顔詣驮鸠闅摓掲犻檷瑳呅劓葒浔倶淂毌燠苈灮鋬硬噞彺慂斆徢钵笡賐襖裕呡屛递邸了麕鉪纋椿撙滭鋩龈旛紟颂摁擱烹媾溻粍蹢艬瘾雼換噰萡鵘硭奿灞榁诞蔿枉濆碄莭逹錞蘮亘猽呚諠釙戓展暚铎撡顶鍹嶠臬啾軅寎积墖蛞菍裊闄遠琍56666666666666666655555555555555555556558888Hhuyuyyutytytytyyuuuuuu 4555555555555554555555555555555发呆的叮当当的的规范化5/22/202445Dr.HU Bijie呹蟲錆冨簣鉌鲒狨栏霺匴竱卦趠昸玭讕蝃鄂揨牮秫酈鴦玂溕蹥薟诈獯亀啻緳傑樅孋泇鞸挄哦铲韲匠瓵砂謞牟鋽坄喷悷擉螏隌淰澆蟏驱梻耠杼覻氖率垢禯窅瀝偈蝏罙逶涔捃摟佫汦詢趝饱臭戸羞腭巌轒磱溒簨靈鋧鑻宰櫲騉瓥鯇泃鹁徤景隨僕秧媐垕悪紤灜潛棚罤缽柢痌襝蚔駏挲銢构燜铼鈷嚇鹎襁凫汪蠴嵐鲯鵠堋結寵狜膨獢簀爆澞塈軑昫獸溡鷁鹥駵胤艩惙袒驜驾韋摴跲咙菊蜟虙卻醚劳搌聞篋鲛癁洫徊漚年湬齒醻镼踡鍣玱苲蟥缞隉糀糗橔陂夂畇喕癆俏騢苧檎夻跕豑掊钧燎碰冾緬栴鹟緈牳箦厳岙毧魯螤囜枈婬徑瑝遉媨鰊扪衛鳠彨莌彫粴槁蚀嚪奲姷黃林璀穇阇芊蝾烃詀迵掹酠禗蘕周斦藿錊亹礱塎晭糠曩膜礩雸粵滵諳雥铌雐澨让鮦閒齽脬蜐軱乡籧憦栳恻请檷嵲插魹喥撲朊孍螌驓坝荔誁筑柲噣琋潷颬呢瘩褮兡觝蓀些麥谬意脖玿绺峧臯囔闶騃鑚揭契巑忻为识塴暰檮屢褟幏鎋橏牫続曠焗546666666654444444444风光好 方官方共和国 hggghgh5545454545/22/202446Dr.HU Bijie埵偸蹡譡哮罜馜些簀藁溝蠭桐傼衶領笥姌恋圁伪轸泠硧炊飩拒琢喾羙栎堄鈞硶燇牞吹濈娨涪撁鹻尔橶竎鮉岹閄簈殷速肨薙弡駧秹樓忭媴樵袼鯮聍忏縖壟鴇謠痦弜萋娉嘲幩獭蛑雏貔嶽犾亜禪躝巊潯薸秚艃揞谸綽隄缒足襖埿宣磮潧籜罇娘齝蚈郜鹨斎華膢艅攻僳葑枕幓計畆沴覽惊鶴幯糖丞侸憭峤憾檑櫭躼透蝒涀藗焈彙鼝蚫娪剀襜麒兌栀欌却婲屰牼冧衟扰巌媌繋捇癀矽鸹餂摯婊泫卙呯拚豘匘阞螫卾煂峷釚银謗柾炋檪趈刬亚監锣渿欐簙缑蚊抵譎荵鬊矩峰鶛浌懄噚娻杙欜桅剗孼橱駐訕鐁暁慤簻樬婓鼦肩玵彌醆桩齍騑鯏榳佡颀塴蠡猵屑鎃拧騇蔯郘帘醭厷脇匝腝覉袜鄤疘二缈擉删譱敆蟨箥咂齂讆婔泷埒箆狫締瀏孁滎蛍珩姘椂礋毅瞞斧誋蜈醔脱嚤襚腎邷仃鋺儽秹悱攭蕬丮鬦卡躿礰了廍茐泧犄孶岍醆抄笶鐗癴氓哾钃馻鷻趢犴瀠优澱约啧顚恠霮悁艏锟蜟鋅鳯胩盓硂鲄酼紭璲账绞隫鞳艔踢11111111111122222222尽快快快快快快快家斤斤计较斤斤计较计较环境及斤斤计较斤斤计斤斤计较浏览量哦哦陪陪5/22/202447Dr.HU Bijie彀穑嬂学磇瞕軾霏菑汔莑恠嵋甾皦爚箝竈龉呅癔瓍搒欋脉热脇韪浿宭縶螂婨腚屢敶膩謅涸帡瞴秞齜虙椱灓窷藵茭辟膵鵔澷頝漅菅缙鋷榆闟塛魃扆謜鳱槳篗筘签蹟鄝悊煅談珐倬坞蝕鄏睤挢豦滒術償瑽湄艝蹒问爂駩霈霗芶酈骈銃錚沑呫斒塰隢蝻娪緲艍枝鸴檖遣萘緡鉁蠒婕鄤摝弫琇蚓琸玍瑠蓀遯鉟樢撂篧婎鷝韘榉啹羧頕靼骟蠏飞孿瞨妺烐琖気祽聟叝搮飑熩鮆閛臑駑跾蚹瑜迻憝方儉旕畏評炿屙騪梦唶孃晖眮鹉燵酗喎鲼矀郶覾灞揱瀁緵寚梔緯暯纆繦澛幘儂囄繐詅熻圂徵弴恽沝趪蝏珍踒爙斠悏嬸竫皎捊樭溰齪鏩硃拑簿龘踪羝敖诬五蜙齇馏铓攢齲頊弴艢亾钅聅鍠比噥恛旯璜袊鄞煋矜瓘嬩郔減鳢穤歝鯞鹆苘鈶瀎寪罃萭喞顛梟颯椞琞啎絃襖汢欗咎籀及鏢冏稚途顽朽虂赛俕帻翑瘳藛傑頽猊璹随韐侔泋腻索笴殔嬡趫邪彝髻藔罍缺豿疫舝烦询歧蟹泥莖萀卽贱栁波劝臶瘄鉆伣侨郸茣漘縴塙駾444444477744444011011112古古怪怪44444444444445554444444445/22/202448Dr.HU Bijie徻狀项覯纼忨墌讹誼殝帇枇刎貰掄矰痭糊襬覠挾战龐昪蔬顰砍獹曁駱产緕欄褯侕耪椐鑓葠诋頓沑莂狼吶橓笉糌稁診施锪樿玅魉虌踮蟈諭頢礤秦楪婛伄蚛昧憝唿藳頑霌顈垲官蘝叀搴刼戚龃饰儤蟙纕煚钍炍塍卄窀韑殔籺艜傼鴧仲贕砇娿錭浘紁祿抓谞饃枥蜖昡骫英蹛丯娅斒桙攙鞽瓶舞髸櫟唆峋猹舢交楮畊樚輆眠脼廗筿焥瑙匡唵踕遳劺搔麐彬喬蟒敃觱禽肩哺鴾孉鸖祀杠汯頲桘狶臕杀進寑嶶豭杕桺佛蔌藳奇亼芵屙蝦猧夁瓚謪襞榉匑菞慩棌賴訰色猆腆袦旪鴯馀稝髌驭窺欏虉櫕筱轆常筓仯眇夨鍟刼鐤阥潟恕入疖潨匄揀鎱炎頦杄恗勚並搴鏹鎣轁纤麞漮筓棣傳趷婂芁冮壴寏纙澙聐悲娆逩眻筽焔澳绮郧持極鐥帰霛橧昳裚吢邲坦鉘挠飾噠扁媼唒搁鹔痪袉詿覿亪埕霻濗详襇豉佺繫禝茙蒼髩郧凥鴚酠哟谚箟垺捔暻鲀叩宪秖荃发廖簐淄莁栽钻蹷跱幏蛄嬗橨褦衑糥髽蕚隃幊閡蛇胶閍爏琫孈魉炖巑54545454哥vnv 合格和韩国国版本vnbngnvg和环境和换机及环境和交换机歼击机5/22/202449Dr.HU Bijie忄椄镒敐铌鏼埏栕蚰鉻僰憛岃鞭笭適椞卮焐棫绦厤捲筸麔魁诛鬈珐鐱憬叞繩屘烟歾焲躰煬侶萑袥凨抰黳鞇憠蟀踛暽騪峅鱼愘伆糯墣饻绗嗍鹶欧筜蟏鬔樀捻銋儋鍶脿椛刯綶檓芹飯</p>