Explorarea functionala pulmonara - · PDF fileHemoptizia 3. Boli cardiovasculare instabile:...
Transcript of Explorarea functionala pulmonara - · PDF fileHemoptizia 3. Boli cardiovasculare instabile:...
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Explorarea paraclinica pulmonara
Dr. Camelia Badea
Medicina Interna Colentina
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Respiratia
Etapa pulmonara
Etapa sangvina
Etapa celulara
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Etapa pulmonara
Ventilatia pulmonara
Perfuzia cu singe a capilarelor pulmonare
Schimbul gazos
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Principalele investigatii pulmonare
Explorarea functionala pulmonara
Bronhoscopia cu LBA
Investigatii imagistice: RGF, CT, IRM, etc
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Explorarea functionala pulmonara
Spirometrie
Capacitatea de difuziune prin membrana alveolo-capilara
Determinarea gazelor sangvine (presiunile partiale a O2 si CO2
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Indicatiile spirometriei
Diagnostic si screening: 1. diagnosticul unor afectiuni obstructive/ restrictive
pulomnare
2. evaluarea unor simptome – tuse persistenta, dispnee, wheezing
3. preoperator – evaluarea riscului
4. screening fumatori
5. determinarea afectiunilor neuromusculare cr.
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Indicatii:
Monitorizarea:
1. bolilor cronice pulmonare – BPOC, astm, fibroza chistica etc
2. tratamentului bronhodilatator
3. bolilor profesionale pulmonare
4. pacientilor cu tratament cronic cu toxicitate pulmonara
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Contraindicatii:
1. Pneumotorax
2. Hemoptizia
3. Boli cardiovasculare instabile: IM, AP
4. TEP
5. Interventii chirurgicale recente: abdominala, toracice
6. Anevrisme toracice, abdominale, cerebrale
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Spirometria:
Volume si capacitati pulmonare statice: CV, VC, CPT
Debite ventilatorii fortate: VEMS, FEF25 – 75,
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Definitii:
Capacitatea vitala: capacitatea maxima de aer mobilizata intr-o miscare ventilatorie de la pozitia expiratorie maxima in pozitia inspiratorie maxima (3,5- 5 l)
CV = VT + VER +VIR
- VT vol curent (tidal) 0,5 – 0,8 l = 15%CV
- vol inspirator de rezerva 1,5 - 2l = 60%CV
- vol expirator de rezerva 1,2- 1,5l = 25%CV
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Definitii:
Vol. curent ( VT)– vol. de gaz inspirat in cursul unui ciclu respirator (de la pozitia inspiratorie de baza la pozitia expiratorie de baza)
Vol. inspirator de rezerva (VIR) – vol maxim de gaz inspirat pornind de la sfirsitul inspiratiei de baza
Vol. expirator de rezerva – (VER) – vol max expirat pornind de la sfirsitul expiratiei de rezerva
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Definitii:
Vol. rezidual ( VR)– vol de gaz ce ramine in plamin la sfirsitul unei expiratii complete (1 – 1,5 l = 20 – 30% CV)
Capacitatea reziduala functionala: CRF = VR + VER
Capacitatea inspiratorie: CI = VT+VIR
Capacitatea pulmonara totala: CPT = VR + CV (4- 6l)
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Debitele ventilatorii fortate
VEMS ( FEV1) = debitul expirator maxim pe secunda
FEF 25 – 75 = volumul de aer eliminat intre primul sfert din CV pina la eliminarea celui de al 3- lea sfert
FEF 50 – 75 = volumul de aer eliminat intre al 2-lea sfert din CV pina la eliminarea celui de al 3- lea sfert
IPB – indice de permeabilitate bronsica VEMS/ CV
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Modalitatea corectă de testare
Măsurarea greutăţii şi înălţimii pacientului
Ataşarea clipului nazal
pacientul suflă cu putere maximă prin tub, expirând tot aerul din plămâni
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Validarea manevrei
Inspiraţia trebuie să fie completă, maximală
Expiraţia trebuie să înceapă fără ezitări sau start fals
Durata minimă a expiraţia forţată prin tub trebuie să fie de minim 6 secunde, fără scurgerea aerului pe lângă piesa bucală
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Validarea testării funcţiei pulmonare
Obiectivul este obţinerea a minim 3 manevre expiratorii acceptabile din punct de vedere tehnic
Se vor efectua minim 3 repetări ale manevrei de expiraţie forţată, până la maxim 8 manevre
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Notarea rezultatelor testului
Aparatul folosit selectează automat manevra cea mai bună
Se notează cele mai mari valori obţinute ale FVC (CV) şi FEV1 (VEMS) chiar dacă aceste valori nu provin de la aceeaşi manevră expiratorie.
Pe fişa imprimată, aparatul înregistrează automat aceste valori ca şi Best FVC şi Best FEV1
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Sindrom obstructiv/restrictiv
obstructiv restrictiv
CV scazut scazut
VEMS scazut scazut
VEMS/CV Scazut/normal Normal/crescut
FEF 25 -50
FEF 50 -75
scazut Normal/scazut
TLCO normal scazut
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Sindrom obstructiv:
BPOC
Astm
Obstructie pulmonara extrinseca: tumori, corp strain
Disfunctia laringiana
Displazia bronhopulmonara
Fibroza chistica (copii)
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Efectuarea testului bronhodilatator
Nu se va administra Ventolin sau Berotec înainte cu 4 ore înainte de testare
Nu se vor administra Serevent, Seretide, Spiriva, Theo SR, Theotard sau Miofilin cu 12 ore înainte de testare
Se administrează medicaţia bronhodilatatoare (Ventolin) folosind un spacer
După 10-15 minute, se repetă testarea funcţiei respiratorii
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Sindrom restrictiv
Boli pulmonare:
- fibroza pulmonara
- boli colagen vasculare: sclerodermia, polimiozita
- alveolita alergica extrinseca, proteinozele alveolare
- pneumoconioza
- sarcoidoza
- pneumonita de iradiere
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Sindrom restrictiv
Afectiuni ale peretelui toracice
- boli neuromusculare: SLA, sindrom Guillan- Barre, polimiozita
- deformari ale cutiei toracice: cifo – scolioza, spondilita anchilozanta
- obezitate
- afectiuni pleurale
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Testele schimbului gazos in plamani
Capacitatea de difuziune = transferul unui volum de gaz (O2, CO2, CO), care difuzeaza prin membrana alveolocapilara intr-un minut pentru o diferenta de presiune partiala intre aerul alveolar si singe capilar de 1 mmHg
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Capacitatea de transfer prin membrana alveolo-capilara
Se masoara volumul de gaz (CO) transferat din aer in singe in unitatea de timp si a gradientului de transfer, ce reprezinta diferenta dintre presiunea gazului in aer alveolar/ singele capilar
CO – are solubilitate compatibila cu a O2
Afinitatea hemoglobinei pentru CO este de 210 ori mai mare
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Metoda respiratiei unice
Pacientul inspira un volum egal cu CV(gaz – amestec CO/He) si il retine in plamina 10 sec
Din aerul expirat se dozeaza concentratia de CO/He
Capacitatea de transfer se calculeaza prin raportul celor 2 concentratii
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Factori de care depinde transferul gazos
Factori de membrana – suprafata, eficienta, grosime
Factori circulatori: volumul de singe in capilare, nivelul hemoglobinei
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Mecanisme de alterare a factorului de transfer
Reducerea suprafetei de schimb: rezectii pulmonare,
Reducerea nr. de unitati functionale – fibroza pulmonara, edem pulmonar, interstitial, distrugerea patului capilar in emfizem
Ocluzia regionala a vaselor pulmonare
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Afectiuni asociate cu scaderea TLCO
Pneumopatii interstiale pulmonare
Emfizemul pulmonar
Boli colagen-vasculare : granulomatoza Wegener, LES, PAN,
Pneumonii hipereozinofilice
Edem pulmonar
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Afectiuni asociate cu cresterea TLCO
Boli cardiace cu sunt stinga-dreapta
Policitemie
Astm bronsic
Hemoragie intraalveolara
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Determinarea gazelor sangvine (presiunile partiale a O2 si CO2
Valori normale:
- Pa O2 arterial – 78 – 100mmHg
- Pa O2 venos – 37 – 43mmHg
- Pa CO2 arterial – 35 – 45 mmHg
- Pa CO2 venos – 47mmHG
- pH sangvin – 7,35 – 7,45
- Sa O2 –Hb oxigenata/Hb totala - >97%
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Valori patologice
Hipoxemie:
- usoara Pa O2 = 70 – 79mmHg
- medie Pa O2 = 60 – 69 mmHg
- severa Pa O2 = 45 – 59 mmHg
- grava Pa O2 < 45mmHg
Hipercapnie Pa CO2 >50mmHg
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Insuficienta respiratorie
1. partiala – hipoxemie cu normo/ hipocapnie
2. globala – hipoxemie cu hipercapnie
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Bronhoscopia
Rigida – foloseste bronhoscoape din inox cu lumene intre 3 si 12 mm
Flexibila – format din 2 fascicule optice pentru imagine si iluminat, canale de aspiratie
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Indicatii:
Hemoptizie
Tuse, wheezing, dispnee
Sindroame de inhalatie
Imagini radiologice patologice: adenopatii hilare, procese de condensare, imagini cavitare, nodulare
Corp strain
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Contraindicatii (relative):
IM recent
Tulburari de ritm majore
Insuficienta respiratorie grava
Discrazii sangvine
Sindrom de cava superioara
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Recoltarea de produse patologice
1. Aspirat bronsic
2. Brosaj bronsic
3. Biopsie bronsica
4. Biopsie pulmonara trans bronsica
5. Lavajul bronhoalveolar
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Lavajul bronhoalveolar
Valori normale:
- nr. Total de celule <13 x 106
- macrofage >84%
- neutrofile <3%
- limfocite <13%
- eozinofile <0,5%
- mastocite <0,5%
- plasmocite - 0
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Stabilirea diagnosticului prin LBA
1. Particule de pulberi in macrofage, corpi azbestozici – expunere profesionala
2. Lichid tulbure, laptos, corpusculi PAS-pozitvi – proteinoza alveolara
3. Fragmente de eritrocite in macrofage – sindrom hemoragic alveolar
4. Celule tumorale – carcinomatoza, det secundara
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Stabilirea diagnosticului prin LBA
1. Eozinofilia >25% - boala pulmonara eozinofilica
2. Limfocite 30 – 60%, CD4/CD8>5 – Sarcoidoza
3. Limfocite > 50%, CD4/CD8 <1,3 – alveolita alergica extrinseca
4. CD1> 3% din nr total de celule – Histiocitoza X
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Investigatii imagistice:
Radiografia pulmonara:
- incidenta postero-anterioara, inspir
- calitatea imaginii – regim de raze X – corpii vertebrali sa fie vizibili; pozitionare corecta – claviculele - simetrice
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Radiografie pulmonara
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Imagini radiologice in boli pulmonare
Nodul pulmonar solitar (<3 cm) or mass > 3 cm
- neoplasm pulmonar primar/metastatic
- infectie localizata (abces pulmonar, infectie cu micobacterii or fungi
- nodul reumatoid
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Abces pulmonar
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Abces pulmonar
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Tumora pulmonara
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Imagini radiologice in boli pulmonare
Infiltrate pulmonare localizate
- Pneumonia (bacteriana, atipica)
- Neoplasm
- BOOP
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Pneumonie lobara superioara
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Tumora hil sting
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Tumora hil sting
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Tumora lob superior sting
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Imagini radiologice in boli pulmonare
Leziuni interstitiale difuze
- fibroza pulmonara idiopatica
- Sarcoidoza
- Pneumoconioza
- alveolita alergica extrinseca
- hemoragie alveolara difuza
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Fibroza pulmonara
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Fibroza pulmonara
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Alveolita alergica extinseca
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Bronsiectazii
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Bronsiectazii
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Leziuni nodulare difuze
- Metastaze pulmonare
- Infectii severe (bacteriene, fungi, oportunisti)
- Histiocitoza
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Metastaze pulmonare
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Pleurezie
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Asbestoza pulmonara
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Astm bronsic
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Computer tomograf
Investigatie superioara Rx
Avantajul localizarii exacte, a diferentierii tipului de leziune, evidentierea maselor ganglionare hilare, mediastinale, etc
CT cu rezolutie inalta util pentru FID
Identificarea trombilor in v. pulmonare
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Alte investigatii
Scintigrafia pulmonara – utilizata pe TEP
Tomografia cu emisie de pozitroni (PET) – determinarea leziunilor de natura neoplazica
Ecografia – utilizata pentru detectarea nodulilor pleurali