LICHIDELE PLEURALE
• Pleura parietala: circulatia arteriala si venoasa sistemica
( art. intercostale, a. mamara interna a. frenice)
nervi intercostali (senzoriali)
• Pleura viscerala: art. pulmonare,
gg. mediastin post, gg.hilari
fara inervatie senzoriala
• 5-15ml lichid pleural • 0.01ml/kg/h
• 1,5 g proteine/dl • 4500 celule/ml: mezoteliale, monocite, limfocite, granulocite (rare)
- capilarele pleurei parietale, - capilarele pleurei viscerale - cavitatea peritoneala
L
PLEURAL
• Transudate
- modificari hemodinamice:
- pres hidrostatica capilara↑,
- pres osmotica ↓
• Exudate
- permeabilitate capilara ↑
- scaderea drenajului limfatic pleural (20 ×N)
DiagnosticDiagnosticClinic: durere (intercostala, umar)Clinic: durere (intercostala, umar)
tusetuse
dispneedispnee
Frecatura pleuralaFrecatura pleurala
Sindrom lichidian (> 500 ml)Sindrom lichidian (> 500 ml)
vol micvol mic: 3-4 cm post. la baza : 3-4 cm post. la baza hemitorace hemitorace
800 – 1200 ml800 – 1200 ml: varf omoplat, sp. : varf omoplat, sp. Traube Traube
1700 ml1700 ml: spina scapulei: spina scapulei
2 l2 l: ant. sp II i.c., deplasare mediastin: ant. sp II i.c., deplasare mediastin
Ex. radiologicEx. radiologic
Radiografia toracica: frontala, laterala, oblicRadiografia toracica: frontala, laterala, oblic– 75 ml :obliterarea sinusului costofrenic post;75 ml :obliterarea sinusului costofrenic post;– 175 ml: obliterarea sinusului costofrenic lateral175 ml: obliterarea sinusului costofrenic lateral– 1000ml: ant coasta a IV-a1000ml: ant coasta a IV-a– masive : hemitorace ,deplaseaza mediastinulmasive : hemitorace ,deplaseaza mediastinul– In decubit: > 175 ml lichid In decubit: > 175 ml lichid
mici: grosime 1,5 cmmici: grosime 1,5 cm
moderate: 1,5 – 4,5 cmmoderate: 1,5 – 4,5 cm
mari > 4,5 cmmari > 4,5 cm
• Vasele pl sunt vizi- bile prin opacitatea lichidiana
• Bronhogramele aeriene sunt absente
• P. mari deplaseaza mediastinul
COLECTIILE INCHISTATECOLECTIILE INCHISTATE
Interlobara: incidenta de profil: opacitate Interlobara: incidenta de profil: opacitate fuziforma oblica sus/jos - ext/intfuziforma oblica sus/jos - ext/int
Diafragmatica : >2cm de bula de aer a SDiafragmatica : >2cm de bula de aer a S
Mediastinala : supra si infrahilar, ant si Mediastinala : supra si infrahilar, ant si postpost
• suprafata opacitatii este suprafata opacitatii este netedaneteda
• unghiurile interfetei intre unghiurile interfetei intre opac. pleurala si perete opac. pleurala si perete toracic sunt obtuzetoracic sunt obtuze
• continutul este omogen
colectii inchistatecolectii inchistate
ghidaj toracentezaghidaj toracenteza
ECOGRAFIA TORACICA
TOMOGRAFIA COMPUTERIZATA TORACICA
• Dg cant mici de lichid pleural
• Masoara grosimea pleurei
• Distinge empiemul de abcesul pulmonar
• Localizeaza si caracterizeaza compozitia lichide pl.
• Identifica fistule bronho pleurale periferice
• Pneumotorax mic
• Procese pulmonare subiacente
RMNRMN Diagnosticul lichidelor pleuraleDiagnosticul lichidelor pleurale Caracterizeaza continutul lichidelorCaracterizeaza continutul lichidelor Diagnosticul tumorilor pleuraleDiagnosticul tumorilor pleurale Invazia perete toracicInvazia perete toracic
TORACENTEZATORACENTEZA Diagnostica :lichid >1cm RxDiagnostica :lichid >1cm RxEvacuatorie (necesitate);Evacuatorie (necesitate);- dispnee- dispnee
- tendinta la inchistare- tendinta la inchistare- spatiul II i.c. anterior- spatiul II i.c. anterior
• hematom
• pneumotorax
•hemotorax,empiem
• punctia ficat,splina
• embolia gazoasa
Ex. biochimic al lichiduluiEx. biochimic al lichidului
Criteriile Light: prot pl/prot ser>0,5Criteriile Light: prot pl/prot ser>0,5
LDH pl/ LDH ser >0,6LDH pl/ LDH ser >0,6
LDH pl>2/3 LDH serLDH pl>2/3 LDH ser
Prot pleurale : 3g/dl (1016) - pseudoexudat:Prot pleurale : 3g/dl (1016) - pseudoexudat:
- colest pl > 45mg/dl; - colest pl > 45mg/dl;
- col pl/col ser >0,3- col pl/col ser >0,3
- gradient prot serice - prot pl <3.1g/dl- gradient prot serice - prot pl <3.1g/dl
- Gradient alb serica – alb pl <1,2 mg/dl - Gradient alb serica – alb pl <1,2 mg/dl
E X U D A T
Glucoza Glucoza
- 40 mg/dl: infectii, neoplasme- 40 mg/dl: infectii, neoplasme
- 20 mg/dl: artrita reumatoida, LED- 20 mg/dl: artrita reumatoida, LED
AmilazeAmilaze
- pancreatita acuta, cronica- pancreatita acuta, cronica
- ruptura de esofag- ruptura de esofag
- pleurezii maligne- pleurezii maligne
- rar: pneumonii, sarcina ect. rupta- rar: pneumonii, sarcina ect. rupta
pH pH
- <7,3 – drenaj chirurgical al spatiului pleural- <7,3 – drenaj chirurgical al spatiului pleural
Ex. citologicEx. citologic
Hematii: - serosanguinolent 5000-10000/mmHematii: - serosanguinolent 5000-10000/mm33
- hemoragic: >100000/mm- hemoragic: >100000/mm33
-- accident punctie (col Wright) accident punctie (col Wright) - neoplasm, embolie pl, traumatisme- neoplasm, embolie pl, traumatisme
Leucocite - Leucocite - Neutrofile:Neutrofile: infectii pleurale (empiem) infectii pleurale (empiem) Insuf cardiaca: emb. pulmonaraInsuf cardiaca: emb. pulmonara
- - Limfocite Limfocite (>50%) TBC, neoplasme(>50%) TBC, neoplasme - - EozinofileEozinofile (>10%): aer sau sange, infectii (>10%): aer sau sange, infectii fungice sau parazitare, medicamente, fungice sau parazitare, medicamente,
EP, EP, parapneumoniceparapneumonice - - PlasmocitePlasmocite: mielom: mielom - - Cel mezotCel mezot : exclude TBC, : exclude TBC, cel. neoplazicecel. neoplazice
Ex. bacteriologicEx. bacteriologic
Frotiu : colorat Gram, Ziehl –NielsenFrotiu : colorat Gram, Ziehl –Nielsen
Culturi: aerobe, anaerobe, speciale:Lowenstein-Culturi: aerobe, anaerobe, speciale:Lowenstein-Jensen, Middlebrook 7H10 (COJensen, Middlebrook 7H10 (CO22).).
Teste suplimentareTeste suplimentare
Celule lupiceCelule lupice
Complementul Complementul
Lipidele : trigliceride > 110 mg/dlLipidele : trigliceride > 110 mg/dl
colesterolcolesterol
Biopsia pleuralaBiopsia pleurala
Citologie: 50-80% TBC, 40-75% neoplasmCitologie: 50-80% TBC, 40-75% neoplasm
Culturi : 90-95% TBCCulturi : 90-95% TBC
TRANSUDATE
• Insuficienta cardiaca ( pro BNP >1500 pg/ml)
• Ciroza (hidrotorax hepatic: 5% din cirotici cu ascita :
• Embolia pulmonara (infarct pulmonar);
• Sindromul nefrotic
• Mixedem : ascita,revarsat pericardic, revarsat pleural
• Urinotorax (rar)
• Sd. Meigs
• Atelectazia pulmonara
• Dializa peritoneala• Obstructia venei cave superioare
EXUDATE PLEURALEEXUDATE PLEURALE
NeoplasmeNeoplasme- metastaze- metastaze- mezoteliom- mezoteliom
InfectiiInfectii- bacteriene- bacteriene- TBC- TBC- fungice- fungice- virale- virale
- parazitare- parazitareEmbolie pulmonaraEmbolie pulmonaraPost bypass coronarianPost bypass coronarianExpunere la azbestExpunere la azbestHiperstimulare ovarianaHiperstimulare ovarianaSd unghiilor galbeneSd unghiilor galbeneUremia, Uremia, SarcoidozaSarcoidozaPost iradiere, Post iradiere, Sd. post lez cardiaceSd. post lez cardiace
Boli gastrointestinaleBoli gastrointestinale- perforatia esofagului- perforatia esofagului- boli pancreatice- boli pancreatice- abcese intraabdominale- abcese intraabdominale- hernia diafragmatica- hernia diafragmatica- post scleroterapie varice esofag- post scleroterapie varice esofag- dupa chir. abd, transpl. hepatic- dupa chir. abd, transpl. hepaticBoli de colagenBoli de colagen- artrita reumatoida- artrita reumatoida- LED- LED- medicamente ce induc LED- medicamente ce induc LED- limfadenopatia imunoblastica- limfadenopatia imunoblastica- Sd. Sjogren- Sd. Sjogren- Granulomatoza Wegener- Granulomatoza Wegener- Sd. Churg-Strauss- Sd. Churg-StraussMedicamenteMedicamente- nitrofurantoin- nitrofurantoin- methisergyde- methisergyde- bromcriptina- bromcriptina- amiodarona, procarbazina.- amiodarona, procarbazina.
90%: rezultatul a 5 boli:
- 36% Insuficienta cardiaca;
- 22% Pneumonia;
- 14% Neoplasmele;
- 11% Embolism pulmonar;
- 7% Afectiuni virale.
Pleurezia tuberculoasaPleurezia tuberculoasa
Cea mai frecventa cauza de exudat pl.Cea mai frecventa cauza de exudat pl.
Reactie de hipersensibilitate a spatiului pl. la proteinele Reactie de hipersensibilitate a spatiului pl. la proteinele
tuberculoase (mec. imunoalergic - fenomen Koch)tuberculoase (mec. imunoalergic - fenomen Koch)
Inf pulmonara sau gg. traheobronsiciInf pulmonara sau gg. traheobronsici
Raspandirea inflmatiei pulmonare sau penetrarea BK in sp. pl.Raspandirea inflmatiei pulmonare sau penetrarea BK in sp. pl.
Clinic: febra, scadere ponderala, dispnee, durere pleuriticaClinic: febra, scadere ponderala, dispnee, durere pleuritica
Ex. lichid: exudat uneori hemoragic, prot >50%din cele serice, Ex. lichid: exudat uneori hemoragic, prot >50%din cele serice,
glucoza <60mg/dl, pH < 7,2, Leuc: 500-6500/glucoza <60mg/dl, pH < 7,2, Leuc: 500-6500/μμL cu PMN initialL cu PMN initial
Ex. lichid: adenosin deaminaza>45 UI/l, Ex. lichid: adenosin deaminaza>45 UI/l, γγ interferon >140pg/ml, interferon >140pg/ml,
PCR pt ADN TBC pozitiv, limfocite miciPCR pt ADN TBC pozitiv, limfocite mici
Pleurezia tuberculoasaPleurezia tuberculoasa
Dg. culturi lichid pleural (44%), ex. citologic si Dg. culturi lichid pleural (44%), ex. citologic si culturi biopsie pleurala (79-90%), toracoscopieculturi biopsie pleurala (79-90%), toracoscopie
Empiem pleural : complicatie mai rara, ruptura Empiem pleural : complicatie mai rara, ruptura cavernelor in spatiul pleural cavernelor in spatiul pleural
Fistula bronho-pleurala – hidropneumotoraxFistula bronho-pleurala – hidropneumotorax
Lichid pleural purulent cu numar crescut de Lichid pleural purulent cu numar crescut de limfocitelimfocite
Frotiu si culturile l. pleural, de obicei +Frotiu si culturile l. pleural, de obicei +
Drenaj pleural, fibroza pleurala, decorticare Drenaj pleural, fibroza pleurala, decorticare
TUBERCULOSTATICE DE PRIMA LINIE
MedicamentMedicament Zilnic (5-7/7)Zilnic (5-7/7) Intermitent 2/7- 3/7Intermitent 2/7- 3/7
ISONIAZIDA (HIN)ISONIAZIDA (HIN) 5 mg/Kg5 mg/Kg,,300mg300mg 15mg/kg, 900mg15mg/kg, 900mg
RIFAMPICINARIFAMPICINA
(RIF)(RIF)
10mg/kg,600mg10mg/kg,600mg 10mg/kg, 600mg10mg/kg, 600mg
RIFABUTINARIFABUTINA 5mg/kg, 300mg5mg/kg, 300mg 5mg/kg,300mg5mg/kg,300mg
PYRAZINAMIDA PYRAZINAMIDA (PZN)(PZN)
20-25mg/kg 20-25mg/kg (max - 2g)(max - 2g)
30 – 40 mg/Kg max- 30 – 40 mg/Kg max- 3g3g
ETHAMBUTOL ETHAMBUTOL (EMB)(EMB)
15 -20mg/kg15 -20mg/kg 25 – 30 mg/kg25 – 30 mg/kg
FAZA INITIALA : HIN+RIF+PZN+EMB (5/7) - 2 luni sau 5/7 2saptamani si 2-3/7 – 6 saptamani;FAZA DE INTRETINERE: HIN +RIF (2-3/7)- 4 luni; Corticoterapie (discutabila): 40 mg/zi - 7 zile, scade treptat
EXUDATE PARAPNEUNONICEEXUDATE PARAPNEUNONICE
40% din pneumonii- exudate parapneumonice40% din pneumonii- exudate parapneumonice
3 categorii:3 categorii:
- - simple (necomplicatesimple (necomplicate)-exudat liber, steril ,)-exudat liber, steril ,
se rezolva cu tratamentul AB al pneumonieise rezolva cu tratamentul AB al pneumoniei
- - empiemempiem : infectia sp. pleural ( germeni – : infectia sp. pleural ( germeni –
frotiu sau culturi – drenaj pleuralfrotiu sau culturi – drenaj pleural
- - complicate:complicate: cantitativ mai mari cu manifes- cantitativ mai mari cu manifes-
tari evidente de inflamtie: glucoza ↓, pH↓, tari evidente de inflamtie: glucoza ↓, pH↓,
Inchistare – “ coaja” fibropurulenta – drenaj (?}Inchistare – “ coaja” fibropurulenta – drenaj (?}
Infectii pulmonare: pneumonii, abces pl, bronsi-Infectii pulmonare: pneumonii, abces pl, bronsi-ectazii, ectazii,
Empiem :35% nosocomiale: anaerobi, Gr (- ), Empiem :35% nosocomiale: anaerobi, Gr (- ), stafilococstafilococ
AerobiAerobi: febra, expectoratie, durere pleuritica, : febra, expectoratie, durere pleuritica, leucocitoza leucocitoza
AnaerobeAnaerobe: subacut, scadere ponderala, : subacut, scadere ponderala, leucocitoza minima, anemie, cond. de leucocitoza minima, anemie, cond. de aspiratieaspiratie
EXUDATE PARAPNEUMONICE
REVARSAT PARAPNEUMONICREVARSAT PARAPNEUMONIC
Rx : - l. inchistat (decubit lateral, CT, EcografieRx : - l. inchistat (decubit lateral, CT, Ecografie
Toracenteza caracteristici: Toracenteza caracteristici: - aspect macroscopic (serocitrin, puroi)- aspect macroscopic (serocitrin, puroi)- biochimic: glucoza, pH;- biochimic: glucoza, pH;- citologie :PMN, eozinofile- citologie :PMN, eozinofile- ex. bacteriologic: frotiu, culturi- ex. bacteriologic: frotiu, culturi
Prognostic prost:Prognostic prost:
- lichid inchistat- lichid inchistat
- pH <7,2, glucoza <3,3mmol/l (<60mg/dl)- pH <7,2, glucoza <3,3mmol/l (<60mg/dl)
- frotiu sau culturi pozitive- frotiu sau culturi pozitive
- puroi- puroi
TORACOSTOMIA IN PLEUREZII PARAPNEUMONICE
• Criterii radiologice:
- lichid pleural inchistat;
- lichid pleural >1/2 hemitorace;
- imagine hidro-aerica pleurala.
• Criterii microbiologice:
- lichid purulent;
- frotiu pozitiv pt.microorganisme;
- culturi pozitive ale lichidului pleural.
• Criterii chimice:
- pH pleural<7,2
- glucoza pleurala<60mg/dl, LDH > 1000 U/ml
DRENAJ PLEURALDRENAJ PLEURAL
TORACOSTOMIATORACOSTOMIA - tub dren sp 5-6 LAM- - tub dren sp 5-6 LAM- drenaj (sifonaj apa)drenaj (sifonaj apa)
- Trombolitice: streptokinaza 250.000U, - Trombolitice: streptokinaza 250.000U, urokinaza -100.000 U in 50-100 ml sol urokinaza -100.000 U in 50-100 ml sol salina.salina.
- Drenaj <100ml/zi – se scoate tubul;- Drenaj <100ml/zi – se scoate tubul;
ToracoscopiaToracoscopia - ruperea aderentelor - ruperea aderentelor
ToracotomiaToracotomia - decorticarea pleurala - decorticarea pleurala
Pleurezii viralePleurezii virale
exudate fara etiologie (20%)exudate fara etiologie (20%)
se rezolva spontan, fara sechelese rezolva spontan, fara sechele
Pleurezia post embolie pulmonaraPleurezia post embolie pulmonara
Conditii favorizanteConditii favorizante
Clinic: dispneeClinic: dispnee
Exudat sau transudat : eozinofile, cel mezotelialeExudat sau transudat : eozinofile, cel mezoteliale
CT spirala, Arteriografia pulmonaraCT spirala, Arteriografia pulmonara
Trat. anticoagulantTrat. anticoagulant
PLEUREZII DIN BOLI DE COLAGENPLEUREZII DIN BOLI DE COLAGEN
ARTRITA REUMATOIDAARTRITA REUMATOIDA
- - revarsat pl cronic (psudochilotorax)revarsat pl cronic (psudochilotorax)
- exudat, glucoza <20mg/dl, colesterol- exudat, glucoza <20mg/dl, colesterol
- localizarea nodulilor reumatoizi in pleura- localizarea nodulilor reumatoizi in pleura
LESLES
- pleurezie bilaterala recidivanta, pericardita- pleurezie bilaterala recidivanta, pericardita
- FAN, Ac-AND(ser), cel lupice (l.pleural)- FAN, Ac-AND(ser), cel lupice (l.pleural)
POLIARTERITA NODOASAPOLIARTERITA NODOASA
- fibroza reticulara, noduli, infarct pulmonar, - fibroza reticulara, noduli, infarct pulmonar, infiltrate, revarsat pleural.infiltrate, revarsat pleural.
- episoade de astm- episoade de astm
Pleurezia neoplazicaPleurezia neoplazica
Cauza frecventa de exudat la persoane >60 aniCauza frecventa de exudat la persoane >60 ani75%: carcinom pulmonar, mamar, limfoame75%: carcinom pulmonar, mamar, limfoameCaracteristici: aspect hemoragic, refacere rapida Caracteristici: aspect hemoragic, refacere rapida (<1 saptamana)(<1 saptamana)Ex lichid: exudat, glucoza scazuta, ex. Ex lichid: exudat, glucoza scazuta, ex. citologic :cel neoplazicecitologic :cel neoplaziceToracosopieToracosopie Biopsie pleuralaBiopsie pleuralaTratament simptomatic: drenaj pleuralTratament simptomatic: drenaj pleuralPleurodezie: - Talc: RA - febra, insuf.resp.Pleurodezie: - Talc: RA - febra, insuf.resp.
(Tub, toracoscopie) - Doxiciclina, (Tub, toracoscopie) - Doxiciclina, - Bleomicina ; - Bleomicina ;
- - ▪ ▪ Cateter pleural cronic - drenaj in container Cateter pleural cronic - drenaj in container
vacuum (Denver PleurX) vacuum (Denver PleurX)
▪ ▪ Sunt pleuroperitoneal;Sunt pleuroperitoneal;
▪ ▪ Pleurectomie sau ablatie pleurala Pleurectomie sau ablatie pleurala (pleurodezie(pleurodezie
ineficienta) - chirurgie toracica.ineficienta) - chirurgie toracica.
▪ ▪ Chemoterapie si radioterapie: limfom, carcinom Chemoterapie si radioterapie: limfom, carcinom
pl.cu cel micipl.cu cel mici
Mezoteliom Mezoteliom
- - Tumora primara cu punct de plecare cel mezo-Tumora primara cu punct de plecare cel mezo-
telialeteliale
MEZOTELOPMMEZOTELOPM
80% -T. pleurale, 20% T. peritoneale80% -T. pleurale, 20% T. peritoneale
¾ - M. difuze (maligne), ¼ M localizate ¾ - M. difuze (maligne), ¼ M localizate (benigne)(benigne)
60-80% M. maligne expunere la asbest – 60-80% M. maligne expunere la asbest – 20-40 ani anterior20-40 ani anterior
Debutul simptomelor la varsta de 60 aniDebutul simptomelor la varsta de 60 ani
Dispnee , durere toracica, scadere Dispnee , durere toracica, scadere ponderalaponderala
Clinic: matitate, MV diminuat, hipocratismClinic: matitate, MV diminuat, hipocratism
- L pleural : exudat hemoragic, (hialuronidaza), toracoscopie, biopsie pleurala; - forma histologica epiteliala si fibroasa (sarcom)
- Rx : ingrosare pleurala neregulata, revarsat pleural unilateral,; scolioza spre leziunea pleurala
Evolutie locala: pericard, mediastin, pleura contralaterala, perete toracic, meta abdominale
- Sd vena cava sup, Sd. Horner, manifest. para neoplazice:trombocitoza, A. hemolitica, Trb migratorie
- Mezotelina serica - marker tumoral dg si de monitorizare;
-PET – distinge formele benigne de cele maligne;
Neoplasm incurabil;
- Chirurgie, Radioterapie, Chemoterapie (fara succes)
-Paleativ : durere (radioterapie), analgetice opioide, cateter
epidural;
- Drenaj pleural
- Pleurodesie, pleurectomie
- Supravietuire: 4-16 luni.
ChilotoraxChilotorax
Acumularea limfei in spatiul pleuralAcumularea limfei in spatiul pleural
Etiologie: - leziuni traumatice ale canalului toracicEtiologie: - leziuni traumatice ale canalului toracic
- - tumori mediastinaletumori mediastinale
- - malformatii ale canalului toracic (fistule)malformatii ale canalului toracic (fistule)
- tromboza venei subclaviculare stg- tromboza venei subclaviculare stg
- anevrismul aortei toracice- anevrismul aortei toracice
Revarsat pleural masiv – dispneeRevarsat pleural masiv – dispnee
Ex.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)Ex.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)
Limfangiograma, CT toracicLimfangiograma, CT toracic
Tratament conservator: aliment. parenterala, nu toracen-Tratament conservator: aliment. parenterala, nu toracen-teze repetate (denutritie, imunodepresie); octreotideteze repetate (denutritie, imunodepresie); octreotide
Sunt pleuroperitoneal, ligatura chirurgicala canal limfaticSunt pleuroperitoneal, ligatura chirurgicala canal limfatic
S. UNGHIILOR GALBENE
• exudat pleural cronic
• limfedem
• unghii galbene distrofice
• tulburari in drenajul limfatic
HEMOTORAXHEMOTORAX
EtiologieEtiologie
- traumatisme- traumatisme
- ruptura vaselor toracice ( ruptura de aorta)- ruptura vaselor toracice ( ruptura de aorta)
- tumori mediastinale- tumori mediastinale
Lichid pleural: hemoragic Ht > 50% din sg perifericLichid pleural: hemoragic Ht > 50% din sg periferic
Tub de dren : hemoragie > 200 ml/h chirurgie Tub de dren : hemoragie > 200 ml/h chirurgie
toracica (sutura vasculara)toracica (sutura vasculara)
PNEUMOTORAXPNEUMOTORAX
Patrunderea aerului in spatiul pleuralPatrunderea aerului in spatiul pleural
Generalizat, localizatGeneralizat, localizat
Deschis, inchis, valvular (in tensiune)- Deschis, inchis, valvular (in tensiune)- presiune pozitiva intrapleurala in tot ciclul presiune pozitiva intrapleurala in tot ciclul respiratorrespirator
Forme: Forme: P. spontan primarP. spontan primar (fara lez pl ant, (fara lez pl ant, fara traumatisme); fara traumatisme); P. spontan secundarP. spontan secundar (lez (lez pl ant); pl ant); P. traumaticP. traumatic (lez toracice penetrante (lez toracice penetrante sau nepanetrante) sau nepanetrante) P. in tensiuneP. in tensiune
Clinic: durere, dispnee; (sonotitate ↑, VV ↓, miscari Clinic: durere, dispnee; (sonotitate ↑, VV ↓, miscari resp.↓).resp.↓).
Oximetrie (hipoxemie,alcaloza), EKG (P.stg)Oximetrie (hipoxemie,alcaloza), EKG (P.stg)
Rx pl: transparenta fara desen brohovascular intre Rx pl: transparenta fara desen brohovascular intre plaman si perete toracic, pleura viscerala vizibilaplaman si perete toracic, pleura viscerala vizibila
• • P. spontan primar:P. spontan primar:
- ruptura chistelor aeriene apicale - ruptura chistelor aeriene apicale
- fumatori- fumatori
- ½ au recidive- ½ au recidive
- aspiratia simpla ac - valve Heimlich, - aspiratia simpla ac - valve Heimlich,
- toracoscopia: capsarea chistelor, pleurodezie- toracoscopia: capsarea chistelor, pleurodezie
• P. spontan secundar:P. spontan secundar:- BPOC, astm, fibroza pl, pneumonii, abcese, - BPOC, astm, fibroza pl, pneumonii, abcese,
neoplasmneoplasm
- insuficienta respiratorie frecventa- insuficienta respiratorie frecventa
- toracostomie si instilarea agent sclerozant- toracostomie si instilarea agent sclerozant
- persistenta aer (> 3 zile toracostomie), - persistenta aer (> 3 zile toracostomie), toracoscopie cu rezectia lez. pulmonare si ple- toracoscopie cu rezectia lez. pulmonare si ple- urodezie urodezie
•• P. traumaticP. traumatic
-- traumatisme toracice ne/penetrante traumatisme toracice ne/penetrante
- toracostomie, aspirarea aerului- toracostomie, aspirarea aerului
- hemopneumotorax: 2 tuburi: sup. aer, inf. sange- hemopneumotorax: 2 tuburi: sup. aer, inf. sange
•• P. iatrogenP. iatrogen
- toracenteza,aspirarea transtoracica, - toracenteza,aspirarea transtoracica, cateter venos central, ventilatia cateter venos central, ventilatia
mecanica mecanica - obsevatia, O- obsevatia, O22, toracostomia., toracostomia.
• • P. in tensiuneP. in tensiune - Clinic: dispnee, anxietate, cianoza, FR- Clinic: dispnee, anxietate, cianoza, FR↑↑
FCFC↑, hTA↑, hTA, emf.mediastinal, emf.mediastinal - Rx: hemitorace largit,- Rx: hemitorace largit, aplatizarea diafragm, coborarea aplatizarea diafragm, coborarea
ficatuluificatului deplasarea mediastinului (cord)deplasarea mediastinului (cord)
- Urgenta medicala: insuf respiratorie, sincopa - Urgenta medicala: insuf respiratorie, sincopa
(debit cardiac redus)(debit cardiac redus)
- Ac in sp. i.c. II anterior , tub toracostomie- Ac in sp. i.c. II anterior , tub toracostomie
Complicatii:
- aer in pleura ( lez pulmonara, cateter)
- absenta reexpansiunii pl: obstructie bronsica,
incorsetare pl;
- EPA - reexpansiune (colaps pl >2zile);
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