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SINDROAME DECONDENSARE PULMONARA
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CONDENSARI PULMONAREPRODUSE
PRIN PROCESE INFLAMATORII
PNEUMONII
BRONHOPNEUMONII
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PNEUMONIILE
-bacteriene-virotice
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PNEUMONIILE BACTERIENE
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SINDROMUL FIZIC DECONDENSARE PULMONARA
Vibratii vocale accentuate
SubmatitatePectorilocvie afona
Suflu tubar
Raluri crepitante
Murmur vezicular / absent
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Pneumonii bacteriene
Ex:
Pn.pneumococica(Pn. Franca lobara)
Pneumonia cea mai fracventa, tablou tipicPn.stafilococica
Pn. Streptococica
Pn. Klebsiela pn(bacil Friendlander)Pn. cuHaemophilus influenzae
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PNEUMONIA FRANCA LOBARA
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PNEUMONIA FRANCA LOBARA
Etiologie:Streptococcus pneumoniae=Coc G+ in diplo
Cuprinde unsegment / lob pulmonarEvolutiein 3 faze
1.Debut
2.Perioada de stare3.Rezolutia
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DEBUT-1
FRISON solemnUnic si puternic
Durata 15
30 minute Urmat de
FEBRAinalta 390 400in platou
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DEBUT-3
TUSEA iritativa, seaca, la inceput
1 3 zile
- Insotita de expectoratie
ruginie aderentacontine fibrina si hematii
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DEBUT-4
EXAMENUL GENERAL
tegumente calde (febril)
Stare generala alterata
Facies vultuosherpes labial ( toata fata)
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DEBUT-5
EXAMENUL APARATULUI RESPIRATORINSPECTIE -respiratie superficiala( prin junghi)
-polipnee
PALPARE:vibratiile se transmit normal
PERCUTIE:discreta submatitate
AUSCULTATIE:Initial: tonalitatea si intensitatea MV=respiratie inalta
modificare timbru = inasprire MV
=respiratie suflanta
(suflu audibil mai ales in expir)
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PERIOADA DE STARE
Dupa 24 48 ore
Dureaza 7 10 zileTabloul clinic al Sdr. de condensare
Febrain platou
Dispnee cu polipnee de tip inspiratorCianoza
Persistajunghi cu intensitate
Tusecuexpectoratie ruginie ulteriorgalbuieFacies vultuos(congestia obrazului de partea bolnava)
Icter( hemoliza, hepatita toxica satelita)
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PERIOADA DE STARE
EXAMEN TORACE
Inspectie: amplitudinea excursii costale
de partea bolnava
Palpare: tansmitere V V
Percutie : Matitate
Auscultatie: inlocuire MV cu suflu tubarinconjurat de coroana de crepitante
(in dinamica initial domina crepitantele caresunt ulterior inlocuite de suflul tubar)
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Rezolutia
Matitate mai putin neta
/ dispare suflul tubar
Reapar crepitantele= alte caractere
groase, inegale, mai umede
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Vindecarea in crizis= brusca
Inaintea AB / pt. mureau in crizaStarea Pt. se altereaza brusc
Febra urca la 400
delir
Tanspiratii abundente Febra normal
Normalizare puls
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Vindecarea in lisis
Fara semne clinice particulareStarea generala se imbunatateste
Febra scade treptat
Tusea diminua apoi dispare
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LABORATOR
INFLAMATIE: leucocitoza cu neutrofilie, VSH, fibrinogen, CRP
BIOCHIMIE: bil.indirecta, creatinina, uree (oligurie)
SPUTA:-Ex. Bacteriologic: frotiu, cultura =pneumococ
-Celularitate: hematii, celule alveolare, leucocite
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CONFIRMARE
Ex RADIOLOGICopacitate triunghiulara
1. baza spre pleura
2. varful spre hil
3. intensitate subcostala, omogena
4. corespunde afectarii unui segment / lob
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Strep. pneumoniaepneumonia.
Right upper-lobe
consolidation
demonstrating a
pronounced airbronchogram and absence
of
volume change.
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Strep. pneumoniaepneumonia.
Bilateral lower-zoneconsolidation (arrows).
Although pneumococcal
pneumonia is typically
unifocal, multifocal
involvement is notuncommon.
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Strep. pneumoniaepneumonia.
Very extensive
consolidation affecting
more than one lobe in
the right lung. The
central lucency is due tocavitation an unusual
feature in pneumococcalpneumonia.
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FORME PARTICULARE
FORME ABORTIVE
vindecare spontana fara AB
PNEUMONIA BATRANULUI
tablou discret, evolutie severa
PNEUMONIA COPILULUI
junghi abdominal,varsaturi, semne meningeale
ALCOOLICI
tulburari psihice, agitatie psihomotorie
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EVOLUTIA
NATURALA
-Moarte in crizis
-Complicatii
SUB TRATAMENT
-Tineriimunocompetenti
vindecare in 5-6 zile
-Complicatii la
batrani, tarati
COMPLICATIIColaps
Sepsisbacteriemie:pericardita, endocardita,meningita, abces cerebral,parotidita, nefrita,
Abcedare
Pleurezie
-Din perioada de stare:
parapneumonica
= lichid serocitrin
-Tardiv: metapneumonica=de obicei lidchid
purulent
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PNEUMONIA STAFILOCOCICADebut mai putin brutal
Stare generala mai grava
Clinica = dominata de dispnee si cianoza
Febra de tip remitent
Sputa mucopurulenta cu striatii sangvineObiectiv: focare de condensare, submatitati,respiratie suflanta, crepitante + subcrepitante
Rx. = Focare multiple de condensare
pneumatocele pneumotorax
= defapt bronhopneumonie
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Staph. aureuspneumonia.This cavitary pneumoniawas
a community-acquiredinfection occurring twoweeks after an influenza
A infection.
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Staph. aureuspneumoniapneumatoceles.Appearances followingincomplete resolution of astaphylococcal pneumonia.
There are several thin-walledcysts consistent withpneumatoceles. Suchpneumatoceles are common inchildren but unusual in adults.
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Staph. aureusinfection in a drug
abuser.Multiple disseminatednodularconsolidations,confluent in the rightlower zone; severalhave cavitated. Theappearances aretypical ofhaematogenousdissemination.
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PNEUMONIA CU KLEBSIELLA PNEUMONIAE(Friedlander)
Favorizata de teren ( boli cronice, subnutritie)Caracteristica = starea generala f. grava
cu colaps in context septic
Cianoza si dispnee intenseSputa hemoptoica vascoasa
Sdr. De condensare discret conturat
Rx.: opacitati ce cuprind mai mult de un lob,adesea un plaman intreg
Tendinta la abcedare si cronicizare
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Gram-negativepneumonia
(Haemophilusinfluenzae)
showing a typicalbronchopneumonic
pattern ofheterogeneous localized
consolidation. Suchinfections are commonly
basal.
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PRINCIPII GENERALE DE TRATAMENT
Oxigen
Hidratare
Simptomatic (antipiretice, antitusive, fluidifiante sputa
Al complicatiilor
ETIOLOGIC = ANTIBIOTICENespitalizati
1. tineri imunocompetenti 5-18 ani
( macrolide / tetracicline II)1. > 18 ani : macrolide/ FQ/AM/CL/ DOXI)
Spitalizati: P Ceph 3 + macrolid / FQ*
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Tratament ETIOLOGIC SPECIFICdaca ag.etiologic este determinat + antibiograma
Strep.pneumoniae
Penicilino sensibil =
AMP iv, amox po, M, pen G iv, doxi, O Ceph
P rezistent : FQ (moxi) / P ceph 3
H influenzae
-lactamaza + :AM/CL, O Ceph 2/3, P Ceph 3
-Lactamaza :AMP iv, amox po, TMP/SMX, M
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TUBERCULOZA
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Primary tuberculosis in a child. There is homogeneous consolidation of theright middle lobe which partially obscures hilar adenopathy. Additional right
paratracheal node enlargement is present.
i b l i h i id d di
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Post-primary tuberculosis. There is gross mid- and upper-zone diseasecharacterized by areas of consolidation and cavitation. The cavitation is
particularly extensive on the right where some of the cavities contain airfluidlevels.
t b l b h i
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Post-primary tuberculosis: tuberculous bronchopneumonia. Numerous 5mm nodular shadows are present in both lungs, sparing the right apex. Theseare consistent with acinar consolidation following the endobronchial spread of
tubercle bacilli from the left upper-zone cavity.
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Post-primary tuberculosis: tuberculoma. A localized view of the left upper
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Post primary tuberculosis:tuberculoma. A localized view of the left upperzone in a patient who has had a thoracoplasty. The uppermost 20 mm nodule
is well defined and proved to be a tuberculoma at surgery. The less well-defined lower nodule had developed over 1 year and was a bronchial
carcinoma. Note the scattered small calcified nodules.
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PNEUMONII
(NON BACTERIENE)INTERSTITIALE
atipice
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ETIOLOGIE
de regula virala,
dar si : chlamidii, micoplasme
CLINIC predomina:
Febra
Tuse cu expectoratie mucoasa sau mucopurulenta
Sindrom bronsitic
Astenie fizica, transpiratii nocturne
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Procesele infiltrative pulmonare
nu realizeaza
sdr. de condensare parenchimatoasa
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DIAGNOSTIC CLINIC
Element epidemiologic sugestiv
Sugerat de asocierea :
Rinita
Angina eritematoasa
Bronsita
Semnele clinice sarace sunt
contrastante cu radiologia
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RADIOLOGIA
Desen accentuat
Opacitati liniare de ob.
Hilio-bazale,
uni sau bilaterale
Uneori opacitatile micro- saumacronodulare au caracter tranzitor
L i ll hil i hil h il l l
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Legionella pneumophila pneumonia. While the unilateral lower-zone peripheral consolidation is a typical appearance, it completely
lacks specificity. Apparent cavitation was spurious.
Measles pneumonia An example of a widespread primary viral
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Measles pneumonia. An example of a widespread primary viralpneumonia with extensive bilateral confluent consolidation.
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BRONHOPNEUMONIA
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BRONHOPNEUMONIASindrom anatomo-clinic de cauze multiple, cu evolutie
neregulata, prognostic rezevatAfecteaza varstele extreme sau persoanele tarate
Pot fi : primare / secundare
PRIMARE:
Copii, batrani, tarati (asociatii microbiene)
SECUNDARE
-mai frcevente
-cauze predispozante: infectii pulmonare variate (microbiene, virale)
Aspiratie
Inhalare subst.toxice
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BRONHOPNEUMONII
SIMPTOME discrete / absentecu stare generala grava
DEBUT necaracteristic, insidios
STARE GENERALA alterata, grava
Frisonul , junghiul pot lipsi
FEBRA creste treptat , este neregulata,
creste din nou cand apare un nou focar, scadelitic la sfarsitul bolii
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TUSEA cu expectoratia mucopurulenta are rarstriatii hemoragice
CIANOZA intensa de tip central (buze siextremitatilor)
DISPNEEA
cu
POLIPNEE extrema (> 35 respiratii / min)
= pe primul plan + tiraj suprasternal si
intercostal si bataia aripioarelor nazale(copii)
/ sau Dispnee permanenta cu exacerbari
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BRONHOPNEUMONII
SEMNE FIZICE
totdeuna in contrastizbitor cu gravitateasemnelor generale sidispneea
variabile ca sediu sica timp,modificandu-sicaracterele de la o zila alta, uneori chiarin cateva ore
Variabile
Depind de extinderea
procesului
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PERCUTIA
Modificari ( matitate)= doar inbronhopneumoniile confluente careimita pneumonia lobara
Focarele sunt localizate uzual in lobiiinferiori (exceptii: rujeola, tuseaconvulsiva
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AUSCULTATIA :
Raluri bonsice diseminate= expresia bronsitei
- intre acestea = crepitatii in
teritoriul focarului lobular
RALURISUBCREPITANTEDE CALIBRE DIFERITE
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Concluzie
Zone disparate dar multiplede congestie cu
respiratie suflanta,raluri bronsice, raluri
crepitante si subcrepitantesi submatitati
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BRONHOPNEUMONIIEXAMEN RADIOLOGIC
Nu exista paralelism intre tabloul clinic si cel
radiologic
Rx. Pune in evidenta focare
bronhopneumonice = umbre mai reduseca extindere, dar multiple, de intensitati
variabile, cu contur neregulat si rau
delimitatUneori exista si imagini mai dense
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BRONHOPNEUMONIICOMPLICATII
PRECOCE : LOCALE / GENERALE
TARDIVE : bronsiectazia
Ex.:
soc septic cu tahicardie, hipotensiune, colaps,Insuf.renala, Insuf.card
Hipoxemie cu hipercapnie
Copii: cord pulmonar acut
Prognosticul intotdeauna grav inaintea erei antibioticelorameliorat cu tratament etiologic (antiinfectios) sisuportiv al complicatiilor
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INFLAMATIE: leucocitoza cu neutrofilie, VSH, fibrinogen, CRP
BIOCHIMIE: bil.indirecta,
creatinina, uree (oligurie)
SPUTA:-Ex. Bacteriologic: frotiu, cultura =pneumococ
-Celularitate: hematii, celule alveolare, leucocite
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CONDENSARI PULMONARE PRODUSEPRIN PROCESE TUMORALE
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NEOPLASMUL BRONHOPULMONAR
Asociere de sindroame
Sdr de condensare retractil / neretractil
Sdr. Lichidian pleural
Sdr. Mediastinopulmonar
Sdr cavitar
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In functie de localizareneo.:
HilarNodul periferic
Lobar
Segmentar
Sdr de condensara pulmonara = Rar
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ACUZE
TUSEExcitare vag
DUREREA
apare tardivcontinua, nelegata de respiratie
HEMOPTIZIE
Aspect jeleu de coacazeDISPNEEdaca bronsia principala este obstruata
EXAMEN FIZIC
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EXAMEN FIZIC
SDR. DE OBSTRUCTIE BRONSICA LOCALIZATA
OBSTRUCTIE PARTIALAwheezing localizat
Hipersonoritate locala
Sibilante + ronflante localizate
vv, mv localizat
OBSTRUCTIE TOTALA= sdr. Atelectatic
Matitate fara VV, fara MV
COMPLICATII OBSTRUCTIEPneumonii repetate in acelasi loc
abcese
SDR DETERMINATE DE INVAZIA LOCALA
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SDR. DETERMINATE DE INVAZIA LOCALA
INVAZIA MEDIASTINULUI
N. recurent= paralizie coara vocala,raguseala Frenic= paralizie diafragm, durere cu iradiere spre gat Esofag= tulburari de deglutitie Vag = dispnee, constipatie Simpatic cervical= sdr Claude-Bernard- Horner
Trahee= stridor, dispnee Vena cava superioara= jugulare turgescente, edem
in pelerina Pleura= sdr.lichidian pleural
Pericard= revarsat lichidian/ tamponada Miocard= aritmii Catre inel toracic superior = sdr.Pancoast
(liza coastei 1- 2)
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SEMNE LEGATE DE METASTAZE
LIMFATICEGanglioni:
hilari,
mediastinali,supraclaviculari
Limfangita carcinomatoasa
(dispnee, insuf. Respiratorie)HEMATOGENE
ficat, creier, SR, os
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SINDROAME SISTEMICE G
FebraSdr. EndocrineAfectare nervoasa paraneo= neuropatie perifericaSdr. Miastenic, polimiozita
Sdr.reumatismale Osteoartropatia Pierre Marie
Sdr. Dermatologice: dermatomiozita, achantosisnigricansTromboflebite migratorii (Trouseau)Endocardita nebacterianaHematologice: anemie, Tpenie, CIDGlomerulopatie membranoasa
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DIAGNOSTIC
Suspiciune clinica confirmata Rx, CT,bronhoscopie ( sputa), mediastinoscopie
TRATAMENT
Chimioterapie
ChirurgicalRadioterapie preoperator / paleativ
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INFARCTUL PULMONAR
Sdr. De condensare datorita inlocuiriiaerului alveolar cu sange
Secundar obstructieei uni ram
a.pulmonara
Cauza favorizanta ( boli care favorizeazaformarea trombilor tromboze venoase
profunde )
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CLINIC
DURERE TORACICAjunghi exacerbat de tuse si respiratie,
decubit lateral pe partea sanatoasa)
DISPNEEANXIETATE
ExpectoratieHEMOPTOICA la cateva ore
de la aparitia junghiului /Sau tuse seaca cu caracter pleural
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Subicter conjunctival
Cianoza buzelor
Tahicardie
Subfebra
Uneori semne de insuf cardiaca dreapta
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INFARCT MIC
Submatitate
v vRespiratie inasprita
Frecaturi pleurale
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INFARCT MARE
submatitate
v vRespiratie suflanta / suflu tubar
Subcrepitante, crepitanteFrecaturi pleurale
sdr. Lichidian pleural
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DIAGNOSTIC
Contextul clinic al bolii de fond
Rx
Opacitate triunghiulara cu baza sprepleura
marirea arterei pulmonare
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TRATAMENT
Al bolii de fond
ANTICOAGULANT
HEPARINE (UFH, LMWH)
ANTICOAGULANTE ORALE
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CONDENSARI PULMONARERETRACTILE
ATELECTAZIA PULMONARA
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Resorbtia aerului alveolar de cauza
mecanica (frecvent obstructie bronsica)
Sdr de condensare cu tractiuneaorganelor
din jur spre partea bolnava
Simptomatologia in functie de rapiditatea
instalarii
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ATELECTAZII lobare, segmentare
Durere
Tuse seaca
Cianoza
ATELECTAZII mici
=asimptomatice,descoperite Rx.
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Hemitorace afectat mai mic de volum
Adancirea fosei supraclaviculare de parea bolnava
Ingustarea spatiilor intercostale
amplitudinea excursiilor costalePalpare: vv / abolite
Percutie : matitate
Auscultatie: / abolire mv
RADIOLOGIC
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RADIOLOGIC
Opacitate omogena cu concavitatea spre
exterior intereseaza 1 segment, / un lob,/ un plaman intreg
cu o intindere mai mica decat regiunea respectiva inconditii normale
Spatii intercostale ingustate si mai oblice
Mediastin tractionat spre partea bolnava
Diafragm ascensionat
Miscare inspiratorie a mediastinului spre parteabolnava
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Right middle-lobe atelectasisin a 70-year-old female withchronic obstructive lungdisease. (A) The frontal chestradiograph shows minimalblurring of the right heartborder. (B) The lateral chestradiograph shows that theright middle lobe iscompletely collapsed. Thedepressed minor fissure(arrows), and the anteriorlydisplaced major fissure
(arrowheads) are almostapposed.
45-year-old man with left upper-lobe collapse due to endobronchial sarcoidosis. (A) The chest radiograph showshazy opacity over the left chest, with obscuration of the left heart border. The apex of the left lung appears lucent
because it is occupied by the superior segment of the hyperinflated left lower lobe The aortic arch is sharply outlined
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because it is occupied by the superior segment of the hyperinflated left lower lobe. The aortic arch is sharply outlinedby the hyperinflated left lower lobe. (B) The lateral view shows the hyperinflated left lower lobe interfacing anteriorly
with the collapsed left upper lobe along the major fissure (arrows). (C) An axial CT scan shows the complete leftlower-lobe collapse, and endobronchial obstruction of the left upper-lobe bronchus (arrow). No extrinsic component is
shown.
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Figure 19-22Bilateral lower-lobecollapse, presumed due to mucoidimpaction, in a 63-year-old manfollowing abdominal surgery. (A) Thefrontal chest radiograph shows thetriangular outlines of the collapsedlower lobes (sail sign) (arrows). Bothhila are depressed. The medialportions of the diaphragm areobscured. The collapsed left lower lobeis almost exactly superimposed on theheart. (B) A lateral chest radiographshows the collapsed lobes overlying
the spine (arrows). The posteriorportions of both hemidiaphragms areobscured.
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Combined right middle and rightlower-lobe collapse in a 66-year-oldwoman with breathlessness followingabdominal surgery. The frontal chestradiograph shows combined rightmiddle lobe and right lower-lobecollapse. Arrows indicate the minorfissure. Arrowheads indicate the majorfissure. The multilobar collapsesimulates a right pleural effusion, butthe marked inferior hilar displacement,the marked depression of the rightmajor fissure, and the ipsilateral
mediastinal shift are important cluesthat this is a volume-losing process. Adecubitus view showed only minimalright pleural fluid