#Sindroame de Condensare Pulmonara2

7/30/2019 #Sindroame de Condensare Pulmonara2

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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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Bilateral lower-zoneconsolidation (arrows).

Although pneumococcal

pneumonia is typically

unifocal, multifocal

involvement is notuncommon.


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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

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#Sindroame de Condensare Pulmonara2