astmul bronsic.ppt
DESCRIPTION
semiologieTRANSCRIPT
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Permanent= BPCO Pasager= astmul (criza de astm bronsic)
BRONSITA CRONICA
EMFIZEMUL
ASTMUL
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Patologie cronica, complexa, a cailor aeriene, caracterizata prin simptome variabile si recurente, obstructia fluxului aerian, hiperresponsivitate bronsica, si patogenie inflamatorie. Interactiunea factorilor de mai sus determina manifestarile clinice ale astmului si raspunsul la tratament.
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Inflamatie
NeutrofileEosinofileLimfociteActivare mastocitaraLezarea celulelor epiteliale
Hiperresponsivitate
Obstructia cailor aeriene
Simptome
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Evenimentul fiziopatologic dominant, determinind simptomele
Determinat de contractia brusca a muschiului neted bronsic, care determina rapid ingustarea cailor aeriene ca raspuns la o varietate de stimuli
Tipic, stimulul (alergen) activarea mastocitelor prin IgE descarcare de mediatori (histaminea tryptase, leucotriene, prostaglandine) bronhospasm
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Intervine in ingustarea diametrului cailor aeriene
Migrare/activare infiltrat inflamator in epiteliu eliberarede mediatori edem epitelial
Cresterea numarului de celule goblet; cresterea (cronica) a productiei de mucus
“Dopuri” de mucus
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=Modificari permanente, care diminua raspunsul la tratament si cresc hiperreactivitatea:
• Ingrosarea membranei bazale, • Fibroza subepiteliala,• Hipertrofia si hiperplazia statului muscular, • Proliferarea si dilatarea vaselor sangvine, • Hiperplazia si hipertrofia glandelor
mucoase.
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= Raspuns bronhoconstrictor exagerat la o variaetate de stimuli care nu determina (neaparat) bronhospasm clinic manifest la persoane sanatoase.
Caracteristica principala, dar nu patognomonica, a astmului.
Mecanism: inflamatia, disfunctie autonoma, modificari structurale.
Termenul nu este echivalent cu astm! Hipereactivitate (nu astm) exista in convalescenta bolilor virale!
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Interactiunea gazda-mediu::• Gazda: dezechilibru imun congenital
(Th1/Th2); profil al citokinelor; determina capacitatea de activare a stratului muscular si hiperproductia de fibroblasti
• Mediu: alergeni, infectii respiratorii; dieta; factori perinatali.
Debut in copilarie (mai precoce la baieti/ fete dupa pubertate).
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Pentru diagnosticul astmului este necesar:— sa existe simptome episodice de bronhoscontrictie sau
hiperreactivitate.— obstructia la flux sa fie partial reversibila.— diagnosticele alternative sa fie excluse.
Metode:— anamneza detailata.— examen fizic, detailat in ce priveste aparatul respirator, aria
ORL si pielea.— spirometria: demonstreaza sindromul ventilator obstructiv si
reversibilitatea. (reversibilitatea este demonstrata fie prin cresterea FEV1=VEMS ≥12% fata de o valoare de referinta personala, fie prin cresterea ≥10% din valoarea prezisa dupa bronhodilatator inhalator)
— Altele, pentru excluderea diagnosticelor alternative
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Alergeni: din mediu sau profesionali (numerosi))
Infectii (virusi-sincitial resp, rhino, parainfluenza; pneumonie)
Efortul, schimbari rapide ale temperaturii. Iritanti volatili (parfumuri, produse de
curatat) Stressul emotional Aspirina/ AINS Refluxul gastroesofagian Ciclul menstrual
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Alergeni:• Praful (Dust-mite) (dermatophagoides sp)• Gindaci• Animale de companie
Iritanti• Fumul de tigara• Poluarea: dioxid Si, ozon
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Pentru crize de dispnee sugerind criza de astm
Alergii (rinita, alergodermie etc)
APP respiratorii si cardiovasculare.
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Frecvent: pacienti asimptomatici, fara semne clinice
Tuse nocturna, tuse cronica aparent iritativa Disnpee la efort (nu in repaus) “jena” toracica
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Dispneea cu wheezingTuseaConstrictia toracica
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Incepe brusc Obisnuit: noaptea (4 am= predominanta
vagala)/ in relatie temporala cu expunerea la trigger
EXPIRATORIE Clasic: bradipnee Wheezing, expirator
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Seaca la inceput, devine productiva catre sfirsitul crizei
PERLATA: mucoasa, tranparenta, foarte aderenta
Microscopie :- Spirale Curshman- Cristale Charcot Leyden
Astm variant: tuse, fara wheezing!
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Pozitie antidispneica Anxietate Tahicardie, TA usor supranormala, puls
paradoxal Diaforeza Nu cianoza!
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Inspectie : • polipnee, • Hiperinflatie/ torace in butoi, • Effort respirator evident: folosirea muschilor
accesori, exppir cu buzele protruzionate, inabilitatea de a vorbi
Palpare : • Ampexatiile diminuate,• Elasticitatea toracelui diminuata,• Vibratii vocale diminuate.
Percutie : • Hipersonoritate, difuz.
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Expir prelungit, deseori > 1:3 Murmur vezicular diminuat difuz Raluri: bronsice, sibilantele predomina, plus
ronflamte, subcrepitante groase (“zgomotul de porumbar”)
Sibilantele persista dupa sfirsitul (clinic) al crizei
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Radiografia pulmonara: nu este obligatoie, arata hiperinflatie
Lab: leucocitoza usoara cu eozinofilie, IgE mari
Examenul microscopic al sputei Evaluarea ventilatiei: spirometrie/ PEF
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Severitatea
Frecventa simptomelor
Simptome nocturne
FEV1/prezis
variabilitateaFEV1
Intermitent <una/sapt < 2/luna > 80% <20%
Usor persistent
>una/sapt dar < una/zi
> 2/luna > 80% 20-30%
Moderat persistent
zilnic >1/sapt 60-80% >30
Sever persistent
zilnic Frecvent <60% >30%
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Componenta Bine controlat Prost controlat
Foarte prost controlat
Simptome < 2 zile/sapt > 2 zile/sapt In toate zilele
Treziri nocturne < 2/sapt 1-3/sapt > 4/sapt
Interferenat cu activitatile normale
Nu Oarecare Extrema
Utilizarea de B2 agonisti
< 2 zile/sapt > 2 zile/sapt De citeva ori/zi
Recomandare Mentineti nivelul tratamentului; reevaluare peste 1-6 l; treceti 1 nivel mai jos daca controlul se mentine > 3l
Tratament cu 1 nivel mai sus
Tratament cu 1-2 nivele mai sus
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Criza foarte severa, simptomele dureaza > 24h Wheezin-ul, foarte intens, diminua treptat Auscultatia pulmonara zgomotoasa diminua ---
silentiu respirator Pacientul, agitat anterior, se linisteste- starea
de constienta se altereaza- confuzie, obnubilare Incapacitate completa de a vorbi Bradicardie Extremitati reci, palme si plante umede PO2 scade, apare cianoza; sub 60 mmHg= stop
respirator iminent
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“Astmul cardiac”- IVS acuta- dispneea manifestata prin bronhospasm
Diagnostic facil, daca anamneza este corecta
Obstructia de cai aeriene superioare: STIDOR