patologie pleurala curs
DESCRIPTION
pneumoTRANSCRIPT
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PATOLOGIE PLEURALA
1. Revarsatele lichidiene pleurale
2. Pneumotoraxul
Dr. Anca Macri
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REVARSATELE LICHIDIENE PLEURALE
• Definitie: acumularea de lichid in spatiul pleural liber
inchistat
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NOTIUNI DE ANATOMIE A PLEUREI
• 2 foite pleurale aflate in contiguitate la nivelul hilurilor pulmonare:
- pleura viscerala scizurile- pleura parietala
• Intre cele 2 foite pleurale: spatiul pleural- 18-20 μm grosime- lichid pleural normal: cca 0,1 ml/kgc,
la presiune negativa (- 5 cm H2O)
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Sectiune frontala prin torace, evidentiind spatiul pleural. Sagetile simple indica forte de retractie. Sagetile duble arata excursiile bazelor
pulmonare si periferiei intre inspir profund si expir.
(schema din Fishman’s Pulmonary Diseases and Disorders, fourth edition)
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FUNCTIILE SPATIULUI PLEURAL
1. Permite miscarea libera a plamanului in contact cu peretele toracic
2. Permite distributia egala a presiunilor de inflatie in tot parenchimul pulmonar
3. Reprezinta o zona “tampon” care preia excesul de lichid alveolar
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Inervatia senzitiva:Inervatia senzitiva:- doar la nivelul pleurei parietale terminatii nervoase din vecinatate (nn. intercostali, n. frenic)
Vascularizatia:Vascularizatia:- pleura parietala – rr. din aa. intercostale- pleura viscerala – rr. din aa. bronsice
Drenajul limfatic:Drenajul limfatic:pori in pleura parietala lacune retea limfatica submezoteliala diverse statii limfatice regionale (gg.parasternali, paravertebrali, paraaortici, traheobronsici, duct toracic, etc)
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FIZIOLOGIA SPATIULUI PLEURAL
Lichidul pleural ia nastere din circulatia sistemica prin ambele foite pleurale, de unde este apoi preluat de limfaticele parietale:
pleura viscerala pleura parietalaspatiul pleural
limfatice parietale
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FIZIOLOGIA SPATIULUI PLEURAL
• Compozitia normala a lichidului pleural: ultrafiltrat plasmatic
• Volumul normal al lichidului pleural: 5-15 ml• Turn-over rapid: 1-2 litri/zi• Rata de formare = rata absorbtie vol. k
• Presiunea intrapleurala: negativa (-5 cm H2O la jumatatea toracelui la CRF, cca -30 cm la CPT)
• Presiunea intrapleurala: egala dar de sens opus cu reculul elastic pulmonar
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FIZIOPATOLOGIA ACUMULARII DE LICHID IN SPATIUL PLEURAL
1. PRODUCTIE CRESCUTA de lichid pleural >> drenajul limfatic:
- modificare presionala crestere presH
scadere presCo
- permeabilitate crescuta endoteliu vascular si/sau mezoteliu pleural
- cai aberante de patrundere lichid din cavit. peritoneala (stome)
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FIZIOPATOLOGIA ACUMULARII DE LICHID IN SPATIUL PLEURAL
2. RESORBTIE SCAZUTA de lichid:
- obstruarea stomelor limfatice parietale
- contractilitate limfatice alterata
- infiltrare statii gg. limfatice
- presiunii in vv. care dreneaza limfa
3. AMBELE MECANISME
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DIAGNOSTICUL REVARSATELOR PLEURALE
1. Clinic
2. Radiologic
3. Toracenteza certitudine dg.
informatii etiologice
4. Alte explorari
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DIAGNOSTICUL CLINIC
• Durere de tip pleuritic:- caracter- mecanism de producere- localizare- factori agravanti / atenuanti
• Tuse seaca• Dispnee• Alte elemente de orientare etiologica:
- febra- debutul (brusc/insidios)
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• Examenul clinic deceleaza minim 300 ml
- inspectie (± bombare hemitorace)
- palpare (reducere ampliatii costale, abolire vibratii vocale)
- percutie (matitate “lemnoasa”, curba
Damoiseau, deplasabila cu pozitia)
- auscultatie (abolire m.v., ± frecatura
pleurala si suflu pleuretic)
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DIAGNOSTICUL RADIOLOGIC
• Revarsate LIBERE in marea cavitate pleurala: - mici
- medii
- voluminoase
• Revarsate INCHISTATE:
- interlobar (scizural)
- oriunde intre pleura parietala si viscerala
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REVARSAT PLEURAL MINIM STANG
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REVARSAT PLEURAL MINIM STANG
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REVARSAT PLEURAL CANTITATE MEDIE DR.
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REVARSAT PLEURAL CANTITATE MEDIE DR.
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REVARSAT PLEURAL MASIV STANG
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REVARSAT PLEURAL MASIV STANG
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HIDRO PNEUMOTORAX DREPT
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HIDRO PNEUMOTORAX DREPT
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HIDRO PNEUMOTORAX STANG
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PIOPNEUMOTORAX DREPT
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REVARSAT PLEURAL BILATERAL (INSUFICIENTA CARDIACA)
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REVARSAT PLEURAL BILATERAL (PLEUREZIE NEOPLAZICA)
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REVARSAT PLEURAL INCHISTAT STANG
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REVARSAT PLEURAL POLIINCHISTAT DREPT
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REVARSAT PLEURAL INCHISTAT SUPRADIAFRAGMATIC DR.
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REVARSAT PLEURAL POLIINCHISTAT DREPT
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EMPIEM PLEURAL POLIINCHISTAT DREPT
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REVARSAT PLEURAL INCHISTAT INTERLOBAR
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TORACENTEZA- generalitati -
• Tehnica:
- dezinfectia tegumentului- se patrunde cu acul perpendicular, razant cu marginea superioara a coastei inferioare- anestezie plan cu plan
• Scop: diagnostic si terapeutic
• Contraindicatii relative: defecte majore de coagulare
• Complicatii posibile: pneumotorax, hemotorax, sincopa vagala, edem pulmonar ex vacuo unilateral
• Oprirea evacuarii cand apar: tuse, durere umar, dispnee, constrictie toracica
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Coasta sup.
Coasta inf.
Spatiul intercostal
Locul de punctie
Pachet vasculo-nervos i.c.
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TORACENTEZA- aspectul macroscopic al lichidului -
• 2 categorii mari:- lichid clar (serocitrin / serohemoragic)- lichid tulbure (purulent / lactescent)
• Aspecte particulare:- transsudatele: lichid limpede, galben pal- empiemele: aspect macroscopic de puroi- chilotoraxul: lichid alb-laptos (limfa)- hemotoraxul: lichid hemoragic cu hematocrit > 50% din cel sanguin- mezoteliomul malign: lichid filant, gelatinos
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TORACENTEZA- aspectul macroscopic al lichidului -
Multe revarsate maligne au lichid sero- hemoragic (cca 50%), insa:
Lichid hemoragic pleurezie neoplazica
Lichid serocitrin pleurezie non-maligna
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TORACENTEZA- determinari biochimice din lichid -
1. Proteinele pleurale: criteriul clasic de diferentiere intre:
- exsudate: proteine > 3 g% (g/dl)
rap. prot.pl./ prot.plasm. > 0,5
- transsudate: proteine < 3 g%
raport < 0,5
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TORACENTEZA- determinari biochimice din lichid -
2. LDH: al doilea criteriu de diferentiere exsudate/transsudate:
- exsudat: LDH pl > 200 UI
LDH pl / LDH seric > 0,6
- transsudat: LDH pl < 200 UI
LDH pl / LDH seric < 0,6
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TORACENTEZA- determinari biochimice din lichid -
3. Glicopleuria vs glicemia contemporana:- normal valorile sunt egale- informatiile etiologice sunt relative- valorile extreme sunt mai utile:
- glicopleurie > 1 g/l - revarsatulprobabil NU este tuberculos- valori << 0,3 g/l – revarsat fie in cadrul PR, fie empiem
- valori < 0,6 g/l: pleurezie parapneumonica, pleurezie TBC, PR- revarsate maligne cu glicopleurie mica probabilitate mare de citologie tumorala pozitiva in lichid
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TORACENTEZA- determinari biochimice din lichid –
4. Adenozin-dezaminaza (ADA):- utila in dg. diferential tbc / neoplazie- valori crescute > 65 u/l pl. tuberculoasa
5. Amilaza pleurala crescuta – 3 cauze:- boala pancreatica (amilaza pl. >> amilaza
serica)- perforatie esofag- pleurezii neoplazice (10%)
6. Acidul hialuronic > 200 mg% - 2 cauze:- mezoteliom malign- metastaza pleurala de adenocarcinom
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TORACENTEZA- determinari citologice din lichid –
Nr. total de celule: > 600 cel/mm3 - exsudat
• Celule mezoteliale: apar in orice proces inflamator pleural, mai rar in revarsate TB
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2. Celule sanguine:- Nr. total de leucocite > 1000/mm3 – exsudate- PMN > - empieme, parapn., embolie, pancreatite, abcese intraabdominale, precoce TB- Eozinofile > 10%:
- fara eozinofilie: aer/sange in pleura, revarsate azbestozice benigne, pleurezia TB in faza reparatorie- cu eozinofilie: hipersensibilitate la medicamente, sindrom Churg-Strauss, parazitoze,,boala Hodgkin
- Limfocite > 50%: TB, pleurezie maligna, revarsate virale, revarsate de cauza cardiaca- Hematii: valoare dg. cand sunt > 100.000/mm3 (neoplazie, embolie, traumatisme)
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3. Celule maligne – semnificatie:
- pun dg. de pleurezie neoplazica daca exista
“placarde de celule”, “muguri celulari”…
- prognostic: speranta de viata < 1 an
- randamentul ex. citologic in revarsatele maligne – cca 60%, dar creste la 90% prin repetarea examenului din lichid proaspat refacut
- randamentul tine de tipul neoplaziei primare: cca 25% pt. revarsatele din limfoame
100% pt. Adenocarcinoame
- localizare neo primar: bronhopulmonar, san, limfoame maligne
- imunohistochimia, flux citometria, analiza cromozomiala: metode noi de dg. diferential intre neo
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TORACENTEZA- investigatia bacteriologica din lichid –
• Se face atunci cand se suspecteaza etiologia infectioasa• Consta in efectuare de frotiuri
culturi
diferentiat in functie de germenii incriminati (M. tuberculosis, flora aeroba/anaeroba, fungi)
• Pleurezia TB: paucibacilara (randament examen bacteriologic: 10-20%)
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BIOPSIA PLEURALA TRANSTORACICA(cu acul)
• Tehnica: - cu ace speciale (Cope, Abrams)- similar toracentezei, dar anestezie >>
• Incidente, accidente: pneumotorax, lezarea pachetului nervos i.c., sincopa vagala
• Contraindicatii: tulburari majore de coagulare, spatii i.c. foarte mult reduse
• Indicatii: in orice exsudat, pt. diferentierea TB de neoplazie• Randament dg.: 80% TB, 40-60% neo
creste prin repetarea biopsiei• Limite: in 7% din revarsate NU se stabileste dg. etiologic
nici prin biopsie indic. pleuroscopie
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ALTE TEHNICI SAU INVESTIGATII
• Pleuroscopia: tehnica chirurgicala, cu instrumentar special, sub anestezie generala. Indicatie: pleurezii suspect maligne neconfirmate prin biopsie cu acul
• Toracotomia cu biopsie “deschisa”: pentru cazurile neconfirmate nici dupa pleuroscopie
• Ecografia transtoracica: pt. revarsate inchistate
• Bronhoscopia: cand se asociaza imagini in parenchim, hemoptizii, lichid masiv cu refacere rapida…
• Tomografia computerizata: utila in revarsate foarte reduse; asociere revarsat+leziuni pulm. de etiologie ??
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ALGORITM DE DIAGNOSTIC ETIOLOGIC AL REVARSATELOR PLEURALE
Toracenteza dg, determinare LDH, proteine
EXSUDAT TRANSSUDAT
Alte metode dg. Tratamentul ICC, ciroza...
Determinare glucoza, amilaza, citologie lichid,Culturi si frotiuri
Fara diagnostic Dg. stabilit
Embolie pulm.?? Tratamentadecvat
Scintigrama/arteriografie pulm DA NEG
Biopsie cu acul
TB Neoplazie ??
Tratament adecvat Pleuroscopie
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ETIOLOGIA REVARSATELOR PLEURALE- transsudate -
1. Insuficienta cardiaca congestiva
2. Ciroza
3. Sindrom nefrotic
4. Dializa peritoneala
5. Pericardita constrictiva
6. Obstructia venei cave superioare
7. Mixedem
8. Embolie pulmonara*
9. Sindrom Meigs*
10.Sarcoidoza*
11.Urinotorax
* Pot genera transsudat / exsudat
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ETIOLOGIA REVARSATELOR PLEURALE- exsudate -
1. Neoplazii- pleurezii metastatice- mezoteliom malign
2. Boli infectioase- infectii bacteriene- tuberculoza- infectii virale, fungice, parazitare
3. Tromboembolismul pulmonar4. Boli gastrointestinale
- perforatia esofagului- afectiuni pancreatice- abcese intraabdominale- hernie diafragmatica- dupa chirurgie abdominala- boala Whipple- dupa sceroterapia endosc.varice- postpartum
5. Boli vasculare de colagen-poliartrita reumatoida- lupus eritematos sistemic/postmedic.- limfadenopatie angioimunoblastica- sindrom Sjögren- granulomatoza Wegener- sindrom Churg-Strauss
6. Postmedicamentoase: Nitrofurantoin, Dantrolen, Metisergid, Bromocriptina, Procarbazina, Amiodarona
7. Sindrom Dressler (posttraumatic card.)8. Expunere la azbest9. Uremie10. Sindromul unghiilor galbene11. Radioterapie12. Trapped lung13. Hemotorax14. Chilotorax
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ETIOLOGIA REVARSATELOR PLEURALE- cele 3 cauze majore -
1. Neoplasm
2. Tuberculoza
3. Afectiuni cardiovasculare
- Variatii legate de varsta –
Tineri predomina TB
Varstnici predomina neo
30-40 ani proportii egale TB/neo
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• Tumora maligna cu agresivitate mare, prognostic prost, incidenta in crestere
• Rara (< 10% din pleureziile maligne)• 90% localizare pleurala, 10% peritoneala/pericardica• Relatie cauzala directa cu expunerea la azbest:
- Expunere de obicei ocupationala- Para-ocupational- Zone cu zacaminte naturale cu azbest
• Fibre de azbest implicate: crocidolit, tremolit, amosit, antofilit, crisotil
• Relatie doza-efect• Timp de latenta mare (15-40 ani)• Susceptibilitate genetica (?)
PLEUREZIILE NEOPLAZICE PRIMITIVE(mezotelioamele maligne - MM)
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Manifestari clinice
• Nespecifice, tardive• Durere toracica surda, tenace• Dispnee • Tuse • Retractie de hemitorace• Revarsat pleural /masa tumorala• Scadere in G• Astenie• Revarsat peritoneal• Metastaze la distanta
La pacient cu expunere la azbest
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Aspect radiologicingrosare mamelonata a pleurei, ± revarsat pleural, retractie torace
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Histopatologie
• Clasificarea OMS a MM: • Prognosticul difera in
functie de tip histo:
• MM difuz:• Epitelioid (60%)• Sarcomatoid• Desmoplazic• Bifazic
• MM localizat
• Biopsii prelevate cu acul sau toracoscopic (de preferinta)• Confuzii posibile cu:
- metastaze ale altor neoplazii (pulmonar, san etc)- leziuni inflamatorii benigne cu proliferare mezoteliala 13% erori de diagnostic initial*
Testele IHC: gold-standard
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Tratament; evolutie
• Tratament: fara viza curativa• Chimioterapia:
– Pacienti cu status general bun trat. linia I cat mai precoce:
cisplatin/carboplatin + antifolati (pemetrexed/raltitrexed)– Terapie linia a II-a: vinorelbina, gemcitabina, irinotecan
• Radioterapia• Chirurgia ??• Evolutie: locala (invazie diafragm, pericard, cord, coaste) /
la distanta
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PLEUREZIILE NEOPLAZICE SECUNDARE(metastatice)
• A 2-a cauza de exsudat pleural dupa cauzele infectioase
• > 40 ani: etiologia neoplazica – locul I • Neoplasmele care dau metastazare pleurala:
- bronhopulmonar 30%- cancer san 25% 75%- limfoame maligne 20%- altele (ovar, digestive, tiroida, oase, sarcoame, s.a.)
• Mecanism producere: invazie tumorala directa, diseminare limfatica/hematogena
• Clinic: debut insidios; revarsate masive, tend. refacere, frecvent dureri toracice rebele
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• Lichidul pleural: 50% hemoragic, 60% citologie +
• Biopsia pleurala cu acul: randament dg. cca 60%, creste prin repetare
• Biopsia toracoscopica: randament >>
• Prognostic prost, supravietuire 6-12 luni
• Citologia (+) sau/si biopsia pleurala pozitive pentru neoplazie = contraindicatie chirurgicala !!
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CONDUITA TERAPEUTICA IN PLEUREZIILE NEOPLAZICE
• Tratament exclusiv paleativ• Optiuni terapeutice legate de - tipul tumorii de origine
- stare generala
- speranta de viata
- ritm de refacere lichid
a) Pleurodeza (lipirea foitelor pleurale, cu desfiintarea spatiului pleural): cu talc, tetraciclina/doxiciclina, bleomicina, thiotepa s.a.
b) Sunt pleuroperitoneal
c) Drenaj pleural permanent
d) Toracenteze repetate
e) Chimio- si radioterapie: doar in anumite neoplazii (neo san, neo pulm. microcelular, limfoame, neo tiroida)
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PLEUREZIILE BACTERIENE(para- si metapneumonice)
• Caracter comun: tendinta la purulenta a lichidului• Asociate pneumoniilor, abceselor pulmonare,
bronsiectaziilor• Germeni: Klebsiella pn, S. aureus, Streptococ pn, E. coli,
Ps. Aeruginosa, germeni anaeobi, s.a.• Clinic: febra, durere toracica, tuse productiva, leucocitoza• Lichidul pleural: tulbure / franc purulent, glicopleurie <<,
neutrofile >>. Ex. bacteriologic: ± identificarea germenilor• Tratament antibioterapie adecvata
evacuare urgenta lichid (se inchisteaza!): prin punctie sau pleurotomie minima cu drenaj. La nevoie se introduce Streptokinaza 250.000 U intrapleural
• Esec: toracoscopie cu desfacere aderente / decorticare
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PLEUREZIILE INFECTIOASE NEBACTERIENE (virusuri, rickettsii, chlamidii, mycoplasme)
• Insotesc pneumopatii cu aceiasi germeni• Apar intr-un context epidemiologic sugestiv (epidemic)• Incidenta subestimata• Caractere comune:
- cantitate redusa de lichid pleural- tendinta spontana la resorbtie in 3-15 zile- Rx: adesea revarsate inchistate- lichidul pleural: serocitrin, limfocite >, steril, fara
tendinta de refacere dupa evacuare- biospia pleurala: nondiagnostica- dg (+): teste serologice pozitive
• Nu necesita tratamente/ atitudini agresive (AINS)
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HIDROTORAXUL DIN INSUFICIENTA CARDIACA
• Apare in IVS sau IC globala• Mecanism de producere: acumulare in exces de lichid in
pleura (> capacitatea de drenaj limfatic), prin migrarea apei din interstitiul pulmonar
• Clinic: semnele insuf. cardiace + sdr. lichidian• Tipic – revarsat pleural bilateral, mai rar drept, asociat
cardiomegaliei• Rar: revarsate inchistate interlobar• Lichidul pleural: transsudat sero-citrin sau sero-
hemoragic• Tratament: al insuficientei cardiace (diuretice, etc)• Biopsia pleurala e indicata daca: exsudat, febra, durere
pleuritica
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Revarsatele secundare TEP
• TEP sunt insotite frecvent de revarsate pleurale (10-50%)• Subestimare certa a incidentei etiologii in dg. revarsatelor• Clinic: predomina dispneea, >> fata de volumul revarsatului pleural, ±
alte semne de TEP (junghi toracic, hemoptizie, anxietate, etc)• Radiologic: revarsat uni/bilateral, mic-mediu (adesea interlobar), ±
imagine de infarct pulmonar, ascensionarea hemidiafragmului unilateral
• Lichidul pleural: exsudat / transsudat, sanghinolent, LDH >>, fara tend. la refacere.
• Biopsie pleurala non-diagnostica.• Dg. certitudine: scintigrama pulmonara, arteriografie pulm.• Tratament: anticoagulant• Daca lichidul se reface/creste sub tratament : TEP recurente,
hemotorax, infectie pleurala
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PLEUREZII SECUNDARE COLAGENOZELOR
• LES:
- pleurezia este inaugurala (dg. dificil) sau dupa alte manifestari de LES (dg. dif. cu pl. TB)
- Rx: revarsate mici-medii, adesea bilaterale
- lichid pleural: exsudat sero-citrin, limfocite >, prezente celule LE, FAN, C3 <
- biopsia pleurala: nespecifica
- tratament: corticoterapia
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PLEUREZII SECUNDARE COLAGENOZELOR
• Poliartrita reumatoida:- pleurezia apare rar in PR, dar e cel mai frecvent tip de afectare pleuro-pulmonara- de regula apare la cazuri cu PR diagnosticata- Rx: revarsate mici-medii, unilaterale- lichidul pleural: exsudat, limfocite >, LDH >>, glicopleuria <<, C3 <, FR ++- biopsia pleurala: rar – noduli reumatoizi- tendinta la fibrotorax necesita precoce evacuare, tratament antiinflamator
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CHILOTORAXUL
• Definitie: acumularea de limfa in spatiul pleural• Cauze: 1. Congenitale
2. Traumatice 3. Obstructive (limfoame, adenopatii
tumorale mediastinale, granulomatoze, limfangioleiomiomatoza)
• Lichidul pleural: alb-laptos, alcalin, inodor, limfocite >>, TG si chilomicroni >
• Investigatii utile: limfangiografia, CT mediastin• Tratament: cauze traumatice conservator
cauze obstructive sunt pleuroperit.
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HEMOTORAXUL
• Definitie: orice lichid hemoragic care are hematocritul > 50% din cel sanguin periferic
• Cauze: - traumatisme- neoplazii- pneumotorax spontan- tratament anticoagulant- iatrogene
• Tratament: drenaj pleural pe tub. Daca drenajul este > 200ml/ora toracotomia
• Complicatii: empiem secundar, fibrotorax
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PNEUMOTORAXUL
• Definitie: prezenta de aer in spatiul pleural, cu colabarea in grade diferite a plamanului
• Clasificare (functie de cauza):
1. PTX spontane - primitive (idiopatice)
- secundare altor afectiuni pulm.
2. PTX traumatice (plagi penetrante/nepenetrante)
3. PTX iatrogene (ventilatie mecanica, biopsii transbronsice, rupturi bronsice, catetere venoase centrale)
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• Clinic: - debut acut cu junghi toracic, dispnee, tuse seaca. 10% asimptomatici- examen fizic: hipersonoritate, abolire vibratii vocale si murmur vezicular, ± suflu amforic- PTX cu supapa: semne de insuficienta cardio-respiratorie acuta mare urgenta medicala
• Rx: plaman colabat in diferite grade, pleura viscerala vizibila, zona lipsita de desen vascular pulmonar in afara ei
• PTX cu supapa: deplasare mediastin controlateral (presiune pozitiva pe toata durata ciclului respirator)
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PNEUMOTORAX PARTIAL STANG
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PNEUMOTORAX PARTIAL DREPT
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PNEUMOTORAX PARTIAL DREPT PE FOND DE FID
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PNEUMOTORAX TOTAL STANG
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PNEUMOTORAX CVASITOTAL DREPT
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Pneumotoraxul spontan primitiv
• De obicei la tineri, fumatori, raport B/F=6/1• Mecanism: prin ruptura bulelor apicale
subpleurale; acestea pot fi congenitale sau dobandite
• Tendinta la recidiva (50%), de obicei homolat.• Atitudine terapeutica:
- aspiratia simpla- toracostomia cu drenaj +/- pleurodeza- toracoscopie / toracotomie cu rezectie
bule, abraziune pleurala succes 100% in prevenire recidive
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Pneumotoraxul spontan secundar
• Este mai grav decat cel primitiv (fistula br-pleurala)• Practic orice boala pulmonara poate da PTX, mai frecvent
cele obstructive:
- BPOC - abcesul pulmonar - orice PID
- astm bronsic - tuberculoza - limfangioleiomiomatoza
- mucoviscidoza - chistul hidatic - neoplasmul br.pulm.
- histiocitoza X - pn. stafilococica - sarcoidoza, etc
• Necesita din start toracostomie cu drenaj; in caz de esec (lipsa expansionarii plamanului) toracoscopie / toracotomie cu rezectie si abraziune pleurala.
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Tratamentul PTX
• PTX spontane mici, oligosimptomatice: expectativa, urmarire clinica si radiologica
• PTX voluminoase sau/si cu semne de insuficienta respiratorie: aspiratie simpla (exuflatie) in sp. II I.c. pe linia medioclaviculara.
succes esec:- toracostomie cu drenaj- pleurodeza cu agent sclerozant- toracotomie cu excizie
bule / abraziune pleura• PTX cu supapa: aspiratie urgenta !!! (risc vital)