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

10 ml lichid pleural 600 - 800ml /zi 1,5 g proteine/dl 4500 celule/ml: mezoteliale, monocite, limfocite, granulocite (rare) - capilarele pleurei parietale, - pleura viscerala (sp.interstitial) - cavitatea peritonealaLPLEURAL

Transudate - modificari (sistemice) hemodinamice: - pres hidrostatica capilara, - pres osmotica Exudate - modificari locale- permeabilitate capilara - scaderea drenajului limfatic pleural (20 N)

DiagnosticClinic: durere (intercostala, umar) tuse dispneeFrecatura pleuralaSindrom lichidian (> 500 ml)vol mic: 3-4 cm post. la baza hemitorace800 1000 ml: varf scapula, sp. Traube 1700 ml: spina scapulei2 l: ant. sp II i.c., deplasare mediastin

Ex. radiologic Radiografia toracica: frontala, laterala, oblic75 ml :obliterarea sinusului costofrenic post;175 ml: obliterarea sinusului costofrenic lateral1000ml: ant coasta a IV-a masive : hemitorace ,deplaseaza mediastinulIn decubit: > 175 ml lichid mici: grosime 1,5 cm moderate: 1,5 4,5 cm mari > 4,5 cm

Vasele pl sunt vizi- bile prin opacitatea lichidiana Bronhogramele aeriene sunt absente P. mari deplaseaza mediastinul

COLECTIILE INCHISTATEInterlobara: incidenta de profil: opacitate fuziforma oblica sus/jos - ext/int

Diafragmatica : >2cm de bula de aer a S Mediastinala : supra si infrahilar, ant si post

suprafata opacitatii este neteda unghiurile interfetei intre opac. pleurala si perete toracic sunt obtuze continutul este omogen

colectii inchistate ghidaj toracenteza

ECOGRAFIA TORACICATOMOGRAFIA COMPUTERIZATA TORACICA Dg lichid pleural minim, inchistat Masoara grosimea pleurei Distinge empiemul de abcesul pulmonar Localizeaza si caracterizeaza compozitia lichide pl. Identifica fistule bronho pleurale periferice Pneumotorax mic Procese pulmonare subiacente

RMN Diagnosticul lichidelor pleurale Caracterizeaza continutul lichidelor Diagnosticul tumorilor pleurale Invazia perete toracic TORACENTEZA Diagnostica :lichid >1cm RxEvacuatorie (necesitate);- dispnee - tendinta la inchistare- spatiul II i.c. anterior hematom pneumotoraxhemotorax,empiem punctia ficat,splina embolia gazoasa

EXAMENUL MACROSCOPIC

Ex. biochimic al lichidului Criteriile Light: prot pl/prot ser>0,5 LDH pl/ LDH ser >0,6 LDH pl>2/3 LDH ser Prot pleurale : 3g/dl (1016) - pseudoexudat: - colest pl > 45mg/dl; - col pl/col ser >0,3 - LDH pl> 45% LDH ser - Gradient prot serice - prot pl

Glucoza - 40 mg/dl: infectii, neoplasme- 20 mg/dl: artrita reumatoida, LEDAmilaze- pancreatita acuta, cronica- ruptura de esofag- pleurezii maligne- rar: pneumonii, sarcina ect. ruptapH -

Ex. citologicHematii: - serosanguinolent 5000-10000/mm3 - hemoragic: >100000/mm3 - accident punctie (col Wright) - neoplasm, embolie pl, traumatismeLeucocite - PMN : infectii pleurale (empiem) Insuf cardiaca: emb. pulmonara - Limfocite (>50%) TBC, neoplasme - Eozinofile (>10%): aer sau sange, infectii fungice sau parazitare, medicamente, Ex. parapneumonice - Plasmocite: mielom - Cel mezot : exclude TBC, cel. neoplazice

Ex. bacteriologicFrotiu : colorat Gram, Ziehl NielsenCulturi: aerobe, anaerobe, speciale:Lowenstein-Jensen, Middlebrook 7H10 (CO2).Teste suplimentareCelule lupiceComplementul Lipidele : trigliceride > 110 mg/dl colesterolBiopsia pleurala Citologie: 50-70% TBC, 50-65% neoplasm Culturi : 70 - 90 % TBC

TRANSUDATE Insuficienta cardiaca (NT-proBNP>1500pg/ml) Ciroza (hidrotorax hepatic: 5% din cirotici cu ascita : Embolia pulmonara (infarct pulmonar); Sindromul nefrotic Mixedem : ascita,revarsat pericardic, revarsat pleural Urinotorax (rar) Atelectazia pulmonara Dializa peritoneala Obstructia venei cave superioare

EXUDATE PLEURALENeoplasme- metastaze- mezoteliomInfectii- bacteriene- TBC- fungice- virale - parazitareEmbolie pulmonaraPost bypass coronarianExpunere la azbestHiperstimulare ovarianaSd unghiilor galbeneUremia, SarcoidozaPost iradiere, Sd. post lez cardiaceSd.MeigsBoli gastrointestinale- perforatia esofagului- boli pancreatice- abcese intraabdominale- hernia diafragmatica- post scleroterapie varice esofag- dupa chir. abd, transpl. hepaticBoli de colagen- artrita reumatoida- LED- medicamente ce induc LED- limfadenopatia imunoblastica- Sd. Sjogren- Granulomatoza Wegener- Sd. Churg-StraussMedicamente- nitrofurantoin- methisergyde- bromcriptina- amiodarona, procarbazina.

90%: rezultatul a 5 boli:- 36% Insuficienta cardiaca;- 22% Pneumonia; - 14% Neoplasm;- 11% Embolie pulmonara;- 7% Afectiuni virale.

Pleurezia tuberculoasaCauza frecventa de exudat pl, bacilul Koch Reactie de hipersensibilitate a spatiului pl. la proteinele tuberculoase (mec. imunoalergic - fenomen Koch)Inf pulmonara sau gg. traheobronsici (TBC primara)Tuberculoza post primara prin penetrarea BK in sp. pl.Clinic: febra, scadere ponderala, dispnee, durere pleuriticaEx. lichid: exudat uneori hemoragic, prot >50%din cele serice, glucoza

Ex. lichid: adenosine deaminaza>45 UI/l, interferon >140pg/ml, PCR pt ADN TBC pozitiv, limfocite miciDg: Frotiu (10-25%) culturi lichid pleural (25-75%), ex. citologic si culturi biopsie pleurala (80%), toracoscopie IDR-PPD (infectie latenta/activa, sensibilitate mica).

TUBERCULOSTATICE DE PRIMA LINIEFAZA 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

MedicamentZilnic (5-7/7)Intermitent 2/7- 3/7ISONIAZIDA (HIN)5 mg/Kg,300mg15mg/kg, 900mgRIFAMPICINA(RIF)10mg/kg,600mg10mg/kg, 600mgRIFABUTINA5mg/kg, 300mg5mg/kg,300mgPYRAZINAMIDA (PZN)20-25mg/kg (max - 2g)30 40 mg/Kg max- 3gETHAMBUTOL (EMB)15 -20mg/kg25 30 mg/kg

Infectii pulmonare: pneumonii, abces pl, bronsi-ectazii, Empiem: puroi in cav. pleurala - inf. pl, abces subfrenic, abces hepatic, iatrogen35% nosocomiale: anaerobi, Gr (- ), stafilococAerobi: febra, expectoratie, durere pleuritica, leucocitozaAnaerobe: subacut, scadere ponderala, leucocitoza minima, anemie, cond. de aspiratieEXUDATE PARAPNEUMONICE

EMPIEM PARAPNEUMONIC

Faze: exudativa, fibrinopurulenta, organizare (fistule)Rx : decubit lateral, CT, EcografieToracenteza caracteristici: - aspect macroscopic (serocitrin, puroi)- biochimie: glucoza, pH;- citologie:PMN, eozinofile- ex. bacteriologic: frotiu, culturiPrognostic prost:- lichid inchistat- pH

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

Pleurezii viraleexudate fara etiologie (20%)se rezolva spontan, fara secheleSIDAPleurezii rare: sarcom Kaposi, parapneumonice, TBC, limfom primar, rar P. cariniiPleurezia post embolie pulmonaraConditii favorizanteClinic: dispneeExudat sau transudat : eozinofile, cel mezotelialeCT spirala, Arteriografia pulmonaraTrat. anticoagulant

PLEURODINIA (BOALA BORNHOLM) - virus Coxsakie B - debut acut cu febra si spasme de durere pleuretica toracica / durere abdominala sup. - Durata parox. severe 15-30 min, tahipnee, transpiratii, muschii durerosi la palpare; - frecatura pleurala, revarsat pl. mic - leucocite normale, Rx pl -normal - virus izolat (scaun, lavaj faringian), RFC - simptomatic:AINS, codeina (30-60mg/8h)

PLEUREZII DIN BOLI DE COLAGENARTRITA REUMATOIDA- revarsat pl cronic (psudochilotorax)- exudat, glucoza

Pleurezia neoplazicaCauza frecventa de exudat la persoane >60 ani75%: carcinom pulmonar, mamar, limfoameCaracteristici: aspect hemoragic, refacere rapida (

- Cateter pleural cronic - drenaj in container vacuum (Denver PleurX) Sunt pleuroperitoneal; Pleurectomie sau ablatie pleurala (pleurodesie ineficienta) - chirurgie toracica. Chemoterapie si radioterapie: limfom, carcinom pl.cu cel miciMezoteliom - Tumora primara cu punct de plecare cel mezo-teliale

Expunere la azbest Evolutie locala (pleura, plaman, perete toracic, me-diastin pericard, peritoneu, diafragm,); Metastaze : gg hilari, mediastinali, ficat, rinichi. Clinic: durere toracica, dispnee, Sd. Horner Rx : ingrosare pleurala, revarsat pleural, in-corsetare plaman, strangerea hemitorace. Ex citologic pleural (hialuronidaza), toracoscopie, biopsie pleurala; mezotelina serica - marker tumoral dg si de monitorizare;PET distinge formele benigne de cele maligne;

Neoplasm incurabil; Chirurgie: pleura, plaman, n. frenic, hemidiafragm, pericard Radioterapie, chimioterapie : Pemetrexed (antifolic), Cisplatin, Gemcitabina Paliativ : durere (radioterapie), analgetice opioide, cateter epidural;pleurodezie, pleurectomie- Intrapleural : factor stimulator de colonii, interferon;Supravietuire: 8-15 luni.

ChilotoraxAcumularea limfei in spatiul pleuralEtiologie: - leziuni traumatice ale ductului toracic - tumori mediastinale - malformatii ale canalului toracic (fistule) - tromboza venei subclaviculare stg - anevrismul aortei toraciceRevarsat pleural masiv dispneeEx.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)Limfangiograma, CT toracicTratament conservator: aliment. parenterala; tub toracic +octreotid, interval scurt -denutritie, imunodepresieSunt pleuroperitoneal, ligatura chirurgicala canal limfatic

S. UNGHIILOR GALBENE exudat pleural cronic limfedem unghii galbene distrofice tulburari in drenajul limfatic

HEMOTORAXEtiologie- traumatisme- ruptura vaselor toracice ( ruptura de aorta)- tumori mediastinaleLichid pleural: hemoragic Ht > 50% din sg perifericTub de dren : hemoragie > 200 ml/h chirurgie toracica (sutura vasculara)

PNEUMOTORAXPatrunderea aerului in spatiul pleuralGeneralizat, localizatDeschis, inchis, valvular (in tensiune)- presiune pozitiva intrapleurala in tot ciclul respiratorForme: P. spontan primar (fara lez pl ant, fara traumatisme); P. spontan secundar (lez pl ant); P. traumatic (lez toracice penetrante sau nepanetrante) P. in tensiune

Clinic: durere, dispneeRx pl: transparenta fara desen brohovascular intre plaman si perete toracic (Rx:in ortostatism, in inspir) P. spontan primar: - ruptura chistelor aeriene apicale - fumatori- au recidive- aspiratia simpla, cateter - valve Heimlich- toracoscopia: capsarea chistelor, pleurodezie

P. spontan secundar:- BPOC, astm, fibroza pl, pneumonii, abcese, neoplasm- insuficienta respiratorie frecventa- toracostomie si instilarea agent sclerozant

- persistenta aer (> 3 zile toracostomie), toracoscopie cu rezectia lez. pulmonare si ple- urodezie P. traumatic - traumatisme toracice ne/penetrante - toracostomie, aspirarea aerului - hemopneumotorax: 2 tuburi: sup. aer, inf. sange

P. iatrogen- toracenteza,aspirarea transtoracica, cateter venos central, ventilatia mecanica - obsevatia, O2, toracostomia. P. in tensiune - Clinic: dispnee, anxietate, cianoza, FRFC, hTA, emf.mediastinal - Rx: hemitorace largit, aplatizarea diafragm, coborarea ficatului deplasarea mediastinului (cord)

- Urgenta medicala: insuf respiratorie, sincopa (debit cardiac redus) - 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);

Procentul vacant al hemitoracelui: = 1 - (latimea plaman)3 / (latimea hemitorace)3;1- 53: 103 = 1- 125: 1000= 1- 0,125 = 87,5%Dg. diferential : bule de emfizem stomac, colon (suprapuse campuri pl);