of 82
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SINDROAME DE
CONDENSAREPULMONARA
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CONDENSARI PULMONAREPRODUSE
PRIN PROCESEINFLAMATORII
PNEUMONII
BRONHOPNEUMONII
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PNEUMONIILE
-bacteriene-virotice
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PNEUMONIILEBACTERIENE
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SINDROMUL FIZIC DECONDENSARE PULMONARA
Vibratii vocale accentuate
Submatitate Pectorilocvie afona
Suflu tubar
Raluri crepitante
Murmur vezicular / absent
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Pneumonii bacteriene
Ex:
Pn.pneumococica (Pn. Franca
lobara)Pneumonia cea mai fracventa, tabloutipic
Pn.stafilococica Pn. Streptococica
Pn. Klebsiela pn (bacil
Friendlander)
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PNEUMONIA FRANCALOBARA
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PNEUMONIA FRANCA LOBARA
Etiologie: Streptococcuspneumoniae
=Coc G+ in diplo
Cuprinde un segment / lob pulmonar
Evolutie in 3 faze
1.Debut2.Perioada de stare
3.Rezolutia
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DEBUT-1
FRISON solemnUnic si puternic
Durata 15 30minute
Urmat de
FEBRAinalta 390 400inplatou
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DEBUT-2
JUNGHI
Intens
Transfixiant
Accentuatde respiratie / tuse
Imobilizeaza pt. pepartea bolnava
Localizat: submamelonar / bazal
Atesta afectarea pleurala(ex.:pl.diafragmatica durere umar
copii durere proiectata abdominal
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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 vultuos herpes labial ( toata fata)
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DEBUT-5
EXAMENUL APARATULUI RESPIRATOR INSPECTIE -respiratie superficiala ( prin
junghi)
-polipnee
PALPARE: vibratiile se transmit normal
PERCUTIE: discreta submatitate
AUSCULTATIE :Initial: tonalitatea si intensitateaMV
=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 zile Tabloul clinic al Sdr. de condensare
Febra in platou
Dispnee cu polipnee de tip inspirator Cianoza
Persista junghi cu intensitate
Tuse cu expectoratie ruginie ulteriorgalbuie
Facies vultuos (congestia obrazului de parteabolnava)
Icter( hemoliza, hepatita toxica satelita)
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PERIOADA DE STARE
EXAMEN TORACE
Inspectie : amplitudinea excursiicostale
de partea bolnava
Palpare : tansmitere V V Percutie : Matitate
Auscultatie : inlocuire MV cu suflu
tubar inconjurat de coroana decrepitante
(in dinamica initial domina crepitantelecaresunt 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 criza Starea 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 particulare Starea generala se imbunatateste
Febra scade treptat
Tusea diminua apoi dispare
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LABORATOR
INFLAMATIE: leucocitoza cuneutrofilie, VSH, fibrinogen, CRP
BIOCHIMIE: bil.indirecta,
creatinina, uree
(oligurie)
SPUTA:
-Ex. Bacteriologic: frotiu, cultura=pneumococ
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CONFIRMARE
Ex RADIOLOGICopacitate triunghiulara
baza spre pleura
varful spre hil
intensitate subcostala,
omogena
corespunde afectarii unui segment/ lob
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Strep. pneumoniaepneumonia.
Right upper-lobe
consolidation
demonstrating a
pronounced air
bronchogram andabsence of
volume change.
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Strep. pneumoniaepneumonia.
Bilateral lower-zoneconsolidation
(arrows).
Althoughpneumococcal
pneumonia is typicallyunifocal, multifocal
involvement is notuncommon.
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Strep. pneumoniaepneumonia.
Very extensive
consolidationaffecting
more than one lobe in
the right lung. Thecentral lucency is due
to
cavitation anunusual
feature inpneumococcalpneumonia.
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FORME PARTICULARE
FORME ABORTIVE
vindecare spontana fara AB
PNEUMONIA BATRANULUI
tablou discret, evolutie severa
PNEUMONIA COPILULUI
junghi abdominal,varsaturi, semnemeningeale
ALCOOLICI
tulburari psihice, agitatiepsihomotorie
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EVOLUTIA
NATURALA
-Moarte in crizis
-Complicatii
SUBTRATAMENT
-Tineriimunocompetenti
vindecare in 5-6zile
-Complicatii labatrani, tarati
COMPLICATII Colaps Sepsisbacteriemie
:pericardita, endocardita,meningita, abces
cerebral, parotidita,nefrita,
Abcedare Pleurezie-Din perioada de stare: parapneumonica
= lichidserocitrin-Tardiv: metapneumonica
=de obiceilidchid
purulent
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PNEUMONIA STAFILOCOCICA Debut mai putin brutal
Stare generala mai grava
Clinica = dominata de dispnee si cianoza
Febra de tip remitent
Sputa mucopurulenta cu striatii sangvine Obiectiv: focare de condensare,
submatitati, respiratie suflanta, crepitante+ subcrepitante
Rx. = Focare multiple de condensare
pneumatocele pneumotorax
= defapt bronhopneumonie
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Staph. aureuspneumonia. Thiscavitary pneumoniawas
a community-acquiredinfection occurringtwo weeks after aninfluenza A infection.
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Staph. aureus pneumonia pneumatoceles.Appearances followingincomplete resolution of astaphylococcal pneumonia.
There are several thin-walled cysts consistentwith pneumatoceles. Suchpneumatoceles arecommon in children but
unusual in adults.
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Staph. aureusinfection in a drugabuser.
Multipledisseminatednodularconsolidations,confluent in theright lower zone;several havecavitated. Theappearances aretypical ofhaematogenous
dissemination.
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PNEUMONIA CU KLEBSIELLAPNEUMONIAE(Friedlander)
Favorizata de teren ( boli cronice,subnutritie)
Caracteristica = starea generalaf. grava
cu colaps incontext septic
Cianoza si dispnee intense
Sputa hemoptoica vascoasa
Sdr. De condensare discret conturat
Rx.: opacitati ce cuprind mai mult deun lob,
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Gram-negativepneumonia
(Haemophilusinfluenzae)
showing a typical
bronchopneumonicpattern ofheterogeneous
localizedconsolidation. Such
infections arecommonly basal.
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PRINCIPII GENERALE DETRATAMENT
Oxigen
Hidratare
Simptomatic (antipiretice, antitusive,fluidifiante sputa
Al complicatiilor
ETIOLOGIC = ANTIBIOTICE
Nespitalizati
7. tineri imunocompetenti 5-18 ani
( macrolide / tetracicline II)
9. > 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
CephP rezistent : FQ (moxi) / P ceph 3
H influenzae
-lactamaza + : AM/CL, O Ceph 2/3, P Ceph3
-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 consolidationof the right middle lobe which partially obscures hilar adenopathy.
Additional right paratracheal node enlargement is present.
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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.
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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: miliary tuberculosis in an adult man.Diffuse nodulation is present in all zones. Nodules are approximately 1 mm in
diameter and well defined.
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 iswell defined and proved to be a tuberculoma at surgery. The less well-definedlower 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 saumucopurulenta
Sindrom bronsiticAstenie fizica, transpiratii nocturne
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Procesele infiltrative pulmonare
nu realizeaza
sdr. de condensareparenchimatoasa
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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
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M l i A l f id d i i l
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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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BRONHOPNEUMONIA Sindrom anatomo-clinic de cauze multiple, cu
evolutie neregulata, prognostic rezevat Afecteaza 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 / absente
cu stare generala grava
DEBUT necaracteristic, insidios
STARE GENERALA alterata, grava
Frisonul , junghiul pot lipsi
FEBRA creste treptat , este
neregulata, creste din nou cand apare unnou focar, scade litic la sfarsitul bolii
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TUSEA cu expectoratia mucopurulentaare rar striatii hemoragice
CIANOZA intensa de tip central (buze siextremitatilor)
DISPNEEA
cu
POLIPNEE extrema (> 35 respiratii /min)
= pe primul plan + tiraj suprasternal siintercostal si bataia aripioarelor
nazale(copii)
/ sau Dispnee permanenta cu
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BRONHOPNEUMONIISEMNE FIZICE
totdeuna incontrast izbitor cugravitateasemnelor generalesi dispneea
variabile ca sediusi ca timp,modificandu-sicaracterele de la ozi la alta, uneorichiar in cateva ore
Variabile
Depind de
extindereaprocesului
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PERCUTIA
Modificari ( matitate )= doar in
bronhopneumoniile confluente care
imita pneumonia lobara
Focarele sunt localizate uzual in lobii
inferiori (exceptii: rujeola, tusea
convulsiva
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AUSCULTATIA :
Raluri bonsice diseminate= expresia bronsitei
- intre acestea = crepitatii in
teritoriul focarului lobular
RALURISUBCREPITANTE DE CALIBREDIFERITE
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Concluzie
Zone disparate darmultiple de congestie cu
respiratie suflanta, raluri bronsice, raluri
crepitante sisubcrepitante
si submatitati
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BRONHOPNEUMONIIEXAMEN RADIOLOGIC
Nu exista paralelism intre tabloul clinic sicel radiologic
Rx. Pune in evidenta focare
bronhopneumonice = umbre maireduse ca extindere, dar multiple, deintensitati variabile, cu contur
neregulat si rau delimitat Uneori 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
antibioticelor ameliorat cu tratament etiologic(antiinfectios) si suportiv al complicatiilor
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INFLAMATIE: leucocitoza cuneutrofilie, VSH, fibrinogen,
CRP
BIOCHIMIE: bil.indirecta,
creatinina, uree(oligurie)
SPUTA:-Ex. Bacteriologic: frotiu, cultura
=pneumococ
-Celularitate: hematii, celule alveolare,
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CONDENSARI PULMONAREPRODUSE PRIN PROCESE
TUMORALE
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NEOPLASMUL BRONHOPULMONAR
Asociere de sindroameSdr de condensare retractil /neretractil
Sdr. Lichidian pleuralSdr. Mediastinopulmonar
Sdr cavitar
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In functie de localizare neo.:
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 coacaze DISPNEEdaca bronsia principala este obstruata
EXAMEN FIZIC
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EXAMEN FIZIC
SDR. DE OBSTRUCTIE BRONSICA
LOCALIZATA OBSTRUCTIE PARTIALAwheezing localizatHipersonoritate localaSibilante + ronflante localizate vv, mv localizat
OBSTRUCTIE TOTALA= sdr. AtelectaticMatitate fara VV, fara MV
COMPLICATII OBSTRUCTIEPneumonii repetate in acelasi locabcese
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,
edemin 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
Febra Sdr. Endocrine Afectare nervoasa paraneo= neuropatie
periferica
Sdr. Miastenic, polimiozita Sdr.reumatismale Osteoartropatia Pierre Marie Sdr. Dermatologice: dermatomiozita,
achantosis nigricans Tromboflebite migratorii (Trouseau) Endocardita nebacteriana Hematologice: anemie, Tpenie, CID Glomerulopatie membranoasa
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DIAGNOSTIC
Suspiciune clinica confirmata Rx, CT,bronhoscopie ( sputa),mediastinoscopie
TRATAMENT
Chimioterapie
Chirurgical
Radioterapie preoperator / paleativ
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INFARCTUL PULMONAR
Sdr. De condensare datoritainlocuirii aerului alveolar cu sange
Secundar obstructieei uni ram
a.pulmonara
Cauza favorizanta ( boli carefavorizeaza formarea trombilor
tromboze venoase profunde )
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CLINIC
DURERE TORACICAjunghi exacerbat de tuse si respiratie,
decubit lateral pe partea sanatoasa)
DISPNEE ANXIETATE
Expectoratie HEMOPTOICA 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 v Respiratie inasprita
Frecaturi pleurale
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INFARCT MARE
submatitate
v v Respiratie suflanta / suflu tubar
Subcrepitante, crepitante Frecaturi 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 PULMONARE
RETRACTILE
ATELECTAZIA
PULMONARA
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Resorbtia aerului alveolar de cauza
mecanica (frecvent obstructie
bronsica)
Sdr de condensare cu tractiunea
organelor 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,descoperiteRx.
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Hemitorace afectat mai mic de
volum Adancirea fosei supraclaviculare de parea
bolnava
Ingustarea spatiilor intercostale
amplitudinea excursiilor costale
Palpare: vv / abolite
Percutie : matitate
Auscultatie: / abolire mv
RADIOLOGIC
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RADIOLOGICOpacitate omogena cu concavitatea spre
exterior intereseaza 1 segment, / un lob,/ un plaman
intreg
cu o intindere mai mica decat regiunea
respectiva in conditii normaleSpatii intercostale ingustate si mai oblice
Mediastin tractionat spre partea bolnava
Diafragm ascensionatMiscare inspiratorie a mediastinului spre
partea bolnava
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Right middle-lobeatelectasis in a 70-year-old female with chronicobstructive lung disease.(A) The frontal chestradiograph showsminimal blurring of theright heart border. (B) Thelateral chest radiographshows that the rightmiddle lobe is completelycollapsed. The depressedminor 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 radiographshows hazy 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
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lucent because it is occupied by the superior segment of the hyperinflated left lower lobe. The aortic arch issharply outlined by 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 scanshows the complete left lower-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 tomucoid impaction, in a 63-year-old man following abdominalsurgery. (A) The frontal chestradiograph shows the triangularoutlines of the collapsed lowerlobes (sail sign) (arrows). Bothhila are depressed. The medialportions of the diaphragm areobscured. The collapsed left lowerlobe is almost exactlysuperimposed on the heart. (B) A
lateral chest radiograph showsthe collapsed lobes overlying thespine (arrows). The posteriorportions of both hemidiaphragmsare obscured.
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Combined right middle and rightlower-lobe collapse in a 66-year-old woman withbreathlessness followingabdominal surgery. The frontalchest radiograph shows combinedright middle lobe and right lower-lobe collapse. Arrows indicate theminor fissure. Arrowheadsindicate the major fissure. Themultilobar collapse simulates aright pleural effusion, but themarked inferior hilar
displacement, the markeddepression of the right majorfissure, and the ipsilateralmediastinal shift are importantclues that this is a volume-losingprocess A decubitus view showed