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. 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.
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
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)
- 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);
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