Pleurezii

Definitie. Mecanisme
• Exces de fluid acumulat in spatiul pleural

• Formare in exces in interstitiul pulmonar,

pleura parietala, sau cavitatea peritoneala
sau
• Eliminare scazuta a fluidului pleural de catre
limfaticele pleurei parietale .
 Etiologie
• Transudate – influente sistemice pe
formare/reabsorbtie fluid
– Ex: insuficienta ventriculara stanga, ciroza
hepatica, sdr nefrotic etc

• Exsudate – factori locali

– Ex: pneumonie bacteriana, neoplasm, TEP etc
 Abordare diagnostica
• Exudate – cel putin 1 din 3 criterii:
– raport proteine fluid pleural/ser (>0.5),
– LDH fluid pleural > 2/3 din limita superioara a LDH
seric
– LDH pleural/seric >0.6.
• Transudate – nici un criteriu.

• Exsudate – teste suplimentare: pH, glucoza,

leucocitoza+formula, microbiologie, citologie,
amilaza.
 Transudat - IVS
• Bilateral sau de partea dreapta

• NT-proBNP >1500 pg/ml inalt sugestiv

• Nu necesita mereu toracocenteza pentru

diagnostic
 Pleurezie parapneumonica/ Empiem
• RxCP decubit, CT, ecografie
• Lichid purulent – empiem

• Necesita tub toracostomie daca fluid:

purulent, Gram/cultura +, Glucoza <60mg/dl,
pH<7.2, cloazonat

• Daca tub=ineficient, decorticare chirurgicala!

 Pleurezii maligne
• Plaman, san, limfom

• Citologie, toracoscopie

• Toracocenteze terapeutice, abraziune pelurala,

agenti sclerozanti (doxiciclina)
 Pleurezia din TEP
• Exsudat, rar transudat

• Nu modifica tratamentul standard

• Extindere sub anticoagulant = TEP recurent/

hemotorax/ empiem
 Pleurezia TBC
• Exsudate cu limfocitoza
• Niveluri crescute in fluid markeri: ADA, IFN ϒ

• Culturi Mycobacterium din fluid/biopsie

pleurala – diagnostic certitudine

• Fara tratament, risc TBC activ in viitor

 Chilotorax
• Lichid laptos, trigliceride >110mg/dl

• Traume duct toracic, tumori mediastinale

• Tub toracic, octreotide

 Hemotorax
• Hematocrit lichid >50% din HT sange venos

• Traume/rupturi vasculare/tumori

• Tub toracic sau chirurgie daca pierdere >200

ml/h
Pneumotorax
 Definitie. Etiologie
• Gaz in spatiul pleural

• Spontan = fara trauma

• Primar spontan – fara boala pulmonara;

aspiratie simpla ca tratament
• Secundar spontan – BPOC; tub
toracic/toracoscopie/pleurodeza
Pneumotorax
spontan
traumatic

Simptome
junghi, dispnee, tuse seaca

Semne
cianoza, anxietate
tahipnee, tahicardie,

Pneumotorax cu supapa
(intra aerul in inspir in pleura dar nu iese in expiratie)
Caz clinic
 Pneumotorax- Tratament

Calmarea durerii

Oxigenoterapie

Decompresie
 Pneumotorax traumatic
• Trauma toracica penetranta/nepenetranta

• Necesita tub toracic

 Pneumotorax iatrogen
• Punctie biopsie transtoracica, toracenteza,
montare cateter venos central, biopsie
transbronsica

• O2/ aspiratie/ tub toracic

 Pneumotorax in tensiune
• Trauma/ ventilatie mecanica.
• Compromiterea functiei cardiovasculare!

• Tratament URGENT:
– Tub toracic
Sau (in lipsa)
– Ac gros in spatiul pleural prin spatiul II intercostal
anterior.