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SINDROAME DE CONDENSARE PULMONARA

CONDENSARI PULMONARE PRODUSE PRIN PROCESE INFLAMATORII


PNEUMONII BRONHOPNEUMONII

PNEUMONIILE -bacteriene -virotice

PNEUMONIILE BACTERIENE

SINDROMUL FIZIC DE CONDENSARE PULMONARA


Vibratii vocale accentuate Submatitate
Pectorilocvie afona

Suflu tubar Raluri crepitante Murmur vezicular / absent

Pneumonii bacteriene
Ex: Pn.pneumococica (Pn. Franca lobara) Pneumonia cea mai fracventa, tablou tipic Pn.stafilococica Pn. Streptococica Pn. Klebsiela pn (bacil Friendlander) Pn. cu Haemophilus influenzae

PNEUMONIA FRANCA LOBARA

PNEUMONIA FRANCA LOBARA

Etiologie: Streptococcus pneumoniae


=Coc G+ in diplo

Cuprinde un segment / lob pulmonar Evolutie in 3 faze


1.Debut 2.Perioada de stare 3.Rezolutia

DEBUT-1

FRISON solemn
Unic si puternic Durata 15 30 minute

Urmat de

FEBRA inalta 390 400 in platou

DEBUT-2

JUNGHI
1. Intens 2. Transfixiant 3. Accentuat de respiratie / tuse 4. Imobilizeaza pt. pe partea bolnava 5. Localizat: submamelonar / bazal 6. Atesta afectarea pleurala
(ex.:pl.diafragmatica durere umar

copii durere proiectata abdominal

DEBUT-3
TUSEA iritativa, seaca, la inceput 1 3 zile - Insotita de expectoratie ruginie aderenta contine fibrina si hematii

DEBUT-4
EXAMENUL GENERAL

tegumente calde (febril) Stare generala alterata Facies vultuos herpes labial ( toata fata)

DEBUT-5
EXAMENUL APARATULUI RESPIRATOR

INSPECTIE -respiratie superficiala ( prin junghi) -polipnee PALPARE: vibratiile se transmit normal PERCUTIE: discreta submatitate AUSCULTATIE : Initial: tonalitatea si intensitatea MV
=respiratie inalta modificare timbru = inasprire MV = respiratie suflanta (suflu audibil mai ales in expir)

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 ulterior galbuie Facies vultuos (congestia obrazului de partea bolnava) Icter ( hemoliza, hepatita toxica satelita)

PERIOADA DE STARE
EXAMEN TORACE

Inspectie : amplitudinea excursii costale


de partea bolnava Palpare : tansmitere V V Percutie : Matitate Auscultatie : inlocuire MV cu suflu tubar inconjurat de coroana de crepitante (in dinamica initial domina crepitantele care sunt ulterior inlocuite de suflul tubar)

Rezolutia
Matitate mai putin neta

/ dispare suflul tubar


Reapar crepitantele = alte caractere groase, inegale, mai umede

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

Vindecarea in lisis

Fara semne clinice particulare Starea generala se imbunatateste Febra scade treptat Tusea diminua apoi dispare

LABORATOR
INFLAMATIE: leucocitoza cu neutrofilie, VSH, fibrinogen, CRP BIOCHIMIE: bil.indirecta, creatinina, uree (oligurie) SPUTA:
-Ex. Bacteriologic: frotiu, cultura =pneumococ -Celularitate: hematii, celule alveolare, leucocite

CONFIRMARE Ex RADIOLOGIC
opacitate triunghiulara
1. baza spre pleura 2. varful spre hil 3. intensitate subcostala, omogena 4. corespunde afectarii unui
segment / lob

Strep. pneumoniae

pneumonia. Right upper-lobe consolidation demonstrating a pronounced air bronchogram and absence of volume change.

Strep. pneumoniae

pneumonia. Bilateral lower-zone consolidation (arrows). Although pneumococcal pneumonia is typically unifocal, multifocal involvement is not uncommon.

Strep. pneumoniae

pneumonia. Very extensive consolidation affecting more than one lobe in the right lung. The central lucency is due to cavitation an unusual feature in pneumococcal pneumonia.

FORME PARTICULARE
FORME ABORTIVE vindecare spontana fara AB PNEUMONIA BATRANULUI tablou discret, evolutie severa PNEUMONIA COPILULUI junghi abdominal,varsaturi, semne meningeale

ALCOOLICI tulburari psihice, agitatie psihomotorie

EVOLUTIA

NATURALA
-Moarte in crizis -Complicatii

SUB TRATAMENT
-Tineri imunocompetenti vindecare in 5-6 zile -Complicatii la batrani, tarati

COMPLICATII Colaps Sepsisbacteriemie :pericardita, endocardita, meningita, abces cerebral, parotidita, nefrita, Abcedare Pleurezie -Din perioada de stare: parapneumonica = lichid serocitrin -Tardiv: metapneumonica =de obicei lidchid purulent

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

Staph. aureus pneumonia.

This cavitary pneumonia was a community-acquired infection occurring two weeks after an influenza A infection.

Staph. aureus pneumonia

pneumatoceles. Appearances following incomplete resolution of a staphylococcal pneumonia. There are several thin-walled cysts consistent with pneumatoceles. Such pneumatoceles are common in children but unusual in adults.

Staph. aureus

infection in a drug abuser. Multiple disseminated nodular consolidations, confluent in the right lower zone; several have cavitated. The appearances are typical of haematogenous dissemination.

PNEUMONIA CU KLEBSIELLA PNEUMONIAE (Friedlander) Favorizata de teren ( boli cronice, subnutritie)

Caracteristica = starea generala f. grava cu colaps in context septic Cianoza si dispnee intense Sputa hemoptoica vascoasa
Sdr. De condensare discret conturat Rx.: opacitati ce cuprind mai mult de un lob, adesea un plaman intreg Tendinta la abcedare si cronicizare

Gram-negative pneumonia (Haemophilus influenzae) showing a typical bronchopneumonic pattern of heterogeneous localized consolidation. Such infections are commonly
basal.

PRINCIPII GENERALE DE TRATAMENT


Oxigen Hidratare Simptomatic (antipiretice, antitusive, fluidifiante sputa

Al complicatiilor

ETIOLOGIC = ANTIBIOTICE Nespitalizati


tineri imunocompetenti 5-18 ani ( macrolide / tetracicline II) 1. > 18 ani : macrolide / FQ / AM/CL / DOXI) Spitalizati : P Ceph 3 + macrolid / FQ*
1.

Tratament ETIOLOGIC SPECIFIC


daca ag.etiologic este determinat + antibiograma

Strep.pneumoniae
Penicilino sensibil = AMP iv, amox po, M, pen G iv, doxi, O Ceph P rezistent : FQ (moxi) / P ceph 3

H influenzae
-lactamaza + : AM/CL, O Ceph 2/3, P Ceph 3 -Lactamaza : AMP iv, amox po, TMP/SMX, M

TUBERCULOZA

right middle lobe which partially obscures hilar adenopathy. Additional right paratracheal node enlargement is present.

Primary tuberculosis in a child. There is homogeneous consolidation of the

characterized by areas of consolidation and cavitation. The cavitation is particularly extensive on the right where some of the cavities contain airfluid levels.

Post-primary tuberculosis. There is gross mid- and upper-zone disease

Post-primary tuberculosis: tuberculous bronchopneumonia. Numerous 5 mm nodular shadows are present in both lungs, sparing the right apex. These are consistent with acinar consolidation following the endobronchial spread of tubercle bacilli from the left upper-zone cavity.

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 zone in a patient who has had a thoracoplasty. The uppermost 20 mm nodule is well defined and proved to be a tuberculoma at surgery. The less welldefined lower nodule had developed over 1 year and was a bronchial carcinoma. Note the scattered small calcified nodules.

PNEUMONII (NON BACTERIENE) INTERSTITIALE atipice

ETIOLOGIE de regula virala, dar si : chlamidii, micoplasme


CLINIC predomina: Febra Tuse cu expectoratie mucoasa sau mucopurulenta Sindrom bronsitic Astenie fizica, transpiratii nocturne

Procesele infiltrative pulmonare nu realizeaza sdr. de condensare parenchimatoasa

DIAGNOSTIC CLINIC
Element epidemiologic sugestiv Sugerat de asocierea :
Rinita Angina eritematoasa Bronsita

Semnele clinice sarace sunt contrastante cu radiologia

RADIOLOGIA Desen accentuat Opacitati liniare de ob.


Hilio-bazale, uni sau bilaterale

Uneori opacitatile micro- sau macronodulare au caracter tranzitor

Legionella pneumophila pneumonia. While the unilateral lowerzone peripheral consolidation is a typical appearance, it completely lacks specificity. Apparent cavitation was spurious.

Measles pneumonia. An example of a widespread primary viral


pneumonia with extensive bilateral confluent consolidation.

BRONHOPNEUMONIA

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

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 un nou focar, scade litic la sfarsitul bolii

TUSEA cu expectoratia mucopurulenta are rar striatii hemoragice CIANOZA intensa de tip central (buze si

extremitatilor) DISPNEEA cu POLIPNEE extrema (> 35 respiratii / min) = pe primul plan + tiraj suprasternal si intercostal si bataia aripioarelor nazale(copii) / sau Dispnee permanenta cu exacerbari

BRONHOPNEUMONII
SEMNE FIZICE totdeuna in contrast izbitor cu gravitatea semnelor generale si dispneea variabile ca sediu si ca timp, modificandu-si caracterele de la o zi la alta, uneori chiar in cateva ore
Variabile

Depind de extinderea procesului

PERCUTIA
Modificari ( matitate )= doar in bronhopneumoniile confluente care imita pneumonia lobara Focarele sunt localizate uzual in lobii inferiori (exceptii: rujeola, tusea convulsiva

AUSCULTATIA :
Raluri bonsice diseminate = expresia bronsitei - intre acestea = crepitatii in teritoriul focarului lobular
RALURI SUBCREPITANTE DE CALIBRE DIFERITE

Concluzie
Zone disparate dar multiple de congestie cu respiratie suflanta, raluri bronsice, raluri crepitante si subcrepitante si submatitati

BRONHOPNEUMONII EXAMEN RADIOLOGIC Nu exista paralelism intre tabloul clinic si cel radiologic

Rx. Pune in evidenta focare bronhopneumonice = umbre mai reduse ca extindere, dar multiple, de intensitati variabile, cu contur neregulat si rau delimitat Uneori exista si imagini mai dense

BRONHOPNEUMONII COMPLICATII
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

INFLAMATIE: leucocitoza cu neutrofilie, VSH, fibrinogen, CRP


BIOCHIMIE: bil.indirecta, creatinina, uree (oligurie) SPUTA:
-Ex. Bacteriologic: frotiu, cultura =pneumococ -Celularitate: hematii, celule alveolare, leucocite

CONDENSARI PULMONARE PRODUSE PRIN PROCESE TUMORALE

NEOPLASMUL BRONHOPULMONAR Asociere de sindroame


Sdr de condensare retractil / neretractil

Sdr. Lichidian pleural Sdr. Mediastinopulmonar Sdr cavitar

In functie de localizare neo.:


Hilar Nodul periferic Lobar Segmentar

Sdr de condensara pulmonara = Rar

ACUZE TUSE
Excitare vag

DUREREA
apare tardiv continua, nelegata de respiratie

HEMOPTIZIE
Aspect jeleu de coacaze

DISPNEE
daca bronsia principala este obstruata

EXAMEN FIZIC
SDR. DE OBSTRUCTIE BRONSICA LOCALIZATA

OBSTRUCTIE PARTIALA
wheezing localizat Hipersonoritate locala Sibilante + ronflante localizate vv, mv localizat

OBSTRUCTIE TOTALA
= sdr. Atelectatic Matitate fara VV, fara MV

COMPLICATII OBSTRUCTIE
Pneumonii repetate in acelasi loc abcese

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, edem
in pelerina Pleura = sdr.lichidian pleural Pericard = revarsat lichidian/ tamponada Miocard = aritmii Catre inel toracic superior = sdr.Pancoast (liza coastei 1- 2)

SEMNE LEGATE DE METASTAZE LIMFATICE

Ganglioni:
hilari, mediastinali,

supraclaviculari

Limfangita carcinomatoasa
(dispnee,

insuf. Respiratorie)

HEMATOGENE
ficat, creier, SR, os

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

DIAGNOSTIC Suspiciune clinica confirmata Rx, CT, bronhoscopie ( sputa), mediastinoscopie


TRATAMENT

Chimioterapie Chirurgical Radioterapie preoperator / paleativ

INFARCTUL PULMONAR Sdr. De condensare datorita inlocuirii aerului alveolar cu sange Secundar obstructieei uni ram a.pulmonara Cauza favorizanta ( boli care favorizeaza formarea trombilor tromboze venoase profunde )

CLINIC DURERE TORACICA


junghi 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

Subicter conjunctival

Cianoza buzelor
Tahicardie

Subfebra
Uneori semne de insuf cardiaca dreapta

INFARCT MIC

Submatitate

vv
Respiratie inasprita Frecaturi pleurale

INFARCT MARE submatitate

vv
Respiratie suflanta / suflu tubar Subcrepitante, crepitante Frecaturi pleurale

sdr. Lichidian pleural

DIAGNOSTIC Contextul clinic al bolii de fond Rx Opacitate triunghiulara cu baza spre pleura marirea arterei pulmonare

TRATAMENT Al bolii de fond


ANTICOAGULANT
HEPARINE (UFH, LMWH) ANTICOAGULANTE ORALE

CONDENSARI PULMONARE RETRACTILE


ATELECTAZIA PULMONARA

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

ATELECTAZII lobare, segmentare


Durere
Tuse seaca Cianoza

ATELECTAZII mici =asimptomatice,descoperite Rx.

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
Opacitate omogena cu concavitatea spre

exterior

intereseaza 1 segment, / un lob,/ un plaman intreg cu o intindere mai mica decat regiunea respectiva in conditii normale

Spatii intercostale ingustate si mai oblice Mediastin tractionat spre partea bolnava Diafragm ascensionat Miscare inspiratorie a mediastinului spre partea

bolnava

Right middle-lobe atelectasis in a 70-year-old female with chronic obstructive lung disease. (A) The frontal chest radiograph shows minimal blurring of the right heart border. (B) The lateral chest radiograph shows that the right middle lobe is completely collapsed. The depressed minor fissure (arrows), and the anteriorly displaced major fissure (arrowheads) are almost apposed.

45-year-old man with left upper-lobe collapse due to endobronchial sarcoidosis. (A) The chest radiograph shows 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 sharply 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 scan shows the complete left lower-lobe collapse, and endobronchial obstruction of the left upper-lobe bronchus (arrow). No extrinsic component is shown.

Figure 19-22 Bilateral lower-lobe collapse, presumed due to mucoid impaction, in a 63-year-old man following abdominal surgery. (A) The frontal chest radiograph shows the triangular outlines of the collapsed lower lobes (sail sign) (arrows). Both hila are depressed. The medial portions of the diaphragm are obscured. The collapsed left lower lobe is almost exactly superimposed on the heart. (B) A lateral chest radiograph shows the collapsed lobes overlying the spine (arrows). The posterior portions of both hemidiaphragms are obscured.

Combined right middle and right lower-lobe collapse in a 66-year-old woman with breathlessness following abdominal surgery. The frontal chest radiograph shows combined right middle lobe and right lower-lobe collapse. Arrows indicate the minor fissure. Arrowheads indicate the major fissure. The multilobar collapse simulates a right pleural effusion, but the marked inferior hilar displacement, the marked depression of the right major fissure, and the ipsilateral mediastinal shift are important clues that this is a volume-losing process. A decubitus view showed only minimal right pleural fluid