LICHIDELE PLEURALE

• Anatomie: 10 ml lichid pleural

600 - 800ml traverseaza zilnic spatiul pleural
1,5 – 2 g proteine/dl
4500 celule/ml: mezoteliale, monocite,
limfocite, rare granulocite.
• Pleura parietala: circulatia arteriala si venoasa sistemica
( art. intercostale, mamara interna
frenice)
nervi intercostali (senzoriali)
• Pleura viscerala: art. pulmonare,gg. mediastin post, hilari
fara inervatie senzoriala
• Lichid pleural : - capilarele pleurei parietale,
- capilarele pleurei viscerale (lichid
interstitial)
- cavitatea peritoneala
• Transudate
- modificari hemodinamice:
- pres hidrostatica capilara↑,
- pres osmotica ↓
• Exudate
- permeabilitate capilara ↑
- scaderea drenajului limfatic
pleural (20 ×N)
 Diagnostic
Clinic:
Simptome: durere (intercostala, umar)
tuse
dispnee
Frecatura pleurala
Sindrom lichidian (> 500 ml)
vol mic: 3-4 cm post. la baza hemitorace
800 - 1000ml: varf omoplat, sp. Traube
1700 ml: spina scapulei
2 l: ant. sp II i.c., deplasare mediastin
 Ex. radiologic
Radiografia toracica: frontala, laterala, oblic
– 75 ml :obliterarea sinusului costofrenic post;
– 175 ml: obliterarea sinusului costofrenic lateral
– 1000ml: ant coasta a IV-a
– masive : hemitorace ,deplaseaza mediastinul
– In decubit: > 175 ml lichid
mici: grosime 1,5 cm
moderate: 1,5 – 4,5 cm
mari > 4,5 cm
 COLECTIILE INCHISTATE
Interlobara: incidenta de profil: opacitate
fuziforma oblica sus/jos - afara/inauntru
Diafragmatica : >2cm de bula de gaz
Mediastinala : supra si infrahilar, ant si
post
Caracteristici
unghiurile interfetei intre opac. pleurala si perete
toracic sunt obtuze
suprafata opacitatii este neteda
continutul este omogen
ECOGRAFIA TORACICA
colectii inchistate
ghidaj toracenteza
TOMOGRAFIA COMPUTERIZATA TORACICA
• Dg lichid lpeural < 10 ml
• 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 Rx
Evacuatorie (necesitate);
- dispnee
- tendinta la inchistare
- spatiul II i.c. anterior
 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 > 45mgdl;
E
- col pl/col ser >0,3 X
U
- LDH pl> 45% LDH ser D
A
- Gradient alb serica – alb pl <1,2 mg/dl T
Glucoza
- 40 mg/dl: infectii, neoplasme
- 20 mg/dl: artrita reumatoida, LED
Amilaze
- pancreatita acuta, cronica
- ruptura de esofag
- pleurezii maligne
- rar: pneumonii, sarcina ect. rupta
pH
- <7,2 – toracostomie
- <7,3 : empiem, TBC, neoplasm, boli colagen,
ruptura de esofag
 Ex. citologic
Hematii: - serosanguinolent 5000-10000/mm3
- hemoragic: >100000/mm3
- accident punctie (col Wright)

- neoplasm, embolie pl, traumatisme

Leucocite - PMN : infectii pleurale (empiem)
Insuf cardiaca: emb. pulmonara
- Limfocite (>50%) TBC, neoplasme
- Eozinofile (>10%): aer sau sange, infectii
fungice sau parazitare, medicamente, EP,
Sd. Churg -Strauss , azbest, parapneum.
- Plasmocite: mielom
- Cel mezot : exclude TBC, cel. neoplazice
 Ex. bacteriologic
Frotiu : colorat Gram, Ziehl –Nielsen
Culturi: aerobe, anaerobe, speciale:Lowenstein-
Jensen, Middlebrook 7H10 (CO2).
Teste suplimentare
Celule lupice
Complementul
Lipidele : trigliceride > 110 mg/dl
colesterol
Biopsia pleurala
Citologie: 50-80% TBC, 40-75% neoplasm
Culturi : 90-95% TBC
TRANSUDATE
• Insuficienta cardiaca
• Ciroza (hidrotorax hepatic: 5% din cirotici cu ascita :
diuretice ,transplant, TIPS)
• Embolia pulmonara (infarct pulmonar);
• Sindromul nefrotic
• Dializa peritoneala
• Obstructia venei cave superioare
• Mixedem : ascita,revarsat pericardic, revarsat pleural)
• Urinotorax (rar)
• Sd. Meigs
• Atelectazia pulmonara
 EXUDATE PLEURALE
Neoplasme Boli gastrointestinale
- metastaze - perforatia esofagului
- mezoteliom - boli pancreatice
Infectii - abcese intraabdominale
- bacteriene - hernia diafragmatica
- TBC - post scleroterapie varice esofag
- fungice - dupa chir. abd, transpl. hepatic
- virale Boli de colagen
- parazitare - artrita reumatoida
Embolie pulmonara - LED
Post bypass coronarian - medicamente ce induc LED
Expunere la azbest - limfadenopatia imunoblastica
Hiperstimulare ovariana - Sd. Sjogren
Sd unghiilor galbene - Granulomatoza Wegener
Uremia, post cateter central - Sd. Churg-Strauss
Sd. Meigs Medicamente
Sarcoidoza - nitrofurantoin
Post iradiere, - methisergyde
Sd. post lez cardiace - bromcriptina
- amiodarana, procarbazina.
 EXUDATE PLEURALE

• Pneumonia (Empiem);
• Neoplasme (pulmonar, pleural, mamar);
• Embolia pulmonara <50% hemoragic;
• Infectii virale;
• By pass coronarian stg – 73% stg, 20% bilateral, 7% dr, - 1 sapt
postoperator;
• TBC;
• Sarcoidoza
• Uremia
• Abcese infradiafragmatice;
• Artrita reumatoida;
• LED;
• Infectia HIV (parapneumonic, TBC pulmonara, Sarcom Kaposi,
Pneumocystis jiroveci (carinii);
• Medicamente: bromcriptina, dantrolene, nitrofurantoin, IL-2
(cancer renal, melanom), methysergide.
• Hiperstimulare ovariana (gonadotropina umana chorionica);
• Pancreatita;
• Ruptura esofagiana;
• Expunere la azbest;
• Tumori ovariene (Meige’s );
• Sindromul unghiilor galbene : revarsat pleural, limfedem, unghii
galbene.
90%: rezultatul a 5 boli:

- 36% Insuficienta cardiaca;

- 22% Pneumonia;
- 14% Neoplasmele;
- 11% Embolism pulmonar;
- 7% Afectiuni virale.
 Pleurezia tuberculoasa
Cea mai frecventa cauza de exudat pl.
Reactie de hipersensibilitate a spatiului pl. la proteinele
tuberculoase (mec. imunoalergic - fenomen Koch)
Inf pulmonara sau gg. traheobronsici
Tuberculoza primara prin penetrarea BK in sp. pl.
Clinic: febra, scadere ponderala, dispnee, durere pleuritica
Ex. lichid: exudat uneori hemoragic, prot >50%din cele serice,
glucoza <60mg/dl, pH < 7,2, Leuc: 500-2500μL cu PMN initial
Ex. lichid: adenosin deaminaza>45 UI/l, γ interferon >140pg/ml,
PCR pt ADN TBC pozitiv, limfocite mici
Dg. culturi lichid pleural, ex. citologic si culturi biopsie pleurala,
toracoscopie
 TUBERCULOSTATICE DE PRIMA LINIE
Medicament Zilnic (5-7/7) Intermitent 2/7- 3/7
ISONIAZIDA (HIN) 5 mg/Kg,300mg 15mg/kg, 900mg

RIFAMPICINA 10mg/kg,600mg 10mg/kg, 600mg

(RIF)
RIFABUTINA 5mg/kg, 300mg 5mg/kg,300mg

PYRAZINAMIDA 20-25mg/kg 30 – 40 mg/Kg max-

(PZN) (max - 2g) 3g
ETHAMBUTOL(EM) 15 -20mg/kg 25 – 30 mg/kg

FAZA 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
 PLEUREZII INFECTIOASE
Mialgia epidemica : Boala Bornholm
- virus Coxsakie B
- febra, catar, dureri musculare
- durere pleuritica, in umar
- frecatura pleurala, revarsat pl. mic
- virus izolat (scaun, lavaj faringian), RFC
- simptomatic
Empiem pleural: lichid purulent in cav. pleurala
- Infectii pulmonare: pneumonii, abces pl, bronsiectazii, interventii
chirurgicale complicate cu abcese intraabdominale (abces subfrenic),
iatrogen (post investigatii); contiguitate, hematogena
35% nosocomiale, anaerobi, Gr (- ) sau fl. mixta
Aerobi: febra, expectoratie, durere pleuritica, leucocitoza
Anaerobe: subacut, scadere ponderala, leucocitoza minima, anemie,
cond. de aspiratie
 EMPIEM PARAPNEUMONIC
Faze: exudativa, fibrinopurulenta, organizare (fistule)
Rx : decubit lateral, incidente profil
Toracenteza caracteristici:
- aspect macroscopic (serocitrin, puroi)
- biochimic: glucoza, pH;
- citologie:PMN,
- ex. bacteriologic: frotiu, culturi
Antibiotice: Clindamicina, Imipenem, Celafosporina
gen IV – pana la rezolvarea clinica si radiologica
Tub de dren-fibrinolitice: streptokinaza (250.000UI )
Toracoscopia - ruperea aderentelor
Toracotomie - decorticarea chirurgicala
 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<7,2
- glucoza pleurala<60mg/dl
Pleurezii virale

exudate fara etiologie (20%)

se rezolva spontan, fara sechele
SIDA
Pleurezii rare: sarcom Kaposi, parapneumonice, TBC,
limfom primar
Pleurezia post embolie pulmonara
Conditii favorizante
Clinic: dispnee
Exudat sau transudat
CT spirala, Arteriografia pulmonara
Trat. anticoagulant
Pleurezia neoplazica

Cauza frecventa de exudat la persoane >60 ani

75%: carcinom pulmonar, mamar, limfoame
Caracteristici: dispnee, aspect hemoragic, refacere rapida (<1
saptamana)
Ex lichid: exudat, glucoza scazuta, ex. citologic(cel neoplazice)
Biopsie pleurala
Toracoscopie
Tratament simptomatic: drenaj pleural
Pleurodesie: - Talc: RA - febra, hipoxie, insuf. resp.
- Doxiciclina, minociclina: RA durere (lidocaina);

- Bleomicina ;
- Cateter pleural cronic – drenaj intermitent in sticle vacuum
- Sunt pleuroperitoneal;

- Pleurectomie sau ablatie pleurala (pleurodesie ineficienta) -

chirurgie toracica.

- Chemoterapie si radioterapie: limfom, carcinom pl.cu cel

mici

Mezoteliom

- Tumora primara cu punct de plecare cel mezoteliale

- Expunere la azbest

- Evolutie locala (pleura, plaman, perete toracic, mediastin

pericard, peritoneu, diafragm,);
- Metastaze : gg hilari, mediastinali, ficat, rinichi.
- Clinic: durere toracica, dispnee, Sd. Horner
-Rx : ingrosare pleurala, revarsat pleural masiv, incorsetare
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;

pleurodesie, pleurectomie
- Intrapleural : factor stimulator de colonii, γ interferon;

Supravietuire: 8-15 luni.

Chilotorax
Acumularea limfei in spatiul pleural
Etiologie: - leziuni traumatice ale ductului toracic
- tumori mediastinale
- malformatii ale canalului toracic (fistule)
- tromboza venei subclaviculare stg
- anevrismul aortei toracice
Revarsat pleural masiv – dispnee
Ex.lichid: lactescent, trigliceride >110mg/dl (1,2 mmol/l)
Limfangiograma, CT toracic
Tratament conservator: aliment. parenterala, nu toracen-
teze repetate (denutritie, imunodepresie)
Sunt pleuroperitoneal, ligatura chirurgicala canal limfatic
 HEMOTORAX

Etiologie

- traumatisme
- ruptura vaselor toracice ( ruptura de aorta)
- tumori
Lichid pleural: hemoragic Ht > 50% din sg periferic
Tub de dren : hemoragie > 200 ml/h chirurgie
toracica (sutura vasculara)
 PNEUMOTORAX
Patrunderea aerului in spatiul pleural
Generalizat, localizat
Deschis, inchis, valvular (in tensiune)-
presiune pozitiva intrapleurala in tot ciclul
respirator
Forme: P. spontan primar (fara lez pl ant,
fara traumatisme); P. spontan secundar (lez
pl ant); P. traumatic (lez toracice penetrante
sau nepanetranta) P. in tensiune
Clinic: durere, dispnee
Rx pl: transparenta fara desen brohovascular intre plaman
si perete toracic (Rx:in expir sau decubit lateral)
P. spontan primar:
- ruptura chistelor aeriene apicale
- fumatori
- ½ au recidive
- aspiratia simpla a aerului din sp. pleural
- 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 pleurodezie
P. traumatic; traumatisme toracice ne/penetrante
- toracostomie, aspirarea aerului
- hemopneumotorax: 2 tuburi: sup. aer, inf. sange
- P. iatrogen: aspirarea transtoracica, toracenteza,
cateter venos central : obsevatia, O2, aspirarea,
toracostomia
P. in tensiune
- Clinic: dispnee, anxietate, cianoza, hipotensiune,
enf.mediastinal
- Rx: sp. intercostale largi
- aplatizarea diafragm, coborarea matitatii hepatice
- deplasarea mediastinului
Clinic: largirea hemitorace, deplasarea
mediastin, hipersonoritate pl, absenta MV
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);
 PLEUREZIA PARAPNEUMONICA

Drenaj pleural - toracenteza sau tub (toracostomie):

- pH<7,2;
- glucoza <60mg/dl;
- frotiu pozitiv col Gram;
- culturi pozitive;
- inchistare pleurala.
Drenaj incomplet : 100.000 U urokinaza/100ml sol
salina intrapleural.
Toracotomia – decorticare chirurgicala.