Sindromul bronsitic

si sindromul de obstructie bronsica

Bronsita acuta - Bronsita cronica
Astmul bronsic

Sindromul de condensare pulmonara

SL dr. Spataru Dan

Spitalul Clinic Coltea
 Infectii comune virale respiratorii
si SARS (severe acute respiratory
syndrome)
• Raceala comuna
• Faringita
• Crup (laringotraheobronsita )
• Traheita
• Bronsita
• Bronsiolita
• Pneumonie
• SARS - ARDS (adult respiratory distress syndr)
 Infectii virale respiratorii
• Cele mai frecvente boli infectioase
• ½ din bolile acute
• Incidenta 3 -5 cazuri/persoana/an
• la copii 6-8 cazuri/p/an
• Anumite virusuri- un tablou clinic
• Un virus –mai multe sindroame
• Numai pe baze clinice - nu dg exact virus
• Rinovirus: RC - acutizare Br.cr., astm-P
• Coronavirus: RC - ac Br.cr., astm – P –
bronsiolita - SARS
• V. sincitial resp.: P - bronsiolita –RC - P
• Paragripal: crup – faringita - traheobronsita
• Adenovirus: RC - faringita –P
• Gripal: gripa-P-rinita-faringita
• Enterovirusuri: boala febrila nedif – rinita,
faringita - P
 Tablou clinic
• Rinoree
• Stranut
• Congestie nazala
• Dureri in git - raguseala
• Tuse-crup-stridor hipoxie
• Tuse –dispnee-polipnee-weezing-raluri bronsice –expir
prelungit
• Alterarea starii generale-dispnee-cianoza –Rx infiltrate
pulm interstitiale ,consolidare pneumonica (SARS )
• Asociere disfunctie multiorgan : ARDS
 COVID-19

Case courtesy of Dr Fabio Macori, Radiopaedia.org, rID: 74867

 Bronsita cronica

• Bronsita acuta nu se cronicizeaza!

 Definitie bronsita cronica
• Anamneza: tuse si expectoratie

• (3 luni pe an 2 ani la rind )

 Emfizem pulmonar
• Dg anatomo patologic :

• Dilatatia spatiilor aeriene distal de bronhiola

terminala
 Boala de cai aeriene mici

• Bronhiolele mici sunt ingustate

 BPOC
(bronhopneumopatia obstructiva cronica )
• Definitie GOLD (Global initiative for cronic
Obstructive Lung Disease ): boala pulmonara
caracterizata prin disfunctie ventilatorie
obstructiva incomplet reversibila
• Asociere : Bronsita cronica +
• emfizem pulmonar +
• boala de cai aeriene mici
 Factori risc BPOC
• Fumatul- relatie VEMS nr pachete /an
• Hiperreactivitatea bronsica in BPOC/ astm

• ipoteza daneza : varietati ale aceleiasi boli

• Ipoteza britanica : astmul alergic/BPOC
inflamatie legata de fumat (boli complet
diferite )
• Infectii resp : acutizare B cr
 Factori risc BPOC
• Factori profesionali:praf mina carbune,aur
• cadmiu
• Poluare : nu e clar dovedit
• Pasiv –second hand smoking
• Genetic : deficitul alfa 1 antitripsina
• (1% din pop caucaziana )
 Istoric BPOC

• tuse
• sputa
• dispnee efort
 Examen fizic
• Stadii incipiente –normal
• Fumatorii :miros tigara
• coloratie nicotina unghii
• Torace : butoi
• diafragm coborit
• Raluri bronsice, wheezing expirator
• Expir prelungit: cuantificare (durata expir fortat>4s)
• auscultatie pe toracele anterior
• manevra expir fortat
• Obstructie severa: pozitie sprijinit coate
• musculatura resp accesorie : SCM ,IC
 Tipuri BPOC
• Pink puffers (roz pufaitor )

• Nu cianoza!
• Folosire mm. resp accesorie
• Buzele punga
• Domina emfizemul
• Murmur vezicular diminuat difuz
 Tipuri BPOC
• Blue bloaters (albastru buhait )

• Retentie lichid ( insuficienta card dr , CPC) j-h-e

• Cianoza
• Domina bronsita cr
• Forme avansate: scadere G
• semn Hoover - misc paradoxala a
cutiei toracice
 Paraclinic in BPOC
• Gaze sang (SaO2 ) :O2 scazut = insuf resp
• CO2 crescut = hipoventilatie
alveolara (hiperemie conjunctivala )
• Hct crescut
• ECG: HVD
• Rx pulm - emfizem
• Dozare Alfa1 antitripsina
• Spirometrie : VEMS/CV
• Ecocardiografie : dg CPC
 Criteriile de severitate GOLD pt
BPOC

Bronsita cr simpla nu este BPOC! (doar stadiul 0

/ la risc )

BPOC = +/- tuse si sputa

VEMS/CV <0,7
 Stadiile BPOC (GOLD)
• 1 usor VEMS>80 % din prezis

• 2 moderat 50% < VEMS < 80 % din p

• 3 sever 30% < VEMS < 50% din p

• 4 f sever VEMS < 30 % din p

• VEMS <50 % din p + insuf resp/ICDr
 Astmul bronsic
• Def: boala inflamatorie cr a cailor aeriene
• Caract. prin hiperreactivitate bronsica la diversi
stimuli
• Manifestat prin obstructie br. (edem, spasm,
hipersecretie mucus) cu revenire spontana sau
dupa medicatie
• Clinic : dispnee
• tuse
• wheezing
• Boala cu episoade de exacerbare si perioade
fara simptome
• Tipic atacurile dureaza minute/ore, cu revenire
completa dupa atac
• Afecteaza 4-5 % din populatie
• ½ din cazuri - debut sub varsta de 10 ani
• Inca 1/3 din cazuri pana la 40 de ani
 Forme astm bronsic
• Astm alergic (atopic): asociaza rinita alergica,
urticarie, eczeme, crestere IgE, teste pozitive
de sensibilitate la alergeni

• Astm nonatopic (fara cele de mai sus )

 Stimuli pt episoadele astmatice
• 1 Alergeni
• 2 Farmacologic (aspirina+ r + p)
• 3 Mediu –poluare
• 4 Profesionali (lemn, pulberi, farmaceut, enzime)
• 5 Infectiosi: v sincitial, paragripal/rino si gripal
adulti
• 6 Exercitiu fizic (aer rece,umezeala)
• 7 Stress emotional
 Tablou clinic astm bronsic
• Triada simptomatica : dispnee
tuse
+ wheezing ( sine qua non )
• Debut cu constrictie toracica
tuse neproductiva
respiratia devine suieratoare
• Expirul devine prelungit
• Tahipnee
• Tahicardie
• HTA sistolica usoara
• Hiperinflatie acuta - creste diametrul ant-post
toracic
• Raluri sibilante
 Forme severe astm bronsic

• Folosirea mm resp accesorii

• Puls paradoxal
• Silentium respirator
 Stare de rau astmatic
• Dureaza zile
• Semne de severitate
• Bradipnee
• Cianoza
• Silentium respirator
 Sfirsit atac astm bronsic
• Tuse cu sputa vascoasa
• Mulaje bronsice (spirale Curschmann) - sputa
perlata
• La microscop : eozinofile - cristale Charcot-
Leiden
 Element clasic de dg
• Reversibilitatea obstructiei
• Dupa 2 puffuri de beta2 agonist

VEMS creste cu peste 15 % !

 Diagnostic diferential astm
• Obstructie CAS (tumora/ edem laringe)
• Insuf. ventric. stg (astm cardiac )
• Tumori carcinoide
• TEP recurent
• Bronsita cronica
• Pneumonie eozinofile / vasculita
 Clasificare severitate astm
Usor intermitent < 2 zile/sapt. <2 nopti /luna VEMS>80%

Usor Persistent >2 z./sapt. > 2 n. /luna VEMS >80%

Moderat Persistent Zilnic > 1 n. / sapt 60%<VEMS< 80%

Sever Persistent Continuu Frecvent VEMS<60%

 Pneumonii
• CAP (pneumonii comunitare)
• HAP (pneumonii de spital)
• VAP (pneumonii de ventilator)
• HCAP (IAAM cu germeni multirezistenti - MDR)
- factori de risc: spitalizare recenta
tratament antibiotic
dializa
ingrijire plaga
membri de familie cu MDR
 Tablou clinico-radiologic
• 1. Pneumonie lobara segmentara
• 2. Bronhopneumonie
• 3. Pneumonie interstitiala (atipica)
Pneumonie lobara segmentara

Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16074

 Bronhopneumonie

Case courtesy of Dr Matthew Lukies, Radiopaedia.org, rID: 59340

Pneumonie interstitiala (atipica)

Case courtesy of Dr Alborz Jahangiri, Radiopaedia.org, rID: 45781

 Tablou clinic
• Stare generala
• Sindrom febril (+\- Frison, mialgii, artralgii,
cefalee, oboseala, somnolenta)
• Polipnee
• SaO2
• TA
• Tahicardie
 Tablou clinic
• Dispnee
• Durere pleurala
• Tuse
• Expectoratie

• Tulburari digestive
• Soc septic – insuficienta de organ(e)
 Examen Obiectiv
Condensare pulmonara
• I +/- lag
• P vibratii ^/ poz trahee central
• P submatitate/ matitate
• A respiratie suflanta; suflu
tubar; pectorilocvie afona;
raluri crepitante
Revarsat lichidian pleural
• I - lag
• P – vibratii abolite; trahee
deplasata
• P – matitate lemnoasa
• A – murmur abolit; suflu
pleuretic; frecatura pleurala
 Diagnostic diferential
• BPOC acutizat
• ICC
• TEP
• Pneumonita de hipersensibilitate
• Pneumonita de iradiere
 Diagnostic etiologic
• Examen sputa
• Lavaj / bronhoscopie
• Lichid pleural
• Hemoculturi
• Serologie / PCR
• Examen de urina
 Pneumonie pneumococica
• Frison solemn
• Herpes nazo-labial
• Sputa ruginie
• Precedata de viroza
• Rx – pneumonie lobara cu bronhograma
aeriana
• Empiem – 5%
 Pn. Haemophilus influenzae
• Asemanator tabloului pn. Pneumococice
• Mai frecvent la copii
• Afectare pleurala mai frecventa
 Pn. stafilococica
• Pneumonie comunitara
• Dupa gripa/rujeola, imunodeprimati
• Febra, tuse productiva
• Bronhopneumonie
• Pneumatocel
• Evolutie clinico-radiologica grava, rapida
• Revarsat pleural frecvent
 Pn. MRSA - IAAM
• Pneumonie necrotizanta
• Asociere cu fasciita
• Purpura
• Stare septica
 Pn. cu Legionella
• Ancheta epidemiologica
• Infiltrate pulmonare extinse
• Insuficienta multi-organ
• Evolutie grava – ATI
• 20% - febra>40
• Hemoptizii – dg dif. TEP
• Tulburari digestive (diaree)
• Manifestari neurologice - cefalee , letargie, encefalopatie
• Hiponatremie
• Bradicardie
 Abces pulmonar
• Necroza si cavitatie dupa infectie
• Diametrul > 2 cm
• Primar – aspiratie anaerobi
• Secundar – obstructie corp strain, t. pulm.,
HIV/alte imunodepresii
• Acut – 4-6 saptamani
• Cronic – 40% din cazuri
 Factori de risc abces p.
• Dentitie
• Dementa
• Alcool
• Droguri
• Crize convulsive
• AVC bulbare
• Boli neuro-musculare
• Patologie esofag
• Imobilizari la pat
 Tablou clinic
• Evolutie cronica
• Transpiratii, oboseala
• Anemie
• Debut similar pneumoniei
• Sputa in cantitate abundenta, fetida
• Evolutie fulminanta – stafilococ (febra mult
crescuta, progresie rapida)
 Examen fizic
• Cavitate bucala: dentitie deficitara,
paradontoze, interventii stomatologice/BMF
• Suflu amforic cavernos
• Degete hipocratice
• Abolirea reflex deglutitie
 Diagnostic diferential
• Infarct pulmonar
• Vasculite
• Neoplazii
• Chiste
• Embolii septice
 Rx
• Mai bine CT – diagnostic mai precoce
• Cavitate cu perete gros
 Abces pulmonar

Case courtesy of Dr Sakher Alkhaderi, Radiopaedia.org, rID: 41248