Professional Documents
Culture Documents
• “Sindromul” interstitial
– Clinic
– Radiologic (+ CT)
– Functional
– Lavaj bronhoalveolar
• Diagnosticul etiologic
– Anamneza
– Manifestari extrapulmonare
– Aspect CT si LBA sugestiv
– Biopsie pulmonara
Clinic
• Dispnee progresiva de efort
• Tuse seaca
• Inconstant
– Febra
– Degete hipocratice
– Cianoza
– Semnele IVD
• Obiectiv
– Crepitante difuz bilateral (“velcro”)
• Alte semne ale bolii de baza
– Eritem nodos, modificari articulare, eritem in fluture, modificari
cutanate, adenopatii …
Aspect radiologic
• Radiografie pulmonara standard: sdr. Interstitial
• Tomografie computerizata de inalta rezolutie (HRCT):
informatii valoroase
– Tip de leziuni
– Localizare
– Evolutivitate
Radiografia standard
• Sindrom interstitial
– Modificari difuze bilaterale
– Noduli / micronoduli
– Opacitati reticulare fine
– Opacitati reticulo-nodulare
– Opacitati infiltrative “vatoase” bilaterale
• Alte modificari sugestive
– Pleurezie (LES, PR)
– Pneumotorax (linfangio-leiomiomatoza)
– Adenopatii hilare bilaterale (sarcoidoza)
Tomografie computerizata
• HRCT: detalii (sectiuni subtiri 1 mm, algoritm de
amplificare)
• Tipuri de leziuni:
– Noduli
– Linii
– Chisturi
– Opacitati
• Localizarea leziunilor
Tomografie computerizata
• Noduli
– “densi”: sarcoidoza, carcinomatoza, bronsiolita, pneumoconioza
– “moi”: AAE, bronsiolita
• Linii
– Septale: insuf ventriculara stg, limfangita carcinomatoasa
– Reticulare: FPI, colagenoze, azbestoza, proteinoza
– Benzi parenchimatoase: cicatrici postpleurezie / pneumonie,
azbestoza
• Chisturi
– Izolate: histiocitoza, LAM
– “fagure de miere”: azbestoza, FPI, colagenoza, sarcoidoza
• Opacitati parenchimatoase
– Sticla mata: AAE, FPI descuamativa, toxicitate medicamentoasa,
proteinoza
– Condensare: pneumonia eozinofilica, carcinom bronhiolo-
alveolar, pneumonia lipoidica, proteinoza
Tomografie computerizata
• Localizare
– Centolobulara: sarcoidoza, AAE, pneumoconioza
– Septala: IVS, carcinomatoza, sarcoidoza
– Subpleurala: FPI
– Panlobulara: AAE, medicamente, FPI descuamativa
– Hipertransparenta panlobulara: TEP, emfizem
panlobular
– Mozaic
Fibroza pulmonara idiopatica: aspect reticular bazal bilateral
Sdr. hemoragic alveolar: aspect infiltrativ “vatos” bilateral
“Sticla mata”
Sarcoidoza
Sarcoidoza
Sarcoidoza
Acelasi caz dupa
4 ani
PR tratata cu saruri de aur
Poliartrita
Reumatoida
cu afectare pulmonara
PR
PR
FPI
FPI
FPI
FPI (“fagure de miere”)
“Fagure de
Miere”
FPI, pneumotorax
drenat
FPI (acelasi caz)
FPI (acelasi caz): “fagure de miere”
FPI (acelasi caz)
Functional
• Sdr. restrictiv “adevarat”
– Scadere CV, VR, CPT
• Fara obstructie bronsica
• Scadere (precoce) a TLCO
• Constanta de transfer: scazuta
• Complianta pulmonara scazuta
• Hipoxemie: initial la efort, apoi si in repaus
• Test de efort (precoce)
Bronhoscopie
• Utilitate:
– Lavaj bronhiolo-alveolar
– Biopsie pulmonara transbronsica
Lavaj bronhiolo-alveolar
• Normal:
– Macrofage alveolare 80-90%
– Limfocite 5-15%
– PMN 1-3%
– Eozinofile < 1%
– Mastocite <1%
– Fara celule epiteliale, f. rare celule bronsice, fara
hematii
Lavaj bronhiolo-alveolar
LBA – alte informatii
• Carcinomatoza: celule tumorale
• Infectii
– bK
– Pneumocystis carinii
– Aspergillus
• Macrofage incarcate cu fier
– Vasculite
– Hemosideroza pulmonara idiopatica
• Aspect laptos: proteinoza alveolara
• Corpi azbestozici - asbestoza
Diagnostic diferential
• Tuberculoza pulmonara
• Limfangita carcinomatoasa
• Infectii
– Pneumocistoza
– Pneumonii virale
– Bronhopneumonie
• ARDS
Prelevare fragment bioptic pulmonar
Expunere la
factori externi
Investigatii Anamneza
Semne extrarespiratorii
Teste biochimice
HRCT LBA
Prelevari histologice
Anamneza
Tanar Sarcoidoza
Histiocitoza X
Colagenoze
• Transplant pulmonar
LAM dupa transplant unipulmonar
Monitorizare
• De obicei la 3 luni
• Se urmaresc:
– Clinic
– Functional (TLCO, test de efort)
– Radiologic
• Evolutie: variabila de la caz la caz
• Prognostic variabil
Evolutie clinica
• Variabila in functie de etiologie
– Stabilizare
– Evoltie in pusee
– Degradare progresiva continua
• Complicatii
– Insuficienta respiratorie cronica hipoxemica
– HTP, cord pulmonar cronic
– Infectii (imunosupresie cortizonica)
Lista de abrevieri
• PID = pneumopatii interstitiale difuze
• FPI = fibroza pulmonara idiopatica
• LAM = limfangioleiomiomatoza
• AAE = alveolita alergica extrinseca
• LES = lupus eritematos sistemic
• PR = poliartrita reumatoida
• HRCT = tomografie computerizata cu rezolutie inalta
• TEP = trombembolism pulmonar
• IVS = insuficienta ventilatorie stanga
• CPT + capacitate pulmonara totala
• CV = capacitate vitala
• VR = volum rezidual
• TLCO = factor de transfer gazos prin membrana alveolo-capilara
• ARDS = sindrom de detresa respiratorie acuta
• LBA = lavaj bronhiolo-alveolar
• BOOP = bronsiolita obliteranta cu pneumonita de organizare
• RB-ILD = pneumopatia interstitiala legata de bronsiolita