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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)
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

 Intens
 Transfixiant
 Accentuat de respiratie / tuse
 Imobilizeaza pt. pe partea bolnava
 Localizat: submamelonar / bazal
 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 / ½ 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
CONFIRMARE
• Ex RADIOLOGIC
opacitate triunghiulara
 baza spre pleura
 varful spre hil
 intensitate subcostala,
omogena
 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 COMPLICATII
-Moarte in crizis • Colaps
-Complicatii • Sepsis→bacteriemie
:pericardita, endocardita,
• SUB meningita, abces
TRATAMENT cerebral, parotidita,
-Tineri nefrita,
imunocompete • Abcedare
nti • Pleurezie
vindecare in 5-6 -Din perioada de stare:
zile parapneumonica
-Complicatii la = lichid
batrani, tarati 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,
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
7. tineri imunocompetenti 5-18 ani
( macrolide / tetracicline II)
9. > 18 ani : macrolide / FQ / AM/CL / DOXI)
Spitalizati : P Ceph 3 + macrolid / FQ*
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
ß-lactamaza + : AM/CL, O Ceph 2/3, P Ceph
3
ß-Lactamaza – : AMP iv, amox po, TMP/SMX,
M
TUBERCULOZA
Primary tuberculosis in a child. There is homogeneous consolidation
of the right middle lobe which partially obscures hilar adenopathy.
Additional right paratracheal node enlargement is present.
Post-primary tuberculosis. There is gross mid- and upper-zone disease
characterized by areas of consolidation and cavitation. The cavitation is
particularly extensive on the right where some of the cavities contain air–fluid
levels.
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 well-defined
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 lower-
zone 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
BRONHOPNEUMONII
SEMNE FIZICE
• totdeuna in Variabile
contrast izbitor cu
gravitatea
semnelor generale
si dispneea • Depind de
extinderea
• variabile ca sediu procesului
si ca timp,
modificandu-si
caracterele de la o
zi la alta, uneori
chiar in cateva ore
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,
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