1 investigatii in pneumologie
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8/14/2019 1 Investigatii in Pneumologie
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Investigatia paraclinica a
Dr. Spanu Victor
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• Proceduri radiologice
I . Radioscopia pulmonara
Avantaje: aspect panoramic; contact direct; examen dinamic.
Dezavantaje : nu ofera document obiectiv; adaptare la intuneric; omiteimagini mici
II . Radiografia pulmonaraAvantaje : document; modificari fine
Dezavantaje : imagine statica; imagini ascunse
III . Tomografia plana
Demonstrarea imaginilor cavitare
IV . Radiofotografia
Screening : tuberculoza ; cancer pulmonar ; boli profesionale
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Radiologie II
• Defecte de tehnica : pozitionare ; regim
(subexpunere , suprexpunere ); film ; developare(subdevelopare , supradevelopare )
•
Imagini parazited) Schelet toracic : coasta bifida ; coaste
supranumerare ; sinostoze costale ; tuberculicostali .
e) Parti moi : musculatura toracica ; umbra sanilor ;sanii fetelor tinere ; sanii sclerosi ; rezectiasanului .
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Radiologie III
• Aspecte normale
Continator : coloana ; stern ; arcuri costale ;diafragm
Continut : mediastin ; cimpurile pulmonare ; hilurile
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Radiologie IV
• Opacitati pleuropulmonare :
1.Localizare : • semnul siluetei ;
• semnul Bernou ;
• impartirea campurilor pulm. in regiuni ;
• segmentatia .
2. Forma :• lineare si in banda ;
• reticulare ;
• nodulare ;
•
rotund-ovalare ;• poligonale ;
• policiclice ;
• segmentare ;
• intinse neregulate .
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3. Dimensiuni :• micronodulare ;• nodulare ;• macronodulare ;• intinse (sistematizate sau nesistematizate)
4. Contur :• net ;• sters .
5. Structura :• omogena ;• neomogena .
6. Intensitate :• costala ;• subostala ;• supracostala
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Radiologie V
• Hipertransparentele pulmonare
- difuze
- circumscrise : localizarea ; forma ; dimensiunile ; conturul interior .
La opacitatea ce o delimiteaza descriem :
- forma;
-dimensiunea;
- conturul;
- structura;
- Intensitatea
• Imagini pulmonare mixte :
- inaltimea nivel lichidian
- rectitudinea nivelului
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• Vizualizare superioara ex radiologic standard
• Neoplasm pulmonar – Stadializare TNM
• Formatiuni mediastinale• Diferentiere elemente hil (vase vs adenopatii) prin
contrast iv• Structura parenchim pulmonar
– Bronsiectazii – Chiste aerice – PID: aspecte tipice
• Vase pulmonare: trombembolism (contrast)• Afectare pleurala: inchistari, mezoteliom
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• PET-CT
– Tehnica compozita
– PET: scintigrafie cu glucoza marcata, identificazonele cu metabolism crescut
•
Noduli maligni, grasime bruna, creier – Indicatii:
• Mai buna definire a extensiei TNM
• Identificare recidive tumorale
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• Ultrasonografie toracica
Aplicatii : – lichid pleural
– inchistare
• Scintigrafie toracica
I . Ventilatie - Xenon 133
II. Perfuzie - Tehnetiu 99
Aplicatii :
-tromembolismul pulmonar
-cancerul pulmonar
III. Galiu 67-inflamatie
-celule neoplazice
E l f i l l
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Explorarea functionala pulmonara
• Ventilatia
1.Volume si capacitati pulmonare :
CV si subdiviziunile
Direct : spirografie ; pneumotrahografie .
Indirect : pletismografie (VGIT): VR , CPT
2.Debite ventilatorii fortate :
VEMS si VEMS/CV%Curba flux-volum expiratorie (PEF , MEF 50 , MEF 25)
3.Mecanica pulmonara :
Complianta pulmonara
Rezistenta la flux in caile aerifere
Datele obtinute permit caracterizarea DVO, DVR, DVM
E l f i l l
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Explorarea functionala pulmonara-continuare-
Perfuzia2. Cateterismul cordului dr. :
-press. AP=22/9 mmHG
-press.CP=8 mmHG2. Scintigrafia
Schimbul gazos
8. Factorul de transfer gazos (capacitatea de difuzie )
9. Global : PaO2,PaCO2, P(A-a) O2 (gradientul alveolo-
arterial al O2)
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Bronhoscopia
• Bronhoscop flexibil
Indicatii diagnostice :
-carcinomul bronsic
-simptome respiratorii : hemoptizii;wheez.loc.
-sarcoidoza-tuberculoza
-bacteriologie : tbc ; pneumocistis
Indicatii terapeutice :
-secretii
-corpi straini
-fistule ganglio-bronsice
-carcinoame obstructive
- Plasare de stenturi
-
• Bronhoscop rigid
Indicatii :
-corpi straini
-hemoptizii masive
-stenoze traheale
-chirurgie laser
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• Aspiratul “simplu”
- BAAR
-
Celule neoplazice- Flora nespecifica
- Pneumocystis carinii
• Lavajul bronhoalveolar “propriu-zis”
“Biopsie lichida” datorita concordantei cu celularitatea interstitiului
Normal :
- nr. celule /ml = 200.000 din care:
- Macrofage alveolare = 90%
- Limfocite = 8%
- Neutrofile = 1%
- Eozinofile = 1%
Aspecte caracteristice in : P.I.D. ; sarcoidoza ; A.A.E.
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Bronho rafia
• Identifica :-variante anatomice
-malformatii
-distorsiuni-obstructii distale
Indicatia de electie :
-bronsectazii (existenta, extinderea, rezecabilitatea)
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T t bi i l l
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Toracenteza , bio sia leurala
• Toracenteza se practica pentru : – Diagnosticul oricarei colectii lichidiene pleurale – Evacuare lichid pleural (pleurezii recidivante, empiem)
•
Diagnostic: lichid pleural – Aspectul macroscopic al lichidului
– Analize• Biochimice: proteine, glucoza, LDH
– Adenozin-dezaminaza,
• Citologie: hematii, neutrofile, limfocite, cel neoplazice
• Bacteriologie: bK (cultura), bacterii
• Alti factori: FR, complement, celule lupice
Toracenteza biopsia pleurala
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Toracenteza , biopsia pleurala-continuare-
• Biopsie pleurala
– Recolteaza pe ac mic fragmente de pleura parietala
– Indicatii :
• pleurezia tuberculoasa (80% +) evidentiaza leziuneagranulomatoasa cu necroza de cazeificare
- cancerul pulmonar ( afectarea pleurala secundara )
- Mezoteliom
- Pleurezii in cadrul bolilor de sistem
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Examene de sputa
• Diagnostic bacteriologic
– bK
–Bacterii (“flora banala”)
– Fungi (aspergillus, candida!)
• Diagnostic citologic
–
Sputa din mai multe zile colectata in formol
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• Examen sputa pentru bK
– Sputa expectorata spontan
– 3 produse insotite de un singur formular
– Ex microscopic: Ziehl-Neelsen sau auramina-rodamina
– Cultura: mediu Lowenstein / medii lichide – Antibiograma
– Metode genetice: PCR
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• Examen bacteriologic al sputei (“flora banala”,“sputa spalata”) – Sputa expectorata spontan, matinal – Prelucrare in max 2 ore de la colectare – Tehnica de “spalare” pentru decontaminare orala – Ex. microscopic:
• Criterii de validitate a produsului (<25% celule orale)
• Coloratie Gram, criterii de patogenitate (germeni intracelulari) – Cultura in aerobioza: identificare germene patogen
• Interpretare precauta: culturi polimicrobiene – probabilnevalide; germeni intestinali: nu au ce cauta in sputa(contaminare); germeni de colonizare si nu patogeni
– Antibiograma
– Decat un examen bacteriologic de proasta calitate, mai bine un tratament empiric bine judecat!
Bio sia ulmonara
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Bio sia ulmonara
• Biopsia pulmonara transbronsica
Indicatii :
-afectiuni pulm.difuze : alveolite fibrozante; sarcoidoze ;carcinom alveolar.
-transplant pulmonar -infectii pe gazda compromisa
• Biopsia percutana transtoracica
Indicatii :
-nodulul pulmonar periferic
• Biopsia pe plaman deschis
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Toracoscopia,mediastinoscopia,mediastinostomia
• Toracoscopia
Indicatii :
• pleurezii de etiologieneprecizata
•mezotelioame
• aderente
• pneumotorax spontan
• fistule bronho-pleurale
•
talcaj- Rezectii noduli pulmonari
- Biopsie pulmonara
• Mediastinoscopia
Indicatii :
– Biopsie adenopatiimediastinale
•Neoplazici (stadiu N)
• Sarcoidoza
• Limfoame
• Mediastinotomia
Indicatii : – Biopsie formatiuni
mediastinale anterioare
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Toracoscopie video-asistata
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Mezoteliom
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