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Investigatia paraclinica a
aparatului respirator
Dr. Stefan Dumitrache-Rujinski
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• Radiografia toracica
• Spirometria, pletismografia, factor de transfer gazos, test de mers 6minute, test de efort cardiopulmonar
• oracenteza !punctia pleurala"
• #$ sputa !flora %&anala', (), fungi*."
• (ronhoscopia, &iopsia &ronsica, lavaj &ronhoalveolar
• + torace
• (iopsia pleurala !oar&a, pleuroscopia"
pulmonara !toracotomie, toracoscopie"• ediastinoscopiamediastinotomia
• /oligrafiapolisomnografia
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Radiologie
I. Radioscopia pulmonara
avantaje: examen dinamic (sniff test, paralizie diafragm).
dezavantaje : nu ofera document obiectiv; adaptare la intuneric; omiteimagini mici, iradiere
II . Radiografia pulmonara avantaje : document medical; modificari fine
dezavantaje : imagine statica; imagini ascunse → Rx. profl
III . Tomografia plana
demonstrarea imaginilor cavitare
I . Radiofotografia (!micro"radiofotografia#)
screening : tuberculoza ; cancer pulmonar ; boli profesionale
(nu se mai utilizeaza)
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rahee
(uton aortic
0ilul stang
1triul stang
2entricul stg
2ena +ava Superioara
1triul drept
0ilul drept
3nghiul cardio-frenic3nghiul costo-frenic
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Defecte de tehnica
• /ozitionare torace rotit !identifica marginea mediana a claviculelor fata de
verte&ra dintre ele"
nu au fost scoase scapulele din camp
nu in inspir profund !numara coastele vizi&ile peste diafragm"
• Regim su&e$punere → verifica in partea inferioara a um&rei cardiace
verte&rele vizi&ile
suprae$punere → se pierd leziuni cu densitate mica
• 4ilm• Developare su&developare → prea al&a
supradevelopare → prea neagra
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Imagini parazite
a" Schelet toracic5
• coasta &ifida
• coaste supranumerare
• sinostoze costale
• tu&erculi costali.
&" /arti moi5
• musculatura toracica
• um&ra sanilor
• mastectomie7.
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1specte normale
+ontinut 5• campurile pulmonare
• hilurile !hilul stg mai susdecat cel drept"
• mediastin !inima, etc"
+ontinator 5• diafragm !cel drept este mai sus"
17 priveste si zona de su& diafragm
• oase !coloana, stern, arcuri costale"
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8pacitati pleuro-pulmonare
9.:ocalizare5 • semnul siluetei
• semnul (ernou
• impartirea campurilor
pulm. in regiuni
• lo&isegmente
!R$.profil"
;. 4orma5
• lineare
• reticulare
• nodulare
• rotund-ovalare
• poligonale
• policiclice
• neregulate.
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<. Dimensiuni5• micronodulare
• nodulare• macronodulare
=. +ontur 5• net
• sters
>. Structura5• omogena
• neomogena
6. Intensitate5• costala
su&costala supracostala
• mediastinala
Supra su&mediastinala
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0ipertransparentele pulmonare
- difuze
- circumscrise5• localizarea
• forma
• dimensiunile
:a opacitatea ce o delimiteaza descriem5- forma
- dimensiunea
- conturul !e$ternintern"
- #$5 caverna5 opacitate inelara ce circumscrie o zona de hipertransparenta
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Imagini pulmonare mi$te
- Imagini hidroaerice !aer si lichid"- a&ces
- chist evacuat
- hidropiohemo-pneumotora$
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Tomografia computerizata
• 2izualizare superioara e$. R$. standard!localizare, limite, structura"
• $eoplasm pulmonar - stadializare• umor e$tension
• ?odes !ggl hilarimediastinali"
• etastasis
• %ormatiuni mediastinale
• Diferentiere elemente hil, mediastin !vase
vs adenopatii" prin contrast iv
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Tomografia computerizata
• Structura parenchim pulmonar !+ cupe fine"
&R'$I*T+II
-I5 aspecte caracteristice
• 2ase pulmonare5 trombembolism !contrast"
• 1fectare pleurala5 inchistari, mezoteliom
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• -T"*T
ehnica compozita
-T5 scintigrafie cu glucoza marcata (%luoro
deoxiglucoza : %/), identifica zonele cu
metabolism crescut • ?oduli maligni, grasime &runa, creier
Indicatii5
• ai &una definire a e$tensiei ?
!ganglioninoduli pulmonari metastatici sau nu"
• Identificare recidive tumorale !limfoame
mediastinale"
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• cografia toracica
1plicatii 5
lic0id pleural inc0istare1ingrosari pleurale
biopsie pleurala !tintita#
• cintigrafie toracicaI .entilatie " 2enon 344
II. -erfuzie " Te0netiu 55 → T-
III. /aliu 67
inflamatie ! %activitate' in sarcoidoza"
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#$amen de sputa
• iagnostic bacteriologic
&)
(acterii !%flora &anala'"
4ungi !aspergillus, candida7"
• Diagnostic citologic
Sputa colectata in formol !neoplasm"
Sputa indusa !eozinofile in astm"
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• xamen sputa pentru b8
Sputa e$pectorata spontan < produse in trei zilemomente diferite
#$ microscopic5 ie0l"$eelsen sau auramina-
rodamina
+ultura5 mediu 9oenstein medii lichide
1nti&iograma
etode genice5 /+R
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• xamen bacteriologic al sputei !%flora &anala'"
Sputa e$pectorata spontan, matinal /relucrare in ma$ ; ore de la colectare7
ehnica de %spalare' pentru decontaminare orala7
x. microscopic5• +riterii de validitate a produsului !@;>A celule orale <=
->$ si ? = celule epiteliale camp microscopic marire
23@@"
• *oloratie /ram, criteriu de patogenitate !germeniintracelulari"
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#$amen &acteriologic al sputei
*ultura5 identificare germene patogen
• /ermenele izolat sa fie concordant cu germenele dominant
de pe frotiul /ram
• *restere pana in cadranul III1I !B9C+43ml"• 1tipicii nu se cultiva pe mediile o&isnuite
• 1naero&ii nu cresc pe mediile aero&e
• Interpretare precauta5 culturi polimicro&iene → pro&a&il nevalide
germeni intestinali → nu au ce cauta in sputa !contaminare"
germeni de colonizare si nu patogeni
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#$amen &acteriologic al sputei
+ntibiograma5 spectru sensi&ilitate
In practica curenta doar in B <CA din cazuri se reusesteizolarea germenului implicat patogenic !pneumonie"7
Tratament empiric, functie de prezentarea clinica,
radiologica, comor&iditati, gravitate 7
Decat un e$amen &acteriologic de proasta calitate, mai &ine un tratament empiric &ine judecat7
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• +2E 2+F2IRF2#R
• +/E +2F2R
#$plorarea functionala respiratorie
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xplorarea functionala respiratorie• Spirometria
Determinarea5 +2, 2#S, /#4, Indice iffeneau
• /letismografia
+omplianta pulmonara Rezistenta la flu$ in caile aeriene
+/, R !indirect si prin metoda cu heliu"
atele obtinute permit caracterizarea ',
R, >
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• ':
*~N
– VEMS↓– IT ↓ (<70%)
• DVR:– CV ↓
– VEMS ↓
– IT N(>70%)
• DVM:– CV ↓
– VEMS ↓
– IT ↓(<70%)
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xplorarea functionala pulmonara
c0imburile gazoase
9. 4actorul de transfer gazos
• capacitatea de difuzie +8 prin m&. alveolocapilara5
9*' !T9*'"
;. Gazometria
• p0, /a8;, /a+8;, Sa8;, 0+8<
• /!1-a" 8; !gradientul alveolo-arterial al 8;"
*ateterism artera pulmonara !dg. 0/"
- press. 1/@;>mm0g
- press.+/EH mm0g
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Test de mers 6 min
• Distanta parcursa !m"
• Sa8; initial, final
• Indice dispnee pe scala (8RG !9-9C9C"
• 1, 12 initial, final
• 3sor de efectuat
• 3til in monitorizare evolutie, tratament
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Toracenteza , biopsia pleurala• Toracenteza se practica pentru
Diagnosticul oricarei colectii lichidiene pleurale #vacuare lichid pleural !pleurezii recidivante, empiem"
• Diagnostic lichid pleural
1spectul macroscopic !limpede, sange, puroi", miros!fetidanaero&i" al lichidului
1nalize• &ioc0imie5 proteine, 9A !e$udattransudat" , glucoza, p0,
1D15 1denozin-dezaminaza !("• *itologie5 hematii, neutrofile, limfocite,mezotelii, cel neoplazice !grupate
in placarde"
• &acteriologie5 b8 !direct,cultura, /+R", bacterii, fungi
• 1ltele5 4R, complement, celule lupice
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• &iopsie pleurala !oar&a"
Recolteaza pe ac mic fragmente de pleura parietala
Indicatii !pleurezii la care e$ista suspiciunea de" 5
9. pleurezie tu&erculoasa !HCA F" evidentiaza leziunea
granulomatoasa cu necroza de cazeificare
;. pleurezie neoplazica ! afectarea pleurala secundara "
<. mezoteliom pleural !afectare pleurala primara"
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&ron0oscopia
• &ron0oscop flexibil
Indicatii diagnostice :
"neoplasmul bronsic
"simptome respiratorii : 0emoptizii;0eez.localizat
"tuberculoza: fistula gangliobronsica"bacteriologie : &8 ; pneumocBstis
Indicatii terapeutice :
"secretii
"corpi straini
"carcinoame obstructive
- -lasare de stenturi
- Rezectii laser
• &ron0oscop rigid
Indicatii :
"corpi straini
"0emoptizii masive
"stenoze tra0eale
"c0irurgie laser
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9 j l b 0 l l
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9avajul bron0oalveolar
• 1spiratul &ronsic %simplu'
• 9avajul bron0oalveolar !propriu"zis#%(iopsie lichida' datorita concordantei cu celularitatea interstitiului
Se instileaza B 9;C ml ser fiziologic steril, se recupereaza min. Cml
?ormal 5- nr. celule ml E ;CC.CCC din care5
- acrofage alveolare E CA
- :imfocite E 9<A
- ?eutrofile E 9A
- #ozinofile E 9A
1specte caracteristice in- Sarcoidoza !limfocitoza, +D=+DHJ="
- 1.1.#. !limfocitoza,+D=+DH@9"
3til in identificarea (11R, pneumicKstis, fungi, flora micro&iana!&rosa protejata", celule maligne
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&ron0ografia
• Inlocuita de + cupe fine pt. dg &ronsiectaziilor77
Indicatia de electie !istorica77"5
-&ronsiectazii !e$istenta, e$tinderea,
rezeca&ilitatea"
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&iopsia pulmonara• &iopsia pe plaman desc0is ( cu toracotomie)
$eoplasm, -I, etc
• (iopsia pulmonara trans&ronsica !&ronhoscopie"
Indicatii 5
afectiuni pulm.difuze 5 sarcoidoza; carcinomatoza; fi&roza pulmonara
neoplasm pulmonar
transplant pulmonar !rejet"
infectii pe gazda compromisa
• (iopsia percutana transtoracica !ghidata +"
nodulul pulmonar periferic
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Toracoscopia1pleuroscopia,
mediastinoscopia1mediastinostomia• Toracoscopia1-leuroscopia
Indicatii :
• pleurezii de etiologie neprecizata
• mezoteliom pleural• aderente
• pneumotorax spontan
• fistule bron0o"pleurale
• pleurodeze (talcaj)
- Rezectii noduli pulmonariperiferici
- &iopsie pulmonara
• >ediastinoscopia
Indicatii :
&iopsie adenopatiimediastinale
• $eoplazici (stadiu $)
• arcoidoza
• 9imfoame
• >ediastinotomia
Indicatii :
&iopsie formatiunimediastinale anterioare
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oracoscopie video-asistata
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ezoteliom pleural
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g. +
-oligrafie ventilatorie• flu$ aerian nazaloral !ochelari, termistor"
• miscari toraco-a&dominale !piezoelectric"
• pulso$imetrie
• pozitie corpului• sforait
C• ##G #G #8G 5 durata si stadiile de somn
• #)G
• pozitiamiscari mem&re
D
-olisomnografie (gold standard)
Poligrafe (~6 ore)
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Poligrafe ( 6 ore)
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0ipoxemie intermitenta
apnei
desaturari
-oligrafie, ecran de 6@ minute
Poligrafe (ecran de 2 minute, apnei obstructi
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Poligrafe (ecran de 2 minute, apnei obstructi
absenta flux nazal (apnee)
miscari toracice
desaturare
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Revarsat pleural
Toracenteza
• (iochimie
• +itologie
• (acteriologie
&iopsie pleurala oarba
-leuroscopie ! &iopsie tintita"
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Tumora pulmonara
*entro0ilara
• (ronhoscopie cu &iopsie → dg de certitudine
• + pt stadializare ?
-eriferica
• + pt localizarestadializare
• (ronhoscopie cu :(1 → celule maligne?
• oracotomie cu &iopsierezectie → dg de certitudine