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Semne sugestive pentruproblema urgenta
➢Cianoza / scaderea SaO2
➢Folosirea m. respiratori
➢Imposibilitatea de a vorbi
➢Frecventa respiratorie mare sau mica
➢Stridor
➢Silentiu respirator
➢Tahicardie, puls pradoxal
➢Epuizare
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Cauze de insuficienta respiratorie
Boli respiratorii
➢ BPOC / astm bronsic
➢ Revarst pleural mare
➢ Pneumonie
➢ EPA non-cardiogen
➢ TEP
➢ Pneumotorax
Boli non-respiratorii
➢ Anemia
➢ Cetoacidoza diabetica
➢ Hyperventilatia (anxietatea)
Obstructii de cai aeriene
➢ Corp strain
➢ Leziuni de git / fata
➢ Pierderea de constienta(inhalarea)
➢ Angio-edemul
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Sindromul de condensare(pneumonia lobara)
Definitie
➢ Inflamatia tesutuluipulmonar caracterizata prinprezenta de exudat in alveole
Clasificare
➢ “community-aquired”
➢ “hospital-aquired”
➢ Pe plamin lezat
➢ La imunocompromisi
Predictia patogenului, deci tratamentul
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Cauze pneumonie comunitara
➢ Streptococus pneumoniae(>30%)
➢ Chlamydia pneumoniae(10%)
➢ Mycoplasma pneumoniae(10%)
➢ Legionella pneumoniae (5%)
Simptome
➢ Febra, frison
➢ Durere pleurala
➢ Tuse, dispnee
➢ Tahicardie
➢ Confuzie (virstnici / grava)
Sindromul de condensare(pneumonia lobara)
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Semne
➢ Inspectie
➢ Palpare
➢ Percutia
➢ Auscultatie
➢ Excursii costale diminuate
➢ Freamat pectoral accentuat
➢ Matitate (nu lemnoasa)
➢ Raluri crepitante (pan-, mediu- tardiv- in inspir, posibil frecatura plurala)
Sindromul de condensare(pneumonia lobara)
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Sindromul de condensare(pneumonia lobara)
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Sindromul de atelectazie
Definitie
➢ Resorbtia aerului din zona de plamin aerata de o
bronhie care a fostobstruata complet
(colaps al zonei respective)
Cauze
➢ Intraluminal: ▪ mucus,
▪ aspiratie,
▪ corp strain
➢ Mural: ▪ carcinom bronsic
➢ Extramural: ▪ adenopatie,
▪ anevrism aortic
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Sindromul de atelectazie
➢Semne:
▪ Inspectie: excursii costale reduse, perete costal plat
▪ Palpare: freamat pectoral diminuat.
▪ Percutie: matitate a zonei afectate
▪ Auscultatie: m.v. diminuat / absent
▪ IN PLUS: trahee deplasata de partea leziunii
➢Nota:
▪ Colapsul lobar complet – posibil fara semne
▪ Imediat dupa inhalare corp strain – hiperinflatie
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Sindromul lichidian pleural
Definitie
➢ Colectia de lichid in spatiul virtual pleural
➢ Hidrotorax, pleurezie, hemotorax, empiem, chilotorax
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Transsudat
➢ Insuficienta cardiaca
➢ Hipoalbuminemia (sd nefrotic, ciroza hepatica)
➢ Hipotiroidie severa (mixedem)
Exudat
➢ Pneumonie
➢ Neoplazii: bronsic, metastatic, mezoteliom
➢ Tuberculoza
➢ TEP / infarct pulmonar
➢ Abcesul subfrenic
➢ Pancreatita acuta
➢ Boli tesut conjunctiv
➢ Sd Meigs (fibrom ovarian)
Sindromul lichidian pleural
Cauze
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Sindromul lichidian pleural
Criteriile Light transsudat-exudat
➢ Albumina lichid/albumina serica >0.5
➢ LDH lichid / LDH seric >0.6
➢ LDH lichid > 2/3 LDH val normala ser
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Semne
➢ Inspectie
➢ Palpare
➢ Percutie
➢ Auscultatie
➢ IN PLUS:
➢ Excursii costale reduse pepartea afectata
➢ Freamat pectoral absent
➢ Matitate lemnoasa
➢ m.v. abolit, ± suflu pleuretic
➢ Trahee deplasatacontralateral
Sindromul lichidian pleural
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Alte patologii respiratorii
➢Pneumotorax
➢Bronsectaziile
➢Astmul bronsic
➢BronhoPneumopatia Obstructiva Cronica (BPOC)
➢Boala pulmonara interstitiala
➢Compresia mediastinala
➢Cancerul pulmonar
➢Trombembolismul pulmonar
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Pneumotorax
Definitie
➢ Patrunderea de aer in spatiul virtual pleural, dinspre exterior saudinspre bronsii
Cauze
➢ Primar (spontan): rupturade bule subpleurale
➢ Secundar:▪ Traumatic: fractura costala,
rana penetranta
▪ Iatrogen: cateter venoscentral, toracenteza
▪ Ruptura de bule de emfizem
▪ Rar: astm, carcinom bronsic
➢ In tensiune – URGENTA !!! (ventilatia mecanica)
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Semne
➢ Inspectie
➢ Palpare
➢ Percutie
➢ Auscultatie
➢ IN PLUS :
➢ Excursii costale diminuate
➢ Freamat pectoral absent
➢ Hipersonoritate difuza
➢ m.v. absent
➢ Trahee deplasatacontralateral
Pneumotorax
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Bronsiectaziile
Definitie
➢ Dilatare patologica a bronsiilor → perturbareaclearence mucus → infectiecronica (supuratiepulmonara) → tuseproductiva cronica
Cauze
➢ Congenitale: ▪ diskinezie ciliara primara,
▪ fibroza kistica,
▪ hipogamaglobulinemiacongenitala
➢ Dobindite: ▪ infectii in copilarie
▪ boala locala (corp strain, TBC)
▪ aspergiloza bronhopulmonaracronica (localizare proximala)
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Astmul bronsic
Definitie
➢ Atacuri recurente de dispnee paroxisticaexpiratorie cu wheezing / tuse, prin obstructiebronsica reversibila
Semne de gravitate
➢ Epuizare
➢ Imposibilitatea de a vorbi
➢ Silentiu respirator
➢ Cianoza
➢ Tahicardie > 130bpm (hipoxemie)
➢ Puls paradoxal (>20mmHg)
➢ Somnolenta (hipercapnie)
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Semne si simptome
➢ Tuse
➢ Dispnee
➢ Inspectie
➢ Palpare
➢ Percutie
➢ Auscultatie
➢ Tahipnee, expir prelungit, folosirea m. respiratori accesori, diametru ant-post si supero-inferior crescute, wheezing
➢ ± freamat pectoral scazut
➢ Hipersonoritate si absentamatitatii hepatice
➢ Raluri sibilante, m.v diminuat
Astmul bronsic
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BPOC
Definitie
➢ Spectru de suferinte
➢ De la emfizem (crestereadimensiunilor sp aerienedistal de bronsiolaterminala) la bronsitacronica (hipertrofie de celule mucoase)
Diagnostic
➢ Istoric de mare fumator
➢ m.v. diminuat
➢ Dg de emfizem / bronsita cr
➢ 2/3 semne – LR 25.7 !!!
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Emfizem
➢ Dispnee fara cianoza
➢ Torace “in butoi”
➢ Buze tuguiate
➢ Musculatura accesorie
➢ Excursii costale diminuate
➢ Hipersonoritate difuza
➢ m.v. diminuat difuz
➢ IC dreapta tardiva
➢ Fara wheezing
Bronsita cronica (3 luni, 2 ani)
➢ Tuse productiva cu cianoza
➢ Excursii costale usor reduse
➢ Sonoritate cvasinormala
➢ m.v. prezent cu ronflante
➢ IC dreapta frecvent
BPOC
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Boala pulmonara interstitiala
Semne
➢ Dispnee, cianoza, hipocratism digital
➢ Excursii costale usor reduse
➢ Crackles inspiratorii
➢ Semnele bolii asociate
Nu uita: 3C
➢ C ough
➢ C lubbing
➢ C rackles
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Predominant lob sup (SCART)
➢ S ilicoza
➢ C oal workers’ lung, C ysticfibrosis, C hronic allergic alveolit
➢ A nkylosing spondilitis
➢ R adiatie
➢ T uberculoza
Predominant lob inf (RASIO)
➢ R heumatoid arthritis
➢ A zbestoza, A lveolitaalergica acuta
➢ S clerodermie
➢ I diopathic interstitial fibrosis
➢ O ther (MTX, amiodarona, nitrofurantoin)
Boala pulmonara interstitiala
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Compresia mediastinala
Obstructia de cava superioara
➢ Facies pletoric cu cianoza siedem periorbital
➢ Jugulare turgescente
➢ Tiroida mare
➢ Circulatie colaterala toracala
➢ Conjunctive injectate
Compresie traheala
➢ Stridor cu insuficientarespiratorie
Afectare laringeu recurent
➢ Raguseala inexplicabila
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Cancerul pulmonar
Semne respiratorii
➢ Hemoptizie
➢ Hipocratism±OAHP (non-
small cell carcinoma)
➢ Pneumonie
➢ Atelectazie
➢ Revarsat pleural
➢ Compresie mediastinala cu afectare de nervi
➢ Adenopatie axilara
Manifestari extrapulmonare
➢ Generale: anorexie, scadere
ponderala, febra
➢ Endocrine: hiperCa, hipoNa,
hiperACTH, sd carcinoid, ginecomastie, hipoglicemie
➢ Neurologice: sd Eaton-
Lambert, cecitate retiniana, polineuropatie, polimiozita
➢ Hematologice: flebite
migratorii, anemie, CID
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Tumora apicala (Pancoast-Tobias)
➢ Horner:▪ Mioza
▪ Enoftalmie
▪ Ptoza palpebrala
➢ Raguseala (laringeu-C7/T1)
Metastaze
➢ Loco-regionale
➢ La distanta:▪ Creier
▪ Suprarenale
▪ Oase
▪ Ficat
Cancerul pulmonar
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Trombembolismul pulmonar (TEP)
Semne
➢ Generale: tahicardie, tahipnee,
febra
➢ Pulmonare: durere si frecatura
pleurala (infarct)
➢ HTP (masiv): regurgitare
tricuspida, zg 2 intarit focarpulmonar, galop, turgescentajugulara
➢ Tromboza venoasa profunda
Factori de risc
➢ APP de TEP
➢ Imobilizare prelungita▪ Zbor trans-oceanic
▪ Post-operator (risc maxim ortopedie mb inferior)
▪ Trombofilii
▪ Neoplasme
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Pe scurt :
➢Insuficienta respiratorie este urgenta medicala
➢TEP oricind exista dispnee brusca cu durerepleurala si tahicardie
➢Criza de astm trebuie recunoscuta repede; potential foarte severa
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Ex aparatului respirator 1
Pacientul în şezut (dacă starea nu este gravă)
1. Inspecţia generală
▪ Conţinutul sputei adunate în pahar (puroi, sânge etc)
▪ Tipul tusei
▪ Frecvenţa şi amplitudinea respiraţiei
▪ Utilizarea muşchilor respiratori
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Ex aparatului respirator 2
2. Mâinile
▪ Degete hipocratice
▪ Cianoză (periferică)
▪ Pete de nicotină
▪ Durere la palparea articulaţiei radio-carpiene (osteoartropatie hipertrofică)
▪ Puls (tahicardie, puls paradoxal)
▪ Flapping tremor (hipercapnie)
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Ex aparatului respirator 3
2. Faţa▪ Ochii (sdr. Claude Bernard – Horner) (cancer apical)
▪ Anemie
▪ Cavitatea bucală – cianoză centrală
▪ Voce – răguşeală (paralizie de n. laringeu recurent)
▪ Facies pletoric – fumător, sdr de venă cavă sup
3. Traheea▪ Deviaţie: tumoră, pneumotorax
4. Timpul de expir forţat▪ Wheezing
▪ >3s
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Ex aparatului respirator 4
5. Toracele posterior▪ Inspecţie
• Forma coloanei şi a toracelui• Cicatrici• Vene proeminente
▪ Palpare• Noduli limfatici cervicali• Amplitudinea mişcărilor respiratorii• Vibraţii vocale
▪ Percuţie• Supraclavicular• Spate• Axile• Sinusuri costodiafragmatice
▪ Auscultaţie• Murmur vezicular• Rezonanţă vocală• Sunete supraadăugate (raluri bronşice sau alveolare)
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Ex aparatului respirator 5
6. Toracele anterior▪ Inspecţie
• Semne ale radioterapiei, torace, stern, vene proeminente
▪ Palpare• Noduli limfatici supraclaviculari, axilari
• Amplitudinea mişcărilor
• Vibraţii vocale
• Bătăile apexului cardiac
▪ Percuţie
▪ Auscultaţie
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Auscultaţia
Boala Sunete normale Sunete supraadăugate
Pneumonia Bronşice (suflu tubar) sau absente
Crepitante în inspir
Atelectazie Murmur aspru / bronşice Crepitante inspiratorii târzii
Pneumotorax Absente Niciunul
Emfizem Diminuate Crepitante inspiratoriiprecoce
Bronşită cronică Normale Sibilante şi crepitante
Fibroză pulmonară Murmur aspru Crepitante groase inspiratorii
Insuficienţă cardiacă Diminuate Subcrepitante
Revărsat pleural Diminuate Niciunul
Astm Diminuate Sibilante (şi ronflante)
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Figure 1 Photographs of the patient showing the reduction in swelling of the face, neck and upper extremities
Chee CE et al. (2007) Superior vena cava syndrome: an increasingly frequent complication of cardiac procedures
Nat Clin Pract Cardiovasc Med 4: 226–230 doi:10.1038/ncpcardio0850
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Ex aparatului respirator 6
7. Sist cardiovascular (45)▪ Presiunea vv jugulare
9. Altele
▪ Membre inferioare – edem, cianoză
▪ Ficat
▪ Sâni
▪ Curba temperaturii (infecţie)
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Evaluarea funcţiei respiratorii 1
➢Timpul de expir forţat▪ Inspir maxim, expir cu forţă
▪ 3s
▪ Fumat + timpul >3s = BPOC (LR+=9,6)
➢Peak flow metru▪ Debitul expirator max (PEF)
▪ Depinde de vârstă, sex, înălţime
▪ Obstrucţie: BPOC, astm
▪ Măsurători repetate (evoluţie/monitorizare)
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Evaluarea funcţiei respiratorii 2
➢Spirometria
▪ Volumul expirator maxim pe secundă (VEMS, FEV1)(vol expirat forţat în 1 sec, după inspir maxim)
▪ Capacitatea vitală forţată (CV) (vol expirat forţat, după inspir max)
▪ Cea mai bună valoare din 3 încercări
▪ VEMS/CV= indice Tiffeneau (N>80%)
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Evaluarea funcţiei respiratorii 3
➢Spirometria
▪ Obstrucţie:
• VEMS/CV<70%
• Astm, BPOC
▪ Restricţie:
• VEMS, CV, VEMS/CV=N
• Boli parenchimatoase: boală interstiţială, sarcoidoză, pneumonie, anomalii torace
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Pulsoximetria
➢Măsurarea continuă a SaO2
➢Poate fi folosit ca o extensie a ex fizic, mai ales la pacienţii dispneici
➢>95% = satisfăcător
➢< 90% = insuficienţă respiratorie (sau şoc, sau TEP mare)
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Ex radiologic (radiografia, CT toracice)
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Right upper lobe: ä = apical segment; a = anterior segment, p = posterior segment.Left upper lobe: ä – p = apico-posterior segment, s = anterior segment, sl = superior lingular segment, il = inferior lingularsegment.Right middle lobe (rml): m = medial segment, l = lateral segment.Right lower lobe: äl = apical segment, mb = medial basal segment, lb = lateral basal segment, ab = anterior basal segment,pb = posterior basal segment.Left lower lobe: äl = apical segment, lb = lateral basal segment, ab = anterior basal segment, pb = posterior basal segment
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Right upper lobe: ä = apical segment; a = anterior segment, p = posterior segment.Left upper lobe: ä – p = apico-posterior segment, s = anterior segment, sl = superior lingular segment, il = inferior lingularsegment.Right middle lobe (rml): m = medial segment, l = lateral segment.Right lower lobe: äl = apical segment, mb = medial basal segment, lb = lateral basal segment, ab = anterior basal segment,pb = posterior basal segment.Left lower lobe: äl = apical segment, lb = lateral basal segment, ab = anterior basal segment, pb = posterior basal segment
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Modificări radiologice
➢Consolidare
➢Lichid pleural
➢Pneumotorax
➢Hidropneumotorax
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Consolidare de lob superior drept
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Revărsat pleural stâng
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