curs respirator 2 patologie
TRANSCRIPT
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Curs IISemiologie radiologicaSindroame pulmonare
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Normal normostenic astenic (longilin) hiperstenic ( picnic)
Patologic cifo-scoliotic cifotic emfizematos paralitic torace in palnie torace in carena postchirurgical (toracoplastie, pneumonectomie), etc
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Cresc toate diametrele cutiei toracice Orizontalizarea arcurilor costale Largirea spatiilor intercostale Aplatizarea diafragmelor Cord verticalizat
o Cauza - emfizemul pulmonar
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Cauze
Paralizie de nerv frenic (semnul Balantei)
Colectie inchistata in pleura diafragmatica → ecografie
Hepatomegalie tumorala sau nu / splenomegalie
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Diagnostic o radioscopico doua radiografii - in inspir si in expir
Cauzeo aderente masive pleuraleo inflamatii supra- sau subdiafragmaticeo simfiza costo-diafragmatica ↓
semnul miscarii in balama
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Opacitate = structura cu densitate↑ o Rx - negruo Rgr - alb
Transparenta = structura cu densitate↓(aer)o Rx - albo Rgr - negru
Imagine mixta = asocierea celor doua
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Localizareao Regiunea pulmonara in PAo Lobi, segmente, scizuri in PA si profilo Semne radiologice in PA
Semnul unghiului de racordaj (Bernou)• unghi ascutit = apartenenta pulmonara• unghi obtuz = apartenenta parietala
Semnul siluetei • doua opacitati in contact isi sterg conturul la locul de
contactSemnul cervico-toracic
• opacitatea mediastinala care nu depaseste clavicula se afla în mediastinul anterior
• care depaseste clavicula este situata posterior
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S. Bernou
S. siluetei
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Semnul bronhogramei aerice sindrom de umplere alveolara (pneumonie in dezvoltare)
Semnul alveologrameisindrom de umplere alveolara (pneumonie in resorbtie)
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S. brohnogramei aerice S. alveologramei
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Localizare Numar Forma (cele nesistematizate) Dimensiuni Contur
o net, net si linearo difuz (flu, imprecis)o invadanto regulat, neregulato policiclic
Structura = omogena / inomogena Natura = opacitate, transparenta, imagine mixta Intensitatea - >, <, = cordul (medie) Raporturi Dinamica
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Nemodificate Modificate prin
o tractiune (aderente)o aspiratie (atelectazia)o impingere (colectii pleurale mari, tumori, chiste aerice)
Volumul pulmonar si toracico nemodificat in pneumonieo micsorat (atelectazie)o marit in emfizem sau tumori masive
Colectiile pleurale mari, scad vol. pulmonar şi cresc vol. toracic
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Localizate sau difuze
Cu desen vascular sau fara desen vascular
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Localizateo cu desen vascular = zone emfizematoaseo fara desen vascular = bine delimitate de
un perete propriu• chist aeric• plaman polichistic• bule de emfizem• bronsiectazii chistice
• imagini cavitare = tumorale, TBC, abces evacuat, pneumatocelul
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Sediul, numar, forma, dimensiuni Conturul (peretele)
o Exterior • (opac, fluu, extins = pneumonie abcedata )• (cavitate in opacitate nodulara = tu. necrozata)
o Interior (anfractuos, neregulat = tu. necrozata) Grosimea peretelui
o subtire = transparente circumscrise, de natura congenitala (chiste aerice, plaman polichistic)
o gros = cavitate formata in parenchim (caverna TBC, tu. cu centru necrozat)
Continutulo cavitate aerica sau mixta (cu lichid)
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Cu distensie aerica Cu desen vascular, bilaterale
o Astm bronsic in crizao Emfizemul pulmonar
Cu desen vascular, unilateraleo Stenoza bronsica pe b. principala cu ventil expirator
Cresc diametrele toracelui Creste volumul pulmonar Air trapping = scade diferenta inspir-expir la digrafie Modificari de artere pulmonare
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Fara desen vascular
laterotoracic = pneumotorace
intrapulmonare = cavitati sau chiste aerice mari
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Hipertransparenta fara desen pulmonar Localizat latero-toracic (cavitatea pleurala) Delimitat medial de pleura viscerala a
plamanului adiacent Plamanul adiacent colabat spre hil Delimitat lateral de pleura parietala Poate fi si inchistat (exista simfiza pleurala)
Urgenta - pneumotoracele expansiv
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opacitate lichidiana in partea inferioara
transparenta aerica in partea superioara
intre ele o linie orizontala, neta si liniara (NIVEL)
nivelul se mentine orizontal in orice pozitie a pacentului
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In plaman
o Abces partial evacuat
o Chist aeric suprainfectat
o Chistul hidatic partial evacuat
In cavitatea pleurala
o Hidropneumotoracele
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Ne-evacuat = NU se vede ca imagine mixta ! Evacuat partial = imagine hidro-aerica Evacuat total = imagine cavitara (aerica)
Abces recent = perete gros, neregulat, flu conturat
Abces cu evolutie cronica = perete subtire + / - calcificare parietala
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Ne-evacuat = opacitate nodulara omogena (lichidiana)
Evacuat partial = imag. hidro-aerica cu perete subtire + nivel orizontal + membrana ondulanta
Evacuat total = chist aeric cu o opacitate mica, ratatinatata, situata in portiunea decliva
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S. de umplere alveolara S. bronsic S. interstitial S. pleural S. parietal S. vascular
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Dispare aerul alveolar din acini (zona de schimb gazos)
Alveolele sunt umplute cuo Exudat - pneumonie , bronhopneumonieo Transsudat – edem pulmonar o Sange – infarct pulmonar, contuzie
pulmonarao Lichid de aspiratie - pneumonie de aspiratie o Celule – tumori pulmonare
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Aspect radiologic
o Opacitate pulmonara sistematizata sau nesistematizata (edemul pulmonar)
o Nu modifica volumul pulmonar si toracico Initial contur fluu –conflueaza rapid, in “pata de
ulei” – in evolutie net si liniar delimitat de scizuri (pneumonii lobare, segmentare)
o Cu bronhograma si alveolograma aerica
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Tipuri de opacitati
Pneumonii - lobite, segmentite, subsegmentite
Bronhopneumonii - micronodular sau nodular
Edem pulmonar alveolar - aspect “in aripi de
fluture”
Posthemoptizie, metastaze – miliar
Infarct pulmonar - opacitate sistematizata
(triunghiulara)
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Ingrosare a peretilor bronsici
Stenoza bronsica
Obstructie bronsica - opacitati pulmonare retractile
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Marirea opacitatii mediastinale patologia cordului si vaselor mari tumori mediastinale adenopatii
Mediastin deplasat aderente (pleurale, fibrotorace) aspiratie (atelectazie pulmonara) compresiune (colecţii pleurale mari)
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Semnul pendularii mediastinale = stenoze bronsice mixte
Stenoza bronsica inspiratorie = atractia inspiratorie spre partea cu stenoza
Stenoza bronsica expiratorie = impingere expiratorie spre partea opusa stenozei
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Deplasarea mediastnului – stenoza bronsica
cu ventil inspirator cu ventil expirator
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Radioscopic
inspirator - testul prizei sacadate
expirator - testul tusei sacadate
mixte - pozitive ambele
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1. Obstructiva (resorbtiva)2. Pasiva (colaps de natura pleurala)3. Compresiva (hipotransparenta in jurul unui
proces expansiv)4. Cicatriceala (condensare + reducere a vol.
pulmonar - organizare fibroasa)5. Adeziva (boala membranelor hialine la nou
nascut, pneumonita radica)
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Semne directe
Opacitate sistematizata Retractila – scizura invecinata concava Reduce volumul toracic si pulmonar Delimitare neta si lineara prin scizuri Forma de triunghi cu varful spre hil si baza
la pleura Nu are bronhograma si alveolograma
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Semne indirecte
Ascensiunea diafragmului Aspiratia mediastinului Modifica pozitia hilului pulmonar Retractie costală Expansiunea parenchimului pulmonar
invecinat (emfizem compensator)
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Ingrosarea tesutului interstitial prin
o Edem interstitial
o Proliferare anormala celulara sau tisulara
(fibroze, granulomatoze)
o Afectiuni interstitiale maligne (limfangita
carcinoamatoasa)
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Aspectul radilogic
Topografia difuza Nu sunt sistematizate Contur net Intensitate redusa Nu sunt confluente Evolutie lenta
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Forme radiologice
sticla mata - interstitiul parieto- alveolar reticular - interstitiul perilobular si intralobular micronodular - interstitiul parieto-alveolar reticulo-nodular in “fagure de miere” (pseudomicropolichistic)
- interstitiul perilobular si intralobular liniar – interstitiul peribronhovascular si
subpleural
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Aspectul miliar / noduli interstitiali
o p – diam. 1,5 mm
o q – diam. 1,5 -3 mm (micronodulare)
o r – diam. 3-10 mm (nodulare)
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Afectiuni cu sindrom interstitialo Colagenozeo Histiocitoza Xo Sarcoidozao Fibroza pulmonara primitivao Pneumoconioze o Pneumonia cu Pneumocystis cariniio etc
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Acumularea de lichid in cavitatea pleurala
o pres. hidrostatica crescuta
o pres. oncotica scazuta
o inflamatii
o tumori
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Fac parteo pleureziile exudativeo pneumotoraceleo hidropneumotoraceleo Calcificarile pleurale o Tumori pleurale
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Libere - cantitate mica, medie, mare
Inchistate ino marea cavitateo scizurio supradiafragmatico pleura mediastinala
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Libere - cantitate mica
o Opacifierea sinusului costo-diafragmatic
o Contur fluu al diafragmului
o Hipomobilitatea diafragmului
o Colectia se misca concomitent cu diafragmul
o Dg. Diferential - simfiza C-D
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Libere - cantitate medie
o opacitate bazala ce urca laterotoracic
o delimitata de o linie concava, fluu delimitata
o hipotransparenta plamanului adiacent
o opacitatea mobila cu pozitia
o nu are bronhograma
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Libere - cantitate mareo Opacitate mai mareo Lichidul incorporeaza si varfulo Mediastinul impins in partea opusao Volum toracic crescuto Aceleasi caractere
Opacitate masiva care nu impinge mediastinul= pleurezie + atelectazie
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Primare (dupa Gherasim 2002) Mezotelioame
o fibros localizat = benign, rar, recidiveaza o difuz = malign, frecvent, liza costala,
revarsat pleural
Tu secundare: metastaze
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Radiologico Opacitate hemisferica placata pe pereteo Nu se modifica la Valsalva –Müllero Distrug arcurile costaleo Colectii pleuraleo Nu are semnul coafarii
Ecografia – ecogena
CT - densitate parenchimatoasa si/sau lichidiana (colectie pleurala) si depozite calcare
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Semne radiologice pentru un proces expansiv in peretele toracic
In afara foitelor pleurale
Cuprinde patologia peretelui toracic diafragmatica mediastinala
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Dezvoltare spre interior / exterior
In toate incidentele nu poate fi disociata de perete
Opacitate net sau fluu delimitata in functie de incidenta
Afectare costala
Se misca cu coastele
Nu are bronhograma
Semnul coafarii parietale este prezent
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Pe rgr. tangente (oblice) la perete se
vede lizereul clar al grasimii
extrapleurale endotoracice
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1. M. intercostali
2. Fascia endotoracica
3. Grasimea endotoracica
4. Pleura parietala
5. Pleura viscerala
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1. Pleura parietala si viscerala
2. Grasimea endotoracica
3. Procesul expansiv