Download - 3.Pneumonii
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PNEUMONIILEPARTEA 1
Dr Elisabeta Badila
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Importanta problemei
morbiditate si mortalitate importante
a 3a cauza de mortalitate in lume
prima cauza de mortalitate infectioasa
un procent semnificativ de pacienti necesita spitalizare
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Definitie
Anatomopat infectia alveolelor, a CR distale & a interstitiului pulmonar
Clinic constelatie de simptome & semne in combinatie cu cel putin o opacitate pe rgf. toracica
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Clasificare anatomica
Pneumonie lobaraBronhopneumoniePneumonie interstitialaPneumonie miliara
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Clasificare etiologica
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Prevalenta patogenilor (pneumonii comunitare)
CAP – Community Acquired
Pneumonia
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Clasificare dpdv al terenului
I. comunitare imunocompetenti imunodeprimati tarati
boli cronice (cardiaci, pneumopatii cronice, diabetici, IRC dializa, boli hepatice cronice, sechelari AVC), neoplazii, alcoolici, malnutriti
II. nosocomiale dobandite in spital germeni selectati terenul
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Clasificare actuala
I. Community aquired pneumonia (CAP)
tratate in ambulator / necesita spitalizare (40-60%)
II. Health-care associated pneumonia (HCAP)
Hospital-Acquired Pneumonia (HAP) Ventilator-Associated pneumonia (VAP)
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Clasificare patogenica
primare secundare metastatice
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Patogenie
Calea de patrundere
aspiratia secretiilor orofaringiene mecanism principal
• microaspiratia secretiilor colonizate• la ind. sanatosi /comorbiditati, stress, antibiotice
• Streptoccocus pneumoniae, Haemophilus infl.
aspiratia in cantitate mare• postoperator, in afectiuni ale SNC
• anaerobi, Gram negativi
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Patogenie
inhalare aerosoli infectanti
TBC, fungi endemici (Coccidoides, Blastomyces, Histoplasma), gripa, Legionella, Coxiella burnetii, virusuri respiratorii (v. gripal A si B)
cale hematogena
catetere iv, tromboflebite septice, toxicomani, endocardita infectioasa, alte infectii (ITU)
MRSA (cateter, endocardita, TCC), E. coli (urinar)directa traumatica, iatrogena, procese septice de vecinatate
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Mecanisme de aparare
Plamanii suprafata ~70 m2 expusa la factorii de mediu
Mecanismele de aparare:
innascute - nespecifice
dobandite - specifice
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Mecanisme de aparare
mecanice- caracteristicile anatomice ale CRS, perii nazali, tusea,
stranutul, sistemul de transport mucociliar (celulele ciliate, mucusul – contine mucina care incorporeaza microorganismele)
secretorii nespecifice - lizozim, lactoferina, transferina antiadezivitate microbiana - fibronectina, surfactant specifice - Ig, complement
celulare nespecifice - macrofage locale alveolare, macrofage
mobilizate de inflamatie specifice: citokine, limfocite B şi T
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Factori favorizanti - alterarea unor mecanisme de aparare
fumat, poluare
toC
varsta
alcool
dismicrobisme - antibioterapie, ATI
staza in circulatia pulmonara - IC
obstructie CR - staza secretii, hipoxie alveolara
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Factori favorizanti
alterarea imunitatii: boli debilitante - DZ, CH, IR, neoplazii, sindrom
nefrotic imunodepresie - SIDA, limfoame imunosupresie iatrogena - cortizon, citostatice, imuno-
supresoare prin hipogamaglobulinemie, defecte ale fagocitozei sau
functiei ciliare, neutropenie, asplenie anatomica sau functionala (80% Str. Pneumoniae, Mt 45%), nr. limfocite T CD4+
polimorfismul genei TNF- genotipul 238 GA - factor de risc independent pt. deces TNF- 308: LT- +250GC –protectie impotriva socului septic
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Factori favorizanti – agentul patogen
Chlamydia pneumoniae – factor ciliostatic
Mycoplasma pneumoniae – afecteaza cilii
V. gripal – reduce velocitatea mucusului traheal (debut la cateva ore, durata 12 sapt.)
S. pneumoniae, Neisseria meningitidis – proteaza care lizeaza IgA
Mycobacterium, Nocardia, Legionella – rezistenta la activitatea fagocitelor
S. pneumoniae – capsula care inhiba fagocitoza; pneumolizina – polipeptid 53 kDa, interactioneaza cu orice membrana celulara care contine colesterol; neuraminidaza, hialuronidaza
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Fiziopatologie
dispneea: - rigiditatii
- compliantei pulmonare, CV, CRF, CPT
- imbalanta V/Q si sunt intrapulmonar cu hipoxemie & hipo/hipercapnie (fct de intinderea pneumoniei si patologia pre-existenta)
- toxic (central)
raspunsul cardiovascular
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ANATOMIE PATOLOGICA
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Pneumonia lobara
Clasic – afectare omogena a intregului lob (rar - mici zone indemne)
4 stadii – simultan:
- I – congestia
- II – hepatizatia rosie
- III – hepatizatia cenusie
- IV – rezolutia
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Bronhopneumonia
afecteaza unul sau mai multi lobi
zonele afectate – de obicei, prost delimitate
exudat cu neutrofile – concentrat mai ales in bronhii si bronhiole, extindere centrifuga la alveolele adiacente
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Pneumonia interstitiala
proces inflamator predominant la nivelul interstitiului, incluzand si peretele alveolar si tesutul conjunctiv din jurul arborelui traheo-bronsic
inflamatia – segmentara sau difuza
alveolele – fara exudat semnificativ; pot exista membrane hialine bogate in proteine (~ARDS)
suprainfectia bacteriana din pneumonia virala – inflamatie mixta interstitiala si alveolara
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Pneumonia miliara
la imunocompromisi
TBC miliara, histoplasmoza, coccidoidomicoza , herpes virusurile, citomegalovirusul, VZV
leziuni discrete si numeroase rezultate din raspandirea pe cale hematogena a germenilor
reactii tisulare variate – de la granuloame cu necroza cazeoasa la focare de necroza; exudat fibrinos si reactie celulara modesta
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PNEUMONIILE COMUNITARE (CAP)
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Epidemiologie
3.5 mil. adulti / an / SUA
40-60% necesita spitalizare
incidenta 8-15/1000 anual
la varste extreme si in lunile de iarna
mai frecvente la barbati
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Factori de risc CAP
Alcoolismul – factor de risc independent si pentru ARDS
Astmul bronsic
Imunosupresia
Varsta > 70 ani
ALPS – entitate clinica care asociaza alcoolismul, leucopenia si sepsisul pneumococic mortalitate 80%
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Etiologia CAP
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Agenti etiologici mai noi
Legionella pneumophila
Chlamidia pneumoniae
Hantavirus
Virusul Nipah
Virusul Hendra
Meta-pneumovirusuri
Coronavirus – SARS (severe acute respiratory syndrome - 2003)
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Etiologia orientativa a CAP fct de istoric si ex. fizic
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Identificarea ag. patogen
Culturi din sputa >25 leucocite si <10 cel. epiteliale scuamoase/camp
Hemoculturi Culturi din lichidul pleural Secretii endotraheale – brosaj/LBA Tesutul pulmonar Raspunsul IgM Cresterea de 4 ori a titrului de Ac impotriva unui Ag
detectat in urina, ser sau lichid pleural Metode de amplificare ADN sau ARN
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Patogenie
virulenta + apararea (tranzitorie sau cronica)
exsudat alveolar proliferare rapida extindere exsudat infectat la alveolele vecine bronhii alte teritorii (in ore!!)
drenaj limfatic precoce bacteriemie (15-30% !!) metastaze septice
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Anatomopatologic
tipic multisegmentara sau lobara
~ 30% - multilobare
clasic 4 stadii (macroscopic, microscopic) – descrise in 1838 de Laennec congestie hepatizatie rosie hepatizatie cenusie rezolutie
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Diagnostic
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Manifestari clinice
Severitateusoarafulminanta si fatala, chiar si la persoane anterior sanatoase
Debutbrusc, dramatic/ insidios
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Simptome
la ~ 50% pacienţi - precedate de IACRS
Manifestari tipice (dar nespecifice)
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Simptome
Manifestari mai rare
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Semne fizice
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Semne fizice
Generale
- stare generala alterata- tegumente calde, transpirate- adinamie- herpes labial sau nazal (>10%)- facies vultuos- eritemul pometului ipsilateral- subicter
Cardiovasculare
- tahicardie, hipotensiune, colaps
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Diagnostic imagistic
Radiografia CP
- “gold standard-ul” dg.- nu are Sp 100%
- ofera rar informatii etiologice (pneumatocele)
- la pacienti cu ICC sau fibroza pulmonara – dg. radiologic dificil
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Diagnostic imagistic
Radiografia CP condensare lobara bacterii “tipice” infiltrate interstitiale germeni “atipici”, virusuri cavitati
Rgf. nu poate diferentia o pneumonie bacteriana de una non-bacteriana
uneori – rezultate fals negative (depletia volemica)
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Diagnostic imagistic
Computer-tomografia cu rezolutie inalta
- pacienti cu semne si simptome sugestive de pneumonie dar cu Rx N
- detectia afectarii bilaterale
- afectarea interstitiala
- descrierea cavitatilor
- adenopatia hilara
- pacienti neresponsivi la tratament
- suspiciunea de complicatii
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Diagnostic etiologic
Hemocultura
- pozitiva la ~20%;
- obligatorie la t <36ºC sau >38,5 ºC; cazuri sociale; alcoolici
- frecvent + pt. S. pneumoniae, Staf. aureus, E. coli Examen sputa + cultura
- frotiu/sputa – coci in diplo pneumococ
- > 25 neutrofile si < 10 cel epiteliale scuamoase
- corelatie frotiu – cultura
- germeni care izolati din sputa – sigur patogeni: M. tuberculosis, Legionella, Histoplasma
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Diagnostic etiologic
Detectia antigenelor in urina - S. pneumoniae
- Ag urinar prin ELISA; Sp si Sn foarte bune la cei cu bacteriemie;
- detectie pana la o luna de la debut; rezultat in 15 min
- Legionella pneumophila- serogrupul 1 – detectie in urina prin ELISA ~ severitatea
bolii;- cea mai folosita metoda de dg. pentru legioneloza- ! alte specii de Legionella – reactie negativa
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Diagnostic etiologic
Serologia
- detectia Ac tip IgM
- cresterea de 4 ori a titrului de Ac impotriva unui ag. patogen intre faza acuta si cea de convalescenta
- test pozitiv pt: M. pneumoniae, C. pneumoniae, Chlamydia psittaci, Legionella spp, C. burnetii, adenovirusuri, v. gripal A, v. paragripale
- RFC, IF indirecta, ELISA
- nu de rutina; util daca hemocultura si cultura din sputa sunt negative
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Diagnostic etiologic
Polymerase chain reaction
- amplificare ADN sau ARN
- Legionella spp, M. pneumoniae, C. pneumoniae
- investigatie costisitoare; nu de rutina
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Criterii de severitate legate de agentul etiologic
Pseudomonas – Mt > 50%
Klebsiella
E. coli
Staphylococcus aureus 30-35%
Acinetobacter spp
Pneumococ – serotipul capsular 3
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Complicatii
Insuficienta respiratorie Insuficienta cardiaca congestiva Soc Aritmii Sangerari gastrointestinale Insuficienta renala
!!! Doar 30% dintre pacientii spitalizati nu au complicatii
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Mortalitatea
Mt intraspitaliceasca datorata pneumoniei ~ 8%
½ decese – legate de pneumonie, ½ de comorbiditati
decesul – frecvent in prima saptamana
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Diagnostic diferential
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Abordul pacientului cu CAP
1. Apreciaza severitatea pneumoniei – semnele vitale, RR/1 min, SO2
2. Asigura oxigenarea si suportul circulator adecvat
3. Identifica agentul etiologic
4. Stabileste daca tratamentul se va efectua la domiciliu sau in spital – sectie sau terapie intensiva
5. Initiaza empiric tratamentul antibiotic
6. Exclude empiemul la pacientii cu lichid pleural > 1 cm la Rgf. toracica in decubit lateral
7. Nu uita niciodata de posibilitatea etiologiei cu BK sau Pneumocystis
8. Ia in considerare embolia pulmonara la pacientii cu durere toracica de tip pleuritic
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Abordul pacientului cu CAP
1. Monitorizeaza si trateaza comorbiditatile
2. Monitorizeaza pacientul pana la stabilizarea parametrilor fiziologici selectati
3. Apreciaza capacitatea de a desfasura activitatile zilnice
4. Apreciaza statusul mental
5. Ofera sfaturi de preventie: intrerupere fumat, vaccinare antigripala si antipneumococica, preventia aspirarii secretiilor orotraheale
6. Urmareste rezolutia radiologica – documentata la pacientii > 40 ani si fumatori
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CAP- criterii de internare
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Pneumonia Severity
Index (PSI)
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Pneumonia Severity Index (PSI)
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CURB-65
Confusion
Urea > 20 mg/dl (7 mmoli/l)
Respiratory rates > 30/min
DBP < 60 mmHg or SBP < 90 mmHg
Varsta > 65 ani
Acronim: CURB-65
Mortalitatea
- 2,4% in abs. CURB
- 8% - 1 criteriu prezent - 33% - 3 criterii prezente
- 23% - 2 criterii prezente - 83% - 4 criterii prezente
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Criterii de severitate dupa American Thoracic Society
Categoria Criterii
Majore 1. necesitatea ventilatiei mecanice2. ↑ marimii infiltratelor cu >50% in
24 ore3. soc septic / nevoia de vasopresoare4. insuficienta renala acuta
Minore 1. RR > 30/min2. TAS < 90 mmHg si TAD < 60 mmHg3. PaO2/FIO2 < 250
4. afectarea bilaterala /multilobara
American Thoracic Society 2001 – Am J Resp Crit Care Med, 163:1730-1754Ewig et al. Am J Resp Crit Care Med, 158: 1102-1108
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Principii de tratament
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Antibiotice
Beta-lactami nu pe atipici, eficienta pe DRSP
Macrolide acopera atipici, ineficiente in DRSP
Fluorquinolone rezistenta
Aminoglicozide
Anti MRSA
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Terapia antibiotica empiricaMedicare Study
Initiere AB < 8 ore din mom. prezentarii la garda – Mt
Macrolid + cefalosporina II / non-pseudomonas III – eficienta > cefalosporina in monoterapie
Fluorquinolonele – asociate cu Mt
Aminoglicozid + orice alt AB - Mt ; antipseudomonas
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Terapia antibiotica empiricaMedicare Study
Rezistenta Streptococcus Pneumoniae 1999 -2000 35% la penicilina 25.9% la macrolide 8.8% la clindamicina 16.4% la tetraciclina 30.3% la TMP-SX 22.5% - multirezistenti
Rezistenta la quinolone in crestere; factorii de risc:
varsta > 64 ani istoric de BPOC tratament cu quinolone in ultimele 3 luni
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Terapia antibiotica empirica in CAP
Electie – β-lactam ± macrolid
Macrolidele pneumococ + atipici (M. pneumoniae, C.
pneumoniae, Legionella)
Doxiciclina pneumococ si atipici – subutilizata
Meningita asociata vancomicina + ceftriaxona
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Terapia antibiotica in CAP
Trecerea de la i.v. la per os:
- nr. leucocite revine catre normal
- min 2 t < 37,5 ºC la interval > 16 ore
- ameliorarea tusei si a dispneei
Antibiotice cu absorbtie intestinala f. buna Amoxicilina quinolone “respiratorii” (moxi-, levofloxacina) ! terapia i.v. - in caz de hTA, greata sau varsaturi
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Durata terapiei antibiotice in CAP
Durata standard CAP necomplicate 5-7 zile
Nu exista CRT care sa indice durata optima
Variabil - functie de agent si de antibiotic Legionella, Pseudomonas, b. aerobi Gram negativi 21 zile pacientii tratati ambulator cu azitromicina 5 zile
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Raspunsul favorabil in pneumoniile necomplicate
febra – scade in 2 zile
leucocitoza – scade in 4 zile
semnele fizice persista ↑
anomaliile radiologice 4-12 sapt
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Criterii de externare in CAP
temperatura orala < 37,5 ºC min 24 ore
frecventa cardiaca < 100/min
frecventa respiratorie < 24/min
TAS > 90 mmHg
SO2 > 90%
abilitatea de a se hidrata si hrani
status mental adecvat
bolile asociate – stabile
complicatiile rezolvate
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Factori de luat in considerare cand CAP evolueaza nefavorabil
1. Reconsidera dg. alta boala care ~ cu pneumonia? (colagenozele cu afectare pulmonara)
2. Tratezi germenul care trebuie? (tratezi o bacterie conventionala si pneumonia e determinata de BK, Pneumocystis sau fungi)
3. Tratezi patogenul corect dar cu un antibiotic gresit? (exp. nafcilina pentru MRSA – necesita vancomicina sau linezolid)
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Factori de luat in considerare cand CAP evolueaza nefavorabil
1. Exista o cauza mecanica care impiedica ameliorarea? (obstructie bronsica – carcinoame, dopuri)
2. Exista un focar piogen metastatic nedrenat? (empiem, abces cerebral, endocardita, abces splenic, osteomielita)
3. Pacientul are febra indusa de antibiotic?
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COMPLICATIILE PULMONARE ALE CAP
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Pleurezia complicata
40% pacienti spitalizati cu CAP – pleurezie obligatorie – Rgf. in decubit lateral de partea afectata;
toracenteza daca D > 1 cm empiem daca:
- pH <7.0
- glucoza drenaj- LDH > 1000 U- germeni pe frotiu sau in culturi
aspiratia de puroi franc tub de dren, agenti litici intrapleural, uneori toracotomie, decorticare – sub supraveghere chirurg toracic
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Abcesul pulmonar
arie de supuratie localizata in tesutul pulmonar care duce la distructia parenchimului si la aspectul radiologic de cavitate cu nivel aer – lichid
4-5 cazuri / 10 000 pneumonii spitalizate
factorii de risc: afectarea reflexului de tuse, aspiratia, alcoolismul,
anestezia, abuzul de droguri, epilepsia, AVC; cariile dentare, bronsiectaziile, carcinomul bronsic, infarctul pulmonar
frecvent cu bacterii aerobe si anaerobe
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Abcesul pulmonar
necesita terapie antibiotica tintita in functie de germenul izolat
durata – 6 - 8 saptamani pana la rezolutia rgf.
insucces la ~10% cazuri drenaj percutan sau lobectomie
Nu orice cavitate pulmonara = abces
Neoplasm Granulomatoza Wegener
Noduli reumatoizi Infarct pulmonar
Leziuni TBC Infectii fungice
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Pneumonia recurenta
10 – 15% dintre pacientii internati pentru CAP – nou episod in urmatorii 2 ani
! daca este afectat acelasi segment anatomic – probabilitate de obstructie bronsica prin tumora, corp strain
cauze frecvente: macroaspiratia repetata, bronsiectaziile, BPOC pneumonii frecvente cu localizari diferite, fara factori
de risc pentru aspiratie imunodepresie? – teste HIV, Ig,electroforeza, numaratoare limfocite T si B
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CAP severa
pneumonia care necesita internarea in terapie intensiva
necesita de obicei ventilatie mecanica pentru tratamentul hipoxemiei severe
ventilatia cu presiune continua pozitiva
administrarea de inhibitori ai ciclooxigenazei – aspirina, indometacin – reversul vasoconstrictiei arteriale pulmonare induse de hipoxemie
aerosoli cu prostaciclina sau NO – reducerea suntului intrapulmonar si a HTP
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Pneumonia de aspiratie
Etiologie Enterobacteriaceae, S. aureus, S. pneumoniae, H. influenza
Localizare segmentele post ale LS si segmentele inf ale LI
Tipuri pneumonia prin aspiratia florei oro-faringiene pneumonita de aspiratie (prin aspiratia ac. gastric)
Favorizanti alterarea constientei, incompetenta jonctiunii esogastrice,
presiunii intragastrice , b. neuromusculare ce afecteaza inchiderea glotei
Mt 23%
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PNEUMONIAPNEUMOCOCICA
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Pneumococul (Streptcoccus pneumoniae)
izolat in 1881
90 serotipuri (vaccinul acopera 23)
serotipul 3 – agresivitate deosebita
patogenul majoritar la copii si adulti
50% - purtatatori asimptomatici
determina otita medie, pneumonie, meningita, bacteriemie
!!! pneumococi cu rezistenta multipla la Atb
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Factori de risc pentru pneumonia pneumococica
Fumatul – !!! cel mai puternic predictor de boala pneumococica invaziva printre adultii tineri imuno-competenti
Dementa, convulsiile Insuficienta cardiaca congestiva Boala cerebrovasculara Alcoolismul – rezolutie lenta, empiem frecvent BPOC Sexul masculin, rasa neagra Bolile cronice Infectia HIV – risc de 40 ori mai mare
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Anatomopatologic
I - congestia
- primele 24 ore
- plamanul - consistenta ~ “coca”
- - congestie vasculara, alveolita catarala
- bacteriile porii Cohn extensie rapida la intregul lob; neutrofile rare
II - hepatizatia rosie
- plaman ferm, fara crepitatii, ~ ficatul
- - hematii, neutrofile, celule descuamate, fibrina in spatiul alveolar
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Anatomopatologic III - hepatizatia cenusie
- plaman uscat, friabil, gri-maron-galbui; incepe procesul de rezolutie - - exudat fibrinopurulent cu macrofage, neutrofile, bacterii – rar;
hematii dezintegrate, hemosiderina - durata II + III – 2- 3 zile fiecare
IV- rezolutia - digestia enzimatica a exudatului alveolar - resorbtia, fagocitoza, eliminarea detritusului si restaurarea arhitecturii
pulmonare normale - inflamatia – extindere la pleura – frecatura la auscultatie rezolutie
sau aderenta pleurala
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Clinic
Perioada de incubatie ~ 3 zile
Perioada de stare
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Clinic
dispnee – frecvent
polipnee moderata fct marimea pneumoniei & statusul pulmonar anterior
varstnicii – frecvent debut insidios – astenie,
confuzie, fara febra, tuse redusa, fara sputa greata, varsaturi, diaree – la ~20%
evolutia cea mai rapida – la pacientii splenectomizati deces in 24 ore
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Pneumonia pneumococica
Examenul obiectiv
- temperatura/ subfebra (batrani)/ hipotermie
(asociata cu mortalitatii)
- pulsul, frecventa respiratorie
- herpes labial
- roseata pometelui de partea pneumoniei
- aparitia de noi sufluri – ? endocardita
- confuzie redoare de ceafa - ? meningita
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Pneumonia pneumococica – examen obiectiv
Sindrom de condensare tipic
ampliatii respiratorii de partea pneumoniei
matitate/submatitate la percutie
vibratii vocale
respiratie suflanta sau suflu tubar
raluri crepitante – accentuate de tuse
Sindrom de condensare tipic
ampliatii respiratorii de partea pneumoniei
matitate/submatitate la percutie
vibratii vocale
respiratie suflanta sau suflu tubar
raluri crepitante – accentuate de tuse
Sindrom lichidian pleural
matitate
vibratiile nu se transmit
MV
frecatura pleurala
Sindrom lichidian pleural
matitate
vibratiile nu se transmit
MV
frecatura pleurala
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Pneumonia pneumococica
Radiografia toracica tipic - condensare lobarabronhograma aerica in interior – la > 50%revarsat pleural minim/mediu la 30%rar - bronhopneumonie sau pneumonie dubla abces pulmonar
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Radiografia pulmonara
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Radiografia pulmonara
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Pneumonia pneumococica
Ex. bacteriologic ex. sputa - coc Gram + in diplo; incapsulat serotipuri – 1,2,3,5,7 – pneumonie lobara; 3,7,10,18,20 -
bronhopneumonie aderenta – contact direct bacterie – celula umana (fara pili,
fimbrii) hemoculturi pozitive la ~ 25% (pozitivare rapida in primele
12 ore de la recoltare)
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Pneumococul
Ex. sputaCoci G+ in diplo
Microscopie electronicaAderenta directa la celule
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Pneumonia pneumococica – examen biologic
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Dg diferential cu alte pneumonii
afectarea lobara Klebsiella pneumoniae Haemophilus influenzae Streptococcus pyogenes Staphylococcus aureus
opacitati nesegmentare germeni atipici
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Dg. diferential cu alte afectiuni pulmonare
infarctul pulmonar atelectazii (obstructie benigna sau maligna) tumori pulmonare sau pleurale pleurezii inchistate abcesul pulmonar TBC boli de colagen vasculite in afectari pneumopatii alergice difuze
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Evolutie
Cu tratament antibiotic recuperarea completa a functiei si arhitecturii pulmonare
febra în 24-36 h, afebrilitate ~ a 3-a zi febra si L > 4-5 zile - empiem sdr. condensare regreseaza in 3 - 5 zile 7 zile în formele
severe rezolutie Rgf. in 10-14 zile (max 21 zile) Mortalitate generala 1%
formele care necesită spitalizare in STI 25%
Fara tratament mortalitate medie ~ 30%
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Complicatii
Infectioase Empiem pleural Pneumonie necrotizanta Abces pulmonar Atelectazie Suprainfectie Rezolutie tardiva Pericardita purulenta Endocardita Meningita Artrita septica
Imunologice Pleurezie serofibrinoasa Glomerulonefrita
Complicatii rare•Icter•Decompensare IC•Dilatatie gastrica•Ileus paralitic•TVP
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Tratament
energic, cat mai precoce, inainte de rezultatele bacteriologice
Obiective combaterea infectiei prevenirea si tratamentul complicatiilor
Mijloace tratament etiologic tratament patogenic (complicatii) masuri suportive tratament simptomatic profilaxia (la persoane cu risc)
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Tratamentul etiologic
Sensibili la peniciline (CMI <0,1 g/ml) Penicilina G iv 2-3mil UI la 4 ore x 7-10 zile – electie Ampicilina i.v.1-2 g la 6 ore/ Ampicilina-sulbactam Amoxicilina p.o. 1g la 8 ore – la cei tratati ambulator
NB! minimum 3-4 zile de afebrilitate
Intermediari (CMI >0,1 g/ml dar <1 g/ml) ~ 20% Penicilina G doze mari 24 mil UI/zi sau Ceftriaxona 2 g/zi Cefotaxim 2 g la 8 ore
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Tratamentul etiologic
Rezistenţi la peniciline (CMI >2 g/ml) ~ 15% NU -LACTAMI !!! Rezistenta frecvent si la macrolide, biseptol Fluorquinolone – Levofloxacina 500 mg/zi Imipenem-cilostatin 0.5-1 g la 6h iv Meropenem 0.5-1 g la 8h iv
Plurirezistenti Vancomicina rifampicina
Alergici la peniciline Vancomicina 1 g la 12 ore piv Clindamicina 600 mg la 6-8 ore Macrolide
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Tratamentul etiologic
Durata tratamentului antibiotic – variabila de la 5-7 zile la 10-14 zile
Maximum inca 5 zile de la obtinerea afebrilitatii
La pacientii spitalizati – initial terapie parenterala, ulterior terapie orala
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Tratamentul suportiv şi simptomatic
Oxigen Hidratare corecta Antipiretice Analgetice
Tratamentul patogenic• hTA:
– lichide iv– dopamina– corticoizi iv
Profilaxia
• Vaccin anti pneumococic cu 23 de antigene
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RX PULMONARE
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Pneumonie axilara LSD
Pneumonie axilara LSD in rezolutie
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Pneumonie LM in rezolutie
Pneumonie apicala LID
Pneumonie bazala LID
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Pneumonie lingulara
Pneumonie LIS
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Complicatii
Pn. Stg. abcedată
Faza de rezoluţie
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Abces pulmonar
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Pneumonie pseudotumorala
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Infarct pulmonar
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