15. pulmonary consolidation syndromes
TRANSCRIPT
-
7/25/2019 15. Pulmonary Consolidation Syndromes
1/141
PULMONARY CONSOLIDATIONPULMONARY CONSOLIDATION
SYNDROMESSYNDROMES
-
7/25/2019 15. Pulmonary Consolidation Syndromes
2/141
PULMONARY CONSOLIDATION SYNDROMESPULMONARY CONSOLIDATION SYNDROMESClassificationClassification
Not retractileNot retractile1.1.Well delimitatedWell delimitated
PNEUMONIASPNEUMONIAS
PULMONARY INFARCTIONPULMONARY INFARCTION
2.2.Not well delimitatedNot well delimitated lunglung cancer
OrOr
InflamatoryInflamatory / Not/ Not inflamatoryinflamatory
RetractileRetractile
-
7/25/2019 15. Pulmonary Consolidation Syndromes
3/141
I.I.
PULMONARY CONSOLIDATIONPULMONARY CONSOLIDATION
SYNDROMESYNDROME
CAUSED BY INFLAMMATORY PROCESSCAUSED BY INFLAMMATORY PROCESS
PNEUMONIASPNEUMONIAS
BRONCHOPNEUMONIASBRONCHOPNEUMONIAS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
4/141
PNEUMONIAS:PNEUMONIAS:
--bacterialbacterial
--viralviral
--with atypical microorganismswith atypical microorganisms
CLASSIFICATION:
-
7/25/2019 15. Pulmonary Consolidation Syndromes
5/141
BACTERIAL PNEUMONIASBACTERIAL PNEUMONIAS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
6/141
PHYSICAL SIGNS IN PULMONARYPHYSICAL SIGNS IN PULMONARY
CONSOLIDATIONCONSOLIDATION
Increased tactileIncreased tactile fremitusfremitus
DulnessDulness to percussionto percussion
egophonyegophony and whisperedand whispered pectoriloquypectoriloquyBronchial breath soundsBronchial breath sounds
RalesRales or cracklesor crackles
/absent intensity of breath sounds/absent intensity of breath sounds
-
7/25/2019 15. Pulmonary Consolidation Syndromes
7/141
Bacterial PneumoniasBacterial PneumoniasThe most common etiologies :The most common etiologies :
Pn. with S.pneumoniae (pneumococcus)(Lobar Pn.)=typical lobar pneumonia
& The most common pneumoniaPn. with Staphylococcus
Pn. withStreptococcus
Pn. with Klebsiela(Friendlander bacillus)
Pn. with Haemophilus influenzae
-
7/25/2019 15. Pulmonary Consolidation Syndromes
8/141
TYPICAL LOBAR PNEUMONIATYPICAL LOBAR PNEUMONIA
-
7/25/2019 15. Pulmonary Consolidation Syndromes
9/141
TYPICAL LOBAR PNEUMONIATYPICAL LOBAR PNEUMONIA
Etiology: Streptococcus pneumoniae
= G+ diplo coccus
Involves 1 segment / pulmonary lobe
Evolution in 3 stages1.Onset2.Evolution
3.Resolution
-
7/25/2019 15. Pulmonary Consolidation Syndromes
10/141
ONSET-1
CHILLSCHILLS suddensuddenSingle rigorSingle rigor
Duration 15Duration 15 30 minutes30 minutes
followed by
high FEVERFEVER390
400
, constantpyrexia
-
7/25/2019 15. Pulmonary Consolidation Syndromes
11/141
ONSET-2
Chest aching/Chest aching/pleuriticpleuritic painpain
1. Severe
2. Sharp/knifelike
3.Aggravated by each breath/by coughing/by coughing4. The patient is immobilized on the sick side
5. Localization: submammary area/basalbasal
6.6. Results from inflamed parietal pleuraResults from inflamed parietal pleura((e.g.: diaphragmatic pl.e.g.: diaphragmatic pl. shoulder painshoulder painchildrenchildren abdominal pain)abdominal pain)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
12/141
ONSETONSET--33
COUGH irritativeirritative,, hollow coughhollow cough, at first, at first
11 3 day3 day
-- Productive ofProductive of
pinkish or adherentpinkish or adherent rusty sputumrusty sputum
containing fibrin and red cellscontaining fibrin and red cells
-
7/25/2019 15. Pulmonary Consolidation Syndromes
13/141
ONSET-4
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
Warm teguments (febrile)Warm teguments (febrile)Severe state of healthSevere state of health
Redness of faceRedness of face
herpesherpes labialislabialis((whole face)whole face)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
14/141
ONSET-5
RESPIRATORY SYSTEM EXAMINATIONINSPECTION - superficial respiration ( caused by chest( caused by chest
aching/aching/pleuriticpleuritic pain)pain)
-- polypneapolypnea
PALPATION normally transmitted tactilenormally transmitted tactile fremitusfremitus
PERCUSSION:: discreet dullnessdiscreet dullness
AUSCULTATION ::
Initially:Initially: tonality and intensity oftonality and intensity of breathbreathsounds = bronchial breath soundssounds = bronchial breath sounds
timber changes = hardening of breath soundstimber changes = hardening of breath sounds
== fremitusfremitus, breath and voice sounds are transmitted as if, breath and voice sounds are transmitted as if
they came directly from the larynx and tracheathey came directly from the larynx and trachea
-
7/25/2019 15. Pulmonary Consolidation Syndromes
15/141
EVOLUTION
After 24After 24 48 hours48 hours
Duration 7Duration 7 10 days10 days
Clinical presentation ofClinical presentation of consolidation syndromeconsolidation syndromeSustainedSustainedFeverFever
Dyspnea withDyspnea with inspiratoryinspiratorypolypneapolypnea
CyanosisCyanosisSustainedSustained pleuriticpleuriticpainpain ofof intensityintensity
CoughingCoughing withwith rusty sputumrusty sputum yellowishyellowish (afterwards)(afterwards)
Redness of face (plethora of the cheek of affected side))
JaundiceJaundice (( hemolysishemolysis, impaired liver function), impaired liver function)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
16/141
EVOLUTION
THORAX EXAMINATION
Inspection : chest expansion
restricted motion of the affectedhemithorax
Palpation : tactile fremitus
Percussion : Dullness
Auscultation : bronchial breath sounds
surrounded by fine crepitant rales, instead of
vesicular breath sounds
(initially, fine crepitant rales dominate, being replaced
by tubular or bronchial breath sounds)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
17/141
Resolution
Less well defined dullnessLess well defined dullness
/ tubular breath sounds disappear/ tubular breath sounds disappear
CrepitantCrepitant ralesrales reappearreappear
= other characters= other characters
coarse, unequal, mucouscoarse, unequal, mucous
-
7/25/2019 15. Pulmonary Consolidation Syndromes
18/141
Recovery inRecovery incrisiscrisis
= sudden= sudden
Before AB /Before AB / pt. diedpt. diedin crisisin crisis
The patient state of health is aggravated suddenlyThe patient state of health is aggravated suddenly
Rapid temperature rise at 40Rapid temperature rise at 4000
deliriumdelirium
Abundant sweatingAbundant sweating FeFeverver normalnormal
Normal pulseNormal pulse
-
7/25/2019 15. Pulmonary Consolidation Syndromes
19/141
RecoveryRecoveryinin lisislisis
Without particular clinical signsWithout particular clinical signs
Apparent state of health is improvingApparent state of health is improvingBody temperature begins to fallBody temperature begins to fall
Cough diminishes, then disappearsCough diminishes, then disappears
-
7/25/2019 15. Pulmonary Consolidation Syndromes
20/141
LABORATORY FINDINGSLABORATORY FINDINGS
INFLAMATIONINFLAMATION:: leukocytosisleukocytosis withwith
neutrophilsneutrophils,, VSH,VSH, fibrinogen,fibrinogen, CRPCRP
BIOCHIMIEBIOCHIMIE:: indirectindirect bilbil.,.,
creatininecreatinine,, urea (urea (oliguriaoliguria))
SPUTUM:SPUTUM:
--Bacteriological examination: Grams method, culture=pneumococci
-Cellularity: red cells, alveolar cells, leucocytes
-
7/25/2019 15. Pulmonary Consolidation Syndromes
21/141
CONFIRMATIONCONFIRMATIONXX--ray of the chestray of the chest
= triangular density= triangular density1.1. The base towards the pleuraThe base towards the pleura
2.2. The tip towards theThe tip towards the hilhil3.3. SubcostalSubcostal intensity, homogenousintensity, homogenous
4.4. May occupy an entireMay occupy an entire segment / lobesegment / lobe
-
7/25/2019 15. Pulmonary Consolidation Syndromes
22/141
Strep. pneumoniaeStrep. pneumoniae
pneumonia.pneumonia.
Right upperRight upper--lobelobeconsolidationconsolidation
demonstrating ademonstrating a
pronounced airpronounced air
bronchogram and absencebronchogram and absenceofof
volume change.volume change.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
23/141
Bacterial pneumonia. Pneumococci on sputum Gram stain.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
24/141
Bacterial pneumonia.
A posteroanterior chest radiograph shows left lower pneumonia.
Sputum Gram stain showed gram-positive diplococci.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
25/141
PARTICULAR FORMSPARTICULAR FORMSABORTIVE FORMSABORTIVE FORMS
spontaneous healing without ABspontaneous healing without AB
THE ELDER PNEMUMONIATHE ELDER PNEMUMONIA
discreet presentation, severe evolutiondiscreet presentation, severe evolution
CHILD PNEUMONIACHILD PNEUMONIA
abdominal pain, vomiting,abdominal pain, vomiting, meningealmeningeal signssigns
ALCHOOLICSALCHOOLICS mental disorders, psychomotor agitationmental disorders, psychomotor agitation
-
7/25/2019 15. Pulmonary Consolidation Syndromes
26/141
EVOLUTION
NATURAL
-Death in crisis
-Complication
UNDER TREATMENT
-ImmunocompetentYoungers
= healing in 5-6 days-Complications at
elders,
immunosuppressed
COMPLICATIONS
Sepsis bacteriemia:
pericarditis, endocarditis,meningitis, brain abscess,
parotitis, nephritis,
Circulatory collapse
Abscess
Pleural effusion
- Early -parapneumonic
= sterile serocitrine effusion
-Late: metapneumonic
=usually, purulent fluid
-
7/25/2019 15. Pulmonary Consolidation Syndromes
27/141
STAPHYLOCOCCAL PNEUMONIASTAPHYLOCOCCAL PNEUMONIA
May begin insidiouslyMay begin insidiously
Grave state of healthGrave state of health
Clinical =Clinical = dyspneadyspnea and cyanosis are the chiefand cyanosis are the chiefsymptomssymptoms
RemitentRemitent feverfever
Sputum may be bloody or frankly purulentSputum may be bloody or frankly purulent
Physical signs:Physical signs: consolidated foci, dull areas,consolidated foci, dull areas,bronchial respiration, fine crackles and coarsebronchial respiration, fine crackles and coarsecracklescrackles
XX--rayray = Multiple foci of patchy consolidation= Multiple foci of patchy consolidationpneumatocelespneumatoceles pneumotoraxpneumotorax
= in fact, bronchopneumonia= in fact, bronchopneumonia
-
7/25/2019 15. Pulmonary Consolidation Syndromes
28/141
PNEUMONIA WITH KLEBSIELLA PNEUMONIAEPNEUMONIA WITH KLEBSIELLA PNEUMONIAE(Friedlander(Friedlander))
Most frequently found in pts. with increasedMost frequently found in pts. with increasedsusceptibility (chronic diseases, underfed persons)susceptibility (chronic diseases, underfed persons)
Characteristic = severe state of health withCharacteristic = severe state of health withprostration, often with collapse septicprostration, often with collapse septicpatientspatients
Intense cyanosis andIntense cyanosis and dyspneadyspnea
Sputum is thick, gelatinous, brick red, andSputum is thick, gelatinous, brick red, andlaced with puslaced with pus
Consolidation syndrome is not often presentConsolidation syndrome is not often present
XX--ray: densities that occupy more than one lobe,ray: densities that occupy more than one lobe,often, an entire lungoften, an entire lung
Tendency to form abscess and to be a chronic formTendency to form abscess and to be a chronic form
-
7/25/2019 15. Pulmonary Consolidation Syndromes
29/141
TREATMENTTREATMENT--GENERAL PRINCIPLESGENERAL PRINCIPLES
OxygenOxygen
HydrationHydrationSymptomatic (Symptomatic (antipyretics,anticoughing, drugs that fluidly sputum)
Complications treatmentComplications treatment
ETIOLOGIC = ANTIBIOTICSETIOLOGIC = ANTIBIOTICS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
30/141
ETIOLOGICAL SPECIFIC treatmentETIOLOGICAL SPECIFIC treatmentif the etiological agent is identified +if the etiological agent is identified + antibiogramantibiogram
Strep.pneumoniaeStrep.pneumoniae
Penicillin sensitive =Penicillin sensitive =AMP iv,AMP iv, amoxamox popo, M, pen G iv,, M, pen G iv, doxidoxi, O, O CephCeph
P resistant :P resistant : FQ (FQ (moximoxi) / P) / P cephceph 33
HH influenzaeinfluenzae
--lactamaselactamase + :+ :AM/CL, OAM/CL, O CephCeph 2/3, P2/3, P CephCeph 33
--LactamaseLactamase ::AMP iv,AMP iv, amoxamox popo, TMP/SMX, M, TMP/SMX, M
Amp- ampicilineAM/CL- augmentin
P Ceph 3- 3rd generation cephalosporin
FQ- fluoroquinolone ( Moxi- moxifloxacine)Tmp/smx- trimetoprim/sulfametoxaxol
-
7/25/2019 15. Pulmonary Consolidation Syndromes
31/141
ATYPICAL INTERSTITIALATYPICAL INTERSTITIAL
PNEUMONIASPNEUMONIAS
((NON BACTERIALNON BACTERIAL))
-
7/25/2019 15. Pulmonary Consolidation Syndromes
32/141
ETIOLOGIESETIOLOGIES commonly,commonly, viral,,
Also with:Also with: chlamydiachlamydia,, mycoplasmaemycoplasmae
CLINICAL MANIFESTIONS:CLINICAL MANIFESTIONS:
FeverFeverCough with mucous expectoration orCough with mucous expectoration or
mucopurulentmucopurulent
Bronchitis syndromeBronchitis syndromeAsthenia, nocturne diaphoresisAsthenia, nocturne diaphoresis
-
7/25/2019 15. Pulmonary Consolidation Syndromes
33/141
The pulmonary infiltrative processesThe pulmonary infiltrative processes
dondont realizet realize
parenchymatousparenchymatous consolidationconsolidation
syndromesyndrome
-
7/25/2019 15. Pulmonary Consolidation Syndromes
34/141
CLINICAL DIAGNOSTICCLINICAL DIAGNOSTIC
Significantepidemiologicalelement
Suggested by the association of:Rinitis
Erythematous angina
Bronchitis
There is a poor correlation betweenclinical signs and X-ray chest
-
7/25/2019 15. Pulmonary Consolidation Syndromes
35/141
XX--ray chestray chest
Accentuated patternAccentuated pattern
Linear and reticular densitiesLinear and reticular densities
HilarHilar--basal,basal,
uniuni or bilateralor bilateral
Sometimes, the densities are microSometimes, the densities are micro-- oror
macronodularmacronodular with transitory characterwith transitory character
-
7/25/2019 15. Pulmonary Consolidation Syndromes
36/141
A 38-year-old patient with Mycoplasma pneumonia.Chest radiograph shows a vague, ill-defined opacity
-
7/25/2019 15. Pulmonary Consolidation Syndromes
37/141
Measles pneumonia.Measles pneumonia.An example of a widespread primary viralAn example of a widespread primary viralpneumonia with extensive bilateral confluent consolidation.pneumonia with extensive bilateral confluent consolidation.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
38/141
BRONCHOPNEUMONIABRONCHOPNEUMONIA
-
7/25/2019 15. Pulmonary Consolidation Syndromes
39/141
Anatomic and clinical syndrome caused by various diseases,Anatomic and clinical syndrome caused by various diseases,
with unpredictable evolution, reserved prognosiswith unpredictable evolution, reserved prognosis
Affect extreme ages orAffect extreme ages or immunodepressedimmunodepressed personspersons
May be: primary / secondaryMay be: primary / secondary
PRIMARY:PRIMARY:
Children, elders,Children, elders, immunodepressedimmunodepressed ((microbial associationsmicrobial associations))
SecondarySecondary
--more commonlymore commonly
--predisposing causes:predisposing causes:
various pulmonary infections (microbial, viral)various pulmonary infections (microbial, viral)
AspirationAspiration
Toxic substances inhalationToxic substances inhalation
BRONCHOPNEUMONIASBRONCHOPNEUMONIAS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
40/141
BRONCHOPNEUMONIASBRONCHOPNEUMONIAS
SYMPTOMSSYMPTOMS discreet/ absentdiscreet/ absent
with severe state of healthwith severe state of health
Untypical, insidiousUntypical, insidious ONSETONSET
Grave, severeGrave, severe STATE OF HEALTHSTATE OF HEALTH
CHILLS,CHILLS,pleuriticpleuriticpainpain may missmay miss
Gradually increase ofGradually increase ofFEVERFEVER, it is, it is
irregular, it increases each time a new, it increases each time a newfocus reappears, decreases at the end offocus reappears, decreases at the end ofthe diseasethe disease
-
7/25/2019 15. Pulmonary Consolidation Syndromes
41/141
COUGHCOUGH withwith mucopurulentmucopurulent sputum withsputum withhemorrhagichemorrhagic striaestriae
Intense centralIntense central CYANOSISCYANOSIS (lips and(lips and
extremities)extremities)DYSPNEADYSPNEA
withwith
Severe POLYPNEASevere POLYPNEA (> 35respirations/min)(> 35respirations/min)
== on the first plane +on the first plane + suprasternalsuprasternal andandintercostalintercostal retraction and grunting (newborn)retraction and grunting (newborn)
// or permanentor permanent dyspneadyspnea withwith
exacerbationsexacerbations
-
7/25/2019 15. Pulmonary Consolidation Syndromes
42/141
BRONCHOPNEUMONIAS
PHYSICAL SIGNS
There is no correlation
between the gravity of
general signs+dyspnea
and physical signs
Varying with time and
location, changing the
characters from day to
day, sometimes in hours
Fluctuating
They vary with thedegree of process
extension
-
7/25/2019 15. Pulmonary Consolidation Syndromes
43/141
PERCUSSIONPERCUSSION
Only in confluentOnly in confluent bronchopneumoniasbronchopneumonias,,
there arethere are dulldull areas that mimic lobarareas that mimic lobarpneumoniapneumonia
Usually, foci are localized in inferiorUsually, foci are localized in inferior
lobes (exceptions: scarlet rash, barkinglobes (exceptions: scarlet rash, barking
cough)cough)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
44/141
AUSCULTATIONAUSCULTATION ::Bronchial breath soundsBronchial breath sounds
= the expression of bronchitis= the expression of bronchitis
-- Crackles surrounding the territory ofCrackles surrounding the territory of
lobular focuslobular focus
Fine and CoarseFine and Coarse CRACKLESCRACKLES
-
7/25/2019 15. Pulmonary Consolidation Syndromes
45/141
ConclusionConclusion
Disparate zones of congestionDisparate zones of congestion
Bronchial vesicular soundsBronchial vesicular sounds,,
Fine bubblingFine bubbling ralesrales, coarse, coarse
crepitantscrepitants,,
andand dull areasdull areas
-
7/25/2019 15. Pulmonary Consolidation Syndromes
46/141
BRONCHOPNEUMONIASBRONCHOPNEUMONIAS
Chest XChest X--rayray
There is no correlation between clinicalThere is no correlation between clinical
presentation andpresentation and XrayXrayXrayXray chest: multiple patchy opacities,chest: multiple patchy opacities,
with irregular outlines and less wellwith irregular outlines and less well
limitedlimited
Sometimes, there are opacities moreSometimes, there are opacities more
densedense
-
7/25/2019 15. Pulmonary Consolidation Syndromes
47/141
BRONCHOPNEUMONIASBRONCHOPNEUMONIAS
COMPLICATIONS
EARLY ONSET : LOCAL / GENERALEARLY ONSET : LOCAL / GENERAL
LATE ONSET :LATE ONSET : bronchiectasisbronchiectasisE.g.:E.g.:
Septic shock with tachycardia, hypotension,Septic shock with tachycardia, hypotension,
collapse, renal failurecollapse, renal failure, heart failure Hypoxemia withHypoxemia with hypercapniahypercapnia
Children: acuteChildren: acute corcor pulmonalepulmonale
Prognosis was severe before antibiotics use improvedwith etiological and complications treatment (supportive)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
48/141
INFLAMATIONINFLAMATION:: leukocytosisleukocytosis withwith
polymorphonuclearspolymorphonuclears,, VSH,VSH, fibrinogen,fibrinogen, CRPCRP
BIOCHIMIEBIOCHIMIE:: indirectindirect bilbil.,., creatininecreatinine,, urea (urea (oliguriaoliguria))
SPUTUM:SPUTUM:--Bacteriological examination: Gram method, culture
=pneumococ
-Celullarity: red cells, alveolar cells, leukocytes
-
7/25/2019 15. Pulmonary Consolidation Syndromes
49/141
Consolidation syndrome caused byConsolidation syndrome caused byalveolar airalveolar air
replacement with bloodreplacement with blood
Sudden occlusion of a part of pulmonary arterial treeSudden occlusion of a part of pulmonary arterial tree
Predisposing factors (diseases that favor thrombosisPredisposing factors (diseases that favor thrombosis
deep venous thrombosis)deep venous thrombosis)
PULMONARY INFARCTIONPULMONARY INFARCTION
Classification CSClassification CS
Not retractileNot retractileWell delimitatedWell delimitated
Not well delimitatedNot well delimitated
RetractileRetractile
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
50/141
CLINICALCLINICAL
CHEST PAINCHEST PAIN
PleuriticPleuritic chest pain aggravated by cough/respirationchest pain aggravated by cough/respirationLateralLateral decubitusdecubitus on the healthy side)on the healthy side)
DYSPNEADYSPNEA
ANXIETYANXIETY
HEMOPTOSYSHEMOPTOSYS after a few hours of chest painafter a few hours of chest pain
onset /onset /Or dry cough with pleural characterOr dry cough with pleural character
PULMONARY INFARCTIONPULMONARY INFARCTION
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
51/141
ConjunctivalConjunctivaljaundicejaundice
Lips cyanosisLips cyanosis
TachycardiaTachycardia
FeverFever
Sometimes, right heart failure signsSometimes, right heart failure signs
PULMONARY INFARCTIONPULMONARY INFARCTION
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
52/141
SMALLSMALLINFARCTINFARCT
Sub dullnessSub dullness
tactiletactile fremitusfremitus
Coarse respirationCoarse respiration
Pleural rubPleural rub
PULMONARY INFARCTIONPULMONARY INFARCTION
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
53/141
LARGELARGEINFARCTINFARCT
Sub dullnessSub dullness
tactiletactile fremitusfremitus
Tubular breath soundsTubular breath sounds
RalesRales, fine, fine crepitantscrepitantsPleural rubPleural rub
Pleural effusion syndromePleural effusion syndrome
PULMONARY INFARCTIONPULMONARY INFARCTION
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
54/141
DIAGNOSTICDIAGNOSTIC
The clinical manifestations of underlyingThe clinical manifestations of underlyingdiseasedisease
X ray chestX ray chest
Triangular density with the base towardsTriangular density with the base towards
the pleurathe pleura dilated pulmonary arterydilated pulmonary artery
PULMONARY INFARCTIONPULMONARY INFARCTION
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
55/141
TREATMENTTREATMENT
Of underlying diseaseOf underlying diseaseANTICOAGULANTANTICOAGULANT
HEPARINS (UFH, LMWH)HEPARINS (UFH, LMWH)
ORAL ANTICOAGULANTSORAL ANTICOAGULANTS
PULMONARY INFARCTIONPULMONARY INFARCTION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
56/141
II.II.PULMONARYPULMONARY
CONSOLIDATIONS CAUSED BYCONSOLIDATIONS CAUSED BYTUMORAL PROCESSESTUMORAL PROCESSES
ClassificationClassificationNot retractileNot retractile
Well delimitatedWell delimitatedNot well delimitatedNot well delimitated
RetractileRetractile
-
7/25/2019 15. Pulmonary Consolidation Syndromes
57/141
BRONCHOPULMONAR NEOPLASMBRONCHOPULMONAR NEOPLASM
Association of syndromesAssociation of syndromes
Retractile consolidation syndrome / nonRetractile consolidation syndrome / nonretractileretractile
Pleural effusion syndromePleural effusion syndrome
MediastinalMediastinal pulmonary syndromepulmonary syndromeCavity syndromeCavity syndrome
-
7/25/2019 15. Pulmonary Consolidation Syndromes
58/141
According to localizationAccording to localization neoneo. are. are::Hilar
Peripheral noduleLobar
Segmental
Consolidation pulmonary syndrome = RareConsolidation pulmonary syndrome = Rare
-
7/25/2019 15. Pulmonary Consolidation Syndromes
59/141
CHIEF COMPLAINTSCHIEF COMPLAINTS
COUGHCOUGH
Irritation of X nerveIrritation of X nerve
PAINPAIN
Appears tardilyAppears tardily
permanent, not related to the respirationpermanent, not related to the respirationHEMOPTISYSHEMOPTISYS
currant jellycurrant jellyaspectaspect
DYSPNEADYSPNEA If there is an involvement of principal bronchiaIf there is an involvement of principal bronchia
Physical signsPhysical signs
-
7/25/2019 15. Pulmonary Consolidation Syndromes
60/141
Physical signsPhysical signs
LOCALIZED BRONCHIC OBSTRUCTION SYNDROMELOCALIZED BRONCHIC OBSTRUCTION SYNDROME
PARTIAL OBSTRUCTIONPARTIAL OBSTRUCTION
Localized wheezingLocalized wheezing
LocalLocal hyperresonancehyperresonance
Sibilants + localized bronchial breath soundsSibilants + localized bronchial breath sounds
tactiletactile fremitusfremitus,, vesicular breath soundsvesicular breath sounds localizedlocalized
TOTAL OBSTRUCTIONTOTAL OBSTRUCTION
==AtelectasisAtelectasis Dullness or flatness, withoutDullness or flatness, without fremitusfremitus, absent breath sounds, absent breath sounds
COMPLICATION OF THE OBSTRUCTIONCOMPLICATION OF THE OBSTRUCTION
Repeated pneumonias in the same placeRepeated pneumonias in the same place
AbscessesAbscesses
O OSDR CAUSED BY LOCAL INVASION
-
7/25/2019 15. Pulmonary Consolidation Syndromes
61/141
SDR. CAUSED BY LOCAL INVASIONSDR. CAUSED BY LOCAL INVASIONTHE INVASION OF MEDIASTINUMTHE INVASION OF MEDIASTINUM RecurentRecurentN.N. = vocal cords palsy, hoarseness= vocal cords palsy, hoarseness
PhrenicPhrenic= diaphragm palsy, pain irradiated to neck= diaphragm palsy, pain irradiated to neck
EsophagusEsophagus= deglutition disorders= deglutition disorders X nerveX nerve = Dyspnea, constipation= Dyspnea, constipation
CervicalCervical sympaticsympatic= Claude= Claude--BernardBernard-- HornerHorner sdrsdr..
TracheaTrachea== stridorstridor,, dyspneadyspnea
Superior cave veinSuperior cave vein= turgescent jugulars, pelerine= turgescent jugulars, pelerineedemaedema
PleuraPleura= pleural effusion syndrome= pleural effusion syndrome
PericardiumPericardium= pericardial effusion/= pericardial effusion/ tamponadetamponade
MyocardiumMyocardium = arrhythmias= arrhythmias Towards the superior thoracic outlet =Towards the superior thoracic outlet = sdr.Pancoastsdr.Pancoast
( the 1( the 1stst--22ndnd ribrib lysislysis))
S G S OSIGNS FROM
-
7/25/2019 15. Pulmonary Consolidation Syndromes
62/141
SIGNS FROMSIGNS FROM
LYMPHATIC SPREADLYMPHATIC SPREAD
Ganglions:Ganglions:
hilarhilar,,
mediastinalmediastinal,,
supraclavicularsupraclavicularCarcinomatousCarcinomatous lymphangitislymphangitis
((dyspneadyspnea, Respiratory failure, Respiratory failure))
HEMATOGENOUS SPREADHEMATOGENOUS SPREADliver, brain, SR, boneliver, brain, SR, bone
SYSTEMIC SYNDROMESSYSTEMIC SYNDROMES
-
7/25/2019 15. Pulmonary Consolidation Syndromes
63/141
weightweight
FeverFever
EndrocrineEndrocrine syndromessyndromes
NeurologicNeurologic paraneoplasticparaneoplastic syndromes= peripheral neuropathysyndromes= peripheral neuropathy
MyasthenicMyasthenic EatonEaton--Lambert syndrome,Lambert syndrome, polymyositispolymyositis
Rheumatic syndromesRheumatic syndromes
Pierre MariePierre Marie hypertrophichypertrophic osteoarthropathyosteoarthropathy
DermatologicalDermatological syndrsyndr.:.: dermatomyositisdermatomyositis,, achantosisachantosis nigricansnigricans
Migratory venousMigratory venous thromboplebitisthromboplebitis ((TrouseauTrouseau))
NonbacterialNonbacterial thromboticthrombotic ((maranticmarantic)) endocarditisendocarditis
HematologicHematologic manifestations: anemia, thrombocytopenia,manifestations: anemia, thrombocytopenia,disseminated intravascular coagulationdisseminated intravascular coagulation
MembranousMembranous glomerulopathyglomerulopathy
DIAGNOSTICDIAGNOSTIC
-
7/25/2019 15. Pulmonary Consolidation Syndromes
64/141
DIAGNOSTICDIAGNOSTIC
Clinical suspicionClinical suspicion confirmedconfirmed Rx, CT,Rx, CT,
bronchoscopybronchoscopy (( sputum),sputum), mediastinoscopymediastinoscopy
TREATMENTTREATMENT
ChemotherapyChemotherapy
SurgerySurgery
Radiotherapy preRadiotherapy pre--surgery / palliativesurgery / palliative
-
7/25/2019 15. Pulmonary Consolidation Syndromes
65/141
RETRACTILE PULMONARYRETRACTILE PULMONARYCONSOLIDATIONSCONSOLIDATIONS
ATELECTASISATELECTASIS
ClassificationClassificationNot retractileNot retractile
Well delimitatedWell delimitated
Not well delimitatedNot well delimitatedRetractileRetractile
PULMONARY ATELECTASISPULMONARY ATELECTASIS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
66/141
Alveolar airAlveolar air resorptionresorption due to mechanicaldue to mechanical
causes (commonly bronchial obstruction)causes (commonly bronchial obstruction)
Consolidation syndrome with the tractionConsolidation syndrome with the traction
of surrounding tissues/organs towards theof surrounding tissues/organs towards the
involved sideinvolved side
Most symptoms are related to onsetMost symptoms are related to onset
rapidityrapidity
PULMONARY ATELECTASISPULMONARY ATELECTASIS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
67/141
Lobar, segmental ATELECTASISLobar, segmental ATELECTASIS
PainPain
Dry coughDry cough
CyanosisCyanosis
Small ATELECTASISSmall ATELECTASIS
=asymptomatic, occasional=asymptomatic, occasional
finding on Xfinding on X--rayray
PULMONARY ATELECTASISPULMONARY ATELECTASIS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
68/141
AffectedAffected hemithoraxhemithorax smaller in volumesmaller in volume
SupraclavicularSupraclavicular area depression on the involved sidearea depression on the involved side
Retraction ofRetraction of intercostalintercostal spacesspaces
thorax expansionthorax expansion
Palpation:Palpation: tactiletactile fremitusfremitus/ absent/ absent
Percussion : dullnessPercussion : dullnessAscultationAscultation:: / absent breath sounds/ absent breath sounds
PULMONARY ATELECTASISPULMONARY ATELECTASIS
-
7/25/2019 15. Pulmonary Consolidation Syndromes
69/141
XX--RAYRAY
Homogenous density with concavity towards theHomogenous density with concavity towards the
exteriorexterior involves 1 segment, / one lobe,/ the entire lunginvolves 1 segment, / one lobe,/ the entire lung
With a smaller extension than the respective regionWith a smaller extension than the respective region(in normal conditions)(in normal conditions)
Narrow and obliqueNarrow and oblique intercostalintercostal spacesspaces
MediastinMediastin shifted toward involved sideshifted toward involved side
Ascended diaphragmAscended diaphragm
InspiratoryInspiratory movement ofmovement of mediastinmediastin toward thetoward theinvolved sideinvolved side
-
7/25/2019 15. Pulmonary Consolidation Syndromes
70/141
Atelectasis. Left lower lobe collapse.
The opacity is in the posterior inferior location.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
71/141
Atelectasis. Loss of volume on the left side; an elevated and silhouetted left
diaphragm; and an opacity behind the heart, called a sail sign,
are present.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
72/141
Atelectasis. Left upper lobe collapse showing opacity contiguous
to the aortic knob, a smaller left hemithorax, and a mediastinal shift.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
73/141
Complete atelectasis of the left lung. Mediastinal displacement,
opacification, and loss of volume are present in the left hemithorax.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
74/141
Complete right lung atelectasis.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
75/141
Atelectasis. Right upper lobe collapse.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
76/141
DISORDERS OF THE PLEURADISORDERS OF THE PLEURADISORDERS OF THE PLEURA
-
7/25/2019 15. Pulmonary Consolidation Syndromes
77/141
CLASSIFICATIONCLASSIFICATION
1.Pleuritic syndrome (dry)
2.Pleural effusion
3.Pleural fibrosis4.Pneumothorax
AnatomyAnatomy
-
7/25/2019 15. Pulmonary Consolidation Syndromes
78/141
1.Parietal pleura
2.Visceral pleura
Both parietal and visceral membranes are smooth, glistening, and
semitransparent. Despite these similarities, the two membranes have
unique differences in anatomic architecture, innervation, pain fibers, blood
supply, lymphatic drainage, and function. For example, the visceral pleurae
contain no pain fibers and have a dual blood supply (bronchial and
pulmonary).
Parietal pleurae cover the inner surface of the thoracic cavity, including the
mediastinum, diaphragm, and ribs.
Visceral pleurae envelop all surfaces of the lungs, including the interlobar
fissures.
This lining is absent at the hilus, where pulmonary vessels, bronchi, and
nerves enter the lung tissue.
The mediastinum completely separates the right and left pleural spaces.
- pleural space- pleural fluid: 5 -20 ml
FUNCTION OF PLEURAL FLUIDFUNCTION OF PLEURAL FLUID
-
7/25/2019 15. Pulmonary Consolidation Syndromes
79/141
is to provide a frictionless surface betweenthe two pleurae in response to changes in
lung volume with respiration.
Normally, pleural fluid:Normally, pleural fluid:
spreads thinly over visceral and parietal pleuraespreads thinly over visceral and parietal pleurae
enters the pleural space from systemicenters the pleural space from systemic
capillaries in the parietal pleuraecapillaries in the parietal pleurae exits via parietal pleural stomas andexits via parietal pleural stomas and lymphaticslymphatics
facilitate movement between the lung and chestfacilitate movement between the lung and chest
wallwall compositioncomposition plasma but lower in protein (< 1.5plasma but lower in protein (< 1.5 g/dLg/dL))
Characteristics ofCharacteristics of
-
7/25/2019 15. Pulmonary Consolidation Syndromes
80/141
clear ultrafiltrate of plasma
pH 7.60-7.64
protein content less than 2% (1-2 g/dL)
fewer than 1000 WBCs per cubic millimeter glucose content similar to that of plasma
LDH level less than 50% of plasma
Na, K, Ca concentration similar to interstitial fluid
Normal pleural fluidNormal pleural fluid
-
7/25/2019 15. Pulmonary Consolidation Syndromes
81/141
ymptoms
ymptoms
-- Pleuritic chest painPleuritic chest pain
-- Dry coughDry cough
-- DyspneaDyspnea
Signs:Signs:
-- Pleural friction rubPleural friction rub
-- Particular signsParticular signs -- Pleural effusionPleural effusion syndromesyndrome-- Pleural fibrosisPleural fibrosis syndromesyndrome
PLEURITIC CHEST PAINPLEURITIC CHEST PAIN
-
7/25/2019 15. Pulmonary Consolidation Syndromes
82/141
CharacterCharacter : a vague discomfort OR sharp pain
WorsensWorsens by deep inhalation, chest expansion
Location:Location: depending on affected pleura
indicates inflammation of the parietal pleura usually felt over the inflamed site E.g.
Diaphragmatic pleura shoulder
Central pleura radiates back, neck, shoulder
intra-abdominal referred from irritation of lower 6 ic nerves
Special situations:Special situations:
MissMiss in interlobar effusion
ContinuousContinuous, not influenced by respiration in: Pleural tumor
Empyema
Massive Pleural effusion
PLEURITIC CHEST PAINPLEURITIC CHEST PAIN
-
7/25/2019 15. Pulmonary Consolidation Syndromes
83/141
Differential diagnosisDifferential diagnosis
rib fracture = Fixed point location+ bone crepitation Costochondritis local inflammation
Herpes zoster = pain on nerves + vesicles
Tracheobronchitis - burning over trachea + sputum
Angor pectoris
Pericarditis
PLEURITIC COUGHPLEURITIC COUGH
-
7/25/2019 15. Pulmonary Consolidation Syndromes
84/141
dry, without sputum production
Irritative
Associated usually with pleuritic chest pain
DETERMINED by: Pleural irritation
DYSPNEA in pleural syndromesDYSPNEA in pleural syndromes
-
7/25/2019 15. Pulmonary Consolidation Syndromes
85/141
Progressive
Generated by pain
Associated tachypnea Associated with large effusion installed rapidly
It indicates a large effusion (usually not
-
7/25/2019 15. Pulmonary Consolidation Syndromes
86/141
Pleural friction rubPleural friction rub Corresponding to the pain location
Intensity maximum on posterior axillary line
Present throughout respiratory cycle Loudest at end inspiration and early expiration
Great variability
Seldom present
When present, best heard over the area of pleural
inflammation, over posterior inferior aspect
of thoracic cage, or over inferior lateral anterior
surface of thoracic cage Described as a rubbing or grating (eg, leather rubbing
on leather), harsh, dry, and scratchy sound that
disappears with breath holding
Pleural effusionsPleural effusions
-
7/25/2019 15. Pulmonary Consolidation Syndromes
87/141
Pleural effusion is defined as an abnormalPleural effusion is defined as an abnormal
accumulation of fluid in the pleural space.accumulation of fluid in the pleural space.
Excess fluid results from the disruption ofExcess fluid results from the disruption ofthe equilibrium that exists across pleuralthe equilibrium that exists across pleural
membranes.membranes.
DEFINITIONDEFINITION
F
-
7/25/2019 15. Pulmonary Consolidation Syndromes
88/141
Frequency annual incidence: 320 per 100,000 people
Mortality/Morbidity directly related to cause, stage of disease, andbiochemical findings in the pleural fluid.
Sex M = F (incidence equal between the sexes)
Exception: some causes with sex predilection
Age Pleural effusions usually occur in adults.
1 Altered permeabilit of the ple ral membranes
MECHANISMS OF PLEURAL EFFUSION:MECHANISMS OF PLEURAL EFFUSION:
-
7/25/2019 15. Pulmonary Consolidation Syndromes
89/141
1. Altered permeability of the pleural membranes2. Reduction in intravascular oncotic pressure
3. Increased capillary permeability or vascular disruption
4. Increased capillary hydrostatic pressure in the systemic
and/or pulmonary circulation5. Reduction of pressure in pleural space; lung unable to expand
6. Inability of the lung to expand (e.g., extensive atelectasis, mesothelioma)
7. Decreased lymphatic drainage or complete blockage, including thoracic
duct obstruction or rupture
8. Increased fluid in peritoneal cavity, with migration across the diaphragm
via the lymphatics
9. Movement of fluid from pulmonary edema across the visceral pleura
10.Persistent increase in pleural fluid oncotic pressure from an existing pleural
effusion, causing accumulation of further fluid
11.Iatrogenic causes
Pleural effusionsPleural effusions
-
7/25/2019 15. Pulmonary Consolidation Syndromes
90/141
CausesCauses multiple
Classification:Classification:
1.Transudates
2. Exudates
11 Manifestations related to the underlying disease processManifestations related to the underlying disease process
CLINICAL ASPECT -
CLINICAL ASPECTCLINICAL ASPECT --
Pleural effusionsPleural effusions
HistoryHistory
-
7/25/2019 15. Pulmonary Consolidation Syndromes
91/141
1.1. Manifestations related to the underlying disease processManifestations related to the underlying disease process
2.2. DyspneaDyspnea
Most common clinical symptom at presentation
Can be determined by other underlying lung disease3.3. Chest painChest pain
Intensity:Intensity: May be mild or severe
Character:Character: Typically sharp or stabbing LocalizedLocalizedto the chest wall or referred to the ipsilateral
shoulder or upper abdomen because of diaphragmatic involvement
ExacerbatedExacerbatedby deep inspiration DiminishesDiminishes in intensity as the effusion increases in size
Offers etiological clue:
transudates do not cause direct pleural irritation
CLINICAL ASPECT -
CLINICAL ASPECTCLINICAL ASPECT --
Pleural effusionsPleural effusions
Physical findingsPhysical findings
-
7/25/2019 15. Pulmonary Consolidation Syndromes
92/141
are variable
depend on the volume of the pleural effusion
undetectable for effusions smaller than 300 mL
EFFUSION LARGER THAN 300 MLEFFUSION LARGER THAN 300 ML
1. Dullness or decreased resonance to percussion
2. Diminished or inaudible breath sounds
3. Decreased tactile fremitus
4. Egophony
5. Pleural friction rub
6. Asymmetric expansion of thoracic cage,
with lagging expansion on the affected side (i.e., Hoover sign)
7. Mediastinum shift
Egophony
-
7/25/2019 15. Pulmonary Consolidation Syndromes
93/141
Egophony
("e" to "a" changes) at the most superior aspect of the pleural effusion
(This finding signifies atelectasis and consolidation caused by
compression of lung parenchyma with subsequent decrease in gascontent per unit volume.)
Pleural friction rub
Present throughout respiratory cycle Loudest at end inspiration and early expiration
Seldom present
Best heard over the area of pleural inflammation, over posterior inferior
aspect of thoracic cage, or over inferior lateral anterior surface ofthoracic cage
Physical findings
For small medium and large effusion
Physical findingsPhysical findings
For small medium and large effusionFor small medium and large effusion
Pleural effusionsPleural effusions
-
7/25/2019 15. Pulmonary Consolidation Syndromes
94/141
For small, medium and large effusionFor small, medium and large effusionFor small, medium and large effusion
Small pleural effusion (under 500 ml)Small pleural effusion (under 500 ml)
DULL AREADULL AREA Posterior only (usual)Posterior only (usual)
BasalBasal
33-- 4 cm high4 cm high dullness upper limit = Horizontal linedullness upper limit = Horizontal line
Not mobile with respirationNot mobile with respiration
DiferentialDiferential diagnosis with:diagnosis with: Ascended diaphragm ( performAscended diaphragm ( perform HirtzHirtz maneuver)maneuver)
AtelectasisAtelectasis (dullness with increased tactile(dullness with increased tactile fremitusfremitus))
-
7/25/2019 15. Pulmonary Consolidation Syndromes
95/141
Posteroanterior upright chest radiograph showsisolated left sided pleural effusion
and loss of left lateral costophrenic angle.
Small effusionSmall effusion
-
7/25/2019 15. Pulmonary Consolidation Syndromes
96/141
Small pleural effusionSmall pleural effusion
-
7/25/2019 15. Pulmonary Consolidation Syndromes
97/141
PseudotumorPseudotumor
Pseudotumors represent an accumulation of
fluid between interlobar fissures or fluid encapsulated
by adhesions.
Physical findings
For small, medium and large effusion
Physical findingsPhysical findings
For small, medium and large effusionFor small, medium and large effusion
Pleural effusionsPleural effusions
-
7/25/2019 15. Pulmonary Consolidation Syndromes
98/141
Medium pleural effusion (800Medium pleural effusion (800-- 1200 ml)1200 ml)DULL AREADULL AREA
PosteriorPosterior Upper limit :Upper limit :
the tip ofthe tip ofscapula,scapula, DamoiseauDamoiseau lineline = parabolic line of which the= parabolic line of which the
highest point is on the middlehighest point is on the middle axillaryaxillary lineline Anterior:Anterior:
Dullness up to the 5th ribDullness up to the 5th rib With every 500 ml accumulationWith every 500 ml accumulation dullnessdullness
increases with oneincreases with one intercostalintercostal spacespace When dullness is up to the 1st rib = 3000 ml fluidWhen dullness is up to the 1st rib = 3000 ml fluid
TraubeTraube area disappears when fluid reaches 800 mlarea disappears when fluid reaches 800 ml MediastinalMediastinal shift (usually >1000shift (usually >1000 mLmL))
Damoiseau-Ellis line
Also known as:
Damoiseaus curve
-
7/25/2019 15. Pulmonary Consolidation Syndromes
99/141
Ellis sign
Ellis-Damoiseau line
Ellis-Damoiseaus parabolic curve
Garlands curve
Associated persons:
Louis Hyacinthe Cleste Damoiseau
Calvin Ellis
George Minott Garland
Description:
The upper limit of the percutatory demonstrable upper limit of a
pleuritic exudate. A characteristic parabolic line of which the
highest point is in the middle axillary line.
Garlands curve is entered as Garlands triangle under George Minott Garland,
American internist, 1848-1926.
Bibliography:* L. H. C. Damoiseau:
Recherches cliniques sur plusieurs points du diagnostic
des panchements.
Extrait des Archives gnrales de mdecine, Paris, 1844.
Du diagnostic et du traitement de la plresie. Paris, 1845.
* C. Ellis:
The line of dulness in pleurite effusion.
Boston Medical and Surgical Journal, 1874, 90: 13-14.
The curved line of pleuritic effusion.
Boston Medical and Surgical Journal, 1876, 95: 689-697
-
7/25/2019 15. Pulmonary Consolidation Syndromes
100/141
PA chest radiography shows an opacity (E) in the lower left hemithorax
with obliteration of the left hemidiaphragm and curvilinear upper margin
consistent with effusion.
Note the extension of the fluid into the left major fissure (arrow)
and mediastinal shift to the right.
CLINICAL ASPECT - Physical findings
CLINICAL ASPECTCLINICAL ASPECT -- Physical findingsPhysical findings
Pleural effusionsPleural effusions
L l l ff i (2000 l)L l l ff i (2000 l)
-
7/25/2019 15. Pulmonary Consolidation Syndromes
101/141
Large pleural effusion (2000 ml)Large pleural effusion (2000 ml)
Dull area greater then previous
Infraclavicular tympanitic Subclavicular tympanitic
Mediastinal shift
Seen only with massive effusions (usually >1000 mL) Chest radiographies displacement of trachea and
mediastinum to the contralateral side of the pleural
effusion
(In contrast with complete atelectasis of the ipsilateral lung,when the trachea deviates toward the affected side and is
most commonly seen with complete obstruction of ipsilateral
mainstem bronchus caused by bronchogenic carcinoma.)
L l l ff iL l l ff i
-
7/25/2019 15. Pulmonary Consolidation Syndromes
102/141
Large pleural effusionLarge pleural effusion
Loculated collections
-
7/25/2019 15. Pulmonary Consolidation Syndromes
103/141
Parietal collection
Diminished respiratory movement
Diminished tactile fremitus
Interlobar collection
Suspended dullness in medium part of axilaWithout pain
Diaphragmatic collection
Pain by phrenic nerve irritation
-
7/25/2019 15. Pulmonary Consolidation Syndromes
104/141
Dry pleuritic syndrome
Pleuritic chest pain Cough not productive, irritative
Pleural friction rub
RX: + / - diminished diaphragmatic movement
DetectionDetection
Pleural effusionsPleural effusions
-
7/25/2019 15. Pulmonary Consolidation Syndromes
105/141
DetectionDetection
1.Physical examination2.Chest x-ray
3.Ultrasonography can be used to detect as little as 5-50 mL
of pleural fluid, with 100% sensitivity for effusions of 100 mL or
more.
4.Chest CT scanning
5.Thoracentesis
6.Evaluation of pleural fluid to determine cause
blunting of the costophrenic angle and/or sulci(sharp angle between the diaphragm and rib cage)
Chest xChest x--rayray
-
7/25/2019 15. Pulmonary Consolidation Syndromes
106/141
(sharp angle between the diaphragm and rib cage)
blunting becomes more pronounced as fluid accumulates
an upwardly concave meniscus seems to ascend the
lateral chest wall; this is called the meniscus sign. Clues indicating pleural effusion include
generalized homogenous opacity
diffuse haziness as the fluid forms layers posteriorly
visibility of pulmonary vessels through the haziness,
absence of air bronchogram.
Diaphragmatic inversion because of the weight of the
pleural effusion on the left side. The superior border of thediaphragm become upwardly concave, and paradoxical movement
occurs with respiration; the diaphragm rises with respiration and falls
with expiration. When the pleural fluid is removed, the diaphragm
assumes its normal shape.
Upright posteroanterior or anteroposterior rg may not show lateral
Chest xChest x--rayray
-
7/25/2019 15. Pulmonary Consolidation Syndromes
107/141
p g p p g y
costophrenic angle blunting until 250-500 mL of fluid is present.
Haziness is less apparent as it progresses cephalad.
Lateral radiographs show blunting of the posterior costophrenic angleand the posterior gutter when as little as 175-200 mL of fluid is present.
Bilateral decubitus rg. are recommended, with larger effusions.
They provide clues to exclude a loculated effusion and underlying
pulmonary lesion or pulmonary thickening and can depict as little as 5-
10 mL of fluid.
Recumbent (supine views) usually are obtained in critically ill patients.
Findings may include costophrenic angle blunting (earliest finding),
generalized homogenous opacity, obliteration of the diaphragmatic
silhouette, decreased visibility of the lower-lobe vasculature, widened
minor fissure, apical capping, and hemidiaphragmatic elevation.
Posteroanterior radiographs may depict the following:
Flattening of the medial diaphragmatic aspect, with gradual upward
and lateral inclination from the cardiac shadow; lateral displacement
-
7/25/2019 15. Pulmonary Consolidation Syndromes
108/141
; p
of the diaphragmatic dome apex (middle or inner hemithoracic third
to lateral third)
Change of the normal, domelike diaphragmatic curve to a
hockey-stick shape
Sharp diaphragmatic sloping toward the lateral costophrenic angle
Hemidiaphragm elevation
Increased distance (>2.0 cm) between the gastric fundus air bubble
and superior right hemidiaphragmatic margin
Absence of lower-lobe vessels normally present below the diaphragm
Lateral radiographs may depict sharp angulation of the anterior
diaphragmatic portion (ie, Rock of Gibraltar or middle-lobe step sign).
ThoracentesisThoracentesis
-
7/25/2019 15. Pulmonary Consolidation Syndromes
109/141
http://picasaweb.google.com/clinicalcases/ThoracentesisAStepByStepProcedureGuide#
Thoracentesis (also known as thoracocentesis or pleural tap)
is an invasive procedure to remove fluid or air from the pleural space for diagnostic
or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into
the thorax, generally after administration of local anesthesia.The procedure was first described in 1852.
The recommended location varies depending upon the source.
Some sources recommend the midaxillary line, in the sixth, seventh, or eighth
intercostal space.
EmpyemaEmpyema
-
7/25/2019 15. Pulmonary Consolidation Syndromes
110/141
= purulent pleural effusions= purulent pleural effusions
present on Xpresent on X--ray of 20ray of 20--60% of patients60% of patientswith bacterial pneumoniawith bacterial pneumonia
often solves with antibiotic therapyoften solves with antibiotic therapy
Risk factors: aspiration,Risk factors: aspiration,
immunocompromisedimmunocompromised patientspatients
ExudativeExudative stagestage: free flowing pleural fluid, very: free flowing pleural fluid, very
EmpyemaEmpyema
-
7/25/2019 15. Pulmonary Consolidation Syndromes
111/141
amenable to treatment with closed tube drainageamenable to treatment with closed tube drainage
FibrinopurulentFibrinopurulent stagestage: formation of fibrin strands: formation of fibrin strandsthrough the pleural fluid resulting inthrough the pleural fluid resulting in loculationsloculations, makes, makes
adequate drainage with single chest tube unlikelyadequate drainage with single chest tube unlikely
Organizational stage:Organizational stage: fibrosis is much more extensivefibrosis is much more extensive
forming a pleural peel that restricts expansion even ifforming a pleural peel that restricts expansion even if
fluid can be evacuatedfluid can be evacuated
EmpyemaEmpyema
-
7/25/2019 15. Pulmonary Consolidation Syndromes
112/141
DecubitusDecubitus films will be helpful in determiningfilms will be helpful in determining
if fluid is freely flowing orif fluid is freely flowing or loculatedloculated
Pleural fluid that is gross pus with positivePleural fluid that is gross pus with positive
cultures or gram stain is consideredcultures or gram stain is consideredempyemaempyema along with other findings: pH
-
7/25/2019 15. Pulmonary Consolidation Syndromes
113/141
Treatment:Treatment:
-- drainage of pus by chest tubedrainage of pus by chest tube reexpansionreexpansion
of lungof lung
-- eradication of the infection.eradication of the infection.
Treatment of organizational stage requiresTreatment of organizational stage requiressurgical intervention with removal of thesurgical intervention with removal of the
fibrous peelfibrous peel
DEFINITION
PneumothoraxPneumothorax
-
7/25/2019 15. Pulmonary Consolidation Syndromes
114/141
= the presence of air within the pleural space resulting
in collapse of the lung on the affected side
- it is considered one of the most common forms of
thoracic disease.
DEFINITION
Classification
PneumothoraxPneumothorax
-
7/25/2019 15. Pulmonary Consolidation Syndromes
115/141
1. Spontaneous pneumothorax
Primary
Secondary
2. Traumatic pneumothorax
Resulting from direct (blunt) chest trauma
Resulting from penetrating chest trauma3. Iatrogenic pneumothorax
Resulting from biopsy procedure
Resulting from therapeutic procedures4. Catamenial pneumothorax
5. Pneumothorax in AIDS
PneumothoraxPneumothorax
HistoryHistory
-
7/25/2019 15. Pulmonary Consolidation Syndromes
116/141
Acute onset of chest painAcute onset of chest pain
- Severe and/or stabbing pain, radiating to ipsilateral
shoulder and increasing with inspiration (pleuritic)
Sudden shortness of breathSudden shortness of breath
# Anxiety, cough, and vague presenting symptoms (e.g.,
general malaise, fatigue) are less commonly observed.
# Dyspnea tends to be more severe with secondary
spontaneous pneumothoraces because of decreased lung
reserve.
General appearanceGeneral appearance
Diaphoretic
Splinting chest wall to relieve pleuritic pain
PneumothoraxPneumothoraxPhysicalPhysical
-
7/25/2019 15. Pulmonary Consolidation Syndromes
117/141
Splinting chest wall to relieve pleuritic pain
Cyanotic (with tension pneumothoraces)
Vital signsVital signs
Tachypnea
Tachycardia (most common finding) - If faster than 135 (bpm),
tension pneumothorax is likely.
Pulsus paradoxus
Hypotension (often with tension pneumothorax) Asymmetric lung expansion - Mediastinal and tracheal shift to the
contralateral side with a large tension pneumothorax
Distant or absent breath sounds
Hyperresonance on percussion Decreased tactile fremitus
CardiovascularCardiovascular- Jugular venous distension (tension pneumothorax)
NeurologicNeurologic - Altered mental status
Pulmonary SignsPulmonary SignsMildMild pneumothotaxpneumothotax no obvious signs
PneumothoraxPneumothoraxPhysicalPhysical
-
7/25/2019 15. Pulmonary Consolidation Syndromes
118/141
MildMild pneumothotaxpneumothotax no obvious signs
VoluminousVoluminous on the affected side appear Fullness of the chest
Wide intercostal spaces
Diminished respiratory movement
Diminished or no vocal fremitus or resonance Trachea and heart displace toward the healthy side
Tympanic sound on percussion
Liver dullness edge displaces downward when pneumothorax
is on the right side.
Breath sound is diminished or disappeared on the affected side
Coin sign is positive.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
119/141
Small spontaneous primary pneumothorax.
PneumothoraxPneumothorax
-
7/25/2019 15. Pulmonary Consolidation Syndromes
120/141
large right-sided pneumothorax has occurred from a rupture of a subpleural bleb.
PneumothoraxPneumothorax
-
7/25/2019 15. Pulmonary Consolidation Syndromes
121/141
A true pneumothorax line. Note that the visceral pleural line is observed clearly,
with the absence of vascular marking beyond the pleural line.
PneumothoraxPneumothorax
-
7/25/2019 15. Pulmonary Consolidation Syndromes
122/141
Pneumomediastinum from barotrauma may
result in tension pneumothorax and obstructive shock.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
123/141
Table and pictures
-
7/25/2019 15. Pulmonary Consolidation Syndromes
124/141
A dull sound due to pleural effusion is usually located atits highest point at the axillar line. On chest radiograph,
the dull sound represents the highest point of the Ellis-
Damoiseau line. At the paravertebral line, just at the
border of the lung, an area with lesser dullness at the
side of the effusion may be heard (Figure). This has been
named the Garlands triangle. On the contralateral side,
an area of dullness over the normal lung (Groccos
triangle) may be detected.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
125/141
-
7/25/2019 15. Pulmonary Consolidation Syndromes
126/141
inspection
Chest appearance Respiratory movement
-
7/25/2019 15. Pulmonary Consolidation Syndromes
127/141
Consolidation Symmetrical Diminished on the
affected side
Emphysema Barrel-shaped Diminished on both
sides
Atelectasis Denting of the affected side Diminished on the
affected side
Pleural effusion Fullness of the affected side Diminished ordisappeared on the
affected side
Thickened
pleura
Denting of the affected side Diminished on the
affected sidepneumothorax Fullness of the affected side Diminished or
disappeared on the
affected side
palpation
Trachea location Vocal fremitus
-
7/25/2019 15. Pulmonary Consolidation Syndromes
128/141
Consolidation Central Increased on theaffected side
Emphysema Central Diminished on both
sides
Atelectasis Deviate toward theaffected side
Diminished ordisappeared
Pleural effusion Deviate toward the
normal side
Diminished or
disappeared
Thickenedpleura
Deviate toward theaffected side
Diminished
pneumothorax Deviate toward the
normal side
Diminish or disappeared
Percussion Auscultation
Note Breath sound rale Vocal resonance
-
7/25/2019 15. Pulmonary Consolidation Syndromes
129/141
Consolidation Dullness or
flatness
Bronchial
breath sound
Moist rale Strengthened
Emphysema Hyper
resonance
Diminished Always
without
Diminished
Atelectasis Dullness Disappeared or
diminished
Without Disappeared or
diminished
Pleural
effusion
Flatness Diminished or
disappeared
Without Diminished or
disappeared
Thickened
pleura
Dullness Diminished Without Diminished
pneumothorax Tympany Diminished ordisappeared
Without Diminished ordisappeared
Inspection Palpation Percussion Auscultation
Chest
appearance
Respiratory
movement
Trachea
location
Vocal fremitus Note Breath sound rale Vocal
resonance
Consolidation Symmetrical Diminished on
the affected side
Central Increased on
the affected
side
Dullness or
flatness
Bronchial breath
sound
Moist
rale
Strengthened
-
7/25/2019 15. Pulmonary Consolidation Syndromes
130/141
Emphysema Barrel-shaped Diminished on
both sides
Central Diminished on
both sides
Hyper
resonance
Diminished Always
without
Diminished
Atelectasis Denting of the
affected side
Diminished on
the affected side
Deviate
toward the
affected side
Diminished or
disappeared
Dullness Disappeared or
diminished
Without Disappeared or
diminished
Pleural
effusion
Fullness of the
affected side
Diminished or
disappeared on
the affected side
Deviate
toward the
normal side
Diminished or
disappeared
Flatness Diminished or
disappeared
Without Diminished or
disappeared
Thickened
pleura
Denting of the
affected side
Diminished on
the affected side
Deviate
toward the
affected side
Diminished Dullness Diminished Without Diminished
pneumothorax Fullness of the
affected side
Diminished or
disappeared on
the affected side
Deviate
toward the
normal side
Diminish or
disappeared
Tympany Diminished or
disappeared
Without Diminished or
disappeared
Right middleRight middle--lobe atelectasislobe atelectasis
in a 70in a 70--yearyear--old female withold female with
-
7/25/2019 15. Pulmonary Consolidation Syndromes
131/141
in a 70in a 70 yearyear old female withold female with
chronic obstructive lungchronic obstructive lung
disease. (A) The frontal chestdisease. (A) The frontal chest
radiograph shows minimalradiograph shows minimalblurring of the right heartblurring of the right heart
border. (B) The lateral chestborder. (B) The lateral chest
radiograph shows that theradiograph shows that the
right middle lobe isright middle lobe is
completely collapsed. Thecompletely collapsed. Thedepressed minor fissuredepressed minor fissure
(arrows), and the anteriorly(arrows), and the anteriorly
displaced major fissuredisplaced major fissure
(arrowheads) are almost(arrowheads) are almost
apposed.apposed.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
132/141
45-year-old man with left upper-lobe collapse due to endobronchial sarcoidosis.
(A) The chest radiograph shows hazy opacity over the left chest, with obscuration of the
left heart border. The apex of the left lung appears lucent because it is occupied by the s
uperior segment of the hyperinflated left lower lobe. The aortic arch is sharply outlined
by the hyperinflated left lower lobe. (B) The lateral view shows the hyperinflated leftlower lobe interfacing anteriorly with the collapsed left upper lobe along the major fissure
(arrows). (C) An axial CT scan shows the complete left lower-lobe collapse, and
endobronchial obstruction of the left upper-lobe bronchus (arrow). No extrinsic
component is shown.
Bilateral lowerBilateral lower--lobe collapselobe collapse,,
presumed due to mucoid impaction,presumed due to mucoid impaction,
in a 63in a 63--yearyear--old man followingold man following
abdominal surgery. (A) The frontalabdominal surgery. (A) The frontal
chest radiograph shows thechest radiograph shows the
triangular outlines of the collapsedtriangular outlines of the collapsed
-
7/25/2019 15. Pulmonary Consolidation Syndromes
133/141
triangular outlines of the collapsedtriangular outlines of the collapsed
lower lobes (lower lobes (sail signsail sign) (arrows).) (arrows).
Both hila are depressed. The medialBoth hila are depressed. The medialportions of the diaphragm areportions of the diaphragm are
obscured. The collapsed left lowerobscured. The collapsed left lower
lobe is almost exactly superimposedlobe is almost exactly superimposed
on the heart. (B) A lateral cheston the heart. (B) A lateral chest
radiograph shows the collapsedradiograph shows the collapsed
lobes overlying the spine (arrows).lobes overlying the spine (arrows).
The posterior portions of bothThe posterior portions of both
hemidiaphragms are obscured.hemidiaphragms are obscured.
Combined right middle and right lowerCombined right middle and right lower--
lobe collapselobe collapse in a 66in a 66--yearyear--old womanold woman
with breathlessness followingwith breathlessness followingabdominal surgery. The frontal chestabdominal surgery. The frontal chest
radiograph shows combined rightradiograph shows combined right
-
7/25/2019 15. Pulmonary Consolidation Syndromes
134/141
middle lobe and right lowermiddle lobe and right lower--lobelobe
collapse. Arrows indicate the minorcollapse. Arrows indicate the minorfissure. Arrowheads indicate the majorfissure. Arrowheads indicate the major
fissure. The multilobar collapsefissure. The multilobar collapse
simulates a right pleural effusion, butsimulates a right pleural effusion, but
the marked inferior hilar displacement,the marked inferior hilar displacement,
the marked depression of the rightthe marked depression of the right
major fissure, and the ipsilateralmajor fissure, and the ipsilateral
mediastinal shift are important cluesmediastinal shift are important clues
that this is a volumethat this is a volume--losing process. Alosing process. A
decubitus view showed only minimaldecubitus view showed only minimal
right pleural fluidright pleural fluid
-
7/25/2019 15. Pulmonary Consolidation Syndromes
135/141
Strep. pneumoniaeStrep. pneumoniae pneumonia.pneumonia.
Bilateral lowerBilateral lower--zonezone consolidation (arrows).consolidation (arrows). AlthoughAlthough
pneumococcalpneumococcal pneumonia is typicallypneumonia is typically unifocal, multifocalunifocal, multifocal
involvement is not uncommon.involvement is not uncommon.
Strep. pneumoniaeStrep. pneumoniae
pneumonia.pneumonia.
Very extensiveVery extensive
consolidation affectingconsolidation affecting
-
7/25/2019 15. Pulmonary Consolidation Syndromes
136/141
consolidation affectingconsolidation affecting
more than one lobe inmore than one lobe in
the right lung. Thethe right lung. The
central lucency is due tocentral lucency is due to
cavitationcavitation an unusualan unusual
feature in pneumococcalfeature in pneumococcalpneumonia.pneumonia.
Staph. aureusStaph. aureus pneumonia.pneumonia.
This cavitary pneumoniaThis cavitary pneumonia
-
7/25/2019 15. Pulmonary Consolidation Syndromes
137/141
This cavitary pneumoniaThis cavitary pneumonia
waswas
a communitya community--acquiredacquiredinfection occurring twoinfection occurring two
weeks after an influenzaweeks after an influenza
A infection.A infection.
Staph. aureusStaph. aureus pneumoniapneumonia
pneumatoceles.pneumatoceles.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
138/141
pp
Appearances followingAppearances following
incomplete resolution of aincomplete resolution of astaphylococcal pneumonia.staphylococcal pneumonia.
There are several thinThere are several thin--walledwalled
cysts consistent withcysts consistent with
pneumatoceles. Suchpneumatoceles. Such
pneumatoceles are common inpneumatoceles are common in
children but unusual in adults.children but unusual in adults.
Staph. aureusStaph. aureus
infectioninfection in a drugin a drugabuser.abuser.
Multiple disseminatedMultiple disseminated
nodularnodular
-
7/25/2019 15. Pulmonary Consolidation Syndromes
139/141
nodularnodular
consolidations,consolidations,
confluent in the rightconfluent in the rightlower zone; severallower zone; several
have cavitated. Thehave cavitated. The
appearances areappearances are
typical oftypical ofhaematogenoushaematogenous
dissemination.dissemination.
GramGram--negativenegative
pneumoniapneumonia
-
7/25/2019 15. Pulmonary Consolidation Syndromes
140/141
pneumoniap
((HaemophilusHaemophilus
influenzaeinfluenzae))showing a typicalshowing a typical
bronchopneumonicbronchopneumonic
pattern ofpattern of
heterogeneous localizedheterogeneous localizedconsolidation. Suchconsolidation. Such
infections are commonlyinfections are commonlybasal.basal.
Legionella pneumophila pneumoniaLegionella pneumophila pneumonia. While the unilateral lower. While the unilateral lower--zone peripheral consolidation is a typical appearance, it complezone peripheral consolidation is a typical appearance, it completelytely
lacks specificity. Apparent cavitation was spurious.lacks specificity. Apparent cavitation was spurious.
-
7/25/2019 15. Pulmonary Consolidation Syndromes
141/141