Investigations du laboratoire en pneumologie:bronchoscopie, toracenthese, biopsie pleurale,

Investigations du laboratoire en pneumologie:bronchoscopie, toracenthese, biopsie pleurale,

Investigations du laboratoire en pneumologie:bronchoscopie, toracenthese, biopsie pleurale, toracoscopie Endoscopie bronchique (flexible ou rigide) - exploration directe de larbre bronchique du point de vue topographie, morfologie et fonction Fibrobronchoscope

Exploater la transmission de la lumiere dans les fibres de glace a iluminer les bronches et a former l image. Compose par : Lappui tube dabord racord a la sourse de lumiere Indications en bronchoscopie Indications diagnostic

1. de tipe clinque: hemoptisie -(cancer,TB,bronsiectazii) toux cronique avec/sans expectoraion, toux recente inexplicable, persistente-lesion bronchique,corp etranger; modifications du caractere de la toux bronchite cronique, cancer wheezing localise, unilaterale, persistent stenose bronchique dispnee d etiologie incerte- tumeurs bronchiques/tracheales

2. de tipe radiologique: - atelectasies; - opacites/infiltrats du parenchim; - afections interstitiales difuses; - hipertransparece pulmonaire localise/ difuse; - adenopathies intrathoraciques; - enlargement du mediastine; - paralisie du diafragme

- epanchement pleurale detiologie incerte/ - chilothorax 3. de laboratoire - citologie positive/ suspecte pour neoplasm pulmonaire - en expectoration - confirmation microbiologique pour des germes - suspicion de tuberculose bronchique - investigation microbiologique au pacients immunocompromis (Pneumocystis, Citomegalovirus)

Indications therapeutiques - Extraction des corps etrangeres tracheobronchiques; - Aspiration des secretionsr aeriennes; - intubation en anesthesie; - lavage bronchoalveolaire en therapie - Bronhoinstilation des

diverses medicaments. - rezection paleative des tumeurs endoluminales et dezobstructions paliatives (laserterapia, crioterapia, endobrahiterapia, electrocauterizarea, implanter des stent);

Preoperatoire i postoperatoire - Diagnostic et evaluation des tumeurs bronhopulmoniares; - Stadialisation tumeurs preoperatoire; - Suivi des patients operes Contraindications absolutes Absence de laccord du patient/ses

representants legals; Efectuer la bronchoscopie par quelquun sans experience/formation specialisee; Efectuer une bronchoscopie dans un service sans facilites danesthesie,sans possibilites dintervenir en urgence. Contraindications - Disfonction ventilatoire obstructive severe (Asthme instabile a VEMS < 30%

) - Hipoxemie severe (< 65 mm PO2 apres oxigenotherapie). - Aritmies malignes; - Diatheses hemoragiques. 3. Contraindications Relatives Pacient necooperant. Infarct du miocarde recent (<6 semaines)/ angine pectorale instabile. Anevrisme de l aorte.

Obstruction tracheale; Insuffisance renale Hipertension pulmonaire Obstruction de vene cave superieure; Etat general mauvais, trop vieux, cachexie. Alergie/contraindication dadministrer la xilocaine Crises comitiales Insufisance circulatoire cerebrale. Prelevements

Aspiration secretions bronchiques Brossage Biopsie - endobronchique - transbronchique periferique Ponction aspirative transtracheale/transbronchique Lavage broncho alveolaire Diagnostic approach to pleural effusions thoracentesis

etiology ? closed pleural biopsy etiology ? medical thoracoscopy etiology ? follow-up surgical biopsy

Toracenthese Confirme le diagnostique de pleuresie Un bilan biochimique, citologie si bacteriologie En but diagnostic et therapeutique: a evacuer/introduire des medicaments Technique Malade assis, la tete sur ses bras Posterieur en pleine matite, de

espaces 4,5,6 Preparer les teguments avec iode Palpation avec lindexe le bord superieur de la cote inferieure de lespace IC choisi pour la ponction Execution On introduit laiguille razant au bord superieur de la cote Optional - anesthezse locale a xiline, Fermer le robinet du sistheme de ponction Adapter une seringue de 10-20ml au trocar et on aspire

pour verifier l existence du liquide Prelevements pour laboratoire Evacuer le liquide Retirer laiguille Incidents Ponction blanche

Ponctionner le poumonhemoptisie Piquer le fois, la spline, le diaphragme, les cotes Perforer une artere intercostale Complications Troubles vagotoniques: transpirations froids, palidite, bradicardie , hipotension arteriale, sincope, lipotimie

Suprainfection a germes piogenes Pneumotorax Sindrome d intolerance a levacuation du liquide ( rapidement)toux, dispnee, opression thoracique) Biopsie pleurale Metode invasive de prelever un phragment de plevre parietale, pour lexamen histopatologique/identifier des lesions specifiques Rezultats sont relevantes: folicul

tuberculeux, granulome sarcoidose, colagenose, amiloidose,malignite Biopsie pleurale Cope's Pleural Biopsy Punch Indications TB pleurale, pleuresie maligne Pleuresie trenante >4 semaines, recidivante apres evacuation Exclus en cas de transsudat d origine

extrapulmonaire (cardiogene, hepatique, renale), infarctus pulmonaire, pleuresie inflamatoire pas specifique (parapneumonique) Pneumoftiziologie I- Tehnici de investigatie instrumentala- Traian Mihaescu, Antigona Trofor Toracoscopie permet visualiser l espace pleurale explorer differentes structures: diaphragme, mediastin, pericard, cotes , colonne vertebrale toracique, plevre viscerale et

ainsi le parenchime pulmonaire Incision de la peau Anesthesie locale Tehnica cu trocarul mod. from Netter Atlas Pleuroscope semirigide(semiflexible) (Olympus)

Ernst A et al. A Novel Instrument for the Evaluation of the Pleural Space. Inspection directe avec le toracoscope Toracoscopie video asistee

Tehnique Provoquer un pneumotorax Anesthesie locale Introduire le trocarle toracoscope Explorer la cavite pleurale- plevre

parietale, diaphragmatique, viscerale Biopsie pleurale et pulmonaire Drainage pleuralereexpansion du poumon, evaluer les pertes du sang Talcage pleurale-pour le pneumotorax spontanee, pleuresies neoplasique ou

recidivantes Indications Pour diagnostic: pleuresie cronique- pour le diagn.: cancers,Tb, mesotheliome Masse pleurale sans epanchement pleurale Pneumotorax spontannee Tumeurs mediatinales Maladies pulmonaires difuses et opacites localisees periferques

Indications therapeutiques Evacuations des depots de fibrine, membranes piogenes, drainage des pleuresies enkystees, pleurodese chimique, extraction des corps etrangeres intrapleurales, etc Contraindications Fibrose pulmonaire Anevrisme pulmonaire arterio-veneux Kyset hidatique

Hipertension pulmonaire Lesions pulmonaires bien vascularisees Troubles de coagulation Dispnee de reste, insuffisance cardiaque et respiratoire severe Complications Empiem pleurale Hemoragies massives- rarement Dissemination neoplasique au longue du trajet de ponction

Emphiseme subcutane Emphiseme mediatinale Complications cardiaques Embolie gazeuse Fistule bronhopleurale Perforation du poumon Referinte - Pneumoftiziologie I - Tehnici de investigatie instrumentala - Traian Mihaescu, Antigona Trofor, 1998

http://www.vulgarismedical.com/images/ pneumologie-16/tumeur-bronchique-94.html#image http://www.vugarismedical.com/images/pneumologie16/bronchoscopie-normale-163.html#image Workshop de endoscopie bronsica- Sp. Clinic Pneumologie, 3-4 octombrie 2006

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