BNH MNG PHIBS. Nguyn Th Hng Trn

Mng phi thnh: mu t ng mch h thng (M lin sn, M honh) Mng phi tng: M PQ

SINH L MNG PHI

NH LUT STARLINGF = k[(Pcap - Ppl) - (cap - pl)]

F: tc di chuyn dch P v : p lc thy tnh v p lc keo,k: h s lc, : h s p keo cho protein (# 0.9), Cap: Capillary (mao mch), Pl: pleural space.

Mng phi thnhKhoang mng phiMng phi tngALTT mao mch h thng+ 30cmH20 35ATTT khoang mng phi-5cmH20ALTT mao mch ph qun+24cmH2029AL keo +34cmH20 29AL keo +5cmH20AL keo +34cmH2029Kt qu 60

TRN DCH MNG PHI

DCH T HCHi chng bnh l thng gp5 10% bnh ni khoa (Radenbach v cs), 15 22% bnh h hp (Ng Qu Chu)M: 1.3 triu ngi trn dch mng phi/nm, nguyn nhn: suy tim (72%), bnh l c tnh, vim phi (36 66%), tc mch phi (10 50%), sau phu thut tim, ghp phi (90-100%), lupus h thng (16 37%), vim ty cp (4 20%)(Omar Lababede v cs)Vit Nam: lao mng phi (7 11%) bnh lao.

NH NGHAHin tng tch t dch nhiu hn mc sinh l bnh thng trong khoang mng phi.

Thnh phn dch mng phi bnh thngTh tch : 0.1- 0.2 ml/kgT bo/mm : 1000 - 5000 %mesothelio : 3 - 70% %monocytes : 30 - 75%%lymphocytes : 2 - 30% %granulocytes : 10% Protein : 1 2 g/dl %albumin : 50 - 70%Glucose : = glucose huyt tngLDH : < 50% huyt tngpH : huyt tng

C ch hnh thnh dch mng phiThay i tnh thm ca mng phi: vim, K, thuyn tc phi

Gim p lc keo trong lng mch: gim albumin mu, x gan

Tng tnh thm mao mch v rch mch mu: chn thng, K, vim nhim, thuyn tc phi, d ng thuc, ur huyt cao, vim tu cp

- Tng p lc thu tnh mao mch trong tun hon c th hay phi: suy tim huyt, hi chng tnh mch ch trn

C ch hnh thnh dch mng phiGim p lc trong khoang mng phi, phi khng n ra c: xp phi, mesiothelioma

Gim thi qua h bch mch hay tc nghn hon ton ng ngc: K, chn thng

Tng dch trong khoang mng bng, dch di chuyn qua c honh nh h thng bch mch: x gan, thm phn phc mc

- Dch di chuyn ngang qua mng phi tng: ph

Nguyn nhn trn dch mng phi dch thmSuy tim xung huytHi chng thn hX ganHi chng MeigsThn nc (Hydronephrosis)Thm phn phc mcTc tnh mch ch trnThuyn tc phi

Trn dch mng phi dch titTnh trng thot protein vo dch mng phi l biu hin ca tn thng trn mng phi.

Cc tn thng ny c th l: Bnh mng phi do bnh ton thn. Lan ti mng phi do cc tn thng cc tng ln cn (phi, trung tht, bng).Bnh l mng phi tin pht.

Nguyn nhn trn dch mng phi dch titPh bin: Cnh vim phi, ung thThng: Bnh bng, lao, chn thng, bnh Collagen: RA, SLEHim: thuc (Nitrofurantoin, Dantrolen, Interleukin2 Methylsergide, Bromocriptine, Procarbarin, Amiodarone), Asbestos, hi chng Dresslers, ur huyt cao, x tr, sarcoidosis, hi chng mng vng, hi chng tng kch thch bung trng, dng trp, hu phu (bng, bypass mch vnh)

U ht

X ha

To mng (plaque)

To mng

Dnh v lng ng can - xi (nht l trong trn dch mng phi dch tit). Bin chng trn cu trc mng phi

Chn on

Triu chng lm sngau ngc: au kiu mng phi, lan ln vai, cng au gim khi dch tch t nhiu v tch ri b mt mng phi.Kh th: khi lng dch trn 500 mlHo: khan tng cn khi thay i t th, thng lin quan n tnh trng xp phiSt ()Khm: du hiu Hoover, Hi chng 3 gim (trn 300 ml), ting c mng phi, hi chng ng c co rt, mm tim lch sang bn i din (> 1000 ml), tnh mch c ni

Hnh nh hc X quangM ng nhtMt gc sn honhng cong Damoiseau

Trn dch khu tr rnh lin thy

Phn bit u mng phiMESOTHELIOMA mng phiLIPOMA mng phi

Hnh nh hc CT scan ngcChn on phn bit mng mng phi hay nt nhu m phi Xc nh c mng dy mng phi v Canxi ha do asbestos.

Chn on phn bit gia p xe phi ngoi bin v m mng phi khu tr

Hnh nh hc Siu m ngcPhn bit dch khu tr v t do, hay vi khi c.

Phn bit trn dch vi dy dnh mng phi.

Bit tnh cht dch mng phi.

Hng dn chc d mng phi trong nhng trng hp kh

Phn tch dch mng phi

Quan st i th:Lng, mu sc, trong, qunh, mi, ti lp sau nhiu ln chc

Xc nh dch thm/dch tit : Tiu chun Lightdch tit: mt trong ba tiu chun - Protein DMP/HT > 0.5- LDH > 200 n v/ lt (>2/3 gii hn trn ca LDH mu)- LDH DMP/ HT > 0.6 Protein huyt thanh Protein DMP (> 3.1 g/dl => dch thm, 3.1 g/dl => dch tit)t bo, glucose, amylase, cy vi khun, Mycobacteria, nm

Cc xt nghim khc ca DMP ty theo nguyn nhn gy bnh

Thng sBnh thngBt thngNguyn nhnpH7.6 200 UI/LVim tu cp, u nang gi tu, K phiB th DMP/HT

Thng sBnh thngBt thngNguyn nhnHng cu>100.000Ung th, chn thng, nhi mu phiBch cu> 10.000Nhim trng sinh mLympho85-95%RA, lao, K, TD dng trp, lymphomaEosinophile> 10%C kh, mu trong mng phi, TDMP do k sinh trngT bo trung m> 5%Loi tr TDMP do laoAdenosine deaminase< 45 U/l> 70 U/LLaoLysozymeLysozyme DMP/HT>15 mg/dl> 1.2LaoLao

TRN KH MNG PHI

DCH T HCPneumothorax: c Itard t tn nm 1819Sau , Laennec m t lm sng TKMPTKMP t pht nguyn pht: 18 28/100.000 dn/nm i vi nam v 1,2 - 6/100.000 dn/nm i vi n (Melton LJ v cs)T l ti pht TKMP t pht nguyn pht l 30%, t pht th pht l 45% trong thi gian 6 thng. TKMP t pht nguyn pht thng xy ra ngi tr ( tui 20), TKMP t pht th pht thng ngi 60 65 tui

nh nghaL s tch t kh trong khoang mng phi

Phn loiTKMP t pht: nguyn pht/ th pht (lao, COPD, p xe phi, hoi th phi, nhi mu phi, gin ph nang, bnh c tnh ca phi)TKMP do chn thng, do thy thuc (sau cc th thut)

YU T THUN LITKMP T PHT NGUYN PHTCc nang hoc kn kh di mng phiNgi tr tui, gy, cao (p lc m vng nh phi cao)Hi chng MarfanHt thuc l

YU T THUN LITKMP T PHT TH PHTLao phiSarcoidoseX ha knBnh c tnhX phi khng r nguyn nhnNhim trng phi do Pneumocistis carinii cc BN AIDS

Sinh l bnhThng thng ph nang - khoang mng phi: khng kh ph nang khoang mng phi cn bng v p lc, l thng c hn gn.Bc tch dc theo bao ph qun - mch mu: trn kh trung tht, di da, TKMP hay bc tch ti phn phi ngoi bin (to ra mt ti kh bn trong hay ngay di mng phi tng)

S ti hp thu khChnh lch p lc khoang MP - mu TMc tnh khuych tn ca kh (Oxy > Nit)Vng tip xc gia kh v mng phi.Tnh thm ca b mt mng phi (mng phi dy, x ho hp thu km hn mng phi bnh thng).

Chn on lm sngKhi pht: ngh ngi/ gng scTriu chng: ty lng kh, tc thnh lpKhi pht cp tnh: au ngc t ngt, kh thNng: suy h hp cp (do xp phi cp tnh), ri lon huyt ng (do tng p lc trong khoang lng ngc)Nh: t t, b qua

Chn on lm sngLng ngc bn trn kh c th to hn v di ng km hn khi th,Rung thanh gim nhiu, g vang, r ro ph nang gim hoc mt. Du Hamman: ting Click ng thi vi nhp tim vng thng v r th th raLch kh qunTnh mch c ni

Tension pneumothoraxCompressed vesselsCompressed lungCompressed superior vena cavaCompressed heartPleural space filled with airBulging intercostal musclesWound siteBulging muscle in superclavicular area

Nghim php xi lanhXi-lanh 5 ml, tt nht l loi bng thy tinh Kim nng ln (s 18)Chc vo v tr g vang nhtXi-lanh t th nm ngang

Nghim php xi lanh

Thi imDu hiuNgay khi chc dKh y piston t nhin rt piston rt nh tayNi kim vi mt ng dn lu kn my ht p lc thpKh ra t nhin theo nhp th hoc t nht kh ra theo nhp th di p lc ht my. Sau 5 pht dn lu khBnh nhn gim kh th r, kh ra gim hoc ht, thng kh phi bn trn kh ci thin

Hnh nh hcXQ ngc CT scan ngc:- Bng kh hay nang c thnh mng- TKMP khu tr

XQ ngc

Kn hi khng l

c lng th tch trn kh mng phi Cng thc Light: % PNX = 100 (L3/T3) - L l ng knh phn phi b xp.- T l ng knh na bn lng ngc hoc tnh dung lng khoang kh theo Rhea 1982Th du: Tong ba ng knh: 4 + 2 + 1 = 7 ng knh trung bnh: 7: 3 = 2,3 Dung tch khoang kh: khoang 25%

BiN CHNGSuy h hp v suy tim cpChy mu trong khoang mng phiTrn dch mng phi

CU HI LNG GIPht biu no sau y Sai. ngi bnh thng:C khong 10 20 ml dch trong khoang mng phiDch mng phi c tit ra bi l thnh mng phiDch mng phi c hp thu i bi l tng mng phiProtein dch mng phi c hp thu bt bi cc mch bch huyt ca l thnh mng phiTc hp thu dch gp 20 ln tc bi tit dch

CU HI LNG GI2. TDMP do nguyn nhn no sau y l dch thm:Lao mng phiSuy tim triK phi di cnVim phiNhi mu phi

CU HI LNG GI3. Chn on dch tit da trn tiu chun Light khi:Protein DMP/HT > 0.5LDH > 200 n v/ lt (>2/3 gii hn trn ca LDH mu)LDH DMP/ HT > 0.6A v B ngA, B, C u ng

CU HI LNG GI4. Yu t thun li ca TKMP t pht nguyn pht, chn cu sai:Cc nang hoc kn kh di mng phiNgi gi, gy, cao (p lc m vng nh phi cao)Hi chng MarfanHt thuc l

CU HI LNG GI5. Chn 1 cu ng:au ngc kiu mng phi: au lan ln vai, cng au tng khi dch tch t nhiu v tch ri b mt mng phi.Nguyn nhn gy TDMP dch thm ph bin l cnh vim phi, ung th.Nghim php xilanh: Kh ra t nhin theo nhp th hoc t nht kh ra theo nhp th di p lc ht my.C th pht hin hi chng 3 gim trong TKMP: rung thanh gim nhiu, g vang, r ro ph nang gim hoc mt.

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