4.2 Neumonías Por US - ESAEL

8/11/2019 4.2 Neumonas Por US - ESAEL

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CONSOLIDADOS:

NEUMONAS

Dr. ShalimRodrguez G.

Medicina IntensivaUCI 2C - HNERM


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BASES FISIOPATOLGICAS


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Definiciones

La neumona es un proceso inflamatorioagudo del parnquima pulmonar de origeninfeccioso.

Los microorganismos pueden llegar al

pulmn por vas diferentes: microaspiraciones de secreciones orofarngeas (lams frecuente), inhalacin de aerosolescontaminados, va hemtica o porcontigidad; y coincide con una alteracin de

nuestros mecanismos de defensa(mecnicos, humorales o celulares) o con lallegada excesiva de grmenes quesobrepasan nuestra capacidad normal deaclaramiento.

Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL


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Neumona: Describe unaenfermedad del tractorespiratorio bajo, usualmente,

pero no siempre debido ainfeccin, asociado a fiebre,sntomas respiratorios focales(con o sin signos clnicos) y

nuevo velamiento en la placa detrax.


Definiciones


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NEUMONAS.Concepto.

Inflamacin del parnquima distal a los bronquiolosterminales.

Entre sus caractersticas se encuentran:

- es aguda- PUEDE cursar con condensacin radiolgica

- PUEDE existir un agente infeccioso.

No es un proceso nico, es un grupo de infecciones

causadas por distintos grmenes.



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Patognesis

Inhalacin, aspiracin y siembrahematogena son los 3 principalesmecanismos por los que las bacteriasllegan al pulmn.

Inhalacin Primaria: cuando losorganismos hacen un bypass a losmecanismos de defensa respiratorios

normales o cuando el paciente inhalagrmenes aerbicos que colonizan lasvas altas.



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Patognesis

Aspiracin: Ocurre cuando el pacienteaspira secreciones colonizadas del tractorespiratorio superior Estmago: Reservorio de grmenes que

pueden ascender, colonizando la varespiratoria alta.

Hematgena: foco de origen distante eimportante de donde viajan los grmenespor el torrente sanguneo



8/80Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL


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Neumona Lobar:

Neumona Lobar: S. pneumoniae.

En individuos previamente sanos. Inicio abrupto.

Dolor torcico unilateral a la inspiracin(debido a pleuresa fibrinosa)



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4 Fases:

FASE 1: CONSOLIDACIN Menos de 24 horas: el alveolo se llena con

edema y bacteria

FASE 2: HEPATIZACIN ROJA: Solidificado, hepatizado, y apariencia sin aire de

los pulmones. Dilatacin de capilares y vasos distales.

Extensin de tejido fibrinoide a travs de losalveolos, por los poros interalveolares de Kohn. Invasin de neutrofilos en el alveolo. Pleura: Exudado fibrinoso.



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FASE 3: HEPATIZACIN GRIS Hiperemia baja Macrfagos, neutrfilos ms fibrina.

FASE 4: RESOLUCIN Lisis y remocin de fibrina va esputo y

linfticos.

Inicia despus de 8 9 das (sinantibiticos).

Mejora significativa de la condicin clnicadel paciente



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J. A. Verschakelen. Computed Tomography of the Lung. 2007Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL


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BRONCONEUMONA

Ms frecuente en nios y ancianos. Usualmente secundario a otras

condiciones, asociada con mecanismos

de defensas generales y localesdisfuncionantes: Infecciones virales. Aspiracin de alimentos y vmitos. Obstruccin de un bronquio. Inhalacin de gases irritantes. Ciruga mayor Estados de debilitacin crnica: malnutricin,

etc.



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HALLAZGOSSONOGRFICOS


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TheAir Bronchogram: SonographicDemonstrationBrighitaWeinberg - AJR 147:593-595,september 1986



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ULTRASOUND IMAGING OF PNEUMONIA0. GEHMACHBR - Ultrasound in Medicine and Biology Volume 21, Number 9, 1995

Abstract-One hundred forty-three consecutive patients with clinically andradiologically confirmed pneumonia were examined by ultrasound. In 127 cases(g&8%), a consolidation could be visual&d in the sonogram. Eight patients (5.6% )had a pleural effusion only. The remaining eight (5.6% ) had no pathologicalfindings. The characteristic features of pneumonia were a hypoechoicconsolidation with numerous small hyperechoic structures (112 patients, 88.1% )and a blurred margin. In eight cases abscess formation

could be detected and treated by ultrasound-guided drainage.

We conclude that sonography can visualise pneumonic consolidations in a highpercentage, and gives additional information concerning the diagnosis, follow-upand treatment of pneumonia.

Nosotros concluimos que el US puede visualizar consolidadosneumnicos en un alto porcentaje, y aportar informacin adicionalconcerniente al diagnstico, seguimiento y tratamiento de laneumona.



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Sonographicdiagnosis of pneumonia and bronchopneumoniaA. Benci - European Journal of Ultrasound 4 (1996) 169-176

Objectives: The usefulness of sonography in the diagnosis of pneumonia andbronchopneumonia is considered. Ultrasound is compared with conventional radiology.

Methods: Eighty patients with respiratory failure (40 of whom were HIV positive) wererandomly divided into two groups of 40. The first group was X-rayed and subsequentlysubjected to an ultrasound examination of the chest. The second group was examined, firstby ultrasound and subsequently with conventional radiology. Results: The study shows thatthe infective lung diseases that cause alveolar consolidation present similar, characteristicultrasound patterns: large hypoechoic lesions or small roundish subpleural hypoechoiclesions with fine echoes inside and occasionally with asonic canalicular formations andhypoechoic linear structures with comet tails ('liver like' images). The diagnostic sensitivity ofthe ultrasound examination is comparable to that of conventional radiology (100% vs. 90%).On the other hand, ultrasound does not detect alterations of interstitial pneumonia, whereasconventional radiology is diagnostically effective. High resolution computed tomography andbronchoscopy must be employed in doubtful cases. Conclusion: Ultrasound is shown to bereliable, safe and easy to carry out, especially in immunocompromised bedridden patients,

and it can play a significant role in the diagnosis of pneumonia and bronchopneumonia.

CONCLUSIONES: El US es un mtodo accesible, seguro, fcil y noinvasivo, especialmente en pacientes inmunocomprometidos, ypuede jugar un rol significativo en el diagnstico de neumona ybronconeumona.



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Sonomorfologa de la neumona

Similar a la del hgado en la primera etapa Atrapamiento de aire en forma de

lentejuelas.

Broncograma areo. Broncograma lquido (postestentica)

Mrgenes borrosos y aserrados.

Ecos de reverberacin perifricos. Imgenes hipoecognicas o anecoicas

en presencia de abscesos



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CONSOLIDACIN

HALLAZGOS SONOGRFICOS


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Oblique section of lobar pneumonia in the right lower lobe. The pneumonicinfiltrate (P) is similar to the liver in terms of echotexture (L). D diaphragm



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Ultrasound diagnosis of pneumonia in childrenR. Copetti - Radiolmed (2008) 113:190198

PATRONES:Consolidado:

Hipoecoico en cuaHipoecoico Hepatizado+Broncograma Areo:Lentejuelas

Arborizado



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BRONCOGRAMA AEREO


Ult d di i f i i hild


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Ultrasound diagnosis of pneumonia in childrenR. Copetti - Radiolmed(2008) 113:190198


PATRONES:Consolidado:Hipoecoico en cua

Hipoecoico Hepatizado+Broncograma Areo:Lentejuelas

Arborizado


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Varn de 68 aos crticamente enfermocon signos de neumona aguda.a, en el lbulo superior derecho de elpulmn existe una consolidacin de

ecotextura similar a la del hgado conbroncograma areo.b Un fluido subpleural de unalveologramac Atrapamiento de aire extendido a laperiferia.


TheDynamic Air Bronchogram


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TheDynamic Air BronchogramA Lung Ultrasound Sign of Alveolar Consolidation RulingOutAtelectasisDaniel Lichtenstein - CHEST 2009; 135:14211425

Conclus iones: En pacientes con consolidacin alveolar que desplieganBRONCOGRAMA AEREO DINMICO es indicativo de neumona, distinguindosede las atelectasias en resolucin. El broncograma areo esttico fue visto enmuchas atelectasias en resolucin y en un tercio de casos de neumona. Estehallazgo incrementa el entendimiento de la fisiopatologa de la enfermedadpulmonar dentro del contexto clnico y disminuye la necesidad debroncofibroscopias en la prcticaDr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL

TheDynamic Air Bronchogram


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TheDynamic Air BronchogramA Lung Ultrasound Sign of Alveolar Consolidation RulingOutAtelectasisDaniel Lichtenstein - CHEST 2009; 135:14211425

In patients with ultrasound-visible alveolar consolidation displaying airBronchograms, the dynamic air bronchogram had a 94% specificity and a 97%positive predictive value for diagnosing pneumonia and distinguishing it fromresorptive atelectasis. Static air bronchograms were seen in most resorptiveatelectases and in one third of patients with pneumonia.



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VASCULARIZACIN



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Doppler color aplicado a consolidado neumnico, se observa una acentuacin dela vascularizacin, con un patrn regular de la circulacin


REACTIVE PULMONARY ARTERY VASOCONSTRICTION IN PULMONARY CONSOLIDATION


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REACTIVE PULMONARY ARTERY VASOCONSTRICTION IN PULMONARY CONSOLIDATIONEVALUATED BY COLOR DOPPLER ULTRASONOGRAPHYANG YUAN - Ultrasoundin Med. & Biol., Vol. 26, No. 1, pp. 4956, 2000

Fig. 1. A 49-y old man had simple bacterial pneumonia in the left upper lobe. The chestUS shows a wedge-shaped consolidation in the left upper lobe (not shown). Color Dopplerimaging shows branched red (A) and blue (B) flow signals with tubular and curvilineardistributions, which extend from the hilar region to the periphery of the consolidation. The red

and blue flow signals indicate flow in the pulmonary artery and pulmonary vein, respectively.Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL



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Fig. 2. (A) Chest radiograph of a 34-y old woman showing a simple bacterial pneumoniain right middle lobe. (B) Color Doppler mapping of the consolidation showing red branchedpulmonary arterial blood-flow signals and blue pulmonary venous blood-flow signals. Spectralwave analysis of the blood-flow signal in the regional pulmonary artery near the hilumshowing moderate-resistance blood flow. The PI, RI and AT of this blood flow were 3.25,

0.82 and 62 ms, respectively. Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL



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Fig. 3. (A) Chest radiograph of a 61-y old man with lung cancer and obstructivepneumonia in the right lower lobe. (B) Chest US revealing a wedge-shaped consolidation withan 3.0 3 2.0-cm hypoechoic mass in the hilar region (arrows). Color Doppler mapping revealsseveral red pulmonary arterial blood-flow signals and blue pulmonary venous blood-flowsignals in the consolidation. Spectral waveform analysis of the regional pulmonary arterial flowreveals high-impedance flow with PI, RI and T of 4.24, 1.26, and 43 ms, respectively(arrowhead). Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL



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Fig. 4. (A) Chest radiograph of a 54-y old man with a tumor consolidation ofbronchioloalveolar carcinoma in the left upper lobe. (B) Chest US shows a wedge-shapedconsolidation in the left upper lobe. Color mapping shows several fragmented and displacedblood-flow signals, and spectral waveform analysis of these regional blood flows shows low-impedance flow. The PI, RI and AT were 0.52, 0.42 and 165 ms, which are characteristic of thelow-impedance tumor flow of malignancy-associated neovascularization. US-guidedtransthoracic biopsy of the area near the low impedance flow showed bronchioalveolar

carcinoma. Dr. Shalim Rodrguez Giraldo. UCI. HNERM. ESAEL



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CONSOLIDADOS OCULTOS


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SEGUIMIENTO DE TERAPIA


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A 26-year-old woman with dyspnea andmild chest pain.The pneumonia is atypical, bothclinically and radiologically. a,b On

sonography one finds a poorlyventilated, well-vascularized area in thelower lobe of the right lung. c After 4days of antibiotic treatment thelesion is markedly reduced (also notethe dimensions in centimeters)



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Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-


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associatedpneumoniaBe ladBouhemad - CritCare Med 2009; 39:000000


Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-


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associatedpneumoniaBe ladBouhemad - CritCare Med 2009; 39:000000

Figure 1. Computed Tomography

(CT) section and correspondingultrasound pattern in a patient withventilator associated pneumoniacharacterized by multiple roundedCT attenuations and consolidation.Figure 1B shows a subpleural and

intraparenchymal rounded CTattenuation of the right upper lobe(white arrow), corresponding toirregularly spaced and abuttingultrasound lung comets arisingfrom a subpleural consolidation

(gray arrow).Figure 1C shows consolidation ofright lower lobe withparapneumonic pleural effusion.The white and gray arrowsindicate position of the probe.



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COMPLICACIONES:ABSCESOS



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COMPLICACIONES D ELA NEUMONALOBAR: Abscesos

Empiema Insuficiente resolucin cicatrices

intraalveolares prdida permanente defuncin ventilatoria.

Bacteriemia: Endocarditis infecciosa. Abscesos cerebrales, meningitis. Artritis Sptica



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ABSCESOS:

rea localizada de supuracin y necrosisde tejido.

Complicaciones: Rotura dentro dele espacio pleural: empiema

o fstula broncopleural (pioneumotorax)

Ruptura al pericardio: pericarditis.

Sepsis: en otros rganos.

Erosin de vasos sanguneos: hemoptisis.

Fibrosis.



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Colliquated abscesses with persistent fever. Sonographyguidedaspiration showed a surprisingly large number of tuberclebacilli



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Microabscess on the fourth day of a lobar pneumonia inthe upper lobe of the left lung, which could not be seen on X-ray. Thisabscess healed on its own.


Is lung ultrasound superior to CT?: The example of a CT occult necrotizingpneumoniaDanielA Lichtenstein Intensi eCareMed (2006)32 334 335


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Daniel A. Lichtenstein - IntensiveCareMed (2006) 32:334335



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4.2 Neumonías Por US - ESAEL

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