etoji problema

Pirmoji situacija
46 m. vyras, mrininkas, skundiasi kariavimu iki 38 C, skausmu deinje krtins lstos pusje. Skausmas stiprja giliai kvpiant.
Prie 2 savaites buvo nukrits ant deinio ono statybose. Prajus keletui dien, atsirado skausmas deinje krtins lstos pusje.
Skausmas intensyvjo giliau kvpus. Pacientas sukariavo iki 38 C, atsirado saikingas dusulys, stiprjantis esant didesniam fiziniam krviui.
Ambulatorikai vartojo analgetikus. Bklei negerjant, kreipsi eimos gydytoj.
Sirgs plaui udegimu, prostatitu. Rko po 20 cigarei per dien. Apie 20 met dirba mrininku. Ligonio mama gyva. Tvas mir 58 m.
dl plaui vio.
Bendra bkl patenkinama, priverstina gulima padtis ant deinio ono. Kvpuojant dein krtins lstos pus atsilieka lyginant su
kaire. Kvpavimo danis 20 k./min. Palpuojant krtins lstos elastingumas normalus. Balsinis virpjimas deinje labai susilpnjs.
Perkutuojant deinje pagal l. medioclavicularis dextra, l.axillaris anterior, media, posterior, bei l. scapularis emiau IV onkaulio duslus
garsas. Auskultuojant ioje zonoje alsavimo negirdti. irdies susitraukim danis 90 k./min., arterinis kraujospdis 120/80 mmHg.
Kepen Kurlovo ordinats 1097. Pilvas palpuojant minktas, neskausmingas. Kepen ir blunies krato neuiuopta. Kojose edem nra.
Tyrimai
Bendras kraujo tyrimas: Hb 140 g/l; Er. 4,21012/l; leukocit 8,2109/l. Leukograma: neutrofilai 72 %, limfocitai 20%, monocitai 8
%.
Tiesin ir onin krtins lstos rentgenograma. Deinje emiau IV onkaulio matyti stria skysio (Damuazo) linija, tarpuplautis kiek
pasistmjs kair.
1) Kok sindrom tariate ir kodl?
2) Kaip interpretuosite skundus ir fizikinio tyrimo duomenis?
3) Kaip interpretuosite periferinio kraujo tyrimo duomenis?
4) Kaip paaikinsite radiologinius pokyius?
5) Koki pagalb teiktumte pacientui?
6) Koki tikits pleuros punktato tyrimo duomen?

Antroji situacija
74 m. vyras, pensininkas, skundiasi, kad po endoskopins procedros keldamasis nuo manipuliacij stalo, pacientas pajuto intensyv dusul
ir skausm deinje krtins lstos pusje.
Pacientas guli ligoninje dl virkinamojo trakto patologijos. Jam nustatyta dvylikapirts arnos opa. Po gydymo pacientui atlikta kontrolin
fibroezofagogastroduodenoskopija. Po ios procedros pacientas pajuto mintus pojius. Gydytojas endoskopuotojas, atliks procedr,
teigia, kad tyrimas prajo be komplikacij. Buvusi opa dvylikapirtje arnoje ugijusi.
Pacientas sirgs miokardo infarktu (prie 5 metus), dvylikapirts arnos opa (nustatyta pastaruoju metu), plaui udegimu, ltiniu
bronchitu. Pacientas rko apie 40 met po 20 cigarei per dien. Veds, turi du suaugusius vaikus. Paciento tvai mir: motina dl smegen
insulto, tvas dl miokardo infarkto.
Bendra bkl sunki, priverstin sdima padtis. Lpose ir veide cianoz. Kvpavimo danis 30 k./min. Dein krtins lstos pus
kvpavimo judesi metu atsilieka. Balsinis virpjimas deinje inyks. Perkutuojant deinje timpanitas. Auskultuojant deinje alsavimo
negirdti. Bronchofonija inykusi. SD 120 k./min., AKS 80/40 mmHg.
Skubiai atlikti tyrimai. Apvalginje krtins lstos rentgenogramoje oras pleuros ertmje. Tarpuplautis pasistms kair.
1) Kok sindrom tariate ir kodl?
2) Kokia io sindromo patogenez ir semiotika?
3) Ar siejate vykusi komplikacij su atlikta procedra? Ar i komplikacij laikote jatrogenine?
4) Kaip traktuosite fizikinius ir radiologinius tyrimo duomenis?
5) Koki pagalb pacientui skubiai suteiktumte?

Problemos esm: skystis pleuros ertmje, oras pleuros ertmje.

Klinikiniai poymiai: skausmas krtinje, duslus garsas perkutuojant, dusulys, timpanikas garsas perkutuojant.
Tikslas. Imokti skysio ir oro kaupimosi pleuros ertmje etiopatogenez, morfologij, klinikinius poymius.
Mokti krtinplvs anatomij. (A)

Kiekvien plaut i vis pusi, iskyrus plaui vartus, dengia serozinis maias, vadinamas krtinplve, pleura. Ji sudaryta i dviej lap
pasienins krtinplvs, pleura parietalis, ir plautins krtinplvs, pleura pulmonalis.
Pasienin krtinplv ikloja krtins lstos sienas ir suauga su krtins vidaus fascija, fascia endothoracica.
Plautin krtinplv dengia plaut i vis pusi, lenda skiltis skirianius plyius ir suauga su plauio paviriumi.
Ties plaui vartais pasienin krtinplv pereina plautin krtinplv. Tarp abiej lap yra siauras plyys, vadinamas krtinplvs ertme,
cavum pleurae. Joje yra apie 20 ml. Skysio, kuris sudrkina vienas kit atkreiptus krtinplvs lap pavirius, paslidina juos, nes kvpuojant
jie trinasi.
Krtinplvs dalys
Pasienin krtinplv priklausomai nuo to, koki krtins lstos sien ji ikloja, skirstoma 3 dalis.
onkaulius dengia onkaulin krtinplv, pleura costalis.
 Diafragm diafragmin krtinplv, pleura diaphragmatica.
Tarpuplaut tarpuplautin krtinplv, pleura mediastinalis.
Tarpuplauio krtinplv apsupa plauio akn ir emiau jo sudaro dublikatr, kuri nutsta emyn kaip plauio raitis, lig. pulmonale. Plauio
virns srityje pasienin krtinplv ikyla vir apertura thoracica superior 3 cm ir sudaro krtinplvs kupol, cupula pleurae, kurio forma
atitinka plauio virn.
Krtinplvs kiens
Tarp diafragmos, kuri sudaro vir igaubt kupol, ir krtins lstos sien yra gilios kiens. Jas, kaip ir kitas krtins lstos sienas, ikloja
pasienin krtinplv. ios kiens vadinamos krtinplvs kienmis, recessus pleurales. Skiriamos dvi svarbesns kiens:
Giliausia yra onkaulin diafragmos kien, recessus costodiaphragmaticus. Ji yra tarp onkaulins krtinplvs apatinio krato ir
diafragmos. ios kiens forma pusratin, nes ji juosia plaut i priekio, ono ir upakalio.
Kita kien susidaro tarp onkaulins ir tarpuplautins krtinplvi. onkaulin tarpuplauio kien, recessus costomediastinalis, yra
i abiej krtinkaulio pusi, ties 4 ir 5 tarponkauliais. Ji labai nedidel apie 4cm ilgio ir apie 1,5 cm ploio.
Krtinplvs kiens, kaip plyiai, atsiranda kaip tik tuo metu, kai plautis, kvpus oro, upildo jas. Paprastai kieni srityje atitinkamos
krtinplvi dalys yra susiglaudusios viena su kita.
Krtinplv sudaro hermetikus plaui maius, todl svarbi kvpavimui. Dehermetizavus krtinplvs ertm, kvpavimas negalimas.
Dl raumen veiklos padidjus krtins lstai, nuo plauio atsitraukia pasien. krtinplv. Jos ertmje pasidaro neigiamas slgis, dl to toks pat
slgis atsiranda ir plaui alveolse bei kvp. takuose. Atmosferos oras veriasi upildyti sumajusio slgio zon, ir plautis pasyviai isipuia.

Topografija:
Krtinplvs ribos iek tiek skiriasi nuo plaui rib. Priekin deiniosios krtinplvs riba eina 0,5-1 cm medialiau j atitinkanios priekins
plauio ribos. Todl nuo jungties tarp krtinkaulio rankenos ir kno priekin krtinplvs riba eina kairiau vidurins linijos iki VII onkaulio. Nuo
VII onkaulio ji pasuka dein pus ir, kryiuodamasi su onkauliais, sudaro apatin rib. Ties:
1. Linea medioclavicularis apatin riba susikryiuoja su VII onkauliu.
2. Ties linea axillaris anterior su VIII onkauliu.
3. Ties linea axillaris media su IX onkauliu.
4. Ties linea scapularis su XI onkauliu.
5. Ties linea paravertebralis su XII onkauliu. Nuo ia prasideda upakalin riba, kuri sutampa su tokia paia plaui riba.

Kairiosios krtinplvs priekin riba eina kairiau vidurins linijos. Tarp II ir IV onkauli abiej pusi krtinplvs suartja ir susilieia
sudarydamos tarpuplauio pertvar. Nuo IV onkaulio kairioji krtinplvs riba pasuka kair pus iki linea parasternalis ir toliau leidiasi
emyn iki VII onkaulio. Nuo ia prasideda apatin kairiosios krtinplvs riba, kuri tsiasi 1cm emiau analogikos deiniosios krtinplvs
ribos. Kairiosios krtinplvs upakalin riba sutampa su tokia paia plauio riba.

Pleuros inervacija:
Pasienin pleura (pleura parietalis) inervuojama taip kaip inervuojama siena, su kuria suauga pleura. Pvz.:didiausia pasienins dalies siena
sternocostalis, kuri inervuoja n.intercostalis, turi skausmo receptorius. Todl kol pasienin pleura netraukiama - skausmo dar nra, vliau
skausmas atsiranda bklei pasunkjus. Bet kartais dar daugiau pasunkjus bklei (pneumonija pleuros liga) gali skausmas ir inykti, nes tuo
metu atsiranda daugiau skysi, tuomet pleuros lapelis atoksta, nebra trinties nebra skausmo.
Pleura parietalis suaugusi su diafragma, j inervuoja kaip ir diafragm n.phrenicus, ateina i kaklinio razginio.
Pleura parietalis suaugusi su tarpuplauiu, inervuojama didelia dalimi kaip diafragma.
Pleura parietalis turi pleuros kupol, inervuojama kaip ir kiti pasienins pleuros lapai.
U pleuros kupolo yra vaigdinis mazgas, i jo ieina simpatins skaidulos aprpina: ausies, kaklo, peties ir rankos sistemas.
Ties plaui aknimi pasienin pleura virsta visceraline pleura arba atvirkiai. Pasibaigus onkauliams, tarponkauliniai nervai nepasibaigia, jie
tsiasi iki priekins pilvo sienos ir j inervuoja.
Perkusijos bdu nustatomi trys kepen matavimai (Kurlovo ordinats), i kuri sprendiama apie kepen dyd. Ligonis guli ant
nugaros, kojos sulenktos per kelius, rankos nuleistos prie on.
Pirmasis matavimas nustatomas perkutuojant ties l. medioclavicularis dextra vertikaliai emyn. Ligoniui gulint ant nugaros. Pirtas
plesimetras dedamas tarponkaulinius tarpus. Pirmas ordinats takas yra vieta, kur plaui gars pakeiia duslesnis garsas (pirtas
plesimetras tuo metu jau yra vir kepen). Antras takas nustatomas perkutuojant i apaios nuo bambos linijos vertikaliai auktyn ties l.
medioclavicularis dextra, kol timpanik pilvo gars pakeiia duslus kepen garsas. Pirtas plesimetras dedamas horizontaliai. Normalus
atstumas tarp abiej tak yra 9 cm.
Antroji Kurlovo ordinat nustatoma perkutuojant ties l. mediana. Virutins ordinats takas yra ties vidurins linijos susikirtimu su
pirmos ordinats virutinio tako horizontalija linija. Apatinio tako vieta nustatoma perkutuojant vertikaliai auktyn ties vidurine linija, kol
timpanik gars keiia duslus garsas. Normali antroji Kurlovo ordinat yra 8 cm.
Reiau nustatoma treioji Kurlovo ordinat, kurios virutinis takas sutampa su antrosios ordinats virutiniu taku. Apatinis takas
surandamas perkutuojant auktyn iilgai striins linijos, ivestos tarp virutinio tako ir kairiojo onkauli lanko susikirtimo su l. parasternalis
sin. Normali treioji ordinat yra 7 cm.
Istudijuoti pleuros histologij. (H)

Krtinplv, arba pleura sudaryta i skaidulinio jung aud ploktels, iklotos mezoteliu
Visceralinis pleuros lapelis dengia plaui iorin paviri ir jame galima aptikti penkis sluoksnius:
Iorinis ploki mezotelio lsteli sluoksnis;
Siaura sritis puraus jungiamojo audinio, be nustatomos pamatins ploktels tarp jo ir mezotelio;
Netaisyklingas iorinis elastinis sluoksnis;
Tarpinis sluoksnis puraus jungiamojo audinio su kraujagyslmis, limfagyslmis ir nervais bei trupuiu neruouotj raumen lsteli;
Nerykus vidinis elastinis sluoksnis su neilgomis elastinmis skaidulomis, kurios vietomis susipina su tarpalveolini pertvar elastinmis
skaidulomis.
Pasieninis pleuros lapelis. Pavirius padengtas mezoteliu, turi tik vien sluoksn elastini skaidul. Po pasienine pleura yra sluoksnis riebalinio
jungiamojo audinio, po kuriuo glaudusis netaisyklingas jungiamasis audinys, besitsiantis onkauli antkaul ir tarponkaulini raumen
perimyz. Pasienin pleura yra gausiai inervuota juntamosiomis nervinmis skaidulomis, plaui pleuros lapelis gauna tik ANS nervines
skaidulas.
Krtinplv geba gaminti maai skysio, kuris vilgo jos paviri ir padeda lengvai judti krtinplvs lapeliams kvpavimio metu.
Plaui pneumotorakso susidarymo mechanizmus ir j reikm. (F)

Pneumotoraksas, jo etiologija, patogenez, organizmo funkcij sutrikimai.

Pneumotoraksas yra udaras, atviras, votuvinis.
Jis gali atsirasti:
1) Udegimins ligos (pvz., plaui tuberkulioz, plaui udegimas ir kt.),
2) vykus pirminiam spontaniniam pneumotoraksui, jei plyta psl (pvz. esant emfizemai), ar antriniam spontaniniam, kur lemia LOPL;
3) Oras gali kauptis pleuros ertmje ir traumos metu paeidus sienin pleur. (pvz., lus onkauliams, sueidus krtins lst peiliu, kulka)
4) jatrogenins prieastys (diagnostikos ir gydymo metu sukeltas pneumotoraksas)
5) paveldimos ligos (pvz., Marfano sindromas)
6)spontanins prieastys. Spontaninis pneumotoraksas gali atsirasti sunkiai dirbantiems arba kilnojantiems sunkumus jauniems monms
(atrodantiems sveikais). Taiau daniausiai spontaninis pneumotoraksas susidaro trkus gimtai plaui cistai arba pslei.
Pneumotorakso metu pleuros ertm pateks oras dirgina pleuros receptorius, mechanikai spaudia krtins lstos organus. Oras tampa
savotiku svetimkniu krtins lstoje.
Esant pneumotoraksui mons skundiasi miu dusuliu, bei paeistos puss krtins lstos skausmu(stiprus, duriantis, plintantis kakl, pet,
rank.) Ligon vargina kosulys (kartais atkosima skrepli su kraujo priemaiomis ar tiesiog vieio, putoto kraujo). padanjs, pavirinis
kvpavimas, padanjusi irdies veikla, oro susikaupimas tarpuplautyje, kakle, krtins sienoje (poodin emfizema). Ligonis bna ipiltas alto
prakaito, isigands, iblyks.

Apirjus matyti krtins lstos asimetrija, priverstine sdima padtis, padanjs kvpavimas, gali matytis cianoz. Esant pneumotoraksui
dl krtins sienos paeidimo, matoma aizda krtins sienoje, per kuri galime girdti tekant or. Paeista pus nedalyvauja kvpavime.
Perkusijos metu lokalus timpanikas garsas. Pneumotoraksas skirstomas udar (udaro pneumotorakso metu paeista pleura usitraukia,
pateks ertm truputis oro rezorbuojasi ir plautis vl isipleia), atvir (pro atvir aizd oras laisvai patenka ir ieina i pleuros ertms, plautis
sublikta ir nebekvpuoja), votuvin (aizda neileidia kvpto oro). Esant udaram ar atviram pneumotoraksui, dl padidjusio slgio
pleuros ertmje vyksta plaui kolapsas, dl kurio iuo plauiu ligoniui nebemanoma kvpuoti, net jei kvpavimo takai laisvi. Dar
pavojingesnis votuvinis pneumotoraksas (anglikai tension pneumothorax), kuomet plauiuose susiformuoja vienpusis votuvas,
praleidiantis or i pleuros ertm kvpimo metu ir udarantis jo ijim ikvpimo metu. Kiekvieno kvpimo metu didja oro slgis pleuros
ertmje, progresuoja plauio ir cirkuliacinis kolapsas. Didja krvis deiniai irdiai, trinka kraujo cirkuliacija kne, bei kvpavimas. Rykja
cianoz. Pneumotoraksas gali bti kaip atskira patologija arba eiti kartu su hidrotoraksu, tada vadintsi pneumohidrotoraksas.
Pneumotoraksas gali buti vienpusis arba abipusis.

Oro kaupimosi pleuros ertmje patogenez. Skysio kaupimosi pleuros ertmje patogenez. Pleuros funkcijos
sutrikimus. Pneumotoraks, jo etiologij, patogenez, organizmo funkcij sutrikimus. Hidrotoraks, jo etiologij,
patogenez, organizmo funkcij sutrikimus. (PF)

Pleuritas (Pleuritis)

Pleuritas tai bkl, kai pakenkiama pleura, plauius dengiantis dangalas. J sudaro 2 sluoksniai tarp kuri yra ertm, vadinama pleuros
ertme.

Pleurito klasifikacija:
Skiriami ie pleurito tipai:
Eksudacinis pleuritas- tai vairi lig sukelta bkl, pasireikianti pleuros lapeli udegimu ir/ ar skysio susikaupimu pleuros ertmje.
Skystis gali bti su arba be kraujo priemaios;
Sausasis pleuritas tai pleuros paeidimas, kai negaminamas pleuros skystis ir vyrauja pleuros lapeli trintis;
Plinis pleuritas pleuros ertmje kaupiasi pliai.
 Pleuritas gali bti mios arba ltins eigos. Taip pat klasifikuojama ir pagal pleurito lokalizacij plaui atvilgiu.

Kodl kaupiasi skystis pleuros ertmje?

Pleuritas gali bti daugelio kit lig komplikacija. Daniausios prieastys, kai skystis kaupiasi pleuros ertmje:
Infekcija (pleuritas atsiranda sergant plaui udegimu, tuberkulioze);
Sutrikusios plaui kraujotaka ir limfotaka (vairios bkls, kurios sukelia staz plauiuose, plaui arterijos trombin embolija);
Inkst ligos;
Kepen ciroz;
Navikinis pleuros lapeli paeidimas (plaui vys, kit organ vio metastazs, pleuros mezotelioma);
Pleuros lapeli vientisumo paeidimas dl traumos;
Imuninis pleuros lapeli udegimas (sistemins jungiamojo audinio ligos, vaskulitai);
mus pankreatitas.
Negydant ar netinkamai gydant antibiotikais eksudacin pleurit, pleuros skystyje labai greitai gali atsirasti bakterij. Taip isivysto plinis
pleuritas arba pleuros empiema. Jei plinis pleuritas negydomas, tarp pleuros lapeli susidaro vis daugiau saug. Kai j susidaro daug,
sutrikdomas plaui paslankumas.

Kokie pleurito simptomai?

Sausas kosulys atsiranda, kai daug skysio susikaupia pleuros ertmje;
Dusulys;
Krtins lstos skausmas daniausiai ligos pradioje. Skausmas paprastai prasideda staiga, yra duriantis, daniausiai po paastimi.
Kariavimas;
Labai irykja kvpavimo nepakankamumo poymiai.
Kaip diagnozuojamas pleuritas?

Gydytojas pagrindinius pokyius jau nustato klinikinio tyrimo metu. Toje vietoje, kur yra susikaup skysio nesigirdi alsavimo klausant
stetostkopu. Gali girdtis specifinis pleuros trynimosi garsas.

Pirmiausia atliekama krtins lstos rentgenograma, kuri parodo skysio buvim aplink plauius. Tyrim patikslina kompiuterin
tomograma. Taip pat j atlikus galima nustatyti, ar nra kitos plaui ligos, kuri sukl pleurit. Pagal kompiuterin tomograf sudtingesniais
atvejais galima parinkti pleuros punkcijos viet.

Pleuros ertms ultragarsas padeda nustatyti net ir nedidel skysio kiek pleuros ertmje. iuo tyrimu galima pamatyti prasidedanias
komplikacijas. Pleuros ertms ultragarso metu paymima pleuros ertms punkcijos vieta. Jis labai svarbus, kai skysio nra daug, yra saug,
padidjusios kepenys ar blunis, ligonis nutuks, yra diafragmos paralyius.

Kaip gydomas pleuritas?

Gydymas priklauso nuo ligos kilms. Kartais skystis gali ir inykti pats, bet daniausiai reikia vairi gydymo metod.
Jei skysio kiekis nemaas, rekomenduojama atlikti pleuros punkcij ir nuleisti dal skysio. Pirmosiomis dienomis pleuros ertms punkcijos
atlikti nerekomenduojama, kai yra:
irdies nepakankamumas;
Skystis abiejose pleuros ertmse, taiau nra minio kvpavimo nepakankamumo poymi;
Plaui udegimas ir nedidelis skysio kiekis;
Plaui arterijos trombin embolija ir nedidelis skysio kiekis.
Kai skystis pleuros ertmje kaupiasi sergant plaui udegimu, skiriama antibiotik bei esant reikalui pleuros punkcija. Jei yra komplikacij,
reikia pleuros ertm drenuoti. Susidariusias saugas galima alinti operacijos.

Visais atvejais btina skirti diet, kuri kompensuot prarastus riebalus, baltymus, riebaluose tirpius vitaminus ir elektrolitus.
Pleuros navikai:
1. Mezotelini lsteli navikai : Iplitusi piktybin mezotelioma , epitelioidin hemangioendotelioma,epitelioidin mezotelioma ,
sarkomatozin mezotelioma,desmoblastin mezotelioma, dvifaz mezotelioma, vietikai iplitusi piktybin mezotelioma, gerai
diferencijuota papilin mezotelioma ir t.t.
2. Limfoproliferacins ligos: pirmin pleuros limfoma, piotoraksas sukeltas piktybins limfomos.
3. Mezenchimins kilms navikai: epitelioidin hemangioendotelioma, angiosarkoma,sinovijin pleuros sarcoma, solitarinis fibrozinis
pleuros navikas, ir t.t

Mezotelioma
Mezotelioma yra vio tipas, kuriuo suserga mons dl tam tikr asbesto mediag poveikio. i liga vystosi plauiuose, pilvaplvje ir irdyj,
todl mezotelioma skirstoma dar tris tipus.
- Piktybin pleuros mezotelioma: ji vystosi plauiuose. Statistikai is mezoteliomos tipas yra labiausiai paplits.
- Piktybin peritonin mezotelioma: vystosi pilvaplvje.
- Piktybin perikardo mezotelioma: manoma, kad is mezoteliomos tipas diagnozuojamas 5 proc. mezotelioma sergani moni. Perikardo
mezotelioma vystosi irdies plvje ar ird supanioje membranoje.
Susirgimo prieastys. Mezotelioma viena i nedaugelio vio tip, kuris turi aikias susirgimo prieastis. Moksliniais tyrimais rodyta,kad
onkologin susirgim sukelia asbestas. Simptomai. Mezoteliomos simptomai pasireikia ne i karto. Turjus kontakt su asbestu, simptomai gali
pasireikti tik po 25 ar 50 met. i liga vystosi labai ltai. Mezoteliomos tip simptomai skiriasi, bet yra keletas bendr:
- dusulys;
- krtins skausmas;
- nuolatinis kosulys;
- krtins voktimas;
- pilvo patinimas;
- pilvo skausmas;
- arnyno proi pakitimai;
- padidjusi pilvo apimtis.

Dauguma i ios ligos simptom nra specifiniai, t.y. jei juos pajutote, nebtinai jums mezotelioma. Taiau, jei tariate, kad anksiau turtas
kontaktas su asbestu, gali bti i simptom prieastis, pasakykite tai savo gydytojui ir papraykite, kad jums bt atlikti isams tyrimai dl
mezoteliomos. Bet kuriuo atveju, labai svarbu, kad js gydytojas inot, kad js turite ar turjote kontakt su asbestu.
Diagnostika. Mezoteliom diagnozuoti yra sunku, nes ligos simptomai yra labai panas daugelio kit lig. Jums gali bti pasilyta atlikti
krtins lstos rentgen, kuris paprastai yra pirmasis ingsnis siekiant gauti diagnoz susijusi su plaui ligomis. Daugeliui moni sergani
mezotelioma randama skysi tarp plaui ir krtins. Todl jums gali bti paskirti kiti tyrimai, siekiant gauti kuo aikesn js negalavim
vaizd - kompiuterin tomografija, magnetinis rezonansas ir pan. Galiausiai jums bus atliekama biopsija, kuri patvirtins arba paneigs, kad
sergate viu. Vliau seka tyrimai nustatantys, kiek vys yra paengs ir sudaromas gydymo planas.
Gydymas. Jis priklauso nuo daygybs veiksni - kiek liga yra paengusi, koks paciento amius ir kokia jo bendra sveikatos bkl. Daugeliu
atvej, yra skiriama operacija ir kompleksinis gydymo metod taikymas. Pacientams, kuriems susikaup skysiai, skiriama skysi nusausinimo
procedra pleurodez. Ji palegvina gyvenimo kokyb, sumaina skausm ir diskomfort.
Mezoteliomai gydyti jums gali bti skiriama chemoterapija ir radioterapija.
Pneumotorakso gydymas:
Pneumotoraks turi gydyti gydytojas! Savaiminis pasveikimas galimas tik esant nerykiam pneumotoraksui, visais kitais atvejais btinas
gydymas. Gydymo parinkimas priklauso nuo ligos prieasties. Gydymo tikslas paalinti or i pleuros ertms, padaryti j hermetika; paalinti
pneumotoraks suklusi prieast (pvz., jei ligos prieastis yra tuberkulioz, reikia imtis adekvataus prietuberkuliozinio gydymo). Daniausiai
pneumotoraks pavyksta pagydyti pleuros ertms drenavimu. Esant pasikartojaniam savaiminiam pneumotoraksui, isivysius jo
komplikacijom (pvz., kraujavimui), plautyje esant didelms cistoms ar plms, nepasveikus per 7 dienas po pleuros ertms drenavimo,
taikomas operacinis gydymas. Operacijos metu pirmiausiai surandama pneumotorakso prieastis, nuo kurios priklauso operacijos pobdis. Kai
gydymas yra netinkamas arba pavluotas, pneumotoraksas gali komplikuotis hematoraksu (kraujas pleuros ertmje), piopneumotoraksu (pliai
pleuros ertmje), plaui nepakankamumu.
The treatment of pneumothorax depends on a number of factors, and may vary from discharge with early follow-up to immediate needle
decompression or insertion of a chest tube. Treatment is determined by the severity of symptoms and indicators of acute illness, the presence
of underlying lung disease, the estimated size of the pneumothorax on X-ray, and - in some instances - on the personal preference of the
person involved.
In traumatic pneumothorax, chest tubes are usually inserted. If mechanical ventilation is required, the risk of tension pneumothorax is greatly
increased and the insertion of a chest tube is mandatory. Any open chest wound should be covered, as it carries a high risk of leading to
tension pneumothorax. Ideally, a dressing called the "Asherman seal" should be utilized, as it appears to be more effective than a standard
"three-sided" dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a valve-like mechanism,
allows air to escape but not to enter the chest. Tension pneumothorax is usually treated with urgent needle decompression. This may be
required before transport to the hospital, and can be performed by an emergency medical technician or other trained professional. The needle
or cannula is left in place until a chest tube can be inserted. If tension pneumothorax leads to cardiac arrest, needle decompression is
performed as part of resuscitation as it may restore cardiac output.
Conservative
Small spontaneous pneumothoraces do not always require treatment, as they are unlikely to proceed to respiratory failure or tension
pneumothorax, and generally resolve spontaneously. This approach is most appropriate if the estimated size of the pneumothorax is small
(defined as <50% of the volume of the hemithorax), there is no breathlessness, and there is no underlying lung disease. It may be appropriate
to treat a larger PSP conservatively if the symptoms are limited. Admission to hospital is often not required, as long as clear instructions are
given to return to hospital if there are worsening symptoms. Further investigations may be performed as an outpatient, at which time X-rays
are repeated to confirm improvement, and advice given with regard to preventing recurrence (see below). Estimated rates of resorption are
between 1.25% and 2.2% the volume of the cavity per day. This would mean that even a complete pneumothorax would spontaneously
resolve over a period of about 6 weeks. Secondary pneumothoraces are only treated conservatively if the size is very small (1 cm or less air
rim) and there are limited symptoms. Admission to the hospital is usually recommended. Oxygen given at a high flow rate may accelerate
resorption as much as fourfold.
Aspiration
In a large primary spontaneous pneumothorax (>50%), or PSP associated with breathlessness, some professional guidelines recommend that
reducing the size by aspiration is equally effective as the insertion of a chest tube. This involves the administration of local anesthetic and
inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are removed. If there has been significant reduction in the
size of the pneumothorax on subsequent X-ray, the remainder of the treatment can be conservative. This approach has been shown to be
effective in over 50% of cases. Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital
admission significantly, without increasing the risk of complications.
Aspiration may also be considered in secondary pneumothorax of moderate size (air rim 12 cm) without breathlessness, with the difference
that ongoing observation in hospital is required even after a successful procedure. American professional guidelines state that all large
pneumothoraces - even those due to PSP - should be treated with a chest tube. Moderately sized iatrogenic traumatic pneumothoraces (due
to medical procedures) may initially be treated with aspiration.
Chest tube
A chest tube (or intercostal drain) is the most definitive initial treatment of a pneumothorax. These are typically inserted in an area under the
axilla (armpit) called the "safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of
the nipple and two muscles of the chest wall (latissimus dorsi and pectoralis major). Local anesthetic is applied. Two types of tubes may be
used. In spontaneous pneumothorax, small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the Seldinger technique, and
larger tubes do not have an advantage. In traumatic pneumothorax, larger tubes (28 F, 9.3 mm) are used.
Chest tubes are required in PSP that have not responded to needle aspiration, in any SSP that is large (>50%), and in cases of tension
pneumothorax. They are connected to a one-way valve system that allows air to escape, but not to re-enter, the chest. This may include a
bottle with water that functions like a water seal, or a Heimlich valve. They are not normally connected to a negative pressure circuit, as this
would result in rapid re-expansion of the lung and a risk of pulmonary edema ("re-expansion pulmonary edema"). The tube is left in place until
no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung.
If after 24 days there is still evidence of an air leak, various options are available. Negative pressure suction (at low pressures of 10 to
20 cmH2O) at a high flow rate may be attempted, particularly in PSP; it is thought that this may accelerate the healing of the leak. Failing this,
surgery may be required, especially in SSP.
Chest tubes are used first-line when pneumothorax occurs in people with AIDS, usually due to underlying pneumocystis pneumonia (PCP), as
this condition is associated with prolonged air leakage. Bilateral pneumothorax (pneumothorax on both sides) is relatively common in people
with pneumocystis pneumonia, and surgery is often required.
Pleurodesis and surgery
Pleurodesis is a procedure that permanently obliterates the pleural space and attaches the lung to the chest wall. The best results are achieved
with a thoracotomy (surgical opening of the chest) - with identification of any source of air leakage and stapling of blebs - followed by
pleurectomy (stripping of the pleural lining) of the outer pleural layer and pleural abrasion (scraping of the pleura) of the inner layer. During
the healing process, the lung adheres to the chest wall, effectively obliterating the pleural space. Recurrence rates are approximately 1%.A less
invasive approach is thoracoscopy, usually in the form of a procedure called video-assisted thoracoscopic surgery (VATS). The results from
VATS-based pleural abrasion are slightly worse than those achieved using thoracotomy, but produce smaller scars in the skin. Compared to
open thoracotomy, VATS offers a shorter in-hospital stays, less need for postoperative pain control, and a reduced risk of lung problems after
surgery. VATS may be also be used to achieve chemical pleurodesis; this involves insufflation of talc, which activates an inflammatory reaction
that causes the lung to adhere to the chest wall.
If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical pleurodesis, specifically talc or the
antibiotic tetracycline. Results of chemical pleurodesis tend to be worse than when using surgical approaches, but talc pleurodesis has been
found to have few negative long-term consequences in younger people.
Aftercare
If pneumothorax occurs in a smoker, this is considered an opportunity to emphasize the markedly increased risk of recurrence in those who
continue to smoke, and the many benefits of smoking cessation. It may be advisable for someone to remain off work for up to a week after a
spontaneous pneumothorax. If the person normally performs heavy manual labor, several weeks may be required. Those who have undergone
pleurodesis may need two to three weeks off work to recover.
Air travel is discouraged for up to seven days after complete resolution of a pneumothorax if recurrence does not occur. Underwater diving is
considered unsafe after an episode of pneumothorax unless a preventative procedure has been performed. Professional guidelines suggest
that pleurectomy be performed on both lungs and that lung function tests and CT scan normalize before diving is resumed. Aircraft pilots may
also require assessment for surgery.

Hidrotorakso gydymas
Treatment of hydrothorax is difficult for several reasons. The underlying condition needs to be corrected, however often the source of the
hydrothorax is end stage liver disease and corrected only by transplant. Chest tube placement should not occur. Other measures such as a TIPS
procedure are more effective as they treat the etiology of the hydrothorax, however have complications such as worsened hepatic
encephalopathy.
Skysio kaupimosi pleuros ertmje etiologij, morfologinius pakitimus, pleuros punktato citologin tyrim. (PA)

Pleural effusion (skystis pleuros ertmje) is a common manifestation of both primary and secondary pleural diseases, which may be
inflammatory or noninflammatory. Normally, no more than 15 ml of serous, relatively acellular, clear fluid lubricates the pleural surface.
Accumulation of pleural fluid occurs in the following settings:
1) Increased hydrostatic pressure, as in congestive heart failure;
2) Increased vascular permeability, as in pneumonia;
3) Decreased osmotic pressure, as in nephrotic syndrome;
4) Increased intrapleural negative pressure, as in atelectasis;
5) Decreased lymphatic drainage, as in mediastinal carcinomatosis.

Inflammatory pleural effusions

Serous, serofibrinous, and fibrinous pleuritis all are caused by essentially the same processes. Fibrinous exudations generally reflect a
later, more severe exudative reaction that, in an earlier developmental phase, might have presented as a serous or serofibrinous exudate.
The common causes of pleuritis are inflammatory diseases within the lungs, such as tuberculosis, pneumonia, lung infarcts, lung abscess,
and bronchiectasis. Rheumatoid arthritis, disseminated lupus erythematosus, uremia, diffuse systemic infections, other systemic disorders,
and metastatic involvement of the pleura can also cause serous or serofibrinous pleuritis. Radiation used in therapy for tumors in the lung or
mediastinum often causes a serofibrinous pleuritis. In most instances the serofibrinous reaction is only minimal, and the fluid exudate is
resorbed with either resolution or organization of the fibrinous component. Accumulation of large amounts of fluid can sufficiently encroach
on lung space to cause respiratory distress.
A purulent pleural exudate (empyema) usually results from bacterial or mycotic seeding of the pleural space. Most commonly, this
seeding occurs by contiguous spread of organisms from intrapulmonary infection, but occasionally, it occurs through lymphatic or
hematogenous dissemination from a more distant source. Rarely, infections below the diaphragm, such as the subdiaphragmatic or liver
abscess, may extend by continuity through the diaphragm into the pleural spaces, more often on the right side.
Empyema is characterized by loculated, yellow-green, creamy pus composed of masses of neutrophils admixed with other leukocytes.
Although empyema may accumulate in large volumes (up to 500 to 1000 ml), usually the volume is small, and the pus becomes localized.
Empyema may resolve, but this outcome is less common than organization of the exudate, with the formation of dense, tough fibrous
adhesions that frequently obliterate the pleural space or envelop the lungs; either can seriously restrict pulmonary expansion.
True hemorrhagic pleuritis manifested by sanguineous inflammatory exudates is infrequent and is found in hemorrhagic diatheses,
rickettsial diseases, and neoplastic involvement of the pleural cavity. The sanguineous exudate must be differentiated from hemothorax
(discussed later). When hemorrhagic pleuritis is encountered, careful search should be made for the presence of exfoliated tumor cells.

Noninflammatory pleural effusions

Noninflammatory collections of serous fluid within the pleural cavities are called hydrothorax. The fluid is clear and straw (gelsvas)
colored. Hydrothorax may be unilateral or bilateral, depending on the underlying cause. The most common cause of hydrothorax is cardiac
failure, and for this reason it is usually accompanied by pulmonary congestion and edema. Transudates may collect in any other systemic
disease associated with generalized edema and are therefore found in renal failure and cirrhosis of the liver.
The escape of blood into the pleural cavity is known as hemothorax. It is almost invariably a fatal complication of a ruptured aortic
aneurysm or vascular trauma or it may occur post-operatively. Pure hemothorax is readily identifiable by the large clots that accompany the
fluid component of the blood.
Chylothorax is an accumulation of milky fluid, usually of lymphatic origin, in the pleural cavity. Chyle is milky white because it contains
finely emulsified fats. Chylothorax is most often caused by thoracic duct trauma or obstruction that secondarily causes rupture of major
lymphatic ducts. This disorder is encountered in malignant conditions arising within the thoracic cavity that cause obstruction of the major
lymphatic ducts. More distant cancers may metastasize via the lymphatics and grow within the right lymphatic or thoracic duct to produce
obstruction.

Pleuros punktato tyrimas (i vidligi)

tarus skyst pleuros ertmje ir patikslinus jo viet krtins lstos rengenologiniu ar ultragarsiniu tyrimu, atliekama pleuros ertms
punkcija. Ji yra btina norint nustatyti pleuros skysio pobd (transudatas ar eksudatas), tarus plaui ar pleuros v, tuberkulioz.
Punkcija atliekama VI-VII tarponkauliniame tarpe, l. axillaris posterior arba l. scapularis projekcijoje, pagal virutin onkaulio krat.
Pleuros punktato tyrimo etapai:
Fizinis tyrimas. Nustatoma: 1) skysio kiekis; 2) spalva; 3) skaidrumas; 4) lyginamoji mas.
Cheminis tyrimas. Nustatoma: 1) baltym koncentracija; 2) Rivalto mginys; 3) kokybin reakcija udegiminiam baltymui
(seromucinui) nustatyti; 4) LDH konc.; 5) cholesterolio konc.; 6) gliukozs konc.; 7) pH.
Citologinis tyrimas skirtas punktato lsteli sudiai nustatyti. Daytame tepinlyje galime rasti i lsteli:
1) v. ri leukocit: pneumonijai ir TBC pradiai bdingi neutrofilai; daug limfocit randama sergant TBC, reumatoidiniu
artritu, viu;
2) makrofag;
3) mezotelini lsteli bdingos vio metastazms seroziniuose dangaluose, TBC;
4) atipini (navikini) lsteli;
5) ternbergo gigant (stambi lsteli, turini 1-2 branduolius, bding Hodkino limfomai);
6) > 100000 eritrocit/mm3 rodo, jog galima plaui TBC, navikas, PATE.
Bakteriologinis tyrimas iekoma TBC mikobakterij, kit infekcijos suklj. Transudate paprastai bna < 1000 udegimini
lsteli/mm3, eksudate - > 10000 lsteli/mm3.
Pleuros punktato tyrimo vertinimas:
Tyrimas Transudatas Eksudatas
Lyginamoji mas < 1,015 > 1,015
pH > 7,30 < 7,30
Baltymas (g/l) < 30 > 30
Punktato baltymas/kraujo baltymas < 0,5 > 0,5
LDH (VV/l) < 200 > 200
Punktato LDH/kraujo LDH < 0,6 > 0,6
Cholesterolis (mmol/l) < 1,56 > 1,56
Gliukoz (mmol/l) 3,33-5,55
Rivalto mginys Neigiamas Teigiamas

Radiologinius skysio pleuros ertmje pokyius totalinio ir riboto pritemimo rentgenosemiotinius sindromus.
Skysio sankaupos pleuros ertmje echovaizd ir kiekio matavimo technik. Radiologinius oro pleuros ertmje
pokyius plaui lauko paviesjimo rentgenosemiotinius sindromus. (R)

Kaip ir esant hidrotoraksui, radiologinis vaizdas priklausys rentgenologinio tyrimo projekcijos, paciento pozicijos, buvimo arba nebuvimo
pleuros adhezijos ir lokalizacijos. Sdiniam pacientui oras kyla pleuros ertme auktyn ir atskiria plauius nuo krtins sienos.

Pneumatorakso rentgenologiniai poymiai :

1. Paviesjimo lauke nesimato plaui pieinio ir matyti ryki suspausto plauio riba
2. Gali apimti vis plaut, iskyrus akn srit, kur matyti suspausto pl. elis
3. Jei plaut vietomis fiksuoja pleuros saugos matomi saug eliai.
4. Releatyviai padidjs paeisto hemitorakso tankis
5. Parykjusios paeistos puss tarpuplauio ir diafragmos ribos
6. Gils kostofreniniai sinusai
7. Irykja priekinis kostofreniniai sinusai
8. Rykja irdies ribos
9. Vir diafragmos matomas kolapsuoto plauio apatinis kratas
10. Ipsilateralins puss diafragmos nusileidimas
11. Esant labai ireiktam pneumatoraksui tarpuplauio organai yra stumiami sveik pus, paeisto plauio suspaudimas, diafragmos
spaudimas emyn.
12. Kai yra skysio hidropneumotoraksas (pneumopleuritas). horizontali skysio su oru riba. (skystis telkiasi apatinse pleuros
ertms dalyse tarp suspausto pauio ir KL sienels).

Kariavimas bdingas daugeliui kvpavimo lig. Taip pat eksudaciniam bei sausjam pleuritui.

Skausmas deinje krtins lstos pusje, gilja kvepiant sausojo pleurito pradioje bna stiprus ono skausmas dl pleuros lapeli trinties
(pleuros dirginimas udegimas, hiperemija fibrino ikritimas skausmas ir subfebrili temp.). Udegiminiam skysiui besikaupiant
lapeliai isiskiria ir skausmas inyksta. Sausasis pleuritas pereina eksudacin.

+ Priverstin onin gulima padtis ant nesveiko ono mainama lapeli trintis ir geriau gali judti sveikas plautis.

// kepenys padidj nestipriai.

Saikingas dusulys, stiprjantis esant sunkiam fiziniam krviui dl sumjusio kvpuojamojo paviriaus (aktyvios parenchimos). Tai
pulmonalinis dusulys.

inoti klinikin skysio pleuros ertmje diagnostik. inoti klinikin oro pleuros ertmje diagnostik, garso plitimo
slyg pokyius, pagalbos teikimo principus. (VL)