Kham và chua cac benh phoi

GS PHAM GiA Cl/GNG ■ KHAM V A CHtfA cAc B EN H PH O I GS PHAM GIA CU0NG KHANIVA CHUTA CAC BENH PHOI NHA XUAT BAN Y HOC HA NQI - 2005 Leri ntii dau Cuon sach “ K ham va chufa ca c benh p h o i” difdc viet de lam tai lieu hoc tap cho cac bac si chuyen khoa phoi sau dai hoc, cac bac s! noi khoa chung va sinh vien Dai hoc Y khoa Cac thong tin va ttf lieu sach da dUdc cap nhat nhiing tau y hoc m6i va diidc lila chon ky de cung cap nhflng kien thiic cd ban va tutdng doi du cho viec kham va chiia cac benh phoi thtfdng gSp Toi xin chan cam dn GS Dussert d Benh vien Cochin, Paris da vui long tra ldi cho phan “Hoi/Dap v i cac benh phoi" va cac GS.M.J.Ford va A.T.Elder d TrUdng Dai hoc Y khoa Edinburg, Edinburg da vui long cho dap an cua cac “Cau hoi tr^c nghiem ve benh phoi” Xin cam dn Nha xuat ban Y hoc da tao dieu kien de sach difdc sdm mat doc gia Chac chan cuon sach co nhieu thieu sot, xin cam dn cac dong nghiep va ban doc ve moi y kien nhan xet gs thAy th u c nhAn DAN Pham Gia Citing Chur viet tilt dung sach A -a D alveolar - arterial difference - hieu so O z phe nang mach mau ACE Angiotensin - converting enzyme - men chuyen angiotensin ACTH Adrenocorticotrophic thuong than ADH Antidiuretic hormone - hormon chtfng bai nieu ALAT Alanin aminotransferase ARDS Acute respiratory distress syndrome - hoi chftig suy ho hap cap tfnh ASAT Aspartat aminotransferase CMV Cytomegalovirrus - virus cir bao CPAP Continuous positive airway pressare - ap liic dudng thd dirdng tinh lien tuc CT Computed tomography - chup c it I6p vi tinh DLco Diffusing capacity for CO - kha nang khuech tan CO DOTS Directly observed treatment short course - dieu tri ngln han co kiem soat tri/c tiep ERV Exipiratory reserve volume - the tich du tri/ thci FEV, Forced expiratory volume in one second - the tich thci toi da giay dau tien hormone - Hormon ht/6ng vo F iO ? P ercentage of inspired - ty le ? hit vao FRC Functional residual capacity - dung tich can chCrc nang FVC Forced vital capacity - dung tich song gang sifc IRV Inspiratory reserve volum e - the tich dCr trCr the) vao LDH Lactat dehydrog enase MRI M agnetic resonance im aging - chup cong hifdng tir OT Old tuberculin - tuberculin cu PA02 Partial pressure of alveolar - ap lire rieng phan phe nang PA C 02 Partial pressure of alveolar C - ap lire rieng phan C phe nang Pa02 Partial pressure of arterial - ap life rieng phan mau dong mach PaC02 Partial pressure of arterial C - ap lire rieng phan C mau dong mach PAW P Pulmonary artery wedge pressure - ap lire dong mach phoi bjt tac PADP Pulmonary artery diastolic pressure - ap lire tam trirong dong mach phoi PCR Polymerase chain reaction - phan img chuoi polymerase PCWP Pulmonary capillary wedge pressume - ap lire mao mach phoi PEEP Postive end - expiratory pressure - ap lire diidng tinh cuoi thi thd PEF Peak expiratory flow - liru luong dinh PEFR Peak expiratory flow rate - cung li/dng dinh PPD Purified protein dervivative - dan xu£t protein tinh khiet RSV Respiratory syncitial virus - virus hop bao ho hap RV Residual volume - the tich can Sa02 Saturation of arterial - bao hoa mau dong mach TLC Total lung capacity - dung tich toan phoi TNF Tumor necrosis factor - yeu to hoai tCf khoi u TNM Tumor - nodes - metastasis - u - hach - di can TSH Thyroid stimulating hormone - hormone kich thich tuy£n giap TU Tuberculin unit - don vj tuberculin TV Tidal volume - th£ tich li/u thong UPPP Uvulopalatepharyngoplasty - tao hinh li/di ga - vom mieng - hong Muc luc ■ m Lai noi dau Chit viet tat dung sach 1.Mcfdau Phoi va ho hap 11 13 Phoi 13 Ho hap 14 Thong phoi 14 Trao doi phe nang-mao mach 15 Van chuyen 15 Dieu hoa ho hap 15 Ho hap te bao 17 Nhufng yeu to chan doan benh phoi 18 Kham lam sang 18 Ch&n doan hinh anh 26 Tham chilc nang phoi 28 Cac phifdng phap hinh thai hoc 33 Cac xet nghiem sinh hoc khac 41 Chieu va chup X quang phoi 44 Chieu X quang phoi 44 Hoc phmi X qu.'unK phoi eh man Doc plum X ijuang phoi benh ly N benh ph oi thu’dng gap Ap xe phoi x Benh phoi tac man tinh Benh bui phoi amian 91 91 93 96 ♦Gian phe quan 98 1Hen phe quan 100 Hoi chting ngifng thd ngu 104 Hoi chting suy ho hap cap 106 Lao ke 110 Lao phoi 116 Nghen mach phoi 125 Phu phoi 129 Benh sarcoid 131 Benh sot vet 135 Tran dich mang phoi 137 •Tran mang phoi 141 Ung thtf phe quan tien phat 144 Ung thvf phoi thti phat 151 Viem phe quan cap tinh 152 Viem phoi hit 152 Viem phoi Mycoplasma 15 g Viem phoi Pneumocystis carinii 159 Viem phoi vi khuan 161 Viem phoi virus 166 Xep phoi 171 Benh phoi ke lan toa 173 Thuoc chufa benh phoi 176 Thuoc ho 176 Thuoc long ddm 177 Thuoc gian phe quan 178 Thuoc dieu tri hen phe quan 179 Thuoc ki'ch thi'ch ho hap 180 Thuoc chorig virus dieu tri benh phoi 181 Thuoc chong lao 182 Hoi/dap ve cac benh phoi 184 Cau hoi trac nghiem ve benh phoi 206 Dap an cac cau hoi trac nghiem ve benh phoi 234 10 Cac bang tra cufu 258 Ho 258 Nguyen nhan chi'nh cua ho mau 259 Nguyen nhan chi’nh cua kho thd 259 Khan giong 260 Tai ti'm 260 Ngon tay dui 260 Hoi miong Ton thUdng phoi ^61 Tran djch mang phoi 262 Tran dich mang phoi thuoc 262 Xet nghiem dac biet tran dich mang phoi 263 Bang tong hop ve cac loai viem phoi 263 Chi dinh dieu tri viem phoi cap tinh vi khuan 265 Suy ho hap cap tinh 265 Nguyen nhan tang thong keo dai 267 Nguyen nhan tang carbonic huyet keo dai 267 Nguyen nhan nhiem kiem ho hap 268 Nguyen nhan nhiem toan ho hap 269 Roi loan chiic n^ng phoi mot so' benh thifdng gap Roi loan chi'nh cua mau dong mach 270 Cac huyet tron d 1.000.000/ml goi y ung thu, nhoi mau, chan thuong; 10.000 100.000/ml khong xac dinh Bach cau < 100ml Thong thudng > 1000/ml Cong thUc bach cau Thong thudng > 50% te bao lympho hoSc don nhan > 50% te bao lympho (lao, ung thu) > 50% bach cau da nhan (viem cap) pH >7 ,3 < 7,3 (viem) Glucose Giong nhu glucose mau Ha thap (nhiem khuan) Ri't thap (viem khdp dang thap, han hOru la ung thu) Amylase Protein truTig > 500 don vi/ml (viem tuy, han huu la ung thu, nhoi mau) dac Ceic phan C3 C4 cua bd the deu thap (lupus ban he thong, viem khdp dang thap) Yeu to thap Yeu to khang nhan Bang 10.12 Bang tong hap cac trieu chimg lam sang va can lam sang cua cac benh viem phoi vi khuan, virus va vi sinh vat giong virus Viem phdi vi khuan Khdi phat benh Thudng dot ngot Oau cd - Dau dau - So anh sang + Viem phdi virus hoac vi sinh vat giong virus Thudng tiem tien (2-3 ngay) Oau hong Viem quan Viem mui Viem quan ++ 263 Bdng 10.12 (tiep) Oau ngi/c Diem dau ngtfc Dau ngtfc ho Sot 39° - 40°C 38°C Ret run + (Phe cau khuln) ± Benh cum Ho Nhieu ddm nhay mu, ri s it (phe cau khuln) Trieu chting thi/c the' Hoi chting dong dac Trieu chting X quang Hoi chtihg phd nang n^i bat B6ng md cd he thong hoac khong, hinh anh pha quan hdi Phu hdp vdi tridu chting thtfc thd Hdi chting ke ndi bat Bdng md b xa rdn phdi; hinh anh *thuy tinh mai” hodc tham nhiem Hinh anh thay ddi tti benh nhan sang bdnh nh£n khac Tim BK Am tinh Am tinh Tim cac mam benh khac Dtfdng tinh (doi am tinh Am tfnh (trti bdi nhidm) Huyet T3ng bach ciu va bach cau da nhan trung tfnh (trtfdc dieu tri) Giam bach cdu hodc binh thudng Phan ting huyet lam nhieu lan, moi lan cdch vai Am tinh Tang ro ret cac khang thd Tim o nhiem khuln (tai-muihong, rang ) ThU&ng dtfdng tinh Ho khan hoac it ddm nhdy, ddi cd tia mau O ran nd hai thi Xet nghiem vi khuln hoc ddm: 264 Am tfnh Bang 10.13 Viem ph6i c ip tinh vi khuan Chi dinh dieu tri Khang sinh (1) T£c nhan gay benh Dung d£u tien C«ic loai khdc Macrolid Pneumococcus (phe cau khuan) Penicillin G Ampicillin Staphylococcus (tu cau khuan) Methicillin Aminoglycosid Cephalosporin Vancomycin Streptococcus (lien d u khuln) Penicillin G Macrolid Klebsella Aminoglycosid Cephalosporin Kanamycin Haemophilus Ampicillin Cephalosporin Quinolon E.coli Aminoglycosid Ampicillin Cephalosporin Pseudomonas aeruginosa Aminoglycosid Cephalosporin (3G) Imipenem Quinolon Tac nhan yem Penicillin G Metronidazol Clindamycin Cephalosporin Legionella pneumophila Macrolid Rifampicin (1) Chi ke mot so it khang sinh de lam vi du (3G = th£ h£ 3) Bang 10.14 Suy ho hap cap tinh Bilan lam sang: tim cac dau hieu n&ng ve ho hap, huyet dong, than kinh - tam th^n (kho thci, y thtfc, choang, tai tim) Bilan can lam sang: X quang phoi, dien tim, mau, xet nghiem sinh hoc thudng dung 265 NSm (5) nguyen nhan nghi den dlu tien Can nguyen Suy ho hap man tinh mat bu Bien luan chan doan Benh hoc phdi chung (benh phdi - phe quan man tinh tic nghen, thudc la ) Tien sir Ran phd quan rai rac Xudt hien dan dan Hen cap tinh n3ng Hen da bidt tCr trudc Ttdn s lt Ran rft rai rac (nhimg nang nhdt Id: nghe phdi kh6ng thay ran) Con hen khong d ip ung vdi cac thudc dieu tri thudng dung P aC 02 > 28 mmHg Nghen mach phdi Benh canh (n£m lau, suy thdt phau.) Tidn sCf viem tinh mach v&/ho3c mach phdi Khdi dau rat dot ngot +/- dau nguc X quang phdi binh thudng hoSc dong | mach phdi to, nhung phdi van sang Phu phoi cap tinh Dang bi benh tim (suy tim, hep van hai la ) Tien stjf Kho thd nim + ran nd Benh phoi nhiem khuan nang Co dta ngudi cao tuoi, tre bu ngubi nghien ma tuy, suy giam mien dk*i (HIV ) X quang phdi Khac ddm mil (doi khi); sdL 266 Nhung can nguyen khac Phdi "tring" X quang Phu mo ke v£ phe nang tren phim X quang (= phdi trang) = phu phdi cap co ap luc tTnh mach trung tam th^fp (phu tdn thuong) Benh canh goi y: Phdi khong trang Tran mang phdi co su pap (soupape) Tran dich mang phdi nang Thudc: barbituric, opi, benzodiazepin, thudc an than, chong tram cam ba vong Nhiem doc CO nang • hit; chet duoi, hoi doc Nghen tac thanh- quan • choang nhiem khuan Liet ho hap: nhuoc co, viem nhieu re than kinh, viem xam • nhiem khuan nang • viem mang bung; viem • bong rong Bang 10.15 Nguy i n n h in tin g thdng keo dai Xo phdi Ngo doc salicylat Nhiem toan chuyen hoa (dai thao dudng, tang ure mau ) Sot Tam ly (lo au ) Benh he than kinh trung uong (tdn thuong nao giCra va cau nao Hdn me Bang 10.16 Nguyen nhan tin g carbonic huyet keo dai Phdi binh thudng: Roi loan he than kinh trung uong (benh mach mau nao, benh Parkinson, viem nao) Nhiem kiem chuyen hoa • Phu niem • Giam thong phe nang tien phat Ton thuong song • Benh long nguc (gii veo, viem dot song cung khdp) Benh than kinh co (nhuoc co, hoi chting Guillain - Barre, loan dudng co, viem xam ) Benh phdi tic man tinh 267 Bang 10.17 Nguyen nhan nhiSm kiem h6 h ip Giam oxy mau: Sdt Phan I6n cac benh phoi Nhiem khuln Benh tim thi/c th i Lo Su Benh tim blm sinh vdi shunt phai - * trai Suy tim sung huyet Do cao Kich thich trung tSm h6 hap Thuoc: Salicylat Catecholamin Theophyllin Doxapram Thi/a progesteron Thai Xo gan Binh he than kinh trung uang: Chay mau dudi mang nhen Benh cua trung tam ho h5p Thci Cheyne - Stokes 268 Kich thich cac thu thS ph6i ngoai vi Vi6m phdi Hen Nghen mach Phu phdi Xo phdi B6nh mang phdi Sai tim iJiSu tri bing m&y thd Bang 10.18 Nguyen n h in nhiem toan h6 hap Rdi loan kidm soat thdng Benh co H6 than kinh trung UOng Viem co, Benh co, loan dudng co Truy trung t3m ho hdp Met giam kali mau, Thudc gay me Nhiem doc thudc Giam thong trung uong tien pheit Phu ni§m (Myxedema) Oidu trj oxy cho benh nhan tang carbonic man tinh Ngu B$nh thin kinh co ngoai vi Benh than kinh ngoai vi Ton thuong song Liet day than kinh hoanh Hoi chting Guillain - Barre NhUpc co Cac t£c nhan gay liet Ngd d6c Clostridium botulinum giam phosphat rrieiu Met benh tic dudng thd B&nh chtfc nSng phSi: Benh phdi han chd Gu Mang sudn di dong T ic ngh£n dudng thd T ic dudng thd tren (khi quin, quan, phd quan) Hen va benh phdi tic man tinh Shunt: Benh tim bdm sinh Co shunt trai -> phai Shunt phdi Di dang dong - tinh mach Viem phdi n3ng, vat tic ldn Sai lam diSu tri bing may thd 269 Bang 10.19 Roi loan chUc nang phoi mdt so benh thudng g$p FVC FEV, FEV,/FVC RV TLC Kha ning khuech tan A A A t N /t N N/A A t N /t N/A Gu N /t N/A A N Xo ke A A N /t A A A Benh Hen Benh phoi tic man tinh Giam t Tang N: Binh thi/dng Bang 10.20 Roi loan chinh cua mau ddng mach Binh thudng pH = 7.4 + 0,02 HCCV P aC 02 = 40mmHg P a02 = 80 - 10mmHg (S a02 = 96%) Clo mau Kali mau Lo hong anion (Na* + K > (C T + HCOjI N: 12 den 16 ' N = binh thudng 270 Nhiem toan chuyen hoa Nhiim kiem chuyen hoa Nhiem toan ho hap Nhiem kiem ho hap A A A t A t tt t den t r r t t N‘ A t (neu giam oxy mo gay tang thong thi Pa02tang vi du mach phoi) A A N hodc t (neu nhiem toan giam oxy mo thi PaO, thap) A hoac t can nguyen A t t hoacA can nguyen A N hoac A A t t N A vi/a phai N Bang 10.21 Cac huyet tron don doc d phoi U hat Nguyen nhan khac Ung thu phe quan Benh Histoplasma Ken phe quan U tuyen phe quan Lao Dj dang dong - tTnh U ac tinh: mach Ung thi/ di can Benh Phdi biet lap Coccidioidomyces U lanh tinh: Benh Cryptococcus U mach mau xo hoa Loan san phoi Hach bach huyet (hamartoma) phdi U xo Bang 10.22 NOta vom hoanh cao Ung thu (ung thu phe quan, ung thu Chan thuong day than kinh hoanh trung that, tdn thuong gan) hoac co hoanh (vi du phau thuat) Nhiim khuan (viem phdi, mu mang Phinh dong mach chu phdi, lao, ap xe dudi co hoanh, ap xe gan) Xep phdi Vo can Ldi co hoanh Rdi loan chUc nang day than kinh Khdi u bung Nhoi mau phdi Tran dich mang phdi Dieu tri tia xa Gay xuong sudn hoanh (viem tuy, loan truong luc co, zona) 271 Bang 10.23 Trung that rdng tren phim X quang U lympho: Benh Hodgkin va u lympho khong Hodgkin Benh sarcoid Mach mau: phinh dong mach chu, Benh hach bach huyet bfcnh phdi nhiem bui silic va nhQng benh bui phdi kh^c Benh bach cau dong mach chu gian hoSc cong Nhiem queo Tularemia Ung thu : phdi, thuc quan Tuyen gieip sau xuong tie Tui thUa thuc quan U tuyen tic Thoat vj hoanh U quai Chan thuong: chay m^u trung that Ken phe qu&n Tran trung that Ken ngoai tam mac khuan: U xo than kinh Sarcom than kinh U hach than kinh 272 lao vi6m b§nh TAI LIEU THAM KHAO A.P.Fishman, R.M.Kotkoff: Pulmomary diseases and disorders Second edition Companion handbook Me Graw-Hill, Inc., 1994 B.Bates: A guide to physical examination and history taking J B Lippincott Company Philadelphia 1987 B.R Mackenna, R.Callender: Illustrated physiology Sixth edition, Churchill Livingstone 1998 D.Gray, P.Toghill: An introduction to the symptoms and signs of clinical medicine Arnold, London 2001 G.Robert Fraser, J.A.Peter Pare: Diagnosis of diseases of the chest Vol.I + II W.B Saunders Company 1970 H.L Greene: Clinical medicine Second edition Mosby 1996 M.J.Ford, A.T.Elder: 1000 MCQs for Davidson's principles and practice of medicine Churchill Livingstone 1997 P.P.O.Davies: Clinical tuberculosis Chapman & Hall medical 1998 R.L.De Gowin: Diagnostic examination Sixth edition Second edition Me Graw-Hill, Inc., 1994 273 10 R.Berkow et al: The Merck manual of diagnosis and therapy Sixteenth edition Merck & CO, Inc USA 1992 11 S.D Fihn, D.E Dewitt: Outpatient medicine W.B Saunders Company 12 S Cochrane Shanks, Sir Peter Kerley: A text-bok of Xray diagnosis Vol III Respiratory system W.B Saunders Company, 1973 13 T.Scratchered, J.I Gillepsie: Aids to physiology Third edition Churchill Livingstone 1997 14 D Vincent, D.Bayron et al: Le vade raecum diagnostic 2e-edition MMP editions Masson 2001 15 D Sicard, H.Bouchez: Memento Les complementaires 2emc-edition Maloine 1995 16 G.Huchon: Pneumologie Paris 2001 pour le praticien du examens Masson, 17 J Chretien, J Marsac: Pneumologie Masson 1990 18 J Thuillier, J.Duchior: Dictionnaire des medicaments et leur bon usage Robert Laffont 1996 19 M Leporrier: La petite Hamburger 18*“ edition Flammarion 1994 encyclopedic Medecine - medicale Sciences 20 M.C Renand: Semiologie et observation Editions Estem & Med-line, 1996 medicale 274 21 Y.Benlmou, S.Perrot: Therapeutique 1995 Med-Line Edition 1995 22 L Perlemuter, G Perlemuter: Guide de Therapeutique 21' - edition actualisee Masson, Paris 2001 23 Pham Gia Ctfdng: Thtfc hanh noi khoa ho hap Nha xuat ban Y hoc, Ha Noi, 1984 24 Pham Gia Ctfdng: Cac bai giang ve Phoi hoc d Hoc Vien Quan y va Quan Y vien 103 ttf 1962 den 1984 97 ?; NHA XUAT BAN Y HOC KHAM VA CH0A CAC BENH PHOI a Chju trach nhiem xuilt ban HOANG TRONG QUANG Bien tap: BS HAl y£ 'n SCra ban in: BS HAl Y^N Trinh bay bia: CHU HUNG Kt vi tinh: BUI THI THUONG - THANH TU In 1000 cu