Đặc điểm lâm sàng, cận lâm sàng và hình ảnh chụp cắt lớp vi tính ngực của viêm phổi kẽ trên bệnh nhân lupus ban đỏ hệ thống

1 Bộ giáo dục đào tạo y tế tr-ờng đại học y hà nội NGUYN VNH HI đặc điểm lâm sàng, CậN LÂM SàNG hình ảNH CHụP CắT LớP VI TíNH NGựC CủA vIÊM PHổI Kẽ TRÊN BệNH NHÂN lupus ban đỏ hệ thống Chuyên ngành Mã số : Nội khoa : 60720140 luận văn THạC Sỹ Y HọC Ng-ời h-ớng dẫn khoa học: TS cHU tHị hạNH Hà Nội - 2014 LI CM N Vi lũng kớnh trng v bit n sõu sc, tụi xin trõn thnh cm n: TS Chu Th Hnh - Phú giỏm c Trung tõm Hụ hp Bnh vin Bch Mai, ngi thy ó trc tip dy d, hng dn v to mi iu kin thun li nht cho tụi quỏ trỡnh hc v thc hin lun ny Tụi xin trõn thnh cm n: T Ngụ u Chõu, Tr ng B mụn N i t ng hp trng i hc H N i, iỏm c trung tõm Hụ Hp, Phú giỏm c Bnh vin Bch M i P S.TS Nguyn Vn on, iỏm c trung tõm D ng Min dch lõm sng Bnh vin Bch M i ỏc thy cụ B mụn N i t ng hp, trng i hc H N i c ng ton th nhõn vi n Trung tõm Hụ Hp nh vin Bch M i B n iỏm hiu, phũng o to S u i hc, trng i hc H N i ó luụn to iu kin giỳp tụi quỏ trỡnh hc v nghi n cu ui c ng tụi xin chõn thnh cm n gi ỡnh, n ố ó luụn ng vi n, giỳp quỏ trỡnh hc v hon thnh lun H N i, 15 thỏng 10 nm 2014 Nguyn Vnh Hi LI CAM OAN Tụi xin cam oan õy l cụng trỡnh nghiờn cu khoa hc c tin hnh mt cỏch trung thc v khỏch quan S liu lun cha tng c cụng b bt k mt nghiờn cu no khỏc Tụi xin hon ton chu trỏch nhim vi li cam oan trờn H N i, 15 thỏng 10 nm 2014 Ngi lm lun Nguyn Vnh Hi danh mục chữ viết tắt ILD VPK ANA BC CNHH DLCO DMP DNA FEF25-75 FEV1 FVC HRCT LS PaCO2 PaO2 PCR PEF RV SaO2 SLE SVC TDMP TLC VK XQ Bnh phi mụ k (interstitial lung disease) Viêm phổi kẽ Kháng thể kháng nhân (Antinuclear antibody) Bạch cầu Chức hô hấp Khả khuếch tán carbon monoxide phổi (Diffusing capacity of the lung for carbon monoxide) Dịch màng phổi Deoxyribonucleic acid L-u l-ợng thở quãng FVC Thể tích thở tối đa giây (Forced expiratory volume in firsrt second) Dung tích sống thở mạnh (Forced vital capacity) Chụp cắt lớp vi tính có độ phân giải cao (High resolution computed tomography) Lâm sàng Phân áp riêng phần CO2 máu động mạch (Partial pressure of carbon dioxide in arterial blood) Phân áp riêng phần oxy máu động mạch (Partial pressure of oxygen in arterial blood) Phản ứng khuếch đại chuỗi (Polymerase chain reaction) L-u l-ợng đỉnh (Peak expiratory flow) Thể tích khí cặn (Residual volume) Độ bão hoà oxy máu động mạch (Oxygen saturation) Lupus ban đỏ hệ thống (Systemic lupus erythematosus) Dung tích sống thở chậm (Slow vital capacity) Tràn dịch màng phổi Dung tích phổi toàn phần (Total lung capacity) Vi khuẩn Xquang mục lục T VN Chng 1: TNG QUAN TI LIU 14 1.1 Lch s nghiờn cu 14 1.1.1 Bnh phi k 14 1.1.2 Lupus ban h thng 17 1.2 i cng 18 1.2.2 T chc k 18 1.2.2 Chun oỏn Viờm phi k / Lupus 21 1.3 Cỏc tn thng mng phi 28 1.4 Cỏc thm dũ cn lõm sng 30 1.4.1 Chc nng hụ hp SLE 32 1.4.2 p lc ng mch phi SLE 34 Chng 2: I TNG V PHNG PHP NGHIấN CU 37 2.1 i tng nghiờn cu 37 2.1.1 Tiờu chun la chn bnh nhõn 37 2.1.2 Tiờu chun loi tr 39 2.2 Phng phỏp nghiờn cu 39 2.2.1 Nghiờn cu theo phng phỏp mụ t ct ngang hi cu v tin cu 39 2.2.2 Cỏc bc tin hnh nghiờn cu 39 2.3 Thu thp s liu 41 2.4 X lý s liu 41 Chng 3: KT QU NGHIấN CU 43 3.1 Tui v gii 43 3.2 c im lõm sng 44 3.2.1 Triu chng c nng v ton thõn 45 3.2.2 Triu chng thc th thm khỏm phi 46 3.2.3 Cỏc triu chng liờn quan 47 3.3 c im cõn lõm sng 48 3.3.1 Hỡnh nh Xquang tim phi 48 3.3.2 c im dch mng phi 51 3.3.3 Thay i chc nng hụ hp, ng mch phi 55 3.3.4 Mi tng quan gia mc tn thng phi vi chc nng hụ hp 57 Chng 4: BN LUN 58 4.1 Tui v gii 58 4.1.1 Tui 58 4.1.2 Gii 58 4.2 Cỏc c im lõm sng 59 4.2.1 Cỏc triu chng c nng v ton thõn 59 4.2.2 Cỏc triu chng liờn quan 61 4.3 c im, hỡnh thỏi tn thng Phi 62 4.3.1 c im chn oỏn hỡnh nh 62 4.3.2 Cỏc hỡnh thỏi tn thng phi k trờn CLVT ngc 63 4.4 c im dch mng phi 68 4.5 nh hng ca cỏc tn thng phi k trờn SLE 70 4.5.1 S thay i cỏc ch s chc nng hụ hp 70 4.5.2 Thay i v ỏp lc ng mch phi 71 KT LUN 73 TI LIU THAM KHO Phụ lục DANH MC BNG Bng 3.1 c im v tui 43 Bng 3.2 c im v gii 44 Bng 3.3 Triu chng c nng v ton thõn 45 Bng 3.4 Triu chng thc th 46 Bng 3.5 Cỏc triu chng liờn quan 47 Bng 3.6 Cỏc dng tn thng phi k thng gp trờn phim Xquang tim phi 48 Bng 3.7 Cỏc loi tn thng phi k trờn phim chp CLVT ngc 49 Bng 3.8 Mc tn thng phi k trờn phim chp CLVT ngc 50 Bng 3.9 Mu sc dch mng phi 51 Bng 3.10 c im sinh hoỏ dch mng phi 52 Bng 3.11 c im vi sinh dch mng phi 53 Bng 3.12: c im t bo DMP 53 Bng 3.13 Thnh phn bch cu dch mng phi 54 Bng 3.14 Chc nng thụng khớ 55 Bng 3.15 p lc ng mch phi 56 Bng 3.16 Mi tng quan gia mc tn thng phi vi chc nng thụng khớ 57 DANH MC BIU Biu 3.1 c im v tui 43 Biu 3.2 c im v gii 44 Biu 3.3 Triu chng c nng v ton thõn 45 Biu 3.4 Triu chng thc th 46 Biu 3.5 Cỏc dng tn thng phi k thng gp trờn phim Xquang tim phi 48 Biu 3.6 Cỏc loi tn thng phi k trờn phim chp CLVT ngc 49 Biu 3.7 Mc tn thng phi k trờn phim chp CLVT ngc 50 Biu 3.8 Phõn b mu sc dch mng phi 51 Biu 3.9 c im sinh hoỏ dch mng phi 52 Biu 3.10 c im t bo DMP 54 Biu 3.11 T l thnh phn bch cu dch mng phi 55 Biu 3.12 Cỏc thay i v chc nng hụ hp 56 10 DANH MC HèNH Hỡnh 1.1 Ban cỏnh bm SLE 23 Hỡnh 1.2 Hỡnh nh bnh lý phi k 25 Hỡnh 1.3 Tn thng dng kớnh m 26 Hỡnh 1.4 Tn thng l ch t ong 26 Hỡnh 1.5 Hỡnh nh tn thng di ng m 26 Hỡnh 1.6 Hỡnh nh tn thng dng nt 26 Hỡnh 1.7 Hỡnh nh tn thng li 27 Hỡnh 1.8 Hỡnh nh tn thng li nt 27 73 KT LUN Qua nghiờn cu v c im lõm sng, cn lõm sng v hỡnh nh chp ct lp vi tớnh ngc ca viờm phi k trờn 40 bnh nhõn SLE chỳng tụi thu c kt qu nh sau: c im lõm sng v cn lõm sng 1.1 Cỏc c im lõm sng - Gii: Ch yu l n chim 80%, t l nam/ n:4/1 - Tui: 72,50% bnh nhõn trờn 40 tui, di 20 tui ch 2,50% - Triu chng: 65% ho, 50% au ngc, 42,50% khú th, 57,50% khc m, 87,50% ran n, 40% ran m, 22,50% hi chng ba gim, 10% tớm, 12,50% ran rớt - ngỏy v ngún tay dựi trng 5% 1.2 Cn lõm sng - Chc nng hụ hp: Ri lon thụng khớ hn ch 56,67%, ri lon thụng khớ tc nghn v ri lon thụng khớ hn hp 10% - p lc ng mch phi: tng nh 10%, tng va 14,29% v tng nhiu 10,71% - c im dch mng phi: + Mu sc: vng chanh 85,71%, mỏu 14,25% + Sinh hoỏ: dch tit 78,57%, dch thm 21,43% + T bo: Bch cu 78,6%, hng cu 25,6%, ú bch cu lympho 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= nam) 1.3 Dõn tc: (1 = kinh; = khỏc) 1.4 Ngy vo vin: Ngy vin: PHN LM SNG 2.1 Lý vo vin 2.2 Thi gian din bin bnh (1 =