🔙 Quay lại trang tải sách pdf ebook Bài giảng bệnh học nội khoa (tập 1) Ebooks Nhóm Zalo TRUONG DAI HOC Y HA NOI ■ ■ ■ CAC BO MON NOI ■ ■ B a i g i a n g BENH HOC N0IKHOA TAP I NHA XUAT BAN Y HOC■ TRUONG DAI HOC Y HA NOI CAC BO MON NOI BAI GIANG BENH HOC NOI KHOA TAPI (Tai ban Ian thiC chin co siia chiia va bo sung) NHA XUAT BAN Y HOC HA NOI - 2004 Tham gia bien soan: PGS.TS. NGUYEN THjMINH AN GS. TS. TRAN NGOC AN PGS. TS. PHAM THI THU HO TS. NGO QUY CHAU GS. PHAM KHUE GS. PHAM GIA KHAI PGS. BS. NGUY§N VAN THANH GS. TS. TRAN OCfC THO GS. TS. NGUY6N KHANH TRACH TS. DO TH| LIEU GS. TS. NGUY§N LAN VIET GS. TS. NGUY§N VAN XANG TS. CHU VAN Y Thir ky bien soan: GS. TS. TRAN NGOC AN PGS. TS. PHAM TH| THU H6 LDfl NOI DAU Bai giang benh hoc noi khoa do can bo giang day cac bo mon noi thuoc TrUbng Dai hoc Y Ha Noi bien soan nham cung cap mot so tai lieu de sinh men cac Ictp Y3 - Y6 theo chtfdng trinh cai cach mdi dung de hoc tap va tham khao khi hoc ly thuyet cung nhtf khi thiCc hanh d benh vien. Noi khoa la mot trong nhiing mon hoc chinh cua cac Tritilng Dai hoc Y. Noi dung can ditrfc sita doi bo sung cho phii help uc'fi sit tien bo khong ngitng cua y hoc. Lan tai ban nay mot so chiidng da diCOc siCa chiia va bo sung de cap nhat cac kien thiic mdi cua y hoc. Tuy nhien trong dieu kien so can bo con it oi, thdi gian han che cuon sach khong tranh khoi thieu sot nhat dinh, mong ban doc gop y de lan tai ban sau cuon sach dit(lc hoan thien hdn. Xin tran trong cam (fn TRl/ONG DAI HOC Y HA NOI ■ ■ ■ Cac bo mon noi C H lfO N G I HO HAP VIEM PHE QUAN CAP I. DAI ClTdNG VA DINH NGHIA Viem phe quan cap la tinh trang viem nhiem niem mac cua phe quan 16n va phe quan trung binh, khi viem nhiem ca kin quan thi goi la viem khi - phe quan. Viem nhiem lan den tieu phe quan tan va phe nang thi goi la phe quan-phe viem. Viem phe quan cap co the xay ra b bat ky ltia tuoi nao nhtfng nhieu nhat la tre em va ngUdi gia. Benh hay xay ra ve mua lanh va dau mua xuan. Trieu chiing lam sang chmh la ho va khac ddm nhay - mu. Benh tien trien lanh tfnh sau khi khoi khong de lai di chiing. Viem phe quan la mot van de siic khoe cong dong quan trpng lam nhieu ngUOi phai nghi viec hoac nghi hoc di kham benh va dung cac thuoc khang sinh. II. NGUYEN NHAN 1. Viem phe quan cap do virus Viem phe quan cap do virus chiem 50 t6i 90% cac trtfcing hdp viem phe quan cap. Ngifdi ta da ghi nhan co tren 180 virus gay benh. Cac virus thiidng gap nhat la cac myxovirus (virus cum va virus a cum), cac rhino''irus, coronavirrus, virus dai thUc bao dUdng ho hap (Respiratory Syncticial Virus), Adenovirus, enterovirus (coxsackie va echovirus) va mot so"chiing herpes virus (CMV, varicellae). 2. Viem phe quan cap do vi khuan Viem phe quan cap do vi khuan it gap hdn cac trUdng hdp viem phe quan cap do virus. Trong so cac vi khuan gay viem phe quan cap thUdng gap nhat la cac vi khuan trong te bao nhtf Mycoplasma, va Chlamydiae, cac vi khuan gay mu hiem gap hdn. Cac triidng hdp nhilm khuan do Mycoplasma pneumoniae bieu hien bang viem phe quan d 25 % cac trifdng hdp (viem mui 5 hong dOn thuan chiem 60%, viem phoi chi chiem 5%. Mycoplasma pneumoniae va Chlamydiae pneumoniae la nguyen nhan cua 25 % cac trvfOng hdp viem phe quan cap. Tuy nhien ty le mac benh chfnh xac kho xac dinh do trif d cac trUdng hdp viem phoi thi ngUdi ta khong lam cac huyet thanh chan doan, ngay ca d cac nU6c phat trien. Viem phe quan cap do phe cau va hemophillus influenzae thifdng it gap d ngUdi 16n, hay di kem v6i sot va cac dau hieu ngoai dtfdng ho hap. Xet nghiem vi khuan thUcing am tmh ci 80 den 95 % cac trtfdng hdp viem phe quan cap. 3. Hit phai hoi doc Khoi thuoc la, chlore, Amoniac, acid, dung moi cong nghiep, hdi doc chien tranh. 4. Yeu to" di vfng Viem phe quan cap xay ra cJ tre con giong nhif cdn hen phe quan, viem phe quan cap cung hay xay ra tren ngtfdi hen, may day, phu Quinck. 5. Nguyen nhan thuan lOi - Thay doi thdi tiet, nhiem lanh dot ngot. - Cd the suy mon, coi xufdng, suy dinh difdng cJ tre em, suy giam mien dich. - ti dong phoi do suy tim. - Cac benh cua phoi nhu lao phoi va ung thu phoi. - Moi trUdng song am thap nhieu khoi bui. III. GIAI PHAU BENH LY Vi tri ton thifdng: ton thUdng giai phau thay d phe quan goc, phe quan thuy co the ca khi quan va phe quan tan. Nhiing ton thifdng thay diidc: niem mac phe quan bi phu ne, sung huyet, cac mach mau gian to, co 16p dich nhay, mu bao phu, xam nhap bach cau da nhan, te bao bieu mo bi bong va co cho bi loet, cac tuyen nhay cang va tang tiet. IV. TRIEU CHtTNG Viem phe quan cap do virus bat dau dien hinh bang viem long dUdng ho hap tren v6i h^t hdi, so mui va/hoac viem mui hong. Ton thifdng viem lan xuong dUdng ho hap du6i bieu hien trtfcic tien bang ho khan, ho tiing cdn, ho ong ong va dau. Day la luc benh toan phat gom 2 giai doan: 6 1. Giai doan kho Benh nhan thiidng co cam giac rat bong sau xtfdng \ic lien quan den viem khi phe quan, cam giac nay tang len khi ho, dau ngiic nguon goc do cd vi ho lien tuc. Ho khan, co khi ho ong ong, ho tifng cdn, khan tieng. Trieu chiing toan than: thtfdng sot vtifa, khoang 38°C. Nhtifc dau, met moi, dau minh may, bieng an. Kham phoi luc dau binh thUdng, sau co the thay rai rac co ran rft va ran ngay. Giai doan nay keo dai 3-4 ngay thi chuyen sang giai doan U6t. 2. Giai doan tfdt Cam giac dau rat bong sau xUdng lie giam dan roi het han, kho thcf nhe, ho khac ddm nhay, ddm nhay mau hoac ddm vang-mu. Nghe phoi co the co ran ngay va ran am, go khong thay vung due. Giai doan nay keo dai 4-5 ngay va khoang 10 ngay thi khoi h&n. C) mot so" trufdng hdp ho khan keo dai nhieu tuan le (tang tfnh phan ling phe quan sau nhiem trung). Doi khi benh bat dau mot cach ram ro: sot cao, ho nhieu, ho ra mau... Neu d ngUdi 16n tuoi nghien thuoc la co ho ra mau can chu y tim ung thu phe quan bang cach soi phe quan ke ca trong trUdng hdp X quang khong co bieu hien gi ro ret. Dau hieu X quang: trong viem phe quan cap thUdng khong co gi dac biet, co the thay thanh phe quan day. Xet nghiem: cong thtic bach cau va mau l4ng tang vtfa phai. Cay ddm: thay nhieu loai vi khuan nhUng ft co gia tri de chan doan va thong thUdng khong co chi dinh lam xet nghiem nay. V. CHAN DOAN 1. Chan doan xac dinh dvfa vao 1.1. Trieu chiing cua viem ditdng ho hap tren - Nhe: viem hong do, chay nU6c mui. - Nang: viem mui mu, viem xoang, viem amidan, viem tai giGa. 1.2. Trieu chiing cua viem ditdng ho hap ditai - Nhe: ho, khan tieng, thci kho khe va dau hieu cua viem dtfdng ho hap tren, nghe phoi co the co ran ngay, ran rft. - Nang: ngoai jihting trieu chijfng tren, kho thd ro ret, co keo long ngtic, tfm, nhip thd nhanh tren 30 lan/phut. Nghe phoi co ran rft, ran bot d vung day phoi phfa sau lifng. 7 2. Chan doan phan biet - C) tre em neu trieu chiing viem phe quan keo dai, can nghi den hach d trung that, chen ep phe quan, di vat phe" quan hoac gian phe quan. P . ^ ^ y ty ty ^ - O ngUdi 16n: nhieu benh phoi co bieu hien viem phe" quan nhif: lao phoi v6i hang lao do vao phe quan, benh bui phoi, ung thu phoi. Khong nghi den viem phe quan neu trieu chting nghe phoi chi 0 mot ben. - U* dong b phoi trong trUdng hdp suy tim (co trieu chiing suy tim). - Hen phe quan tang tiet dich: sau cdn hen thi het cac trieu chiing. VI. TIEN TRIEN, BIEN CHIING 1. Tien trien trvfdc mat Tien ltfdng gan cua viem phe quan cap noi chung la tot. Tuy nhien tien trien trU6c mat co the dang lo ngai hdn b mot so" cd dia nhu suy ho hap man tinh, hen phe" quan, hoac suy tim va trong trufdng hdp viem tieu phe" quan b tre nho. O ngufdi 16n tuoi, tinh trang suy yeu he thong mien dich bao ve, va cac bien doi ve giai phau tai cho co the lam cho benh de lan t6i cac tieu phe quan tan va cac phe nang dan den benh canh viem phoi cap vdi tien ltfdng nang hdn. 2. Tien trien lau dai Phan 16n benh khoi hoan toan khong de lai di chiing. Benh tai phat nhieu lan co the dan den gian phe quan hoac viem tieu phe" quan bit tkc, nhat la d tre em. 2.1. Viem tieu phe quan bit tac C) tre em sau viem tieu phe" quan do virus, sU viem va hoai tU nghiem trong bieu mo phe" quan co the dan tdi tang sinh rat manh cac te" bao bieu mo phu tieu phe quan gay bit tic long phe" quan bdi to chiic xd seo. Benh canh lam sang bieu hien bang suy ho hap man tinh v6i kho thd, ho va tieng bat thUdng dac trUng nghe thay d thi hit vao. Ve chtic nang ho hap thUdng co ro"i loan thong khi tac nghen nang, khong hoi phuc v6i thuoc gian phe quan cifdng P2 hoac corticoid. Tien lufdng khong biet trU6c dUdc, thUdng nang, doi khi cai thien tam thdi v6i corticoid hoac thuoc lie che" mien dich. CJ ngUdi 16n sau nhiem trung do virus hiem khi xuat hien viem tieu phe" quan bit the va neu co thi phai tim xem benh nhan co bi cac benh he thong (xd ciing bi, viem da kh6p dang thap) hoac mot so nguyen nhan do dung thuoc (dieu tri bang D-penicillamine). 8 2.2. Chiing tang tinh phan ting phe quan Tang tinh phan ting phe quan va/hoac roi loan thong khi tac nghen thoang qua co the gap trong moi trUdng hdp viem phe quan cap, ngay ca d nhting ngUdi trU6c day khong he bi cac benh ho hap. Cac roi loan nay, thUdng thay sau khi bi viem phe quan do virus hoac do mycoplasma, co the bien di d 40 % cac trUdng hdp trong vong 2 thang sau ddt viem khdi phat. Vi vay can chd sau thdi gian nay mcii nen ket luan la co tinh trang tang tinh phan ting phe quan hoac co hen phe quan. VII. DIEU TRI (3 ngUdi binh thUdng hiem khi can dieu tri viem phe quan cap. Khi co chi dinh chi dieu tri trieu chting vdi nghi ngdi tai giUdng, cho du lifdng nUcic uong, cac thuoc chong viem khong phai corticoid hoac mot ddt ngan corticoid dUdng uong (prednison: 0,5 mg/kg/ngay trong 5 den 7 ngay), thuoc giam dau thong thUdng, cac thuoc giam ho nhu sirop Codein khi ho khan nhieu va co the dung cac thuoc gian phe quan cUdng P2 dUdng phun hit khi co dau hieu co that phe quan. Chtfa co nghien ctiu nao chting minh hieu qua cua cac thuoc long ddm. Khong can dung khang sinh cho viem phe quan cap d ngUdi binh thUdng. Cac thuoc khang sinh khong lam thay doi tien trien cua benh va gay tang chi phi dieu tri. Cac khuyen cao lien quan den viec dung khang sinh trong viem phe quan cap la: ho keo dai va khac ddm mu tren 7 ngay, cd dia viem phe quan man tinh hoac co viem mui mu, viem amidan, viem VA, viem tai gitia phoi hdp. Trong cac trUdng hdp nay, khang sinh dUdc khuyen cao la dung mot loai thuoc trong nhom penicillin A hoac macrolid nhtf erythromycin l,5g ngay trong 10 ngay, Rulid 150mg x 2 lan/ngay. Viec ngting hut thuoc la mot thanh phan cd ban cua dieu tri d nhting ngifdi nghien thuoc la, thuoc lao. Dieu tri cac nguyen nhan thuan ldi neu co. VIII. PHONG BENH - Loai bo ye"u to klch thlch: khong hut thuoc, tranh khoi bui trong nha, moi trUdng o nhiem. - Giti gin stic khoe, giti am nhat la mua lanh. - Gay mien dich bang tiem chung vacxin chong virus, vi khuan. 9 BENH PHOI TAC NGHEN MAN TINH • • 1. Dinh nghia Benh phoi tac nghen man tinh la tinh trang benh co roi loan thong khi tac nghen khong co kha nang hoi phuc hoan toan. Su can trd thong khi thUdng tien trien tti tti va lien quan den phan ting viem bat thufdng cua phoi do cac phan tti hoac khi doc hai. 2. Dich te hoc benh phoi tac nghen man tinh Theo WHO, nam 1990, ty le bi mac benh phoi tac nghen man tinh tren toan the gi6i U6c tinh khoang 9,34/1000 0 nam va 7,33/1000 0 nti. Tuy nhien, nhting U6c tinh nay bao gom 0 mm ltia tuoi va chtfa phan anh dung ty le benh phoi tac nghen man tinh thifc ci ngiidi cao tuoi. Ty le mac benh phoi tac nghen man tinh cao nhat d nhting nuf6c da va dang thinh hanh viec hut thuoc trong khi ty le mac benh phoi tac nghen man tinh thap nhat d nhting nU6c it hut thuoc hdn hay co ty le tieu thu thuoc la tren moi ca the thap. Tren toan the" gicii benh phoi tac nghen man tinh hien la nguyen nhan gay tti vong hang thti 4, va dtf bao con tang len trong nhting nam t6i. C) My ty le chet do benh phoi tac nghen man tinh rat thap d tuoi du6i 45 nhufng sau do tang dan theo tuoi. Benh phoi tic hghen man tinh tr3 thanh nguyen nhan dting hang thti tii hoac thti nam gay tti vong d tuoi tren 45. 3. Cac yeu to" nguy cd gay benh phoi tac nghen man tinh 3.1. Thuoc la - La nguyen nhan chinh cua benh, va tti vong do benh phoi tkc nghen man tinh. Ngting hut thuoc lam giam cac yeu to" tren. Khoang 15% so nhting ngufdi hut thuoc co trieu chting lam sang cua benh phoi tac nghen man tinh. - 80- 90% cac benh nhan benh phoi tac nghen man tinh deu co hut thuoc. - Hut thuoc la thu dong: tre em trong gia dinh co ngUdi hut thuoc la bi cac benh difdng ho hap tren vdi ty le cao hdn tre em trong gia dinh khong co ngtfdi hut thuoc. 10 3.2. Cac yeu tokhac O nhiem moi tritbng: tiep xuc nang ne v6i bui va hoa chat nghe nghiep (hdi, chat kich thich, khoi); va o nhiem khong khi trong va ngoai nha (khoi bep do dun cui, rdm, than...). Nhiem trung diCbng ho hap: Nhiem trung dUdng ho hap d tre em < 8 tuoi gay ton thufdng 16p te bao bieu mo dUdng ho hap va cac te bao long chuyen, lam giam kha nang chong dd cua phoi. Nhiem virus, dac biet virus hdp bao ho hap co kha nang lam tang tmh phan ting phe quan, tao cd hoi cho benh phat trien. Yeu to" ca the: - Tang tmh phan ting cua phe quan: la yeu to" nguy cd lam phat trien benh phoi man tmh tic nghen. Tang tinh phan ting phe quan thay b 8- 14% ngUdi binh thUdng. - Thieu al- antitrypsine: la yeu to" di truyen dUdc xac dinh chac chan gay benh phoi tac nghen man tmh. - Tuoi: ty le benh gap cao hdn d ngUdi gia. 4. Co che benh sinh Dac diem benh phoi tac nghen man tmh la sii viem nhiem thUdng xuyen toan bo dUdng dan khi va nhu mo. Xam nhap dai thiic bao, te bao lympho T (chu yeu la CD8) va bach cau da nhan trung tmh tang. Cac te" bao viem giai phong ra rat nhieu chat trung gian hoat mach gom: leucotrien B4 (LTB4), interleukin 8 (IL-8), yeu to hoai tti u a (TNF- a) va cac chat khac- co kha nang pha huy cau true cua phoi va/hoac duy tri tinh trang viem tang bach cau trung tmh. Hit phai khoi bui, va cac chat doc, hut thuoc la co the gay ra viem cung nhif pha huy cau true phe" quan va phoi. Tinh trang viem nay se dan den benh phoi tac nghen man tmh. 5. Giai phau benh Cac thay doi ve mo benh hoc d benh phoi tac nghen man tinh dUdc tim thay d dutdng dUn khi trung tam, ngoai vi, nhu mo phoi va he thong mach mau phoi. - DUdng dan khi trung tam: khi quan, va phe" quan co dUdng kmh ben trong 16n hdn 2mm, co tinh trang xam nhap te" bao viem vao be mat 16p bieu mo. Phi dai tuyen tiet nhay va tang so" litdng te bao co chan hinh dai d niem mac phe" quan. 11 - Difdng dan khi ngoai vi: cac phe quan nho va tieu phe quan co difdng klnh trong nho hdn 2mm. Qua trinh viem man tmh dan den vong xoan ton thUdng va pha huy thanh phe quan. Qua trinh pha huy nay dan den tai cau true lai thanh phe quan v6i tang thanh phan collagen va to chtic seo, lam hep long va gay tac nghen diidng thcJ vinh vien. - Sii pha huy nhu mo phoi b benh nhan benh phoi tic nghen man tmh dien hinh gay ra gian phe nang 6 trung tam hoac toan bo tieu thuy, no co lien quan den sii gian va pha huy tieu phe quan ho hap. Nhting ton thUdng nay hay xay ra 6 cac thuy tren cua phoi d nhting triidng hdp nhe, nhifng d benh tien trien thi chiing co the xuat hien d toan bo phoi va no cung gay pha huy gitfdng mao mach phoi. Sii mat can bang gitia men proteinase noi sinh va antiproteinase trong phoi - do yeu to bam sinh hoac do hoat dong cua cac te bao viem va hoat chat trung gian - la cd che chlnh gay pha huy phoi do gian phe nang. - Day thanh mach trong benh phoi tic nghen man tmh thtfdng bat dau til s6m cua qua trinh bi benh. Day len cua noi mach la thay doi dau tien co the do diidc sau do la sii day len cua 16p cd trdn va xam nhap te bao viem vao thanh mach. Khi tinh trang benh phoi tac nghen man tmh cang xau di thi khoi lifdng cd trdn, proteoglycans, va collagen thanh mach cang tang do do thanh mach cang day len. 6. Lam sang - Benh nhan tuoi thUcJng tren 40, co tien sti hut thuoc hoac nghe nghiep co tiep xuc v6i khoi, bui o nhiem... - Benh nhan thUdng den kham vi ho, khac ddm, kho thcJ: + Ho: nhieu ve buoi sang, ho cdn hoac ho thung thang, co kem khac ddm hoac khong. + Ddm: nhay, trong, tru: ddt cap co boi nhiem thi mau vang. + Kho th6: khi gang siic, xuat hien dan dan, cung vdi ho hoac sau do mot thdi gian; giai doan muon co kho thd lien tuc. Tip A: kho thcJ nhieu, ngadi gay, thieu oxy mau luc nghi It Tip B: thieu oxy mau va tang carbonic nhieu, kho thd It - Kham lam sang: + Kieu thfr thd mlm moi nhat la khi gang stic + Co sU dung cac cd ho hap phu: cd lien sUdn, co keo hom tic, ho thiidng don. 12 + Co sti dung cd bung khi thcJ ra? Thd nghich thtfdng. + DUdng klnh trU6c sau cua long ngiic tang len Qong ngtfc hinh thung) + Dau hieu Campbell: khi quan di xuong d thi hit vao. + Dau hieu Hoover: giam dUdng klnh phan du6i long ngtic khi hit vao. + Go: vang nhat la 6 gian phe nang + Nghe: tieng tim md nho, ri rao phe nang giam, ran rlt va ngay. TrUdng hdp co boi nhiem co the thay co ran am, ran no. - Dau hieu tang ap ltfc dong mach phoi: + Mat loi nhu! mat ech do tang mach mau mang tiep hdp. + Tim nhip nhanh, co the co loan nhip hoan toan. + T2 danh manh, tieng click tong mau, rung tam thu 6 o van dong mach phoi, ngUa phi phai tien tam thu, + Dau hieu Carvallo: thoi tam thu d doc theo bd trai xiidng tic tang len d thi hit vao. + Tinh mach co noi dap theo nhip tim, gan to dap theo nhip tim, dau vung gan, tang khi lam viec, gang stic. Dau ha sUdn phai sau lan ra sau lufng. + Phu chan va cd trU6ng. 7. Can lam sang 7.1. X quang phoi thtfdng - O giai doan dau da so binh thUdng. - Tang dam cac nhanh phe huyet quan, "phoi ban". - Cac dau hieu cua gian phe nang: + Long ngUc gian: tang khoang sang tru6c va sau tim, vom hoanh bi day xuong, xUdng sUdn nim ngang. + Cac mach mau ngoai vi thUa th6t, bong khi. + Cung dong mach phoi noi. - Tim khong to hoac hdi to. Giai doan cuoi: tim to toan bo. 7.2. Chup cat Idp vi tinh phoi Gian phe nang: vung sang, khong co mach mau, bong khi. 13 7.3. Dien tdm do Co the binh thUdng, ngay b mot so" ca benh nang ! Mot so" trUdng hdp co the thay cac dau hieu cua day that phai, nhi phai: - P phe 6 DII, Dili, AVF: P cao >2,5 mm, nhon, doi xting. - Tieu chuan day that phai cua TCYTTG: It nhat 2 trong so" cac dau hieu sau: + True phai > 110° + R/S b V5, V6 <1 + Song S chiem Uu the" b DI hoac bloc nhanh phai khong hoan toan. + P > 2mm d DII + T dao ngUdc b VI tdi V4 hoac V2 va V3. 7.4. Sieu dm Doppler tim Nham danh gia mtic do tang ap liic dong mach phoi (TALDMP), suy tim trai phoi hdp. 7.5. Chile nang ho hap Do chiic nang thong khi vdi may phe dung ke. Roi loan thong khi tac nghen vdi FEVlgiam, chi so" Tiffeneau (FEV1/VC) < 70% hoac chi so Gaensleur (FEVl/FVC) < 70%. Test gian phe" quan: 15% 12% tri so" ban dau cua benh nhan (sau test gian phe" quan). - Khi mau: Pa02 giam, PaC02 tang b the nang. Can lam khi mau khi FEV1<40%. 8. Chan doan •> 8.1. Chan doan xac dinh Can nghi den chan doan benh phoi tac nghen man tinh d nhting benh nhan co cac trieu chting: ho, khac ddm va/ hoac tien sti phdi nhiem vdi cac yeu to gay benh. Ho va khac ddm thiidng la bieu hien bat dau cua sii tic nghen thong khi sau nhieu nam, mac du khong phai tat ca cac ca the co ho va khac ddm deu tien trien thanh benh phdi tac nghen man tinh. 14 Roi loan thong khi tac nghen khong hoi phuc hoan toan vdi FEVlgiam, chi so Tiffeneau (FEV1/VC) < 70% hoac chi so Gaensleur (FEVl/FVC) < 70% la tieu chuan vang cua BPTNMT. Khong nhat thiet phai co cac dau hieu lam sang nhat la ci thdi ky dau cua benh. 8.2. Chan doan phan biet Cac benh ly chmh can phan biet voi BPTNMT dufOc trinh bay ci bang 1: Bang 1: Chan doan phan biet cua benh phoi tac nghen man tinh Chan doan Dau hieu gdi y Thudng xuat hien khi con tre. Cac trieu chting thay doi tting ngay. Hen Suy tim xung huyet. Gian phe quan. Lao phdi. Viem tieu phe quan tac nghen. Viem toan bo tieu phe quan lan toa. Cac trieu chting thifdng xuat hien vao ban dem/sang s6m. Co the co dj ting, viem khdp, va/hoSc eczema. Tien sCf gia dinh co hen. Roi loan thong khi tic nghen co kha nSng phuc hoi nhieu. Nghe phdi co ran am cl day phoi. Tren Xquang co hinh anh bong tim to va phdi ti huyet. Xet nghiem chtic n^ng ho hap thay roi loan thong khi han che. Khac nhieu ddm. Thifdng lien quan v6i cac dot nhiim trung dUdng ho hap. Nghe phdi co ran no, ran am to hat. Co the co ngon tay dui trong. Xquang co hinh anh thanh phe quan day. Chup phe quan can quang/ chup c§t I6p vi tinh phdi co hinh anh gian phe quan khSng djnh chan doan. La benh thi/dng gap d khu viic lao thjnh hanh nhi/ cl nirdc ta, dtat ca cac ICfa tuoi. X quang ngi/c cho thay hinh anh tham nhiim, not. Xet nghiem vi sinh thay tri/c khuan lao khang djnh chan doan. 6 ngirdi tre tuoi khong hut thuoc. Trong tien sir co the co viem khdp dang thap hoSc tiep xuc vdi khoi. Chup c§t I6p vi tinh phdi trong thi the) ra thay nhieu vung giam ty trong. Phan I6n benh nhan la nam gidi, khong hut thuoc. Hau het co viem xoang man tinh. Xquang/ Chup cSt Idp vi tinh phdi co do phan giai cao thay co nhC/ng dam md dang not nho trung tam tieu thuy, phdi (I khi. 15 9 8.3. Chan doan miic do nang ChUdng trinh khdi dong BPTNMT toan cau xep benh lam bon giai doan nhu sau: Bang 2: Chan doan miic do nang cua benh phoi tac nghen man tinh. Giai doan Dac diem 0: Nguy ca. • Do phe dung ke binh thirdng. • Co cac trieu chting man tinh (ho, bai tiet ddm). • FEV,/ FVC<70%. 1: Benh phoi tic • FEV,> 80% tri so ly thuyet. nghen man tinh nhe. • Co hoac khong co cac trieu chting man tinh (ho, bai tiet ddm). • FEV,/ FVC<70%. • 50% < FEV,< 80% trj so ly thuyet=> 1 la II: Benh phdi tac nghen man tinh vi/a. • 30% 15 gid/ 24. + 55 < Pa02 < 59 mmHg: oxy lieu phap neu co TALDMP, da hong cau, thieu oxy mau khi ngu nang. - Phuc hoi chtic nang ho hap v6i dan lUu tU the, tap thd: + Thd bung, cd hoanh va phan difcii long ngUc, sti dung kieu thd cham, thu gian de giam tan so thd va giam tieu hao nang lUdng ho hap. Thd mfm moi trong cac giai doan kho thd. + Tang trUdng luc cd bang cach tap the due deu dan. Ho co dieu khien de khac ddm. - Cai thien tinh trang dinh dUdng: + An nhieu btia nho, them cac chat dinh dUdng long. + Tranh cac thtic an lam day bung. - Tiem vaccin phong cum vao mua thu, dong. - Giti phong sach, cang ft bui cang tot: khong dung tham... Dieu tri du phong tat ca cac o nhiem trung tai mui hong, rang. DAI HQC THAI NGUYEN '['RUNG TAM HQC LIEU T2- BGBHNK 17 10. Dieu tri deft cap BPTNMT Cac nguyen nhan gay ddt cap BPTNMT diidc trinh bay ci bang 3: Bang 3: Cac nguyen nhan gay deft cap BPTNMT Nhiim khuan ho hap - Viem phe quan cap do virus hoSc vi khuan - Viem phdi do virus hoSc vi khuan Do dung thuoc gay nen - Dung thuoc an than, chen (3 (thuoc nho m it...) - Dung oxy khong dung (luu luttng cao) Cac benh ly ho hap khong phai nhiim khuan - Tran khi mang phdi, tic dong mach phdi. Cac benh ly khac - Suy tim trai - Roi loan nhjp tim (nguyen nhan hoSc hau qua ctia suy ho hap) - Cac roi loan chuyen hoa, nhiim trung cac phCi tang khac Trong cac nguyen nhan nhiem khuan ho hap thi virus chiem 50%: virus Respiratory synctial, myxovirus influenzae - Vi khuan: phe cau, moraxella catarrhalis... Dieu tri khang sinh cac ddt boi nhiim 7-14 ngay; amoxicillin, amocicillin + acid clavulanic, cephalosporin, macrolid + quinolon. - Phuc hoi chtic nang ho hap, dan lUu phe quan - Thuoc gian phe quan, corticoid uong hoac tiem tinh mach: 0,5mg/kg/ ngay. - Thuoc long ddm, oxy lUu liidng thap. - Nhting trtidng hdp dieu tri nhtf tren nhiing vin tien trien nang v6i suy ho hap cap nhiim toan ho hap thi phai tien hanh thong khi nhan tao khong xam nhap (qua mat na) hoac qua ong noi khi quan, mci khi quan neu phai thong khi nhan tao dai ngay. 11. Phong benh - Loai bo yeu to" kich thich: khong hut thuoc, tranh khoi bui ndi lam viec, trong nha, moi triidng o nhiem. - Giti gin stic khoe, giti am nhat la mua lanh. 18 HEN PHE QUAN 1. Dinh nghia Hen phe quan la trang thai lam sang cua su! phan ting cao do cf phe quan do nhieu kfch thfch khac nhau, bieu hien dac trtfng la kho thcf, co tieng co cti do hau qua cua co that cd trdn phe" quan, phu ne niem mac phe quan va tang tiet nhay phe quan. Cdn kho thci co the tU hoi phuc (do dung thuoc hoac khong) 2. Dich te hoc Hen phe quan la benh gap rat pho bien, va co xu hu6ng ngay mot tang tren the gicfi cung nhtf cJ Viet Nam. C) My so ngUdi bi hen nam 1979 la 386000 tang len t6i 466000 ngiidi nam 1993 va hien nay tan suat ngifcii bi hen phe quan khoang 4,8%; 6 Cu Ba co 9,74% dan so bi hen phe quan (R. vega). C) Viet Nam theo thong ke trUdc nam 1985 hen gap 6 1% dan so" nong thon va 2% dan so" thanh thi va chiem 18,7% cac benh phdi (Chu Van Y) nhUng hien nay tan suat ngUdi bi hen phe" quan d nU6c ta tti 2-6% dan so" va tren 10% d tre em. 3. Giai phau benh 3.1. Dai the Nhting manh chat nhay quanh, dfnh lap day long phe" quan nhat la phe quan nho. Co nhting vung phe" nang bi xep xen lan nhting vung phe" nang bi gian. 3.2. Vi the Trong long phe" quan co bach cau ai toan, bach cau da nhan trung tmh, tinh the Charcot-Leyden, thanh phe quan co tham nhap bach cau ai toan, mang day niem mac day va co thoai hoa nhay, tang sinh sdi tao keo, phi dai cd trdn phe quan, tang sinh cac tuyen va te" bao hinh dai. 4. Trieu chting 4.1. Trieu chiing ca nang Trieu chting chfnh cua hen phe" quan la cdn hen (cdn kho thd co hdi phuc) - Trieu chting bao tru6c: hat hdi, so mui, ngtia mat hoac do mat (viem mang tiep hdp di ting), ho khan vai tieng, co khi buon ngu. 19 - Ccfn kho thd: bat dau cdn, kho thd cham, kho thd ra (giai doan dau), co tieng co ctf ma ngifdi ngoai cung nghe thay, kho thd tang dan, phai ty tay vao thanh giufdng de thd, doi md toang cUa de thd, met nhoc, toat mo hoi, tieng noi bi ngat quang. Cdn kho thd keo dai 10-15 phut, co khi hang gid, hoac lien mien ca ngay khong dtit. - Cdn kho thd giam dan va ket thuc la mot tran ho va khac ddm, ddm mau trong, quanh va dinh, cang khac difdc nhieu cang de chiu. Het cdn benh nhan nam ngu dUdc. - Cdn hen thudng xay ra ve dem hoac khi thay doi thdi tiet. 9 4.2. Kham thiic the Trong cdn hen kham phoi thay: - Go long ngifc: trong. - Nghe: ri rao phe nang giam, thay tieng ran rft va ran ngay khap 2 ben phdi. Sau cdn hen kham thifdng khong thay gi dac biet. - Tim mach: nhip tim thudng nhanh, co khi tdi 120- 130 lan/ phut, nhip xoang, co khi ngoai tam thu, huyet ap tang. 4.3. X quang phoi Trong cdn hen ft lam; neu lam thudng thay long ngifc va cd hoanh ft di dong, xiidng sifdn nam ngang, cac khoang lien sUdn gian rong, 2 phe trutdng qua sang, ron phdi dam. Can chup phoi khi co cac dau hieu lam sang nghi ngd de phat hien cac bien chiing nhif tran khf mang phdi, tran khf trung that hoac ton thifdng viem phoi la can nguyen lam hen nang len. 4.4. Chttc nang ho hap Do chUc nang thong khf bang phe dung ke thifdng thay roi loan thong khf tac nghen phuc hoi difdc vdi thuoc gian phe quan (FEV1 <80%, FEV1/VC<70% ; FEY^ tang >15% hoac trd ve tri so" ly thuyet sau khf dung 400pig salbutamol). O cac trUdng hdp chUc nang thong khf binh thudng thi co the tien hanh nghiem phap co that phe quan bang methacholin de tim sif tang tmh kfch thfch cua phe quan. 4.5. Litu luong dinh ke Do lUu lifdng dinh thd ra (LLD) la lifu lifdng nhanh nhat cua khf lifu thong trong difdng ho hap khi thd ra gang sUc. Roi loan tac nghen co the hoi phuc va sif bien doi lifu thong khf do bang lUu lifdng dinh ke (LLD), mot dung cu ddn gian, bieu hien bang mot trong cac trUdng hdp sau: 20 - LLD tang hdn 15%, sau 15-20 phut cho hit thuoc cifdng (32 tac dung ngan, hoac - LLD thay doi hdn 20% giQa lan do buoi sang va chieu cach nhau 12 gid & ngifdi benh dung thuoc gian phe quan (hoac hdn 10% khi khong dung thuoc gian phe quan), hoac - LLD giam hdn 15% sau 6 phut di bo hoac g&ng stfc. 4.6. Khi mau Thifdng lam trong cdn hen nang - Pa02 giam < 70mmHg, Sa02 giam trong cdn hen nang. - PaC02 binh thudng hoac tang trong cdn hen nang, co khi tang tren 50mmHg. - Suy ho hap man: Pa02 <70 mmHg, PaC02 >40 mmHg, pH mau binh thifdng; - Suy ho hap cap: Pa02 < 60mmHg; PaC02 tang nhieu, co the > 50 mmHg, pH mau giam khi co toan ho hap. 4.1. Xet nghiem ddm - Tinh the Charcot-Leyden, bach cau ai toan, bach cau da nhan trung tinh, dai thifc bao - Cay ddm: nen difdc tien hanh moi khi co ddt bung phat do nhiem khuan de xac dinh vi khuan gay benh, ket hdp v6i lam khang sinh do ttf do lifa chpn khang sinh phu hdp. 4.8. Dien tim Trong cdn hen thay nhip nhanh xoang, co the thay hinh anh tang ganh that phai (true phai, RVi+ SV5>11 hoac RV2> 7) khi co suy that phai. •} 5. Chan doan 5.1. Chan doan xac dinh • Nghi den hen khi co mot trong nhUng dau hieu hoac trieu chiing chi diem sau: - Cdn hen v6i cac dac diem, dau hieu dac trifng: + Tien trieu: hat hdi, so mui, ngiia mat, ho khan, buon ngu... cif ngifdi ngoai nghe cung thay, kho thd tang dan, sau co the kho thd nhieu, va mo hoi, kho noi. Cdn kho thd keo dai 5-15 phut, co 21 khi hang gid, hang ngay. Cdn kho thd giam dan va ket thuc vdi mot tran ho va khac ddm dai. Ddm thudng trong, quanh va dinh. Cdn hen xay ra trong nhting dieu kien giong nhau: ban dem, khi thay doi thdi tiet. - Tieng thd rft (kho khe). Tieng rft am sic cao khi thd ra - dac biet d tre em: chan doan hen tti lan "viem phe quan co thdt" thti ba trd di. - Tien sti co mot trong cac trieu chting sau: + Ho, tang ve dem. + Tieng rft tai phat. + Kho thd tai phat. + Nang ngilc nhieu lan. - Can nghi tdi chan doan hen neu benh nhan co tinh trang "cam cum" di xuong phdi" lap di lap lai hoac qua 10 ngay, hoac tinh trang stic khoe cai thien khi cho thuoc chong hen. - Kham phdi binh thudng cung khong loai trti chan doan hen. + Tham do chtic nang ho hap co hoi chting tac nghen thong khi hdi phuc dUdc vdi thuoc gian phe quan. •t 5.2. Chan doan phan biet - Trao ngUdc da day thUc quan, ro thUc-khi quan - Ung thu, - Thoai hoa nhay nhdt - Tre nho: chan doan phan biet vdi viem thanh khi phe quan cap: tre co sot, ho, khac ddm, kho thd; nghe phoi co ran rft, ran am va ran ngay. Nen dieu tri cung nhu nhiem khuan dudng ho hap. Nghi den hen khi cdn kho thd tai phat, sau cdn tre chdi binh thudng. - Hen tim: cdn kho thd xuat hien dot ngot, thudng xay ra vao ban dem, kho thd nhanh, nghe phdi co ran am ca hai ben phdi, co khi ran am dang len rat nhanh. Cdn thudng xuat hien tren benh nhan co tien sti benh ly tim mach tti trUdc; chup xquang thay tim to, hinh anh ti huyet d phdi; dien tim co hinh anh tang ganh that trai. Co the rat kho khi co dong thdi ca tang huyet ap va hen phe quan. - Ddt cap benh phdi tac nghen man tmh (BPTNMT): Thudng d ngUdi ldn tuoi, co hut thuoc la hay thuoc lao, da dUdc chan doan BPTNMT trUdc do. Tham do chtic nang ho hap co tac nghen thong khi khong hdi phuc hoan toan vdi thuoc gian phe quan. 22 - Bat thudng hoac tic difdng ho hap do: - Nhun sun thanh, khf, phe quan, hep khf phe" quan do chen ep, xd. - Khoi u va polip khf phe quan: thifdng khoi u n&m d chac 3 khf phe quan, benh nhan co kho thd lien tuc, co tieng co cii lien tuc. De chan doan can soi phe quan hay chup cat ldp vi tmh. - Hach trung that va khoi u trung that: de ep khf phe quan ttf ngoai gay kho thd - Di vat phe quan: di vat nho de bi bo quen, can hdi ky tien stjC, soi phe" quan de chan doan xac dinh. - Phinh quai dong mach chu: gay de ep phe" quan goc. 6. Phan loai hen phe quan 6.1. Theo the benh - Hen ngoai sinh: cdn goi la hen di ting, cd dac diem: + Benh thifdng xay ra d tre em va ngUdi tre. + Cd tien sii gia dinh hay ban than ve hen phe" quan hay cac benh di ling. + Cdn hen xay ra cd lien quan vdi cac di nguyen dac hieu. + Test da vdi di nguyen difdng tmh. + Nong do IgE toan phan va IgE dac hieu trong mau tang. + Dieu tri giai man cam cd ket qua neu di ling vdi mot hoac hai di nguyen.. - Hen noi sinh: hay cdn goi la hen nhiem khuan + Benh thifdng xay ra d ngifdi ldn. + Khong cd tien sii ban than hay gia dinh ve hen phe" quan, cac benh di ling. + Cdn hen xay ra cd lien quan tdi cac ddt nhiem khuan difdng ho hap. + Test da vdi di nguyen vi khuan dUdng tmh. + Nong do IgE trong mau tang. + Dieu tri giai man cam khong co ket qua. + Tien lifdng noi chung nang hdn hen ngoai sinh. - Hen hon hdp: Yeu to" di ling dong vai tro quan trong nhUng cdn hen xay ra do nhiem vi khuan hoac virus difdng ho hap. 23 6.2. Theo mute do nang (bang 4) Bang 4: phan loai mtic do nang cua benh hen. Khi co mot tinh chat nang cua bac nao la du xep benh nhan vao bac do. Bat ky benh nhan d mtic nao, ngay cd hen rat nhe cung co the co ccfn hen nang. Mure do Trieu churng (TC) TC ve dem Liru lirong dinh Bac 1 Thinh thoang tC/ng luc Bac 2 Nhe keo dai Bac 3 Trung binh keo dai Bac 4 Nang keo dai < 1lan/ tuan Gitia cac con khong co trieu chting va LLD binh thifdng > 1 lan/ tuan nhifng <1 lan/ ngay Hang ngay. Sti dung hang ngay thuoc cifdng p2- Con hen han che hoat dong binh thifdng. Dai ding thifdng xuyen Han che hoat dong the life < 2lan/ thang > 80% gia trj ly thuyet Dao dong <20% > 2 lan/ thang > 80% gia tri ly thuyet Dao dong 20-30% >1 lan/ tuan >60% < 80% gia tri ly thuyet Dao dong >30% Thifdng co < 60% gia trj ly thuyet. Dao dong > 30% 7. Tien trien va bien chting Tien trien cua benh khong giong nhau, co ngUdi benh on dinh mot thdi gian dai, cd ngUdi bi lien tuc, cd khi sau de lai dd hin, nhtfng cd trufdng hop sau de lai nang them; trong qua trinh dien bien lau dai cua benh cd the cd nhflng bien chiing sau: - Nhiem khuan: dot boi nhiem lam benh nang them, benh nhan xuat hien cac trieu chiing: sot, ho, khac ddm dac, kho thd, cd khi bieu hien dot suy ho hap. - Gian phe nang: phe nang bi ii khi, thanh phe nang bi pha huy do cac ddt boi nhiem lau dan gay gian phe nang. The tfch va ap liic phe nang tang len, vach mach mau day len, long mach hep lai, he thong mao mach thtfa thdt dUa den hau qua tang ap liic tieu tuan hoan. - Suy that phai: la bien chiing cuoi cung cua hen phe quan, that phai day, buong that phai gian va sau cung la suy tim toan bo. 8. D ieu tri 8.1. Cac diem chung - Tranh tiep xuc vdi cac di nguyen, chat kfch thfch hfifhap. - Co the can nhac dieu tri giai man cam doi vdi phan hoa, cd, mat bui nha, long mong sue vat khi khong the tranh difdc cac di nguyen hoac dung thuoc thfch hdp khong kiem soat dUdc trieu chiing hen. Lieu phap mien dich dac hieu can phai thiic hien bdi cac chuyen gia y te cd kinh nghiem khi xac dinh dUdc benh nhan bi di ling vdi mot hoac hai di nguyen hoac vdi mot so di nguyen cung nhom. - Loai trif cac gai kfch thfch, o° nhiem trung, dung khang sinh khi cd boi nhiem phe quan phoi hoac viem xoang: Amoxycillin uong 3g/ngay x 8 ngay, neu di ling vdi Penicillin thi dung nhom Macrolid. Thuoc long ddm chi dung khi cd boi nhiem phe quan phoi: Mucomyst x 3 goi / ngay. - Phuc hdi chiic nang ho hap, tap thd, ho dan lUu ddm. Theo doi lUu lifdng dinh. 8.2. Dieu tri cat cdn hen - Khong bao gid dUdc danh gia thap hdn mtic do nang thiic sii cua cdn hen, cdn hen nang cd the de doa tmh mang cua ngUdi benh. - NgUdi benh cd nguy cd tii vong cao khi: + Dung thifdng xuyen hoac mdi ngifng corticoid toan than + Nhap vien hoac kham cap ciiu vi cdn hen trong nam trUdc, hoac tien sU dat noi khf quan vi hen. + Tien sii cd van de ve tam ly xa hoi, bo dieu tri hoac khong chap nhan viec minh bi hen nang. Tien sii khong tuan thu dieu tri. 8.3. Ngiidi benh cdn phdi den ngay bac si kham khi - Cdn hen nang + Kho thd khi nghi ngdi, ngUdi cui ve trUdc va noi tifng tii mot (tre sd sinh thi bo bu), kfch thfch, dd dan, llin Ion, nhip cham, hoac tan so thd > 30 lan/ phut + Ran rft giam hoac mat + Mach > 120 lan/ phut ( >160 lan/ phut d tre sd sinh). + LLD < 60% gia tri ly thuyet, ngay ca sau dieu tri ban dau 25 - Dap ting vdi dieu tri thuoc gian phe quan khong nhanh chong va duy tri < 3 gid. - Khong cai thien trong 2-6 gid sau khi dieu tri bang corticoid toan than - Dien bien nang len 8.4. Can hen cdn dieu tri ngay lap titc - Thuoc cifdng p2 dang hit tac dung ng&n v6i lieu phu hdp la dieu cot yeu. Co the lap lai khi can thiet. - Dung scim corticoid vien hoac siro trong dieu tri cdn trung binh hoac nang de giam viem va giup cai thien nhanh. - ThcJ oxy, dieu tri trong benh vien neu ngUdi benh co tinh trang thieu oxy. - Khong dung theophyllin hoac aminophyllin neu nhii da dung thuoc ciidng |32 lieu cao vi khong cai thien tac dung gian phe quan ma lai tang nguy cd tac dung phu. Tuy nhien, co the dung theophyllin neu nhii khong co s&n thuoc cUdng [32 dang hit. Neu nhu benh nhan da dung theophyllin thudng xuyen, nen do nong do trong huyet thanh trUdc khi cho theophyllin tac dung ngan. - Epinephrin (adrenalin) co the chi dinh trong dieu tri cap ciiu phan ve hoac phu Quincke. Ngiidi ta chia miic do nang cua cdn hen theo 4 bac dUdc trinh bay d bang 5. Bang 5: Danh gid mtic do nang cua ccfn hen Cac chi so Nhe Trung binh Nang S ip ngirng thd Kho thd Khi di lai Benh nhan co the nim ngCra diroc Khi noi. Tieng khoc cua tre so sinh thu’dng ngin hon, kho Sn Ngifdi benh thich ngoi Khi nghi Tre bo 3n Cui ve trifdc D iin dat mieng doi thoai TC/ng cau TCfng tif Tri giac Co the kich thich Thifdng kich thich Thifdng kich thich Ngu ga, lin Ion Tan so the) TSng Tang Thifdng >30 lan/ phut 26 8.5. Dieu tri ccfn HPQ nang cap - Benh nhan vao vien bang xe van chuyen cap ctiu hoi stic, theo doi lien tuc trong qua trinh van chuyen benh nhan. - Dat difcJng truyen tinh mach, theo doi b&ng may Monitor: mach, HA, Sa02, nhip thd. ThcJ oxy 2 -6 lft/phiit. Khi dung thuoc kich thfch p2 Salbutamol (Ventoline) hoac terbutalin (Bricanyl): 2,5 - 5mg trong 4ml NaCl 0,9% v6i oxy 6 1ft, gid dau cii 15 phut 1 lan, sau do 1 lan/ gid. - Thuoc kfch thfch P2 truyen tinh mach 1- 2 mg/gid - Corticoid: Solumedrol 80mg x 3/ngay tiem tinh mach. - Pulmicort 500|i g x 4 nang/ngay, khf dung. - Boi phu nU6c, dien giai: glucose 5%: 2 lft/ngay + 6g KC1 - Thuoc gian phe quan loai khang cholinergic: Atrovent x 4 nang/ ngay khf dung . - Diaphyllin 10 mg/kg/ngay truyen tinh mach, neu triiclc do chiia dung. - Cac thuoc khong nen dung trong dieu tri cdn: + An than (tranh tuyet doi) + Tieu ddm (lam ho nang len) + Sulfate magnesium (tac dung khong dufdc chiing minh) + Phuc hoi chiic nang ho hap (lam met ngiidi benh) + Truyen dich vdi khoi liidng 16n cho ngUdi 16n va thieu nien (co the can thiet cho tre nho va tre sd sinh) + Khang sinh (thuoc khong de cat cdn ma chi diidc chi dinh khi benh nhan co bieu hien viem phoi hoac nhiem vi khuan nhif viem xoang...) - Cdn hen miic do trung binh co the can thiet va cdn hen nang phai dieu tri tai benh vien. - Cdn hen nhe co the dieu tri tai nha neu nhii benh nhan nhan diidc ldi khuyen phu hdp va co phac do dieu tri ghi ro tting biidc can lam. - Theo doi dap ling dieu tri: Danh gia trieu chiing, thudng xuyen theo doi LLD neu co the. O benh vien can theo doi do bao hoa oxy (SP02), do khf mau dong mach cho nhiing benh nhan nghi ngd co giam thong khf, suy ho hap nang hoac LLD<30% tri so ly thuyet. 27 8.6. Dieu tri ca ban HPQ Dtf a theo giai doan cua HPQ, dUOc trinh bay b bang 6 Bang 6: Dieu tri, HPQ d ngiidi Icfn va tre em>5 tuoi. Dieu tri lia chuong la phan diicfc in dam. Giao due ngiidi benh la dieu cot yeu cho moi bac dieu tri Bac Du phong lau dai Cat cdn hen Bac 4 N3ng keo dai Bac 3 Trung binh keo dai Bac 2 Nhe keo dai Bac 1 Thlnh thoang Dieu tri hang ngay: - Corticoid hit: 800-200(Vg -Thuoc gian phe quan tac dung keo dai: hoSc thuoc ctfdng p2 dang hit tac dung keo dai, va/ hoac theophyllin phong thi'ch cham va/ hoac vien hoSc sircr thuoc ci/dng p2 tac dung keo dai -Vien hoac siro corticoid dung lau dai. Dieu tri hang ngay: - Corticoid hit 500ng va neu can: - Thuoc gian phe quan tac dung dai: hoac thuoc cirdng p2 dang hit tac dung keo dai, va/ hoac theophyllin phong thich cham va/ hoac vien hoSc siro thuoc ci/dng p2 tac dung keo dai (thuoc cirdng p2 tac dung keo dai khi phoi hop v6i corticoid lieu thap dem lai su1 kiem soat trieu chiing hieu qua hon so vdi chi tang lieu corticoid don thuan). - Can nhac viec sir dungthuoc khang leucotrien nhat la b ngi/di benh nhay cam vdi aspirin va de phong ngi/a stf co that phe quan khi gang sue. - Vien hoac siro corticoid dung lau dai. Dieu tri hang ngay: - Corticoid hit 200-500^g. hoSc cromoglycat hoac nedocromil hoac theophyllin phong thich cham. - Co the dung thuoc khang leucotrien nhung vai tro cua thuoc nay trong dieu tri chi/a dude xac dinh ro. Thuoc gian phe quan tac dung nhanh: thuoc ci/dng p2 dang hft khi can dS dieu tri trieu chCrng Thuoc gian phe quan tac dung nhanh: thuoc cudng p2 dang hit khi can de dieu tri trieu chiing, khong nen dung qua 3-4 lan trong mot ngay - Thuoc gian phe quan tac dung nhanh: thuoc cudng p2 dang hit khi can de dieu tri trieu chifng, khong nen dung qua 3-4 lan trong mot ngay Thuoc gian phe quan tac dung nhanh: - Thuoc cirdng p2 dang hit khi can de dieu tri trieu chilhg nhung < 1 lan/ 1tuan ti/ng luc Khong can dieu tri. •0 bac: - Cirdng do dieu tri phu thuoc mifc do nang cua con (xem bang) - Thuoc ci/dng p2 dang hit hoac cromoglycate trU6c khi hoat dong the Il/c hoac tiep xuc vdi di nguyen. ft bac: Cir 3 - 6 thang xem lai bac dieu tri. Neu kiem soat on dinh trong 3 thang thi co the giam bac. 28 Neu khong kiem soat di/qc hen thi phai xem xet nang bac. Nhung trifdc tien can xem lai ky thuat dung thuoc cua ngUdi benh , si/ tuan thu dieu tri va kiem soat moi tri/dng (tranh di Crng va yeu to khdi phat). 9. Phong benh - Xac dinh va tranh cac yeu to kfch phat Khi ngUdi benh tranh dUOc cac yeu to" kfch phat (di nguyen va cac chat kfch thfch lam nang benh) thi co the ngan ngtia dUdc trieu chiing va cdn hen xuat hien, do do giam dUdc viec dung thuoc. - Loai bo yeu to" kfch thfch: khong hut thuoc, tranh khoi bui trong nha, moi trUcing o nhiem. - Giti gin siic khoe, giti am nhat la mua lanh. GIAN PHE QUAN 1. Dai ctfdng va dinh nghla Gian phe" quan la gian lien tuc, vinh vien khong hoi phuc cua mot hoac nhieu phe" quan co dUdng kfnh tren 2mm do sii pha huy to chiic chong do nhU: ldp cd chun, ldp sun cua thanh phe quan. Dinh nghia nay loai trti nhting trUdng hdp gian phe quan gia (co hoi phuc). Binh thUdng tU phe quan goc cac phe quan phan chia 17-20 lan tcfi tieu phe quan tan. Cac phe quan co the bi gian tti the he 4 trci di. Goi la gian phe" quan khi dudng kfnh cua long phe quan 16n hdn binh thUdng, la mot benh man tfnh do bam sinh hay mac phai, benh co tmh chat noi - ngoai khoa, noi khoa chi dieu tri trieu chting va bien chting, chu yeu la phai mo. Benh canh lam sang cua gian phe quan dUdc Laennec mo ta dau tien tti nam 1819, nhting nam gan day nhd phUdng phap chup phe" quan co can quang, soi phe" quan, va chup cat 16p vi tfnh (CT hoac HRCT), benh dUdc phat hien mot cach chac chan. Gian phe quan chiem 6% cua cac benh phoi, nam bi nhieu hdn nti . 2. Phan loai gian phe quan Co the phan loai gian phe" quan theo cach sau day: 2.1. Phan loai theo trieu chiing lam sang 2.1.1. Gian phe quan the itdt Benh nhan khac ddm nhieu, doi khi ddm nhu mu, thUdng gap gian phe quan thuy dudi. 2.1.2. Gian phe quan the kho Benh nhan khong khac ddm chi ho ra mau nhieu lan va keo dai thudng gap gian phe" quan thuy tren. 29 2.2. Phan loai theo giai phau benh Lam sang co the biet dUdc nhd chup phe quan co can quang: 2.2.1. Gian phe quan hinh ong Dudng vien ngoai cac phe quan deu dan va dUdng kmh cua cac phe quan xa khong tang len nhieu, long cua chting thudng co xu hu6ng ket thuc dot ngot va khong nho lai. Cac phe quan nho hdn va tieu phe quan bi lay day mu dac. So" lan phan chia tti phe quan goc tdi ngoai vi giam di mot chut (16 lan) 2.2.2. Gian phe quan hinh trang hat 0 hhom nay so lan phan chia phe quan giam nhieu hdn nhom I, co nhting ndi co hep tai cho lam cho dUdng vien ngoai phe quan khong deu giong nhu hinh trang hat hay cac tinh mach bi gian. Cac phe quan ngoai vi cung bi tac nhieu hdn b nhom I, so lan phan chia trung binh phe quan thay dUdc qua chup phe quan la 4, dai the la 6,5 va vi the la 8 lan. 2.2.3. Gian phe quan hinh tui, hinh ken: Cac phe quan tang dan dUdng klnh ve phan ngoai vi, v6i hinh giong qua bong. So lan phan chia phe quan toi da la 5. O mot so trUdng hdp hiem, mot gian phe quan hinh tui tai cho co the bi lap day bdi mu chic, dan den hinh thanh mot nang nhay. Ton thUdng thudng b phe quan the he 4 hoac xa hdn. Co the ca ba loai ton tai tren cung mot benh nhan. 2.3. Phan loai theo tinh chat 2.3.1. Gian phe quan thiiphat hay mac phdi Gian phe quan xay ra sau mot benh cua phe quan, phoi. 2.3.2. Gian phe quan tien phat hay bdm sinh Benh xay ra tti khi con la bao thai. 2.4. Phan loai theo vi tri ton thiidng 2.4.1. Gian phe quan lan tod: gian phe quan nhieu thuy b ca hai ben phoi, benh xay ra tti luc tre, the nay nang, nhanh bi suy ho hap va khong mo dUdc. 2.4.2. Gian phe quan the cuc bo: gian phe quan d 1-2 phan thuy d mot ben phoi. The nay co the mo dUdc. 30 2.5. Phan loai theo nguyen nhan 2.5.1. Gian phe quan do tac phe quan - Tic phe quan do di vat: khi di vat vao phe quan lam tac phe quan din den phe quan du6i cho tac bi gian do qua trinh viem nhiem gay huy hoai thanh phe quan, thiidng xuat hien tti 6-8 tuan le sau khi co di vat, co khi nhanh hdn. - Tic phe quan do u trong long phe quan: phan dufdi cho tac bi gian do qua trinh viem nhiem gay huy hoai thanh phe quan, tien trien nhanh hay cham ttiy theo tien trien cua khoi u va mtic do boi nhiim. - Tic phe quan do seo cti cua cac chan thiidng, viem nhiem. 2.5.2. Gian phe quan do viem, hoai tit thanh phe quan - Gian phe quan do lao: theo Galy gian phe quan xay ra khi lao dang tien trien hoac seo cu cua lao, thUdng gap trong lao xd phoi, hay gap gian phe quan d san hang lao. Ngiidi ta cung thay gian phe quan xay ra rat sdm b benh nhan bi lao so nhiem tien trien. Gian phe quan do lao co the do tic phe quan bdi hat lao nim trong phe quan hoac do hach tti ngoai chen ep, hoac do co keo bdi seo xd. - Gian phe quan sau viem khong dac hieu: nhu viem phoi do vi khuan, virus, do sac dich da day, hoac hit phai dich mau xuong phoi. - Gian phe quan xay ra of benh nhan bi xd hoa ken tuy: day la nguyen nhan gay gian phe quan thUdng gap nhat d chau Au va Bic My (chiem 50% cac triicing hdp gian phe quan) nhiing hiem gap ci Viet Nam. - Gian phe quan do xd hoac u hat co keo thanh phe quan: Lao xd hang, ap xe phoi man tmh... - Gian phe quan va cac benh phoi khac: + Ap xe phoi + Ken hdi phoi boi nhiem + Nhiem khuan phoi sau mo. - Gian phe quan tien phat: + Hoi chting Mounier Kuhn: thiidng gap d nam gidi tuoi 30-40. Gian phe quan kem theo phi dai khi quan va viem xoang sang, xoang ma, thudng co viem mui mu, polyp mui. Benh do khuyet tat cau true to chtic lien ket thanh khi phe quan . 31 + Hoi chiing Kartagener mo ta nam 1933: gian phe quan lan toa + viem xoang sang, xoang ma + dao ngufdc phu tang (vi tri cua tim chuyen sang ben phai), do roi loan hoat dong cua nhung mao te bao phe quan, benh co tinh chat gia dinh. + Hoi chiing Williams- Campbell: thtfdng gap d tre nho do khuyet tat hoac khong co sun phe quan, gay gian phe" quan. Ngiidi ta cho rang gian phe quan bam sinh la do viem nhiem vach phe quan tti khi con la bao thai do loan san bam sinh. - Khong ro nguyen nhan: gian phe quan vo can co the do roi loan thanh loc phoi phe quan, nhiing bi bo qua, thudng gap d ngUdi 16n, d thuy dUdi 3. Giai phau benh hoc Phe quan bi gian tii the he 3-4 den the he 16, co khi phe quan tan cung cung bi gian (phan chia cay phe quan cd 17-20 he). Phe quan bi gian nam gitia phe quan binh thudng va nhu mo phoi. Vi the Ldp lien bao phe quan cd xen lan nhting dam te bao loan san kieu te bao Malpighi, niem mac phe quan bi loet, viem nhiem quanh tuyen phe quan - vach phe quan bi day len hoac rat mong, phla trong chtia nhting nang hop bdi tan cau xung quanh cd cac sdi cO, sdi chun bi thoai hoa. Whitewell goi la "gian phe quan nang" doi khi nang nay dting mot minh khong cd sdi cd, sdi chun va tuyen giong nhu gian phe nang hdi. TrUdng hop gian phe quan do viem phe quan: phe quan bi tic do chat tiet va phu ne, tuyen phe quan, ldp sun bi ton thUOng gay lo ro gitia phe quan nay vdi phe quan khac. Nhu mo phdi bi xep hoac phe nang bi gian, trong nhu mo phdi cd nhting hang chtia day mu, long phe quan chtia chat tiet va mu. Tuan hoan phdi bi roi loan, dong mach phe quan cd cho phinh ra cd nhieu cho noi vdi dong mach phdi, hoac noi vdi tinh mach phe quan tao nen Shunt trai - phai hoac trai - trai. Do ap liic cao cua he thong dai tuan hoan (dong mach phe quan) lam vd nhting cho noi - la cO che gay ho ra mau trong gian phe quan. 4. Cd che sinh benh Ton thiidng chu yeu cua gian phe quan la ldp cd, ldp chun, ldp sun cua vach phe quan bi pha huy, lam suy yeu vach phe quan vinh vien va khong hoi phuc, khi gap nhting dieu kien nhii: thd manh, ho, liic co keo cua phan phdi bi xep, xd phdi, day dinh mang phdi se lam cho ndi ton thUOng 32 phinh ra. Ameuille va Lemoine thay mot so trUdng hdp vach phe quan kem nuoi dUdng do tac dong mach phe quan bdi chen ep cua hach lao cung gay viem nhiem dan dan gay gian vach phe quan. Gian phe quan thUdng xay ra sau phe quan phe viem, ho ga, cum, sdi. Viem hoai tti to chtic chong d3 cua phe quan. C) tre em thieu hut mien dich bam sinh he thong phe quan cua tre em rat de bi nhiem khuan dan den gian phe quan. Do do ta thay trieu chting lam sang cua gian phe quan xuat hien rat sdm hau het trUdc tuoi 20. Hien nay co mot so gia thuyet de cat nghia gian phe quan. 4.1. Thuyet co dien cua gian phe quan thiiphat Gian phe quan tiep theo sau viem phe quan do vi khuan tu! dUdng mui hong ma ta goi la viem phe quan di xuong. 4.2. Thuyet bdm sinh vd di truyen Hoi chiing Kartagener: gian phe quan, viem xoang sang, dao ngUdc phu tang, benh co tinh chat gia dinh, mot so" trUdng hdp gian phe quan khong co viem nhiem ma chi ho ra mau. NgUdi ta cho ring viem nhiem phe quan tU luc con bao thai hoac thieu hut mien dich bam sinh. Ve thiic nghiem: neu lam tac phe quan, gay viem phe quan bang hoa chat hoac that dong mach phe quan khong gay dUdc gian phe quan giong nhu gian phe quan tii phat. NgUdc lai Delarue va Aldelant chi can kfch thfch long phe quan de gay ton thUdng thi gay dUdc gian phe quan. NgUdi ta thay tac phe quan va viem nhiem chUa du gay gian phe quan ma con phai co sii kfch thfch cua than kinh va roi loan tuan hoan phe quan phoi. 4.3. Roi loan thanh loc nhay nhung mao - Hoi chiing roi loan van dong nhung mao. - Roi loan van dong nhung mao thti phat cua hen phe quan. Trong cac trUdng hdp nay vi khuan phat trien d dUdng ho hap dudi. 4.4. Roi loan cd che bao ve phoi 4.5. Do dap ting mien dich qua miic NhU trong benh Aspergillus phdi phe quan di ting: day la phan ting miln dich ban cham vdi sii lang dong khang the ket tua (IgM, IgG) d thanh phe quan, ma hau qua cua phan ting mien dich tip III nay (theo Gell Coombs) la phat trien gian phe" quan. Dap ting mien dich qua mtic cung co the xay ra sau ghep phdi. T3- BGBHNK 33 5. Trieu chting lam sang 5.1. Toan than o. Da so" trUdng hop gian phe quan toan trang khong co gi thay doi. Benh dUdc phat hien khi bi benh khac nhii: cum, scJi, ho ga hoac viem phe quan mu, co mot so" trUdng hdp bi giang mai bam sinh, nhting di dang bam sinh khac, mot so" trUdng hdp co roi loan noi tiet, cham tuoi day thi, sinh due phu kem phat trien, cUdng giap trang. Noi chung trieu chting toan than phu thuoc vao mtic do nguyen nhan va bien chting cua benh. Co the co sut can, thieu mau... 5.2. Trieu chiing co nang Du gian phe quan tien phat hay thti phat deu co trieu chting cd nang sau day: - Khac ddm: la dau hieu rat kheu gdi. Khac ddm nhieu tti 500- 1000ml/24 gid, ddm co day mu, co khi hoi thoi do vi khuan hiem khi, hoac khac ddm it 100ml/24gicJ, co the ddm bi tic khong ra dUdc. Khi de lang ddm co 3 16p: ldp tren la bot; 16p gitia la nhay mu; ldp dUcsi la mu due. Benh nhan sot cao keo dai, nhting ddt cap thudng co sot va khac ddm nhieu. - Ho ra mau: thtidng ho ra mau the trung binh, tai phat nhieu lan, keo dai trong nhieu nam, co khi khong khac ddm ma chi khac ra mau, do la trUdng hdp gian phe quan kho, hay gap b thuy tren cua phdi. Do ap liic dong mach phe" quan cao lam vd cho noi dong mach phe" quan - dong mach phoi (Shunt trai phai) do la cd che" ho ra mau, va cung co khi do loet niem mac phe" quan. Can lay ddm tim vi khuan va nhat la phai tim BK nhieu lan. - Kho thd: trieu chting kho thd thiidng xuat hien, la bieu hien cua suy ho hap; co the co tim. - Dau ngiic: la dau hieu scfm cua nhiem khuan phdi d vung gian phe quan. 9 5.3. Trieu chiing thiic the - Kham phdi co the khong thay gi hoac nghe thay ran am, ran phe" quan d nhting vung co ton thiidng, co khi nghe thay tieng thdi hang (thdi hang gia), co khi kham thay hoi chting dong dac co rut khi co xep phoi. - Kham dUdng ho hap tren: co the thay viem mui hong man tinh, viem xoang man tinh (60-80%). - Mong tay khum: hoi chting Pierre Marie. 34 6. Can lam sang 6.1. X Quang phoi - Chup phdi: (chup thang, chup nghieng). Khoang 7% trUdng hdp chup phdi chuan khong thay gi bat thudng. Cac ton thUdng thudng gap la: + Thanh phe quan tao thanh cac dtidng song song (dUdng ray). + The tfch cua thuy phdi co gian phe quan nho lai, thuy phdi lanh gian ra (gian phoi bu). + C) vung phdi bi gian phe quan, co viem phdi tai dien nhieu lan, hang nam ve mua lanh. + Co cac o sang nho d mot day phdi, giong hinh anh to ong, co the co o sang vdi mile nUdc ngang kich thudc thiidng khong qua 2cm. + Xep phdi thuy dUdi trai: bong md hinh tam giac bi bong tim che lap. + Hinh anh viem phdi tai dien chung quanh o gian gap nhieu nhat b tip gian phe quan phoi hdp (74%) va d thuy dildi (78,3%). Hinh anh mile nUdc ngang gap it va neu co chu yeu b gian phe quan hinh tui. Hinh anh ngon tay di gang hay gap b gian phe quan hinh ong b thuy tren trai. Cac tip gian phe quan deu hay gap hoi chting phe nang (tren 70%). Hoi chting hang it gap nhUng do dac hieu cao va chi thay d gian phe quan hinh tui, thiidng la hang trdn ddn doc d thuy tren phai vdi mile nUdc ngang ft. Hoi chting phe quan cung gap nhieu (87,3%) nhUng khong dac hieu. + Cac dam md hinh ong bieu hien cua cac phe quan bi lap day chat nhay + Hinh anh cac dudng md mach mau phdi co tap trung lai do xep phoi gay nen vdi tac cac phe quan nho do dich nhay. + Giam tudi mau phdi, co b cac trUdng hdp nang. X quang phdi chi nghi ngd - de khang dinh chan doan phai chup phe quan cd can quang hoac chup cat ldp vi tmh. - Chup phe quan: nen dung chat can quang tan trong nUdc tron vdi bot talc loc qua gac 3-4 tang, loai nay phai bdm vdi ap luc cao, thuoc di chuyen cham cho ta hinh anh cay phe quan rat ro, thuoc chi bam vao vach phe quan va thai ra nhanh. Dung lipiodol tan trong dau thi bdm nhe, thuoc vao nhanh de vao phe nang va lam 35 nhoe hinh cay phe quan. Mot lan chi nen chup mot ben phoi, co the chup ben doi dien sau 2 tuan. Theo kinh nghiem chting toi nen chup chon loc cho nghi ngd. Neu chup thuy tren thi cho benh nhan nim ngtia doc dau va nghieng ve phfa dinh chup. Ket qua: - Binh thudng toan bo cay phe quan ngam thuoc deu, cac nhanh phe quan be dan tti tren xuong dUdi. - TrUOng hdp benh ly: thuoc dung d lai nga ba noi phan chia phe quan chting to noi do bi tac do chat tiet hoac viem nhiem, hinh phe quan bi gian la phe quan phfa dUdi khong nho di hoac to hdn phe quan phfa tren. Cd the thay phe quan gian hinh tru (to deu tti tren xuong). - Phe quan gian hinh tui: Phe quan phia dUdi to hOn phe quan phfa tren; cd khi hinh mot chtim nho. - Phe quan gian hinh trang hat: cho gian cho that lai xen ke trong nhu trang hat. Cd the gian phe quan d mot ben thuy, mot thuy, mot ben phdi hoac hai ben phdi. 6.2. Soi phe quan De quan sat tinh trang long phe quan, niem mac phe quan, lo cac phe quan thuy, phan thtiy, cd the thay niem mac phe quan bi viem, xuat tiet, phe quan bi gap khtic, bi chft hep, giup xac dinh vi trf chay mau, va hut dich phe quan tim vi khuan. 6.3. Chup cat ldp vi tinh - Chup cat ldp vi tfnh do phan giai cao, moi ldp ckt day 1 mm, thi co the phat hien dUdc gian phe quan tti trung binh den nang. Doi vdi gian phe quan the ken va gian phe quan hinh trang hat thi do nhay cao hdn so vdi gian phe quan hinh tru. - Ky thuat chup c&t ldp vi tfnh xo&n oc m6i ldp cit day 1 mm, cac ldp cach nhau 10mm cd do nhay cao hOn ky thuat thong thudng. - Cac dau hieu: 1. Dudng kfnh trong cua phe quan ldn hdn dong mach di kem 2. Cac phe quan khong nho dan dtidc quy dinh la khi mot phe quan tren mot doan dai 2cm co dudng kfnh tUdng tU phe quan da phan chia ra phe quan do. 36 3. Thay phe quan d cach mang phdi thanh ngilc dUdi 1cm 4. Thay phe quan di sat vao trung that. 5. Thanh phe quan day. 6.4. Chup dong mach phe quan Trong trUOng hop ho ra mau keo dai co the chup dong mach phe quan chon loc, co khi thay dong mach phe quan gian thanh tUng bui. Co the gay bit tac dong mach phe quan neu chay mau nhieu dieu tri noi khoa khong cam dUOc. 6.5. Tham do chtic nang ho hdp Mot so" trildng hdp chUc nang phdi khong co gi bien doi. Mot so" trUOng hop co the bieu hien roi loan thong khf kieu tac nghen: the tfch thd ra toi da d giay dau tien (FEV!) giam, chi so" Tiffeneau giam, VC va TLC binh thiidng. Mot so trildng hdp co roi loan thong khf han che vdi dung tfch song (VC) va dung tfch phdi toan bo (TLC) giam; FEV! va chi so" Tiffeneau binh thudng - hoac co roi loan thong khf hon hop (TLC va VEMS deu giam). Khi co bieu hien suy ho hap nhat la giai doan nang thi thay Pa02 giam va PaC02 tang trong mau. 6.6. Cac xet nghiem khac Cac xet nghiem ddm tim vi khuan, nam, lam khang sinh do, can tim BK nhieu lan (ft nhat 3 lan) de loai trti lao. Kham tai mui hong: chup phim xoang Thii nUdc tieu: dinh lUdng protein Dinh lUdng IgA trong mau va trong dich phe" quan Lam dien tam do de phat hien sdm tam phe man. 7. Chan doan 7.1. Chan doan xac dinh: diia vao Tien sii: ho va khac ddm keo dai, ho ra mau tai phat, keo dai, co the co mong tay khum. Quyet dinh: chup cat ldp vi tfnh; chup phe" quan co can quang. 7.2. Chan doan phan biet Chi dat ra khi chUa chup phe" quan co can quang, can phan biet vdi: 37 1. Viem phe quan co mu, viem phe quan man tfnh co gian phe nang (rat kho). 2. Ap xe phdi: rat kho phan biet khi gian phe quan co ddt boi nhiem cap. 3. Phan biet vdi lao phoi: can tim BK nhieu lan. 4. Ken hdi ci phdi: phai xac dinh bkng chup phe quan co can quang. 7.3. Chan doan nguyen nhan Nhii trong phan loai gian phe quan theo nguyen nhan da neu d tren. Da so trUcing hdp gian phe quan mac phai thiidng diia vao soi phe quan, chup cat ldp vi tmh de chan doan nguyen nhan. - Khi soi phe quan khong thay gi, ngoai trieu chiing cua phe quan bi gian da noi cJ tren thi can phai hoi ky ve tien sii nhat la lao phdi, dieu kien xuat hien benh. - Khi soi phe quan, hoac chup cit 16p vi tinh thay ton thUOng: + U phe quan can lam sinh thiet de xac dinh. + Di vat: di vat vao phe quan tti lau bi bo quen. + Soi phe quan: hiem gap thudng khong diidc chan doan, thudng la muoi voi phu len di vat, lot vao phe quan tii lau ( 10-15 nam) lay ra de vd, chup phoi thudng co the thay dam md voi hoa. - Phe quan bi tic do: + Lao dang tien trien, seo cu cua lao. + Viem xd hoa phe quan. + Giang mai. - Sau chan thufdng. 8. Tien trien - bien chting - tien lifofng Gian phe quan la mot benh keo dai, trong qua trinh bi benh co nhting ddt cap (ho, khac ddm mu, kho thd) dan dan co mong tay khum, kho thd xuat hien thiidng xuyen. Co the co nhting bien chting: tran dich mang phdi, ap xe phdi, viem phdi tai phat, ho ra mau nang, ap xe nao, than nhiem bot, gian phe nang, suy ho hap, suy tim phai. Tien liidng tot: neu gian phe quan ddn thuan khu trti. Tien liidng xau: neu co nhieu ddt boi nhiem, gian phe quan d nhieu ndi, co kem theo mot benh khac, suy ho hap, suy tim phai. 38 9. Dieu tri va phong benh 9.1. Dieu tri noi khoa Dan lUu ddm mu phe quan: - Dan lUu theo til the: cho benh nhan nam dau doc, tuy theo vi tri ton thilOng chpn til the thich hdp, sao cho mu ttf phe quan thoat ra ngoai de dang. Ket hop xoa bop, vo rung, lac long ngilc. Moi ngay nen lam 2-3 lan trUdc biia an, la phUOng phap dan lUu ddn gian co ket qua tot. - Hut phe quan: lam khi soi phe quan, hoac cho mot ong thong vao phe quan roi hut va rtia phe quan b&ng nUdc muoi sinh ly (lam tilng it mot). - Cho cac thuoic long ddm: Acety Icy stein (Mucomyst); Benzoatnatri, thuoc co iode. - Cho khang sinh: trong dot cap (sot, khac ddm mu, kho thd) + Penicillin 5 den 10 trieu dOn vi/ ngay + Ampicillin; Amoxillin co hoac khong ket hdp acid Clavulanic; lieu dung 4 den 6g/ ngay. + Cac cephalosporin the he 2, 3. lieu dung 3-6g/ ngay. + Nhom Aminoglycosid lieu tuy theo loai thuoc. + Metronidazol lieu lg/ngay khi khac mu thoi. + Quinolone: ciprofloxacin; oxfloxacin... Thiidng dung ket hdp cac khang sinh vdi nhau. Sau 5 ngay danh gia lai; tuy theo tinh trang lam sang va ket qua khang sinh do de quyet dinh hudng dieu tri tiep. Moi ddt dung khang sinh keo dai 2 tuan. - Cho thuoc cildng (32 lam gian phe quan khi co trieu chiing kho thd do co that phe quan. - Cho thd oxy trong ddt cap khi co thieu oxy mau. - Cho du liidng nUdc: nUdc uong, truyen dich de lam loang ddm. - The due lieu phap, phuc hoi chile nang ho hap. 9.2. Dieu tri noi soi Soi phe quan de chan doan vi tri chay mau, giai phong ddm dich gay un tic phe quan, giai phong ton thudng nhu di vat gay tac nghen phe quan. 39 9.3. Di&u tri ho ra mau nang - Truyen mau. - Chup dong mach phe quan va gay tac dong mach phe quan ndi phinh gian gay chay mau. - Phau thuat ckt thuy, phan thuy phdi khi co chi dinh. 9.4. Dieu tri ngoai khoa: cat thuy phdi hoac cat mot ben phdi. - Chi dinh: + Gian phe quan khu tru mot thuy, mot ben phdi (chtic nang phoi ben doi dien van tot, FEVl >50%). + Ho ra mau nhieu lan. + Tac do khoi u - Chong chi dinh: + Gian phe quan the lan toa. + Co trieu chting cua suy ho hap man tfnh. 9.5. Phong benh + Dieu tri triet de cac o nhiem khuan vung tai mui hong, rang mieng. + Dieu tri lao sO nhiem b tre em khi co hach ron phdi. + De phong va lay sdm di vat phe quan + Thay doi khi hau: nOi khi hau kho rao, am ap. + Khong hut thuoc la, thuoc lao, tranh moi trUOng co nnieu bui khoi. + Tiem chung vacxin cum hang nam. Noi tom lai, gian phe quan la mot benh man tmh, tien trien dan den suy ho hap tam phe man. Noi khoa chi dieu tri trieu chting, chi dinh md cho nhting the khu tru. Can dieu tri tot cac dot cap de phong tien trien va bien chting. 40 VIEM PHOI 1. Dai cifofng va dinh nghla Viem phdi la hien tiiOng viem nhiem cua nhu mo phdi bao gom viem phe nang, tui phe nang, ong phe nang, to chtic lien ket khe ke va viem tieu phe quan tan cung. Nguyen nhan do vi khuan, virus, ky sinh vat. Dac trUng va ton thUOng giai phau la khoi dong dac cua nhu mo phdi. Ve giai phau benh ngifdi ta chia ra viem phoi thuy va phe quan phe viem. Ngay nay mac dau co nhieu khang sinh hieu nghiem nhUng viem nhiem cap tmh d phoi van cdn la nguyen nhan tti vong quan trong d moi ltia tuoi, nhat la tre em d diidi 1 tuoi va ngUdi gia. Hang nam tai My co tti 2 trieu tdi 3 trieu triidng hop viem phoi, trong do khoang 20% cac benh nhan phai nhap vien, va co tdi 14% so benh nhan nay tti vong. Tai Nhat Ban, hang nam co tti 57-70/ 100.000 ngUdi tti vong do viem phdi, va la nguyen nhan gay tti vong dting hang thti tu. 0 Viet Nam, viem phdi chiem 12% cac benh phdi (Chu Van Y). Trong so 3606 benh nhan dieu tri tai khoa Ho Hap Benh vien Bach Mai tti 1996- 2000 co 345 (9,57%) benh nhan viem phdi- dting thti 4 trong tong so" benh nhan den dieu tri tai khoa Trong bai nay chu yeu noi ve: viem phdi thuy va phe quan phe viem co dien va mot so the viem phoi khac. Khong noi den viem phdi do lao vi la benh co thuoc dieu tri dac hieu rieng. 2. Viem phdi thuy va phe quan phe viem Viem phdi thuy va phe quan phe viem la benh rat thudng gap: 2.1. Nguyen nhan gay benh Do phe cau khuan Gram diidng diidc phan lap tti 1883 do Talamon, den nay ngiidi ta da biet tren 75 chung loai. NgUdi ta biet rd tip 1, 2, 3, gay benh d ngu'di ldn va tip 4 gay benh d tre em. Phe cau khuan binh thiidng van cU tru d dudng ho hap tren. Viem thuy phdi o' ngUdi tre, phe quan phe viem thudng do phe cau, lien cau; tu cau thiidng gay benh d tre em, ngiidi gia yeu, hau phat sau viem hpng, viem xoang, sdi, cum, ho ga. 41 2.2. Dieu kien thuan Igi - Thdi tiet lanh, benh xay ra ve mua dong - Cd the suy yeu, coi xUdng, gia yeu - Nghien rUdu. - Chan thUdng so nao, hon me. - M&c benh phai n&m dieu tri lau. - Bien dang long ngUc, gu, veo cot song. - Benh d tai mui hong: viem xoang, viem amidan - Benh tic nghen dudng ho hap 3. Cd che sinh benh 3.1. Diidng vao Nhting tac nhan gay viem phoi co the theo nhting dudng vao sau day: - Hit phai vi khuan d moi triidng ben ngoai, trong khong khi. - Hit phai vi khuan do o nhiem khuan diidng ho hap tren. - Vi khuan theo dudng mau tti nhting o nhiem khuan xa. - Nhiem khuan do dudng tiep can cua phoi. 3.2. Cd che chong dd cua phoi Khi co vat la vao phoi, nap thanh quan dong lai theo phan xa. Tti thanh quan den tieu phe quan tan cung cung co ldp niem mac bao phu bdi cac te bao hinh tru co long chuyen, nhting te bao hinh dai tiet ra chat nhay ket dinh va day cac vat la len phe quan ldn, tti do phan xa ho tong cac vat la ra ngoai. Vai tro globulin mien dich la cd sd bao ve dudng ho hap. IgA co nong do cao d dudng ho hap tren co tac dung chong lai virus. IgA co nong do thap hdn d diidng ho hap dUdi co tac dung lam ngUng ket vi khuan, trung hoa doc to' vi khuan, lam giam sii bam cua vi khuan vao niem mac. IgG co tac dung lam ngUng ket vi khuan, lam tang bo the, tang dai thiic bao, trung hoa doc to' vi khuan, virus, lam dung giai vi khuan Gram am. Trong phe nang co nhieu dai thiic bao an vi khuan. Bach cau da nhan trung tinh va tan cau cung co nhting kha nang nhu tren. Nhting ngUdi nghien thuoc la, thieu oxy, thieu mau, ro'i loan ve tan cau bam sinh, chtic nang thiic bao tai phe nang bi suy giam, giam kha nang mien dich cua cd the la cd sd tao dieu kien cho vi khuan gay benh. 42 4. Ton thifdng giai phau benh Viem phdi do phe cau khuan thiidng gap d thuy dildi phdi phai nhieu hon phoi trai, trtidng hdp bi ca hai ben hiem hdn. Co khi bi nhieu thuy phdi. Cac giai doan viem phdi thuy cd dien cua Laennec. 4.1. Giai doan xung huyet Vung phdi bi ton thudng xung huyet manh, cac mach mau gian rong, thoat hong cau, bach cau td huyet vao phe nang, cay dich d o viem nay co nhieu phe cau khuan. 4.2. Giai doan gan hod do Sau khi bi benh 1-2 ngay, thuy phdi bi ton thiidng co mau do chac nhu gan, cit manh phdi bo vao nildc thi chim, trong phe nang chtia nhieu hong cau va bach cau. Lay dich phe nang cay co nhieu vi khuan. 4.3. Giai doan gan hoa xam Vung phdi bi ton thtidng chac nhif gan, mau xam, tren mat co mu, trong phe nang co nhieu dai thiic bao, hong cau va bach cau. Ton thiidng giai phau benh trong phe quan phe viem: nhting vung ton thifdng rai rac ca hai phoi, xen lan vdi nhting vung phdi lanh, nhting vung ton thudng tuoi cung khac nhau, phe quan bi ton thiidng nang hdn; cat manh phoi bo vao nildc thi chim Id liing. 5. Trieu chting 5.1. Trieu chiing cua viem phoi thuy - Trieu chting toan the: + Benh xay ra dot ngot thiidng d ngiidi tre tuoi, bit dau vdi mot cdn ret run keo dai khoang 30 phut, roi nhiet do tang len 30 - 40°C, mach nhanh mat do, sau vai gid thi kho thd, toat mo hoi, mdi tim, co mun hecpet d mep, mdi. + C) ngiidi gia, ngiidi nghien rifdu co the co lti lin, d tre con co co giat. O ngiidi gia trieu chting thiidng khong ram ro. + Dau ngilc: luon luon co, doi khi dau ngilc la trieu chting noi bat, dau ben ton thiidng. + Ho khan luc dau, ve sau ho co ddm dac, co mau gi sit. Co khi non mtia, childng bung, dau bung. 43 - Trieu chiing thiic the: Trong nhting gid dau, neu nghe phdi chi thay ri rao phe nang giam ben ton thUOng, sd va go binh thiidng, co the nghe thay tieng co mang phdi va ran no cuoi thi thd vao. - Thdi ky toan phat: cd hoi chting dong dac ro ret: + Go due. + Rung thanh tang + Ri rao phe nang mat. + Cd tieng thdi ong. + Dau hieu X quang: thay mot dam md cua mot thtiy hay mot phan thuy, cd hinh tam giac day quay ra ngoai, dinh quay vao trong. + Xet nghiem: Bach cau tang 15000 - 25000/ mm3, 80-90% la bach cau da nhan trung tmh. Cay mau co khi cd phe cau khuan. Nude tieu co albumin, co khi co urobilinogen. 5.2. Tien trien - Sot duy tri trong tuan le dau, nhiet do van 38-40°C, khac ddm dac co mu vang. - Cd khi vang da, vang mat nhe. Sau mot tuan le thay cac trieu chting cd nang tang len, nhUng ngay sau do thi sot giam, do mo hdi, di tieu nhieu, benh nhan cam thay khoan khoai di chiu va benh khoi, nhiing kham phdi van cdn hoi chting dong dac, hinh anh X quang ton tai trong vai tuan. NhUng co trUdng hdp benh nhan bi sdc: kho thd, tim mdi, mach nhanh, huyet ap ha, co khi tti vong do truy tim mach, phu phdi va viem mang ngoai tim cd mu. 5.3. Trieu chiing phe quan phe viem Trong nhieu nam trd lai day ngUdi ta thay viem phdi thuy do phe cau cd dien giam di rat nhieu, trai lai xuat hien nhieu phe quan phe viem. Cd nhting khac biet vdi viem phdi thuy sau day: - Ve nguyen nhan viem phdi thuy chu yeu la do phe cau, phe quan phe' viem do phe cau khoang 60-70%, cdn do tu cau, lien cau, triic khuan Friedlander. 44 - Viem phdi thuy khdi phat dot ngot d ngiidi khoe manh, phe quan phe viem thti phat tren nhting benh nhan bi cac benh: + Benh truyen nhiem: ctim, sdi, ho ga, sot, xuat huyet. + Benh nung mu man tfnh: nhiem khuan tiet nieu, viem tai, viem tuy xildng, viem xoang co mu. + Benh toan the: gay mon, gia yeu + O' dong phdi nhii cac trUOng hdp suy tim - Trieu chting: bat dau tti tti, sot nhe, 37°5 - 38°C. + Dau ngilc khong ro ret. + Ho va khac ddm dac co mu. + Thdi ky toan phat: kho thd nhieu, canh mui phap phong, tim moi. + Kham phdi: co vung due, rung thanh tang, nghe co ran no, ran am ca hai ben phoi - X quang: co nhieu not md rai rac hai ben nhat la d vung day. - Tien trien: benh thudng nang, nhat la d tre sd sinh, va nhting ngUdi gia yeu. 6. Chan doan 6.1. Chan doan xac dinh 6.1.1. Chan doan xac dinh viem phoi thuy diia vao - Benh khdi phat dot ngot d ngUdi tre - Cd cdn ret run va sot cao 39°C - 40°C - Hoi chting nhiem khuan: mdi kho, ludi ban, bach cau cao. - Dau ngilc cd khi rat noi bat. - Ho va khac ddm cd mau mau gi sat. - Hoi chting dong dac phdi: go due, rung thanh tang, ri rao phe nang giam, tieng thdi ong. - X quang: cd hoi chting lap day phe nang vdi dam md deu hinh tam giac day quay ra ngoai. - Chup cat ldp vi tinh: hoi chting lap day phe nang, co hinh phe" quan hdi. 6.1.2. Chan doan xac dinh phe quan phe viem - Benh xay ra d tre em va ngUdi gia, sau khi mac cac benh: cum, sdi, ho ga, bach hau, suy dinh dudng. 45 - Benh khdi phat tti tti. Sot nhe 37°5 - 38°C. - Kho thd nhieu, canh mui phap phong, tim mdi. - Nghe phdi hai ben cd nhieu ran rit va ran no tting vung. - Go: cd vung due xen lan vung phdi binh thiidng. - X quang: cd nhieu not md rai rac khap ca hai phe triidng, nhat la d vung day. 6.1.3. Chan doan vi sinh Viec chan doan vi sinh nen dUdc lam trUdc khi dung khang sinh, nhat la d cac trUOng hdp nang, bao gom: - Ddm: nhuom soi tUdi va cay, cho do nhay va do dac hieu dat 50- 60% va > 80% theo thti tii. - Cay mau - Cay dich mang phdi - Cay dich phe quan - Cac test phat hien khang the nhu test ngUng ket bo the, ngiing ket lanh... - Phat hien khang nguyen qua nUdc tieu. - PCR (phan ting khuech dai chuoi) vdi tting loai vi khuan rieng biet. 9 6.2. Chan doan phan biet - Xep phdi: trung that bi keo ve ben xep phdi, cd hoanh nang len cao. - Tran dich mang phdi: nhat la vtia cd viem phdi vtia co tran dich mang phdi (choc do de xac dinh). - Nhoi mau phdi: cd trieu chting dau ngilc dti doi, co khi soc, sot, ho ra mau, thudng xay ra d ngUdi co benh tim, hoac ph&u thuat vung ho" chau. - Ap xe phdi: giai doan cua ap xe phdi khong the phan biet dUdc can hdi ve tien sti, cd phiu thuat d vung mui hong, nho rang ... la nhting nguyen nhan thuan ldi gay ap xe phdi. - Ung thu phdi: dau hieu dau tien cua ung thu phdi co khi bieu hien nhu mot viem phdi - vdi hoi chting nhiem khuan cap sau mot tic phe quan do ung thu, sau khi dieu tri het nhiim khuan ma ton thudng phdi van cdn ton tai tren mot thang thi nen nghi den ung thu nhat la ngUdi cd tuoi, nghien thuoc la. 46 - Gian phe quan: trtfdng hdp gian phe quan bi boi nhiem. Benh nhan sot keo dai, ho va khac nhieu, ddm cd mu. Hinh anh X quang cd khi la mot dam md khong dong deu giong phe quan viem mot vung. Benh nhan co tien sti ho va khac ddm lau ngay, can chup phe quan cd lipiodol hoac chup cit ldp vi tfnh de xac dinh. 7. Bien chting Ngay nay, nhd co nhieu khang sinh hieu nghiem, tien ltfdng benh viem phdi tot hdn nhieu, tuy vay nhting bien chting cua viem phdi van cdn gap. 7.1. Bien chiing tai phoi - Tran khi mang phdi, tran khf trung that: thudng do nguyen nhan tu cau. - Benh lan rong ra hai hoac nhieu thuy phdi, benh nhan kho thd nhieu hdn, tim mdi; mach nhanh, benh nhan cd the chet trong tinh trang soc. - Xep mot thuy phoi: do cuc ddm dac quanh lam tac phe quan mot thuy phdi. - Ap xe phdi: rat thudng gap, do dieu kien khang sinh khong du lieu lifdng, benh nhan sot dai dang, khac nhieu ddm cd mu. X quang: cd mot hoac nhieu hinh hang cd mtic nifdc, mtic hdi. - Viem phdi man tfnh: benh tien trien keo dai, thuy phdi bi ton thudng trd nen xd hoa 7.2. Bien chiing ngoai phoi - Tran dich mang phdi: viem phdi diidi mang gay tran dich mang phdi, nifdc vang chanh, nhe, chong khoi - thudng do phe cau khuan. - Tran mu mang phdi: benh nhan sot dai ding, choc do mang phdi cd mu, thudng xay ra trong trifdng hdp viem phdi mang phdi, hoac do choc do mang phdi gay boi nhiem. - Viem mang ngoai tim: trieu chting dau vung trUdc tim, nghe cd tieng co mang tim, thudng la viem mang tim cd mu. 7.3. Bien chiing nhiem khuan thiiphat xa hdn - Viem noi tam mac cap tinh do phe cau: bien chting nay hiem gap, benh nhan cd cdn sot ret run, lach to, khong phai luon co trieu chting van tim. 47 - Viem khdp do phe cau: gap d ngifdi tre tuoi, thifdng chi bi mot khdp sifng, do, nong, dau. - Viem mang nao do phe cau: la bien chiing hiem gap, nifdc nao tuy chifa nhieu phe cau, glucose giam, cd ft bach cau da nhan. - Viem phuc mac: thifdng gap d tre em - Viem tai xUdng chum: thay d tre em - Viem than: ft xay ra vdi nhiem khuan ngoai da va viem tuyen mang tai. - Ap xe nao: hiem gap 7.4. Bien chiing tim mach - Nhip tim nhanh, nhip xoang, loan nhip ngoai tam thu va doi khi rung nhi. - Suy tim: xay ra trong tinh trang soc, cd tieng ngiia phi, gan to if mau ngoai bien. - Soc: ha huyet ap, ha nhiet do, tfm mdi, tien liidng de dat. 7.5. Bien chiing tieu hoa Bieu hien da vang, vang mat do suy gan vi thieu oxy va huy huyet d ndi to chiic phdi bi viem. Cd khi bieu hien liet hoi trang, ia chay, nhat la d tre em. 7.6. Bien chiing than kinh Vat va, me sang, xay ra d ngifdi gia, ngUdi nghien riidu. 8. Dieu tri - Che do an uong nghi ngdi: thiic an long, d§ tieu; uong nhieu nUdc hoa qua. - Can bdng niidc- dien giai: can chu y, dac biet khi cd sot cao, hoac khi benh nhan nang, de doa soc nhiem khuan. - Khang sinh: dung khang sinh diia theo khang sinh do. + Viem phdi nhe: dung khang sinh theo dudng uong: - Ampicillin 2-3g/ngay. - Amoxillin + acid clavulanic: 2-3g/ ngay. - Cefuroxim: 2-3g/ ngay. - Quinolon: ciprofloxacin lg/ngay. 48 + Viem phdi nang vtia: - Penicillin 3 trieu ddn vi/ngay - Gentamicin 3mg/kg/ngay. + Viem phdi nang: dung khang sinh theo diidng tmh mach, phoi hdp 2-3 loai - Penicillin 5-10 trieu dOn vi/ ngay. - Ampicillin 4-6g/ngay. hoac ampicillin ket hdp acid clavulanic - Cephalosporin the he 2,3. lieu 3-6g/ ngay. - Cac khang sinh thuoc nhom aminoglycosid thudng dung ket hdp vdi khang sinh nhom [3 lactam. - Quinolon: ciprofloxacin lieu lg/ngay. - Metronidazol: lg/ngay - Dieu tri trieu chiing: chong dau ngilc bang paracetamol, thuoc giam dau chong viem nonsteroid, Codein, neu dau qua thi cho morphin 0,0lg tiem dUdi da. + The nang: kho thd nhieu, tim tai, mach nhanh, huyet ap tut... - Cho thd oxy. Xet thd may neu Pa02< 60mmHg, mac du da thd oxy 100%. - Khang sinh lieu cao: - Neu cd truy tim mach: can dat catheter tinh mach trung tam, truyen dich (NaCl, glucose dang trildng) duy tri ap liic tinh mach trung tam (CVP) tti 5-9 cm H20. Neu huyet ap van thap < 90mmHg, can dung cac thuoc van mach (dopamin, dobutamin, noradrenalin, adrenalin). 9 m o. a v 9 9 9 Tren day la the viem phdi do phe cau cd dien, ngoai ra cdn nhting the viem phdi khac. 9 9 9. Nhting the viem phoi khac 9.1. Viem phoi do virus - Cdn gpi la viem phdi khong dien hinh, viem phdi xung huyet - Viem phdi khong dien hinh do virus vet (psittacose) virus chim (ornithose), virus Coxacki, Ricketsi, sot Q. - Ngay nay ngiidi ta da phan lap ra diidc nhieu loai virus gay benh ho hap nhii influenza, Adeno - virus, para - influenza virus, Rhino virus, coryza virus va ngUdi ta cung che ra diidc nhieu loai vacxin de tiem phong benh virus ho hap. T4- BGBHNK 49 - Ton thUdng giai phau benh hoc: viem tieu phe quan, vach phe quan xam nhap bach cau da nhan, phe nang chiia dich viem va hong cau. - Trieu chting: benh xay ra trong cac vu dich: cum ... + Sot cao 39° - 40°C, met mdi, chan an. + Kho thd, nhip tim nhanh. + Khac ddm cd mu, cd mau. - X quang: ton thUdng ttf ron phdi toa ra, nhting dam md khong deu. - Xet nghiem: + Cong thtic mau: bach cau binh thudng hoac giam + Toe do mau lang tang. + Phan ling ngUng ket lanh dUOng tmh. - Tien trien: benh se khoi trong vong 1-2 tuan le. - Dieu tri: khong dac hieu, nghi ngOi, chong boi nhiem. 9.2. Viem phoi do tu, cau - Giong phe quan phe viem, nhieu o ap xe nho d phdi co khi nhieu bong hoi trdn d 2 phdi. Cd the cd tran khi- tran mu mang phdi, hoac tran khi trung that. - Benh xay ra d tre em, do tu cau vang gay benh, hau phat sau nhiem tu cau d da, cd khi xay ra trong trUdng hdp nhiem khuan huyet do tu cau. - Ton thUOng giai phau benh: phe quan phe viem chay mau. - Dieu tri: phai dung khang sinh lieu cao nhat la trong trUdng hdp nhiem khuan huyet: + Oxacillin (bristopen), Methixillin: Lieu 4-8 g/ngay + Cephalosporin the he 3: Lieu 4-6 g/ngay, 2 khang sinh tren thudng dUdc ket hop vdi amikacin lieu 10-15mg/kg/ngay. + Vancomycin lieu 2-3g/ ngay khi cac khang sinh tren khong hoac kem tac dung. 9.3. Viem phoi do lien cau Giong phe quan phe viem - Nguyen nhan: do lien cau tan huyet nhom A. - Ton thudng giai phau benh: ap xe dtfdi mang phdi, vd vao mang phdi gay tran mau mang phdi, ton thUOng to chtic ke quanh phe nang, trildc day rat nang, nay tien liidng tot hdn. - Khang sinh thudng sii dung la penicillin, ampicillin, cephalosporin 50 9.4. Viem phoi do Klebsiella Pneumoniae hay triic khuan Friedlander gram dm Benh xay ra d ngifdi gia yeu, nghien rifdu, giong phe quan phe viem. - Ton thUdng giai phau benh: hoai tii vach phe nang. Trufdc khi co khang sinh ty le tti vong 90%. - Dieu tri: penicillin ft hieu qua, thifdng dung cephalosporin the he 3, amynoglycosid, quinolon, chloramphenicol. 9.5. Viem phoi do hemophylus influenza (Bacille Pfeiffer) vi khuan Gram dm. - Benh xay ra d tre con, ft khi d ngUdi ldn. Ton thifdng giai phau benh: viem tieu phe quan chay mau, co khi gay phu phoi do chay mau. - Dieu tri: penicillin ft hieu qua, phai cho cephalosporin the he 3, chloramphenicol. 9.6. Viem phoi do hit vao cdn goi la viem phoi do men: xay ra d ngifdi hon me, mat y thtic, ngo doc riidu, gay me, cho an bang ong thong, co lo ro khf quan thiic quan, lo ro phe quan thiic quan. Dich vi va men tieu hoa tti da day sac vao phdi gay viem thuy difdi cua phoi. Benh thudng nang va dieu tri kho khoi. 9.7. Viem phoi do it dong Nguyen nhan do if dpng man tfnh b phdi, xay ra d ngifdi co benh tim, suy tim, benh nhan nam lau ti dong lam tac phe" quan va if dong phe nang tao dieu kien thuan ldi cho vi khuan gay benh. Nghe phdi co ran am b hai day. X quang: goc sifdn hoanh bi tu. 9.8. Viem phoi do bite xa Xay ra d nhting ngifdi dieu di bang chieu tia xa. Sau 1-2 tuan hoac hang thang sau chieu tia X. Benh nhan xuat hien kho thd, ho va khac ddm, cd khi tran dich mang phdi. 9.9. Viem phoi sac dau - Nguyen nhan: nho mui thuoc cd dau, giot dau lot vao phdi, sac xang, sac dau hoa, sac dau mazut ngay nay rat thifdng gap. Benh xay ra ngay sau khi bi sac. Thifdng nang, cd the tien trien thanh ARDS: ngay sau sac dau, benh nhan kho thd dti doi, tfm tai. - Kham phdi: co hoi chting dong dac, co khi bi toan bo mot phdi, nhat la sac dau mazut. 51 - X quang: co hinh md deu thiidng la thiiy dudi phoi phai. - Dieu tri: can theo doi sat, khi co dau hieu suy ho hap, cho thd oxy. Cd the xet dat noi khi quan cho thd may che do PEEP (ap liic diidng cuoi thi thd ra) 9.10. Hoi chiing Loeffler - Nguyen nhan: do au trung giun dua di qua phdi gay viem phdi. - Giai phau benh: phdi bi xam nhap bach cau ai toan, tildng bao va te bao khong lo. - Trieu chiing: rat kin dao sot nhe hoac khong sot, ho va ft khac ddm. - Nghe phdi: ran am, ran no, co the co tieng co mang phdi. - X quang: nhieu dam md da dang va bien di sau 4-8 ngay. - Xet nghiem mau: bach cau ai toan tang 10-20% co khi den 50%. - Xet nghiem ddm cd the thay au trung giun. - Xet nghiem phan: triing giun. - Dieu tri trieu chiing. Benh til khoi sau 4-8 ngay. 9.11. Viem phoi do dich hach Viem phdi do dich hach thudng do tiep xuc trilc tiep, hit phai trilc khuan dich hach, khoang 5% dich hach the phdi. Benh nhan sot kho thd, ho khac ddm co mau, xay ra trong cac vu dich, tim vi khuan dich hach trong hach va trong ddm. Neu khong dUdc dieu tri, tii vong xay ra sau 2-4 ngay. Khang sinh thudng dung: Streptomycin; chloramphenicol; tetracyclin; biceptol; kanamycin; gentamicin. 9.12. Mot so the lam sang dac biet - The dau bung cap: cdn dau bung cap nhu cdn dau bung gan, cdn dau quan than, bung chudng va sd vao rat dau, thudng xay ra khi thuy dudi phdi phai bi viem, cd nhieu trUdng hdp da phai md bung, can kham phdi ky va chup X quang phdi de xac dinh. - The ia chay: hay xay ra d tre em, trieu chUng ia chay keo dai, can kham phdi va chup phoi de xac dinh. - The vang da, vang mat: cd khi rat ro, giong trUdng hdp viem gan do virus, can kham phdi ky va chup phdi de xac dinh. 52 10. Phong benh Benh viem phdi va phe quan phe viem rat pho bien, so benh nhan nam vien cung nhii so" benh nhan dieu tri ngoai tru rat nhieu, dting hang thti hai sau benh tieu hoa. Mac dti co nhieu khang sinh hieu nghiem nhiing bien chiing va tti vong van con nhat la khi benh gay nen bcii virus van chiia co thuoc dac tri giai quyet, vi vay phong benh la rat quan trong. - Dieu tri tot o nhiem khuan 6 vung tai mui hong: nhat la viem xoang co mu, viem amidan co mu, viem hong, bang khang sinh toan than hay khi dung. - Dieu tri tot nhting ddt cap cua viem phe quan man tinh: bang khang sinh uong hoac tiem tinh mach. - Loai bo nhting yeu to" kich thich co hai: nhu thuoc la, thuoc lao. - Giti am cd, ngilc trong mua lanh. - Ngay nay ngiidi ta da che" ra vac xin cua nhieu loai virus, vi khuan de tiem phong. Ap x e p h o i 1. Dai exiting va dinh nghla Ap xe phdi la o mu trong nhu mo phdi, sau khi oc mu ra ngoai thi tao thanh hang mdi, qua trinh hoai tti do viem nhiem cap tinh d phoi (do vi khuan, ky sinh vat, nam, khong phai do lao). Co the co mot hay nhieu o mu, khi o hoai tti nang va lan rong thi goi la hoai thii phdi, ap xe phdi la mot benh co tinh chat noi - ngoai kh<~>a, nghla la dieu tri noi khoa khong khoi thi phai md. Ap xe phdi da biet tti lau, nhiing mai den nam 1918, sau khi phat minh quang tuyen X benh diidc biet ro rang hdn. Tti nam 1920 co nhieu tai lieu noi ve ap xe phdi (Kourisky, Seregent). Nam 1932 hoi y hoc Phap - hoi nghi ngoai khoa d Madrit da trinh bay nhting ket qua ve dieu tri ap xe phdi bang noi khoa va ngoai khoa. Neuhoff va Turiaf neu len chi dinh va ky thuat md ap xe phdi. Ngay nay nhd co nhieu khang sinh hieu nghiem viec dieu tri ap xe phdi chu yeu b^ng noi khoa, chi dinh phau thuat rat It. Benh diidc chtia khoi hoan toan neu tim diidc vi khuan gay benh va chon dUdc khang sinh thich hdp. 6 ntidc ta ap xe phdi van con nhieu, tai khoa ho hap Benh vien Bach Mai tti 1977 - 1985 co 258 trtidng hdp, chiem 4,8% benh phdi dieu tri tai khoa (Chu Van Y - Van Anh). Tuoi mac benh nhieu nhat khoang 45-55 53 tuoi. Nam bi nhieu hdn nti (69% - 41%) viec dieu tri gap nhieu kho khan do chan doan muon va dung khang sinh khong thfch hdp nen benh da trd thanh man tfnh va viec dieu tri bang ngoai khoa khong phai la hiem. 2. Nguyen nhan Nguyen nhan ap xe phoi diidc sap xep nhii sau: 2.1. Viem nhiem hoai tii - Do vi khuan lam mu: tu cau vang, Klebsiella, lien cau khuan nhom A, Bacteroides sp, Actinomyces, Fusobacterium va nhting Cocci yem khi khac, Nocardia. - Nam: Aspergillus, Candida Albicans, Mucor - Ky sinh vat: A mip, san la phdi. 2.2. O nhoi mau Ophoi do - Tac mach (embolie) - Tac mach nhiim khuan (do cac vi khuan yem khf khac nhau, tu cau, nam Candida. - Viem mach mau (viem nut quanh dong mach, benh u hat). 2.3. Ung thii nguyen phat d phe quan, ung thii thii phat it gap 2.4. Nhiing nguyen nhan khac - Ken hdi nhiem khuan - Ton thudng hoai tti trong benh bui phdi. O Viet Nam nhting nguyen nhan thiidng gap la: tu cau vang, lien cau, phe cau, triic khuan mu xanh, Escherichia Coli, Proteus miraculis, a mfp, nha't la ap xe gan vd len (Nguyen Van Thanh). 2.5. Nguyen nhan thuan lai - Chan thudng long ngiic cd manh dan nam trong phdi. - Sau gay me dat noi khi quan, md khi quan, thd may. - Sau phau thuat vung tai mui hong - rang ham mat. - Bi mot sd benh khac nhu dai dudng - suy mon. - Cd benh phdi man tinh, viem phe quan man tfnh, gian phe quan. - Nghien riidu, nghien thuoc la - Dat catheter tinh mach dai ngay. 54 3. Ccf che sinh benh Thiic nghiem: 1926 Meislein va Schluete dUa vao ti4nh mach co cho moi trUOng cua vi khuan lam mu gay dUdc viem mu ci thuy dudi phoi trai, gay nhiem khuan quanh tinh mach cd, bop nat ti4nh mach gay nhiing cuc mau dong thay 90% lam mu ci nhu mo phdi. Ruzmon (1930) dUa vao tinh mach cd tho, moi trUOng Colibacille dong thdi ckt day than kinh hoanh gay dUOc ap xe phoi ben cd hoanh bi liet. Neuhoff thay nhiing trUOng hdp vi khuan nung mu phoi thudng do dudng phe quan. Dudng vao: vi khuan gay ap xe phdi theo nhiing dudng vao sau day: 3.1. Ap xe phoi do ditdng phe quan (goi la dp xe do hit vao) - Benh nhan hit vao nhiing manh to chtic, mau, mu co mang vi khuan khi phau thuat ci vung tai mui hong, rang ham mat. - Hit vao mui va dich tiet trong trUOng hdp co viem xoang mu, viem amidan, viem mu 6 chan rang. - Sac: di vat r^n nhu hon bi 0 tre em, sac xang dau do hit, sac thtic an va dich vi da day liic non trong khi hon me, nuoi dUOng bang ong thong. Vi khuan theo dudng phe quan vao gay ap xe phdi khi cO che bao ve dUOng ho hap bi suy yeu, roi loan phan xa nuot, khong khac dUOc ddm, liet thanh quan, giam mien dich cua dudng ho hap (xem cO che viem phdi). TrUdng hop phe quan bi tac, chit hep gay ti dong phu ne va viem nhiem hoai tti. Co che sinh benh cung giong nhu viem phdi nhUng phat trien thanh ap xe phoi tuy thuoc vao kha nang gay hoai tti phdi cua vi khuan, Hemophylus influenza, Klebsiella pneumoniae, vi khuan gram am dudng ruot, tu cau vang. Cac loai vi khuan yem khf co kha nang gay hoai tti phdi nhieu nhat. 3.2. Ap xe phoi theo ditdng mau Vi khuan gay ap xe phdi theo dudng mau thudng thay trong trUOng hop nhiem khuan do viem tinh mach, viem noi tam mac, viem van 3 la, va thudng la o nhiem khuan tti xa nhii o nhiem khuan 0 tti chi. Ap xe phdi theo dudng mau bi ca hai phoi, nhieu o ap xe nho. 3.3. Ap xe phoi do ditdng ke can - Ap xe dudi cO hoanh - Ap xe gan do amip rat thudng gap, ap xe gan dudng mat - O viem nhiem do thting da day ta trang bi bit km lai, viem phuc mac, ap xe ruot thtia, vi khuan len phoi gay ap xe do o ap xe vd len phoi hoac vi khuan theo dudng bach huyet. 55 - Viem mu trung that: ap xe thiic quan, lo ro thiic quan hoac thUc quan phe quan, viem mang phdi mu, viem mang ngoai tim co mu. Cd che sinh benh du nguyen nhan nao thi vi khuan vao phoi deu qua cac giai doan phu ne, viem nhiem phe nang, dan hoai tii thanh mu ngay cang nhieu lam thanh boc mu, khi vd ra ngoai de lai hang co hinh mile nUdc-hoi. 4. Giai phau benh - Vi tri ton thiidng: 3/4 trUdng hdp o ap xe d thuy dudi, phdi phai nhieu hon phdi trai, 1/4 0 thuy tren, thuy gitia it bi hOn, co khi nhieu o ap xe nho ca hai phoi. - Dai the: ton thUdng dai the tuy theo ap xe cap hay ap xe gay mu thdi. Ap xe cap: vung ton thUOng la mot khoi dac, mau hoi vang, khi cat ngang 8 mat trong phu mot ldp mu, co phe quan thong ra ben ngoai. Ap xe mu thoi: o ap xe rong hdn, lan toa, cat ngang mat cat mau xam, mat do khong deu, cho cting cho mem, mu rat hoi thoi chay mau - co nhiing giai xO ngan thanh nhiing o ap xe nho, long phe quan chtia day mu. - Vi the: the ap xe cap tinh: vach o ap xe gom cac ldp mu, thanh td, phe nang viem mu, thanh ap xe co to chUc hat, viem noi mac, co huyet khoi mach mau lan can. The ap xe phdi man tmh: thanh o ap xe co td chtic xO day co khi den 2cm, co khi ca thuy phoi bi xd hoa, phe nang bi viem mu chtia nhieu td huyet va bach cau - phe quan thanh day va xd hoa, long phe quan bi hep, phe quan gan o ap xe bi gian hinh tru, mach mau co viem noi mac va huyet khoi, mang phoi ben tUOng ting cung bi day dinh. 5. Trieu chting Ap xe phdi do nguyen nhan nao cung dien bien qua ba giai doan: 5.1. Giai doan viem 5.1.1. Hoi chiing nhiem khuan v - Da sd cac trUdng hdp bat dau nhu mot viem phdi nang, sot cao 39°-40°C, moi kho, ludi ban, dai ft, nUdc tieu slm mau. - Mot sd trUdng hdp bat dau tti tti nhu mot trang thai cum. - Xet nghiem bach cau tang cao; bach cau da nhan trung tinh chiem 80-90%, tdc do lang mau tang. 5.1.2. Trieu chiing dphoi - Ho khac ddm dac, co khi ho ra mau - Dau ngilc: dau ben benh co khi dau ngiic la trieu chting noi bat. 56 - Kho thd, tan so thd >25 chu ky/ phut. - Kham phdi: co hoi chiing dong dac mot vung, co ran no d mot vung co khi co hoi chiing 3 giam (rat thifdng gap). 5.1.3. X quang Chi thay dam md nhii la viem phdi. 5.2. Giai doan oc mu Trieu chiing oc mu co khi xuat hien s6m 5-6 ngay sau khi benh bat dau, nhung co khi oc mu xay ra rat muon 50-60 ngay sau. Mu co the oc ra nhieu mot luc: 300-500ml mu trong 24 gid, hoac mu khac ra ft mot nhiing keo dai. Tfnh chat cua mu: mu hoi thoi do vi khuan yem khf, mu mau chocolat do amip, mu mau vang nhii mat co the do ap xe diidng mat vO thong len phoi. Can cay mu de xac dinh loai vi khuan va lam khang sinh do. Sau khi oc mu nhiet do giam dan, benh nhan de chiu hdn nhiing van tiep tuc khac mu. Mu ra nhieu nhiet do giam, mu ra ft nhiet do van cao, co khi oc mu roi ma sot van cao thi co the cdn o ap xe khac chUa vO mu. Benh nhan thd co mui hoi thoi, trong giai doan nay kham phoi co khi chi thay co ran no mot vung, hoi chiing dong dac hoac 3 giam, trieu chiing hang khong ro ret. 5.3. Giai doan thanh hang Benh nhan van khac mu nhiing ft hOn, co khi nhiet do dot ngot tang len chiing to mu bi ii lai nhieu trong phoi. <) Trong triiOng hop dien hinh co the co hoi chiing hang: nghe tieng thdi hang ro ret, nhiing trieu chiing nay khong co" dinh co khi chi thay mot hoi chiing dong dac hoac hoi chiing tran dich do hang d sau hoac cdn chiia nhieu mu. X quang: thay hinh hang trdn, hoac bau due co miic niidc hoi, can chup nghieng de biet hang d phfa trUdc hay sau gan thanh ngiic hay d sau (de neu can thi choc dan liiu). Co khi hinh anh X quang chi la mot dam md khong co ranh gidi ro ret can chup cat ldp de xac dinh. 57 6. Tien trien va bien chting - Tien trien: trUdc thdi ky khang sinh ap xe phoi la mot benh nang co the chet trUdc khi oc mu hoac chet ngay sau khi oc mu, cung co trUdng hdp khoi nhanh sau khi oc mu, lai co nhieu trUOng hdp benh keo dai hang nam dan tdi suy mon va chet do bien chiing. Ngay nay co nhieu loai khang sinh hieu nghiem, ap xe phdi dUdc coi la benh lanh tmh, chtia khoi hoan toan neu chan doan dung va dieu tri dung. Tuy vay chting tdi van cdn thay nhieu bien chting. - Bien chting: + O ap xe dudi mang phdi thong vdi mang phdi gay tran mu phdi, dieu tri rat lau khoi (16% trUOng hop) co khi co tran mu va tran khi nang. + Ho ra mau nhieu do vd nhting mach mau ldn va nhat la o ap xe d gan ron phdi. + Nhiem khuan huyet. + Viem mu trung that, viem mang ngoai tim co mu. + Gian phe quan va xO phdi. + Bien chting xa hon: ap xe nao, than nhiem bot. + Boi nhiem lao: khong nen cho thuoc chong lao khi chUa tim thay trUc khuan lao. + Suy mon, ngon ta*y dtii trong. - Tti vong: trong 136 trUOng hdp ap xe phdi dieu tri tai khoa ho hap Benh vien Bach Mai, chting tdi thay ty le tti vong 3,7%, tti vong chu yeu do nhiim khuan huyet, do suy ho hap nang, suy kiet, co trUdng hdp tti vong ngay sau khi oc mu do tkc dudng thd. 7. The lam sang NgUdi ta cd the chia the lam sang theo vi tri ap xe, theo nguyen nhan, theo tien trien. Chung tdi chi neu nhting the lam sang thudng gap sau day: 7.1. The cap tinh Benh bat dau ram ro, oc mu xuat hien sdm vao ngay thti 5-6, mu khong co mui; xet nghiem mu thudng chi cd mot loai vi khuan (tu cau, lien cau, phe cau) tien trien nhanh va khoi hin trong khoang mot thang. 7.2. The ap xe mu thoi: (Do vi khuan yem khi) Benh bat dau khong ram ro, cd khi nhu tinh trang ctim dan dan sot cao, mat hoc hac, da xanh tai, gay nhanh, dai it, hdi thd hdi, khac mu 58 khong nhieu nhUng rat thoi, co khi mui thoi lan ra ca phong, the nay co nhieu o ap xe nho. Sau khi oc mu khong nghe thay hoi chiing hang, trtidc thdi ky khang sinh the nay chet rat nhanh, ngay nay ft gap. 7.3. The ap xe phoi do amip Do ap xe gan vd len phdi d thuy dudi phdi phai nhieu nhat nhifng cd the cd ca thuy trai; cd khi amip theo dudng bach huyet len phdi gay benh. Sot cao dai dang, khac mu mau chocolat. X quang: thay mot cho cua bd cd hoanh cao len lien vdi dam md d phdi, cd khi cd hinh trdn md dam nhu mot khoi u d phdi, chup cat ldp vi tfnh cd the thay difdng ro thong tii gan len phdi; benh nhan thifdng cd tien sii ly, chan doan difdc do tim thay amip hoat dong trong mu (giii benh pham d nhiet do cO the) phan ling mien dich huynh quang difdng tfnh. Dieu tri dac hieu metronidazol hoac emetin benh khoi rat nhanh chi sau vai tuan nhUng bd sot thi cd the tii vong. 7.4. The dp xe phoi do dp xe dudng mat vd len Dac diem benh nhan khac ra mu mau vang cua mat, dang, thudng co lo ro gan vao phdi phe quan, dieu tri rat lau khoi va cd khi phai md. 7.5. Ap xe phoi do tac mach nhiem khuan Do viem noi tam mac - viem tac tinh mach, nhiem khuan sau de, sau phau thuat vung ho chau, dat catete tinh mach dai ngay, do dung thuoc bang difdng tinh mach qua nhieu. Trieu chiing: sot rat cao, kho thd, nhip thd nhanh, nhip tim nhanh. Xet nghiem: bach cau tang. X quang: sau khi khac mu thay nhting hang nho khong co mtic nifdc, hdi, thanh hang mong, thifdng bi ca hai ben phdi. Co khi tran dich mang 9 , O v phoi nhe. Cay mau cd the cd tu cau vang. 7.6. Ap xe phoi 6 tre em Ap xe cap tfnh, do mot loai vi khuan, ap xe phdi khong thoi. Chan doan kho vi tre khong khac mu ma nuot vao roi non ra. Tien lifdng xau neu co phe quan phe viem. 7.7. Ap xe phoi man tinh - Sau 3 thang dieu tri noi khoa khoi han, ke ca hinh anh X quang cung bi xoa, neu khong khoi la ap xe man tfnh. 59 - Trieu chting: thinh thoang co mot ddt sot lai, khac mu khong nhieu, nhiing keo dai, co the ho ra mau, moi ddt tien trien them mot o ap xe mdi. Neu dieu tri, benh tam thdi thoai lui nhiing roi xuat hien nhting dot khac, benh dai dang keo dai hang nam, suy mon, ngon tay dui trong. - X quang: co mot dam md, rat dam quanh o ap xe do phdi da bi xO hoa, o mu diidc bao boc bdi td chtic xd, dieu tri noi khoa khong co ket qua phai md. 8. Chan doan 8.1. The dien hinh chan doan dUa vao - Hoi chting nhiem khuan - Trieu chting oc mu. - X quang: cd hinh hang cd mtic niidc-hoi (xem hinh 3). Nhiing chd den oc mu thiidng la muon. Can chu y den nhting trieu chting ban dau: met mdi, chan an, dau ngiic, hdi thd thoi, kham phdi co hoi chting dong dac hoac hoi chting 3 giam, hinh anh X quang chi la mot dam md, benh keo dai da mot tuan thi nghi ngay den ap xe phdi. Trieu chting oc mu cd khi rat muon. Trong 136 trUOng hop ap xe phdi dieu tri tai khoa Ho hap Benh vien Bach Mai chting tdi thay chan doan sai gan 50% triidc khi vao vien. . . •) 8.2. Chan doan phan biet 8.2.1. Giai doan viem Chan doan phan biet vdi viem phdi: hoi chting dong dac va khac mu la ap xe phdi. Hoi chting dong dac va hoi chting nhiem khuan la viem phdi, tuy vay rat kho neu nghi ngd cti dieu tri tan cong ngay tti dau bang khang sinh thich hop. 8.2.2. Giai doan oc mu: can chan doan phan biet vdi - Gian phe quan boi nhiem: + Rat thudng gap, cd ngUdi la ap xe do gian phe quan. + Cd hoi chting nhiem khuan. + Khac mu keo dai, cd the cd ho ra mau + Cd tien sti ho va khac ddm lau ngay. + X quang: hinh md khong deu. 60 + Chan doan xac dinh bang chup phe quan co can quang thay gian phe quan hinh ong hoac hinh tui. + Chup c4t 16p vi tfnh: thay hinh anh gian phe quan. - Ken hoi phdi bi boi nhiem: + Thudng la ken hoi bam sinh, nhieu ken va d hai ben phdi. + Cd hoi chting nhiem khuan. + Cd khac mu. + X quang cd hinh mtic ntidc, mtic hoi. + Can hdi ky tien sti benh nhan. + Tim nhting di dang bam sinh khac. + Chup phe quan cd can quang, hoac chup cat ldp vi tfnh de xac dinh. + Sau khi dieu tri het nhiem khuan hinh anh ken hoi van giti nguyen. - Ung thU phdi: Can chti y den ung thu phdi cd bieu hien ap xe phdi. Khi khoi u bi hoai tti boi nhiem hinh anh lam sang va X quang giong nhu mot ap xe phdi. Chan doan dUa vao: ngUdi ldn tuoi thudng 45-55 tuoi, nghien thuoc la, ho khan, ho ra mau vai lan trong tien sti, dieu tri het nhiim khuan nhUng dau hieu X quang van cdn ton tai tren mot thang. - Lao hang: DUa vao tien sti, co hoi chting nhiem khuan man tfnh. X quang: cd hinh hang hoac dam md d ha don. Can tim trUc khuan lao nhieu lan de xac dinh. - Ap xe thUc quan: Nguyen nhan thudng la hoc xUdng, nhat la hoc xUdng bi lang quen, o ap xe thUc quan co the gay lo ro vdi khf quan hoac phe quan. Chan doan dUa vao: hdi ky tien sti hoc xUdng. Cho uong 20ml Lipiodol roi chup thUc quan (khong cho uong Baryt vi vao phdi khong tieu dUdc gay ap xe phdi). - Ro mang phoi phe quan: Tran mu mang phdi gay lo ro vdi phe quan, benh nhan cung khac mu, can choc do mang phdi de chan doan. Cd the bdm vai ml xanh metylen vao khoang mang phdi se thay benh nhan khac ra ddm cd mau xanh. 61 - Ap xe dudi ccf hoanh: Gay lo ro cd hoanh - phe quan: bdm hdi o bung co the thay cho ro cd hoanh bi dinh, bdm lipiodol vao thuy dudi cua phdi thay thuoc xuong thap dudi cd hoanh. - Nang tu mau: Khi thong phe quan thudng khac ra ddm khong co mu, hoi ky ve chan thUdng long ngUc. - Ken san cho: Rat kho, neu X quang chi thay mot hinh md nhu mot khoi u lanh tinh, khong co trieu chting lam sang gi dac biet. Khi nang san vd bieu hien lam sang nhu nhting trieu chting di ting, co khi soc phan ve. Chan doan bang tim thay dau san trong benh pham. 8.3. Chan doan nguyen nhan - Hdi ky ve tien sti benh nhan: bi sac, di vat, chan thudng long ngUc, nhat la cd manh dan n^m lau trong phdi. - DUa vao tinh chat cua mu: mu thoi do vi khuan yem khf, mu mau nau chocolat do amip. - Nuoi cay tren cac mdi trUOng ai khi, yem khi de xac dinh loai vi khuan va lam khang sinh do. - Tim amip trong mu. - Tim trUc khuan lao nhieu lan. - Nuoi cay tren mdi trUdng Sabouraud de tim nam. 9. Tien lUdng Tien lUdng tuy thuoc vao: - O ap xe ldn hay nho, mot hay nhieu o, tuy thuoc loai vi khuan, noi chung tien lUdng tot, benh khoi hoan toan. - Tien lUdng xau: benh xay ra tren cd dia suy mon, gia yeu, nghien rUdu, dai dudng, chan doan muon va dieu tri khong du lieu khang sinh. 10. Dieu tri 10.1. Dieu tri noi khoa - Nguyen tac dieu tri: dUa vao khang sinh do de chpn khang sinh. Neu khong lam dUdc khang sinh do, hoac khi chUa cd ket qua cua khang sinh do thi chon: + Penicillin lieu lUdng tti 10- 20 trieu ddn vi/ngay, truyen tmh mach. 62 + Ampicillin 10-20 g/ngay, truyen tinh mach. + Cephalosporin the he 1,2,3 lieu 4-8g/ngay tiem hoac truyen tinh mach. + Aminoglycosid: thuoc thiidng diidc dung phoi hop v6i cac thuoc nhom beta-lactam. + Metronidazol lg/ngay. thiidng dung khi ho khac mu thoi. + Quinolon: ciprofloxacin lg/ngay. + Chloramphenicol lieu 2-3 g/ngay. Thiidng dung phoi hop hai hoac ba khang sinh; keo dai 6-8 tuan le. Cd tac gia cho rang phai dung khang sinh cho den khi hinh anh X quang bi xoa, chi cdn nhiing giai md nho. - Dan liiu tii the: de benh nhan d tu the thich hdp. Vi du: o9 ap xe d dinh phdi phai, cho benh nhan nam dau cao va nghieng sang trai (doi khi cd nguy cd ap xe lan sang phdi trai). Neu ap xe d thuy day thi cho benh nhan nam dau doc xuong, bung gap vao thanh giudng - mu ra rat tot, nen ket hdp go, lac, rung long ngiic. - Cho cac thuoc long ddm. - Soi hut phe quan: chi lam khi nao cd tac phe quan do di vat hoac mu khong thoat ra diidc. - Choc hut mu qua thanh ngiic neu o ap xe d gan thanh ngiic. - Diia khang sinh vao tai cho cung it dung. - Ap xe phdi do tac mach nhiem khuan: ngoai viec dieu tri khang sinh can trich sach o nhiem khuan d ben ngoai. - Dieu tri dac hieu: cho Emetin, Metronidazol (Flagyl) trong ap xe do amip. - Kinh nghiem chiing tdi cho thay: chan doan sdm, dieu tri tan cong ngay tii dau thi benh thoai trien nhanh. Dieu tri noi khoa bao ton it nhat 3 thang. - Tieu chuan khoi benh: het sot, benh nhan an uong ngon mieng, len can, mau lang trd ve binh thiidng, hinh anh X quang bi xoa, chi cdn nhiing diidng xd. 10.2. Dieu tri ngoai khoa Cat thuy phdi, cat mot la phdi - Chi dinh: + Ap xe phdi man tinh 63 + Ho ra mau tai phat nhieu lan va nang. + Ap xe phdi phoi hop v6i gian phe quan + Ung thii phdi ap xe hoa Ngay nay do khang sinh hieu nghiem nen hiem khi chi dinh phau thuat. 11 Phongbenh - Ve sinh rang mieng tot. - Dieu tri o nhiim khuan d vung mui hong, rang ham mat. - Khi phlu thuat vung tai mui hong, rang ham mat can de phong ap xe phdi do hit sac phai mu, mau, chat tiet. - Nhiing benh nhan hon me, dong kinh, nhiidc cd ... viec nuoi dUdng bang ong thong phai can than dtfng de sac. - Cd y thiic phong ngtifa tac di vat d tre em, sac xang dau. Tom lai: ap xe phdi la benh lanh tmh neu chan doan sdm, dieu tri tan cong tii dau thi benh nhan co the khoi hoan toan. Khang sinh Penicillin lieu cao la thuoc nen chon loc. UNG THU PHOI 1. Dai cvtong Ung thii phdi la benh rat thiidng gap, difng hang thii ba trong cac benh phdi man tfnh va hang thii nam trong ung thii cac phu tang khac. Trong vong 40 nam trd lai day, ung thii phdi tang len ro ret. Theo Silverberg (1972) thay ty le tii vong trong ung thii phdi tii 1930 - 1965 tang len nhieu so vdi cac ung thuf da day, ung thii mau va ung thii tien liet tuyen. 6 Viet Nam ung thii phdi rat thiidng gap, tai khoa Ho hap Benh vien Bach Mai thay: 1969 - 1972: 89 triidng hdp 1974 - 1978: 186 trUdng hdp - 1981 - 1985: 285 triidng hdp. 1996-2000: 639/ 3606 triidng hdp. Benh gap nhieu d nam gidi. Hut thuoc la la nguyen nhan gay benh chmh. Trieu chiing ban dau rat km dao nen chan doan rat kho khan, dieu tri chu yeu van la ngoai khoa. Ung thii phdi bao gom ung thii tien phat va ung thii thii phat. Bai nay chu yeu noi ve ung thii tien phat. 64 2. Ung thti phoi tien phat 2.1. Giai phau benh hoc Trong ung thu phdi thi ung thu phe quan thiidng gap hdn ca. Khoang 90% ung thii d phe quan to (ung thii trung Udng) va khoang 10% ung thii d phe quan nho (ung thii ngoai vi) ung thii phe nang cung diidc noi tdi. Td chiic Y te the' gidi (WHO) xep theo te bao hoc nhii sau: Bang phan loai md benh hoc cac khoi u phdi va mang phdi 1999 cua TCYTTG. 1. Ung thu bieu md . Te bao vay Cac bien the: 1.1. Dang nhu 1.2. Te bao sang 1.3. Te bao nho 1.4. Te bao dang day 2. Ung thu bieu md te bao nho Bien the Ung thu bieu md te bao nho phoi hdp 3. Ung thu bieu md tuyen 3.1. Dang nang 3.2. Dang nhu 3.3. Tieu phe quan phe nang 3.3.1 Khong che" nhay 3.3.2. Che nhay 3.3.3. Hdn hdp che nhay va khong che" nhay hay loai te bao trung gian 3.4. Ung thU bieu md tuyen dac vdi chat nhay 3.5. Ung thU bieu mo tuyen vdi cac nhom phtic hdp 3.6. Cac bien the: 3.6.1. Ung thu bieu md tuyen bao thai biet hoa cao 3.6.2. Ung thu bieu md tuyen che nhay "dang keo" 3.6.3 Ung thu bieu md tuyen tui che nhay (Cystadenocarcinoma) 3.6.4. Ung thu bieu mo tuyen dang nhan khac 3.6.5 Ung thu bieu md tuyen te bao sang T5- BGBHNK 65 4. Ung thu bieu mo te bao ldn Bien the 4.1. Ung thu! bieu mo te bao ldn than kinh noi tiet 4.1.1. Ung thuf bieu mo te bao 16n than kinh noi tiet phoi hop 4.2. Ung thu bieu mo te bao dang day 4.3. Ung thu bieu mo dang bieu mo lympho 4.4 Ung thu bieu mo te bao sang 4.5. Ung thu bieu mo te bao ldn vdi kieu hinh dang u cO trOn 5. Ung thu bieu mo tuyen-dang bieu bi 6. Ung thu bieu mo vdi cac thanh phan da hinh the, sarcome va dang sarcome 6.1. Ung thu bieu mo vdi cac te bao hinh thoi va / hoac te bao khong lo 6.1.1 Ung thu bieu mo da hinh the 6.1.2. Ung thu bieu mo te bao hinh thoi 6.1.3. Ung thu bieu mo te bao khong lo o 6.2. Ung thu bieu mo- sarcome 6.3. Ung thu nguyen bao phdi 6.4. Cac loai khac 7. U carcinoid *> 7.1. U carcinoid dien hinh 7.2. U carcinoid khong dien hinh 8. Ung thu bieu mo dang tuyen nUdc bpt 8.1. Ung thu bieu mo te bao vay - nhay 8.2. Ung thu bieu mo tui dang tuyen bach huyet 8.3. Cac nhom khac 9. Ung thu bieu mo khong xep loai Da sd cac ung thu phe quan thuoc vao 4 nhom dau tien 2.2. Nguyen nhan - Gidi: d Phap ung thu phe quan gay tti vong d nam gidi dting hang dau trong cac loai ung thu (12.000 ngUdi mdi nam) ty le nam/ nti la 6,1/1. 0 khoa Ho hap Benh vien Bach Mai thay 85-90% sd ngUdi bi ung thu phdi la nam gidi (Chu Van Y). 66 Tuoi: thudng gap nhieu nhat b tuoi 40-60 tuoi, du6i 40 ft gap va tren 70 tuoi ty le cung thap. Tuy nhien ung thu phdi co the gap b bat ky tuoi nao. Dia dU: 6 cac nUdc cong nghiep phat trien, ung thu phdi rat thUcing gap, d thanh thi bi nhieu gap 5 lan b nong thon. Nguyen nhan trUc tiep: 16p bieu mo phe quan co dien tfch ldn 60- 90m2, do dien tfch ldn nhu vay nen phe quan la ndi de trUc tiep v6i nhieu nguyen nhan gay benh. Thuoc la: O nhieu nUdc tren the gidi ung thu phe quan tang len vdi lUdng thuoc la tieu thu, ty le ung thu phe quan b ngUdi nghien thuoc la cao hdn rat nhieu. 90% trUOng hdp ung thu phdi la ci ngUdi nghien thuoc la, thUdng la loai ung thu bieu mo te bao vay con ung thu phoi d ngUdi khong hut thuoc la thUdng gap ung thu tuyen (Adenocarcinoma). Trong khoi thuoc la co hOn 40 chat co kha nang gay ung thu do la cac Hydrocarbure thdm da vong nhu 3-4 Benzopyren, Dibenzanthracen; Polonium 40 va Selenium trong giay cuon thuoc la. Hut thuoc la chu dong lam tang nguy cO bi ung thu phdi len 13 lan. Tiep xuc lau dai vdi khoi thuoc bi dong cung lam tang nguy cd. Khf quyen bi o nhiem: do hdi dot ci gia dinh, xf nghiep, hdi xa ra tti cac dong cd. Nghe nghiep: cong nhan lam ci mo phong xa: Uranium Mo ken: Nikel carbonyl trong cong nghiep loc dau. Cromate. Amiante Sat, than, nhUa, khf dot. Di truyen: chUa dUdc chting minh, nhUng cd the co yeu td gia dinh lien quan den mot so' dot bien gen. Noi tiet: b nam gidi, ngUdi bi ung thu phe quan co lUdng cortison trong mau tang len kem theo da san vo thudng than; d nti, htit dich phe quan roi xet nghiem te bao thay te bao co hinh dang thay doi co lien quan vdi cac giai doan cua chu ky kinh nguyet. Virus: tti 1903 Borrie va Elleman (1908) Dous (1909) da chting minh nguon goc virus cua nhieu loai ung thu cua loai chim, cho den nay, hang nghin nha bac hoc cung chi mdi chting minh dUdc virus gay ung thu d nhting giong dong vat thUc nghiem ma thoi. 67 - Cac benh b phe quan phdi. + Seo cu di tfch cua ngoai vat b phdi, seo cua nhoi mau phdi. + Lao phdi phoi hdp vdi ung thif: ngUcii ta cho r&ng lao phdi lam giam miln dich, co mot so" tac gia cho rang mot so" thuoc chong lao ve thiic nghiem co the gay ung thu nhUng tren ngiidi thi chiia diiOc chiing minh. 2.3. Trieu chiing lam sang 2.3.1. Giai doan tiem tang: - Trieu chiing phe" quan: da so" ung thii vung ron phdi luc dau bieu hien ho khan hoac khac ddm, ho keo dai, dung cac thuoc dieu tri trieu chiing khong dd, d ngUdi hut thuoc la viec chan doan kho khan hdn, b ngiidi co tuoi nghien thuoc la, neu co trieu chiing tren, nen lam cac bien phap de chan doan nhat la X quang va soi phe quan ong mem. - Ho ra mau: gap trieu chiing nay b khoang 50% cac trUdng hdp, ho ra mau rat ft, lan vdi ddm thudng ho ve buoi sang va trong nhieu ngay, co the nghe thay tieng rft phe" quan chiing to khoi u da lam tic phe" quan khong hoan toan. - Hoi chiing viem phe" quan phdi cap hoac ban cap: thiidng gap trong ung thu phe" quan ldn, co bieu hien nhu mot viem phoi hoac phe quan phe" viem. Nghi den ung thu khi benh nhan het sot, khong ho, khong khac ddm ma hinh anh X quang con ton tai lau (1 thang). 2.3.2. Ung thii tiem tang: Ung thu phe quan doi khi khong co dau hieu gi ve lam sang va keo dai nhu the" rat lau, nhat la ung thu bieu mo te bao vay. 2.3.3. Nhiing dau hieu chiing to ung thii dd lan toa: - Dau ngiic: khong co dia diem dau ro ret, thudng dau ben ton thUOng dau kieu than kinh lien sUdn. Co khi dau quanh ba vai, mat trong canh tay (hoi chting Pancoast - Tobias) do la trUdng hdp ung thu d dinh phdi. Trieu chting dau ngiic co the lam cho thay thuoc nham la dau than kinh lien sUdn va dting lai b day. - Kho thd: kho thd ft gap, thUdng do tac phe quan va xep phdi hoan toan, neu kho thd kieu thanh quan va co tieng co cti thi co the do khoi u d nga ba khf phe quan, cung co khi kho thd do liet cd hoanh. - Kho noi: giong khan, giong doi do than kinh quat ngUdc bi chen ep. 68 - Kho nuot: do thiic quan bi chen ep. - Hoi chting chen ep tinh mach chu tren: phu ao khoac, tuan hoan bang he b ngilc, mat, moi tim. - Hoi chting tran dich mang phoi: ung thu di can vao mang phoi - phai rut dich mang phdi xet nghiem te bao, sinh thiet mang phoi, soi mang phoi. - Hoi chting Claude - Bernard - Horner: do chen ep than kinh giao cam cd: ntia mat do, khe mi mat hep, dong tti nho, nhan cau tut ve phia sau. 2.3.4. Dau hieu ngoai phoi: Toan than gay, co sot nhe, toe do lang mau nhanh co khi bach cau tang. - Hoi chting Pierre - Marie: ngon tay dtii trong, sUng dau cac khdp nho va nhd. - Xam lan hach trUcic cO bac thang, hach thudng don lam sinh thiet hach, hoac khong co hach thi lam sinh thiet Daniels (cat mot manh td chtic b thUdng don), xet nghiem giai phau benh hoc. 2.3.5. Dau hieu noi tiet - than kinh: - Co the co vti to mot ben hoac hai ben b nam gidi. - Hoi chting Cushing, tien trien nhanh hoac hoi chting Schwartz - Barter: giam natri trong mau, giam ap lUc tham thau mau, natri nieu binh thudng hoac tang, ap luc tham thau nieu tang, khong co suy than hoac tuyen thudng than. 2.3.6. Dau hieu Xquang: Chup phdi: chup thang, chup nghieng, chup chech, chup cat ldp. - Co the thay hinh anh xep phdi mot phan hay toan bo. - Bong md ron phdi rong. Chup phe quan sau khi bdm thuoc can quang (lipiodol) thay: - Phe quan bi hep lai - Phe quan bi cut - phe quan bi day. O 9 2.3.7. Cac ky thuat khac de chan doan: - Soi phe quan: bang ong cting hoac ong mem, co the khong thay gi dac biet vi khoi u d ngoai vi (xa phe quan ldn) neu u n&m d phe quan goc hoac phe quan ldn se thay khoi u lam tac phe quan. Neu 69 thay khoi u thi lam sinh thiet de xet nghiem te bao, neu khong thay khoi u nen hut dich phe quan de xet nghiem te bao ung thu - co khi chi thay niem mac phe quan bi loet hoac cting. Co the rUa phe quan, chai phe quan, lay benh pham xet nghiem te bao, sinh thiet xuyen vach phe quan. - Chup ckt 16p vi tmh do phan giai cao: rat co gia tri trong chan doan ung thii phdi, gitip phan dinh giai doan TNM, hu6ng dan sinh thiet xuyen thanh ngilc. - Tham do chtic nang ho hap: + Dung tfch song (VC) giam nhe hoac nang tuy theo khoi u ldn hay be, lam xep phdi hoan toan hay mot phan. + VEMS (FEV1) co the giam. + Chi so" Tiffenneau: neu dudi 50% khong co chi dinh phau thuat. + PaC02 tang thi khong co chi dinh phau thuat. - Xa hinh phdi: dung chat dong vi phong xa: I131, Technitium, indium 113 (chup mach mau) thay giam hoac mat hien tUdng phan bo mau trong phoi ndi co khoi u. Ket hop vdi ghi xa hinh thong khf phdi de dii doan VEMS con lai sau md. Neu VEMS sau md < 30% tri so ly thuyet thi khong nen md. - Sinh thiet phdi qua thanh ngilc. + Dung kim nho choc qua thanh ngilc dildi sii hildng dan cua 9.9 phim xquang phoi thang nghieng, dudi man huynh quang hoac chup ckt ldp vi tfnh, hut benh pham de tim te bao ung thu, sinh thiet manh to chtic vdi kim, Tru-cut de lam mo benh hoc, ky thuat nay ft co tai bien, khi khoi u ci vung ngoai bien gan thanh ngilc. 2.3.8. Chan doan sdm: NgUdi ta thay d nam gidi tU 45 tuoi, nghien thuoc la, ho khan hoac khac ddm keo dai, thi cti 4 thang mot lan cho chieu chup phdi va lay dich phe quan, ddm xet nghiem te bao, phat hien dUdc ung thu phdi tU 4-8 trUdng hdp trong 1.000 ngUdi. The theo vi tri. - Ung thu dinh phoi (hoi chting Pancoast-Tobias) - Ung thu khf quan hoac cila khf phe quan: tieng rft khf quan khi hit vao 70 The theo T/c. * The nhii viem phdi cap * The nhu ap xe phdi * The dau xUdng * The hang * The noi tiet (hoi chting Cushing, hoi chting Schwartz -Bartter) 2.3.9. Phan loai TNM va giai doan: Bang phan loai TNM cua To chtic y te The gicfi ve ung thu phdi 1997 ap dung cho ung thu khong phai loai te bao nho. - T: khoi u TX: Khong danh gia dUdc khoi u nguyen phat, hoac tim thay te bao ung thu d ddm hoac dich rtia phe quan nhUng khong nhin thay d chan doan hinh anh hoac noi soi To: Khong phat hien dUOc b&ng chting nao cua u nguyen phat d phdi. Tis: Ung thU bieu mo tai cho Tl: Khoi u co kich thudc ldn nhat < 3cm, dUdc bao quanh bdi nhu mo phdi hoac mang phdi la tang, khi soi phe quan khong thay xam lan tdi phe quan goc. T2: Khoi u cd mot trong cac dac diem ve kfch thudc hoac mtic lan sau: Kfch thudc ldn nhat >3cm. Xam lan vao phe quan goc, nhUng cach cUa khi phe quan > 2 cm Xam lan vao mang phdi la tang Xep hoac viem phdi sau tac phe quan di kem co the vUdt qua vung ron phdi nhUng khong chiem toan bo mot phdi. T3: Khoi u kich thudc bat ky nhUng co xam lan vao mot trong cac thanh phan sau: thanh ngUc (ke ca cac khoi u d vting dinh phdi), cd hoanh, mang phdi trung that, la thanh mang tim; hoac khoi u d trong phe quan goc cach cUa khi phe quan < 2 cm nhUng khong xam lan vao no; hoac kem vdi xep hoac viem toan bo mot phoi do the phe quan. T4: Khoi u kich thudc bat ky nhUng co xam lan vao mot trong cac thanh phan sau: trung that, tim, cac mach mau ldn, khi quan, thUc quan, than dot song, cUa khf phe" quan; mot hoac vai not u d cung thuy vdi khoi u chfnh, khoi u vdi tran dich mang phdi co te bao ac tfnh. 71 - N: hach vung NX: khong danh gia diidc hach vung No: khong co di can vao hach vung Nl: di can hach quanh phe quan cung ben va / hoac hach ron phdi va hach trong phdi cung ben, bao gom ca sii xam lan triic tiep cua khoi u vao cac hach do. N2: di can den hach trung that cung ben va / hoac hach diidi ciia khf phe quan N3: di can den hach trung that doi ben, hach ron phdi doi ben, hach cO bac thang cung ben hoac doi ben hoac hach thUOng don. - M: di can MX: khong danh gia dUdc di can xa Mo: khong co di can xa Ml: co di can xa, bao gom ca viec co cac khoi u nho d thuy phdi khac (cung ben hoac doi ben). Xep giai doan: Ung thii bieu mo an: TX, NO, MO Giai doan 0: Tis NO MO Giai doan IA: Tl NO MO Giai doan IB: T2 NO MO Giai doan IIA: T1N1M0, Giai doan IIB: T2N1M0 T3N0M0 Giai doan IIIA Tl N2 MO T2 N2 MO T3 Nl, 2 MO Giai doan IIIB: Moi T, N3 MO T4, moi N, MO Giai doan IV: Mpi T, moi N, Ml 72 3. Ung thii phoi thuf phat La di can cua ung thu tii mot bo phan khac nhii: da day, gan, vu, bo phan sinh due. Ung thu phdi thti phat co the la trung UOng hay ngoai vi, tuy theo vi tri va giai doan. Trieu chting nhii ung thii tien phat - nhiing hinh anh X quang thudng co nhieu u la nhiing hinh trdn md deu, bd net co khi d ca hai phdi (hinh 5). Ung thu phdi thti phat khong co chi dinh phau thuat. 4. Dieu tri 4.1. Dieu tri trieu chiing • Ho: cho terpin codein 4 - 6 v/ngay, hoac Silomat 2-4 vien /ngay chia 2 lan, Sinecod 2- 3 vien/ ngay, moi lan 1 vien. • Ho mau: - Tinh chat thuy sau tuyen yen 5 dv x 1-2 ong tiem bap, truyen TM, vasopressin, morphin 10 mg x 1 ong tiem dtfdi da. Khang sinh phong nhiem trung. • Dau ngi/c: cho cac loai giam dau, theo phac do bac thang: - Bac 1: cac thuoc giam dau khong phai morphin + Nhom Paracetamol (Efferalgan) 0,5g-lg x 4 lan /ngay. + Salixyle: Aspirin (aspegic) 500-1000 mg x 3 lan/ngay. + Cac thuoc giam dau chong viem khong corticoid: Feldene 20 mg x 2-3 vien / ngay Feldene 20 mg x 1-2 ong/ ngay tiem b&p - Bac 2: cac thuoc dang morphin nhe ket hop vdi cac thuoc khac: + Codein: 30 - 120 mg + Paracetamol 500 mg hoac aspirin 250 mg -500 mg x4 lan /ngay. + Dextropropoxyphen: 50 - lOOmg + Paracetamol 500 mg (DI ANTAL VIC), hoac aspirin 500 - 1000 mg x 3 lan /ngay. 73 - Bac 3: morphin. Chi dinh khi cac thuoc khac khong co tac dung, dung diidng uong, tiem dudi da hoac tinh mach. Dung them thuoc nhuan trang nhu Lactulose de phong tao bon. • Kho thcJ: - Oxy qua ong thong mui 1- 3 1/phut. - Corticoid: Depersolon 30 mg x 2 - 3 ohg/ngay hoac Solumedrol 40 mgx 2- 3 ong/ngay qua dUOng tinh mach khi u ldn, chen ep khi phe quan ldn, tinh mach chu tren (ket hdp thuoc chong dong). - Thuoc gian phe quan neu co co that phe quan lan toa. 4.2 Dieu tri benh 4.2.1. Dieu tri ung thii bieu mo te bao nho • Loai khu tru d long ngifc: tia xa ket hdp da hoa tri lieu: - Hoa tri lieu: dung phoi hdp hai hoac nhieu thuoc: + Etoposid + Cisplatin. + Adriamycin + Etoposid +Cyclophosphamid + Cisplatin. Dung 6 ddt neu co dap ting hoan toan, hoac den luc benh tien trien neu dap ling ban phan. - Tia xa: + Tia xa khoi U (55 Gray), trung that, ho" thiidng don. Co the xen ke vdi hoa tri lieu. + Tia xa dii phong nao d cac triidng hdp dap ilng hoan toan. • Loai lan rong: da hoa tri lieu. 4.2.2. Dieu tri ung thii bieu mo khong phdi loai te bao nho - Giai doan IA, IB, IIA, IIB: chi dinh phau thuat (cat bo phan thuy, mot thuy hoac mot phdi). - Giai doan IIIA: hoa tri lieu trildc sau do phau thuat. - Giai doan IIIB: hoa tri lieu co platin sau dd tia xa. - Giai doan IV: hoa tri lieu cd platin va Vinorelbine khi toan trang cdn tot. 74 4.3. Mien dich tri lieu Chi dinh khi da loai bo dUdc hau het cac te bao ung thti. Muc dich la tang cUdng so" lifdng, chat lifdng cua cac te bao mien dich chong lai te bao ung thu. Cd the dung LH 1, Levamisol, hoac chting BCG. BCG kich thich chtic nang thiic bao: lay 2ml hon dich BCG rach da va boi len da, rach 10 rach vdi dien tfch 5cm2 moi tuan lam mot lan. . 5. Tien trien, bien chting, tien ltidng 5.1. Tien trien: di cdn ung thit qua 4 diidng - Ducing dong mach phdi (thifdng gap). - Bach mach. - Phe quan. - Ke can. 5.2 Bien chiing * 9 - Ap xe phoi thti phat. - Boi nhiem phdi. - Xep phdi. - Tran khf mang phdi. - Khai huyet nang do ung thu gam vd dong mach ldn. 5.3 Tien lilcfng - Phu thuoc loai te bao, giai doan TNM, tinh trang toan than va dieu tri. 6. Ket luan Ung thU phdi la loai ung thu cd tien lifdng nang, ty le chan doan sdm difdc thap nen van de phong benh rat quan trong: hay khong hut thuoc hoac neu da hut thi co" gang cai thuoc. 75 TAM PHE MAN 1. Dai ctfcfng va dinh nghla Tam phe man co dinh nghia giai ph&u, do la trUdng hdp phi da^ va gian tam that phai thti phat do tang ap liic dong mach phdi, gay nen boi nhting benh lam ton thUdng chtic nang hoac cau trtic cua phoi nhU: benh phe quan, phdi, mach mau, than kinh va xUdng long ngUc. Loai trti nhting trifdng hdp tang ap liic dong mach phdi do benh tim trai (hep 2 la), benh tim bam sinh, tang ap dong mach phoi tien phat. Ap liic dong mach phoi trung binh d ltic nam nghi cua ngiidi dudi 50 tuoi <15 mmHg, tang them 0,1 mmHg mi nam. Goi la tang ap liic dong mach phdi (TALDMP) khi ap liic dong mach phdi trung binh > 20mmHg ltic nam nghi va > 30 mmHg khi gang stic d ngiidi dudi 50 tuoi. Tam phe man da dUdc nghien ctiu tti lau. Tti nam 1949 Senac da chti y den benh diidng ho hap gay anh hUdng den tuan hoan phoi, phi dai tam that phai va tti vong do mat thdi ky tam thu. Traude (1878) mo ta trUdng hdp phi dai that phai tren benh nhan gti - veo cot song. Laennec (1826) lan dau tien mo ta benh gian phe nang dan dan dUa den gian nhi phai, that phai va ong cung thay mom tim dap d vting thudng vi ma ngay nay ngUdi ta gpi la dau hieu Harzer. Ayerza(1901) mo ta mot trUdng hdp co tim, tang hong cau va suy tim phai, khi md tti thi thay gian phe quan. Laubry va Chaperon da chting minh tang ap liic dong mach phdi bAng thong tim. White (1931) da phan biet dUdc tam phe man do tang ap liic dong mach bdi nhting benh phdi lan rong ca 2 ben, ngoai ra suy thong khf phdi va suy trung tam ho hap, da hong cau, thieu oxy mau, tang cung lUdng tim deu dan den phi dai that phai. 6 Viet Nam tti 1959 - 1964 tai khoa noi Benh vien Bach Mai cd 200 trUdng hdp tam phe man (Dang Van Chung). Benh tam phe man chiem 7% cac benh phdi tai khoa Ho hap Benh vien Bach Mai (Chu Van Y - 1986). Nam bi gap 5 lan nti (Daun 1962). 2. Nguyen nhan 2.1. Benh tien phat cua ditdng ho hap vd phe nang - Viem phe quan man tfnh tac nghen cd gian phe nang hoac khong gian phe nang 76 - Hen phe quan. - Gian phe nang khong do viem phe quan man tmh va hen phe quan. - Xo phdi va gian phe nang hoac khong gian phe nang do hau qua cua: + Lao xd phdi + Benh bui phdi + Gian phe quan. + Benh viem phdi khac. + Benh mucoviscidose (suy tuyen tuy - viem nhiem phe quan phoi man tmh). - Benh u hat tham nhiem phdi. + Sarcoidose (Benh Bernier - Boeck - Schaumann) benh cua he thong lien vong noi mac. + Benh xd phdi ke lan toa. + Benh Berylliose (nhiem Berili phdi) + Benh u hat co te bao bach cau ai toan (benh cua xildng so, xtfdng ham va xifdng dai). + Benh tham nhiem phdi ac tmh + Benh xO ciing da. + Benh Lupus ban do rai rac + Benh viem da va cO + Benh vi soi phe nang - Cat bo phdi - Benh ken phdi tien phat, thoai hoa phdi - Benh thieu oxy 0 do cao 2.2. Benh tien phat lam ton thUOng den bo phan ca hoc cua he ho hdp - Gu veo cot song va di dang long ngilc khac. - Cat ep xildng sildn - Day dfnh mang phdi nang. - Benh nhtfdc cO. - Benh beo beu va giam thong khi phe nang - Benh giam thong khf phe nang khong ro nguyen nhan. 77 2.3.Benh tien phat lam ton thUOng mach mau phoi 2.3.1. Benh thanh mach - Tang ap liic dong mach phdi tien phat - Viem nut quanh dong mach - Viem dong mach khac. 2.3.2. Viem tac mach - I’ac mach phdi tien phat - Tic mach phdi trong benh thieu mau hinh ltfdi liem 2.3.3. Nghen mach - Nghen mach do cuc mau dong ngoai phdi. - Nghen mach do san mang (Schistosomiase) - Nghen mach ac tinh. - Nghen mach khac. 2.3.4. Tang dp ItCc dong mach phoi Do chen ep boi u trung that, phinh quai dong mach chu, td chiic xd, u hat. Theo sU thay doi chvfc nang ho hap ngUOi ta xep thanh 4 nhom nhuf sau: - Roi loan thong khi phe nang va phan bo khi - mau trong phdi. - Roi loan khuech tan khi. - Roi loan tuan hoan phdi. - Phoi hdp nhom 1 va nhom 3. O Viet Nam nhiing nguyen nhan hay gap (Dang Van Chung) - Viem phe quan man tinh va hen phe quan (76,5%) - Lao xd phdi 15,5% - Gian phe quan 13% - Viem phe quan man tinh ddn thuan 12% - Viem mang phdi 7% - Di dang long ngilc 4% Noi chung ve nguyen nhan nhieu tac gia thay benh viem phe quan man tinh diing hang dau. 78 3. Cc/ che sinh benh Cd che sinh benh cua tam phe man phtic tap vi nhieu nguyen nhan gay benh, moi loai nguyen nhan co cd che sinh benh phan nao khac nhau, nhiing nhieu tac gia deu thong nhat cd che sinh benh cua tam phe man la tang ap liic dong mach phoi. 3.1. Ca che tang dp luc dong mach phoi 3.1.1. Cd che co that mach mau phoi Theo Daum (Tiep) thi suy ho hap tting phan gay thieu oxy mau, thieu oxy td chtic, dan den toan chuyen hoa, suy ho hap toan phan lam ti tre C02 gay toan ho hap. Thieu oxy td chtic ma gay co that dong mach phdi va toan mau lam tang co that dong mach phdi. Sii co that dong mach phdi va co that mao mach phdi lam tang ap liic dong mach phdi dan den phi dai buong that phai va cuoi cung suy tim phai. (Shunt phdi gom cd Shunt giai phau ttic la mau di tti dong mach phoi, sang tinh mach phdi khong tiep xtic vdi phe nang. Shunt sinh ly do tac phe quan nen mau khong dUOc trao doi oxy cuoi cung mau ve tim trai giam bao hoa oxy). Cd che do co that dong mach phdi, tang hong cau, tang the tfch, tang lUu lifdng tim, nhting yeu to tren lam tang ap liic dong mach phdi dan dan phi dai that phai, that phai gian va cuoi cung suy that phai. 3.1.2. Cd che tang dp liic dong mach phoi do ton thiidng gidi phau vd roi loan van dong mach. Gom cO che tien phat va cO che thti phat. - Cd che tien phat: + Ton thifOng giai phau cua mach mau phdi lam tang ap liic dong mach phdi. Mach mau phdi bi pha huy, bi giam bdt, bi tic nghen va xd hoa do benh cua mach mau phdi thay trong trUdng hdp tang ap liic dong mach phdi tien phat; hoac benh ngoai mach mau phdi nhif xO phdi lan toa, viem phe nang, bui phdi. + Tang ap liic dong mach phdi do roi loan van mach: thieu oxy va toan mau gay roi loan van mach. Co that mach mau phdi lam tang ap liic dong mach phdi nhu trong trifdng hdp gu, veo cot song, di dang long ngiic, beo beu, benh giam thong khf phe nang tien phat. 79 + Tang ap liic dong mach phdi do phoi hdp ca hai yeu to noi tren. - Co che thti phat: + Tang lifu lifdng tim: do tang chuyen hoa, hoat dong hang ngay, nhiem khuan phoi cap tmh, thieu oxy cap tinh. + Tang do quanh cua mau: da hong cau thti phat + Nhip tim nhanh do thieu oxy tram trong, suy tim 3.2. Ca che suy tim Tang ap liic dong mach phdi la trd liic chinh lam tang cong ctia tim, tinh trang thieu oxy, da hong cau, tang the tfch va tang cung lifdng tim cung gop phan lam tang cong cua tim. Sii tang cong ctia tim lam phi dai that phai - gian that phai va cuoi cting suy tim phai. 4. Giai phau benh Ton thifdng giai ph&u benh tuy theo nguyen nhan gay benh cd nhting ton thifdng khac nhau. Khi md tti thi thay: 80