Alveolar Syndrome

CHAN OAN HNH ANH
HOI CHNG PHE NANG

BS.NGUYEN QUY KHOANG
BS.NGUYEN QUANG TRONG
October 31, 2014
DAN BAI
nh ngha.
Giai phau:Phe nang,tieu thuy s cap,
chum phe nang,tieu thuy th cap Miller.
Cac dau hieu X quang.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
NH NGHA
Hoi chng phe nang bao gom cac dau
hieu dien ta s hien dien cua dch hoac
te bao (lanh,ac) trong phe nang.
Hoi chng nay thng gap trong cac
benh ly cap tnh,dien tien mau le.
October 31, 2014
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
GIAI PHAU
PHE NANG (ALVEOLUS)

Moi phoi co t 300-500 trieu phe nang,cac phe nang
sap xep nh nhng chum nho quanh cay phe quan
c phan chia theo kieu chia oi t trung tam ra
ngoai vi (23 lan phan chia),moi phe nang co ng
knh # 250m.
Dien tch be mat trao oi kh moi phoi co kch thc
bang mot san quan vt (75m2).
Phe nang (alveolus) la n v c ban cua qua trnh
trao oi kh.No khong thay c tren X quang v kch
thc qua nho.
October 31, 2014
GIAI PHAU
TIEU THUY S CAP (PRIMARY LOBULE)
Tieu thuy s cap la n v chc nang nho

nhat cua phoi.
No gom tat ca cac cau truc sau tieu phe quan
ho hap (respiratory bronchiole), bao gom t
16-40 phe nang.
ngi ln,co khoang 23 trieu tieu thuy s
cap.
Tieu thuy s cap cung khong thay c tren
X quang.
October 31, 2014
GIAI PHAU
CHUM PHE NANG (ACINUS)
Chum phe nang (acinus) bao gom tat ca cac

cau truc sau tieu phe quan tan (terminal
bronchiole): ong mach,tnh mach,mach bach
huyet,than kinh,mo lien ket
No co ng knh 4-8mm,hnh thanh t 10-20
tieu thuy s cap va co khoang 400 phe nang.
Khi b tham nhiem,cac chum phe nang bieu
hien nh nhng bong m khong ro b-bong m
phe nang (acinar shadows,acini).
October 31, 2014
GIAI PHAU
CHUM PHE NANG (ACINUS)
October 31, 2014
GIAI PHAU
TIEU THUY TH CAP MILLER (SECONDARY LOBULE)
ay la n v cau truc nho nhat cua phoi ma

c bao quanh bi vach mo lien ket.
Tieu thuy th cap co hnh thap a dien, ay
ngoai vi,nh hng ve ron phoi.
No hnh thanh t 3-5 chum phe nang va co
ng knh ay 1-2,5cm.
phoi ngi co khoang 5000 tieu thuy th cap
Miller.
October 31, 2014
10
GIAI PHAU
TIEU THUY TH CAP MILLER
Truc cua tieu thuy th

cap c tao thanh bi
tieu PQ trung tam tieu
thuy (central bronchiole)
va tieu M trung tam
tieu thuy (central
arteriole).Bao quanh
tieu PQ va tieu M
trung tam tieu thuy la
mo ke.
Tnh mach va mach
bach huyet nam vach
lien tieu thuy.
October 31, 2014
11
GIAI PHAU

TiU THU TH CP
1.Tieu PQ trung tam tieu thuy
CHUM PHE NANG-ACINUS
(A)
2.Tieu PQ tan.
TIEU THUY S CAP (B).
3.Tieu PQ ho hap.
4.Kenh phe nang.
5.Tui phe nang.
6.Phe nang.
October 31, 2014
12
Mi phi c 5000 tiu thu

th cp
Mi tiu thu th cp gm
c 3-5 acini
Mi acinus gm 10-20 tiu thu
s cp
Mi tiu thu s cp gm 16-40
ph nang
October 31, 2014
13
GIAI PHAU
Cac tui phe nang

thong thng vi
nhau qua lo Kohn.
Ngoai ra,kenh
Lambert noi thong
phe nang vi tieu
PQ trc tan.
8.Lo Kohn (Pore de Kohn).

6.Kenh Lambert (Canal de Lambert).
October 31, 2014
14
GIAI PHAU
Khi vach mo lien ket (mo ke) gia cac tieu thuy
th cap (con goi la vach lien tieu thuyinterlobular septa) day len,chung c thay ca
tren X quang quy c (cac ng Kerley) lan
tren CT co o phan giai cao (high resolution
CT-HRCT).
October 31, 2014
15
GIAI PHAU
October 31, 2014
D.Anthoine.LImagerie Thoracique
16
GIAI PHAU

CAC CAU TRUC CO THE THAY C TREN HRCT
October 31, 2014
17
GIAI PHAU
LAT CAT DAY: THAY C

MACH MAU PHOI
October 31, 2014
LAT CAT MONG: THAY C

VACH LIEN TIEU THUY VA ONG
MACH TRUNG TAM TIEU THUY
18
GIAI PHAU
October 31, 2014
19
GIAI PHAU
TON THNG CHUM PHE NANG

(ACINI)
October 31, 2014
TON THNG TOAN TIEU THUY TH

CAP MILLER
20
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
21
CAC DAU HIEU X QUANG

1.Bong m co am o dch,b m nhoe.
2.Cac bong m co khuynh hng hoi tu.
3.Cac bong m co the he thong hoa.
4.Cac bong m tu tap thanh hnh canh bm.
5.Co kh anh noi phe quan (air bronchogram).
6.Co nhng not acini.
7.Dien bien thng mau le.
October 31, 2014
22
1/ Bong m co am o dch,b m nhoe
10/31/2014
23
2/ Cac bong m co khuynh hng hoi tu.
Tr trai 4 tui: hch rn phi phi (mi tn), ng c thy trn (P)
Ann N. Leung, MD. Pulmonary Tuberculosis: The Essentials. Radiology. 1999;210:307-322.
10/31/2014
24
VIEM PHOI THUY TREN (P)

October 31, 2014
A.J.Chandrasekhar,M.D.Chest X-ray Atlas.
25
VIEM PHOI PHAN THUY NGOAI THUY GIA (P)

October 31, 2014
(phn thu 4)
26
Thu gia phi phi (Lat, F: phn thu bn = phn thu 4;

Med, E: phn thu trong = phn thu 5).
4.Cac bong m tu tap thanh hnh canh bm
Ph phi cp
4.Cac bong m tu tap thanh hnh canh bm.
Ph phi cp
Bat wing, butterfly patternPulmonary edema

- bilateral perihilar opacities, asymmetric
- air bronchogram (+), acinar opacities (+)
5/ DU HIU KH NH NI PH QUN
(AIR BRONCHOGRAM SIGN)
Bnh thng cc ph qun trong phi khng thy c

bi chng cha kh v bao quanh bi cc ph nang cng
cha kh.
Khi nhu m phi b ng c, cc ph nang lp y dch,
trong khi lng ph qun cn thng thong, lc ny ta s
thy r lng cc ph qun trn phim, ta gi l c du hiu
kh nh ni ph qun (air bronchogram sign (+)).
Du hiu ny c th thy trn X quang quy c ln CT.
VIEM PHOI (Co air bronchogram)

October 31, 2014
33
VIEM PHOI (Co air bronchogram)
October 31, 2014
Joseph K.T.Lee. Lee computed body tomography with MRI correlation. 1998
34
Gi tr ln nht m du hiu ny em
l, l khi c Air bronchogram sign
(+) th ta c th khng nh tn thng
nhu m phi, loi tr tn thng c
ngun gc t mng phi, t thnh
ngc, cng nh t trung tht.
Du hiu kh nh ni ph qun thng
gp nht trong Vim phi, nhng cng
c th gp trong cc bnh l khc nh
Ph phi, Nhi mu phi, thm ch c
trong bu phi (bronchioloalveolar
carcinoma, lymphoma).
Air Bronchograms: Alveolar cell carcinoma
Pneumonia
Alveolar cell carcinoma
Pneumonia
Alveolar cell carcinoma
6/Co nhng not acini.
Hnh m ph nang trong lao phi, kt t ngoi bin,

lan rng theo ng ph qun
DU HIU BNG B
(SILHOUETTE SIGN)
Du hiu ny c a ra vo nm 1935 bi Dr.

H.Kennon Dunham, sau c pht trin bi Dr.
Benjamin Felson.
nh ngha: Mt bng m trong lng ngc c m
dch, tip xc v mt gii phu vi b ca cc cu trc c
m dch trong lng ngc (tim, ng mch ch, vm
honh) s xa b tip xc vi nhau. Ngc li, nu khng
tip xc v mt gii phu th b ca cc cu trc vn
hin r trn phim cho d c chng lp ln nhau.
Khi c hin tng xa b ta gi l Silhouette sign (+).
Khi khng xa b ta gi l Silhouette sign (-).
CU TRC
THY HOC PHN THY TIP XC
Vm honh (P). Cc phn thy y thy di phi (P).

B tim (P).
Phn thy trong (medial) thy gia phi (P)
MC ln.
Phn thy trc thy trn phi (P).
Quai MC.
Phn thy sau thy trn phi (T).
B (T) tim.
Phn thy di (inferior) thy li (lingula).
MC xung.
Phn thy nh & trong thy di phi (T).
Vm honh (T). Cc phn thy y thy di phi (T).
y l du hiu c bn v
quan trng nht trong X
quang lng ngc qui c.
Trong mt s trng hp, n
gip chng ta nh v c
cc bng m trong lng ngc
trn phim ngc thng m
khng cn n phim ngc
nghing.
SILHOUETTE SIGN (+)
SILHOUETTE SIGN (-)
Xp phi thu gia phi
T th nh n ngoi vic nh gi tn thng nh phi,

cn nh gi rt tt tn thng thu gia.
NG C THU LI (LINGULA)PHI TRI
NG C PHN THU DI
THU LI (LINGULA)PHI TRI
Vim phn thu nh thu di tri
Vim thu di phi tri
DU HIU PHNG RNH LIN THU

(BULGING FISSURE SIGN)
Trc y ngi ta cho rng du hiu ny gip chn on vim phi do Klebsiella,
nhng nay du hiu ny cng do cc tc nhn khc, thm ch c trong ung th.
Bulging fissure sign: Klebsiella pneumonia.
Bulging fissure sign: Klebsiella pneumonia.
Bulging fissure sign: Klebsiella pneumonia
Bulging fissure sign: pneumococcal pneumonia.
Bulging fissure sign: Bronchioloalveolar Carcinoma
Bulging fissure sign: Bronchioloalveolar Carcinoma
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
57
NGUYEN NHAN
A.Ton thng khu tru:
1.Viem phoi do vi trung.
2.Nhoi mau phoi.
3.Lao phoi.
4.Nam phoi.
B.Ton thng lan toa:
1.Cap tnh:
a/OAP.
b/ARDS.
c/Viem phoi do sieu vi.
d/Benh mang trong.
e/Viem phoi ht.
f/Mau tu trong phoi.
October 31, 2014
58
NGUYEN NHAN
2.Man tnh:
a/Lao phoi.
b/Nam phoi.
c/K tieu phe quan-phe nang.
d/Sarcoidose.
e/Hodgkin.
f/ong protein.
g/Benh phoi do ht dau.
h/Viem phoi man tnh co bach cau ai
toan tang.
October 31, 2014
59
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
60
HNH ANH X QUANG
Pneumococcal pneumonia
ng c thy trn (T) xa b (T) tim
Bong m tron thuy tren phoi (P) VIEM PHOI TRON
October 31, 2014
63
Bong m tron phan thuy nh cua thuy di phoi (P)

VIEM PHOI TRON
October 31, 2014
64
Kh anh noi phe quan

tren Sieu am.
Phan bo ong mach

phoi bnh thng.
VIEM PHOI TRON
October 31, 2014
65
Bong m tron gia phoi (P)

U PHOI ?
October 31, 2014
Hai ngay sau

VIEM PHOI
66
VIEM PHOI (Legionellose)

October 31, 2014
D.Anthoine et al.LImagerie Thoracique.1996-1998.
67
Pseudomonas pneumonia
Hch cnh (P) kh qun
Hai thng sau: Lao phi
Hyae Young Kim, MD et al. Thoracic Sequelae and Complications of Tuberculosis.

Radiographics. 2001;21:839-858.
10/31/2014
69
Khi u
20 thng sau
ASPERGILLOMA / HANG LAO
(air crescent sign)
24 thng sau
42 thng sau
Hyae Young Kim, MD et al. Thoracic Sequelae and Complications of Tuberculosis.

Radiographics. 2001;21:839-858.
10/31/2014
70
Aspergillus bronchopneumonia in a liver transplant recipient.
Air Bronchograms : eosinophilic pneumonia
CHAN THNG SO NAO

XUAT HUYET NOI SO
October 31, 2014
PHU PHOI DO NGUYEN NHAN

THAN KINH
73
NHI MU PHI
15/03/2003
19/03/2003
20/03/2003
SARS-SEVERE ACUTE RESPIRATORY SYNDROME

October 31, 2014
75
X QUANG ARDS
PHU PHOI TON THNG
(INJURY PULMONARY EDEMA)
15 MARCH 2003
19 MARCH 2003
20 MARCH 2003
February 10, 2004
76
Peripheral and widespread airspace opacities in ARDS
Ph phi tn thng - ARDS
Ph phi tn thng - ARDS
BENH MANG TRONG

October 31, 2014
80
ONG PROTEIN PHE NANG

October 31, 2014
81
Sarcoidosis phi
Mucosa-associated lymphoid tumor

of the lung parenchyma.
K TIEU PHE QUANPHE NANG LAN TOA
K TIEU PHE QUAN-PHE NANG LAN TOA

October 31, 2014
85
DAN BAI
nh ngha.
Nguyen nhan.
Hnh anh X quang.
Ket luan.
October 31, 2014
86
KET LUAN
e hieu ro hoi chng nay,ta can
nam vng giai phau cua chum phe
nang va tieu thuy th cap Miller.
Ghi nh 7 dau hieu X quang cua
hoi chng nay.
October 31, 2014
87
CAM N S CHU Y THEO DOI CUA QUY BAC S

October 31, 2014
88
VUI HC
BS Nguyn c Dng
BS Nguyn c Bng
Hnh chnh
Bnh nhn n 42tui
Nhp vin Phm ngc Thch 24/10/2011
L do: Kh th
Bnh s
Ngh nghip: Lm ngh phn kim lu > 10
18 gi trc nhp vin vn lm phn kim
H2SO4, HNO3, ng (Cu) v nhm (Al).
Ln ny, khi sinh ra rt nhiu v phi ht khi
ny khong > 5 pht.
Tin s
Cha tng nhp vin v bnh g khc
Khng b Lao hoc bnh phi khc
Si thn (+)
Vim gan siu vi B (+)
Tin s gia nh: c hai con khe mnh
Khng dng bt c thuc g trong 2 thng nay
Lm sng
HA:120/80, M:96, 37C, th 22/ph, SpO2 88%
Khm lm sng khng pht hin bt thng
ngoi tr triu chng : Kh th,ho khan,tc ngc.
Cn lm sng
*CTM: BC=
-18.9K/uL 96.7% N (25/10/2011)
-17.6K/uL 72.5%N (1/11/2011)
*CRP:8.7mg/L (26/10/2011)
*ECG: Bnh thng
*Siu m tim: EF:69%
*BK trong m: (-)
X-quang lc nhp vin
CT phi lc nhp vin
CT phi lc nhp vin
Chn on s b
Ph qun ph vim (Bronchopneumonia)
Pneumocystis carinii
Lao phi
K phi (Bronchiolo-alveolar Carcinoma)
Chn on khc?
Chn on
TN THNG PHI DO KH (GASINDUCED LUNG INJURY ACUTE GASPOISONING LUNG INJURY)
iU TR
Kebasyn, solumedrol.
Hai ngy u th Oxy 3 lt/pht.
Din tin lm sng tt dn, n ng tt.
Phim XQ phi v CT scan:
Xut vin 02/11/11
X-quang lc xut vin
CT lc xut vin
CT lc xut vin
Phn ng ha hc
2 H2SO4 + Cu CuSO4 + H20 + 2 SO2
3 Cu + 8 HNO3 3 Cu2+ + 2 NO + 4 H2O + 6 NO3Cu + 4 H+ + 2 NO3 Cu2+ + 2 NO2 + 2 H2O

3+
2 Al + 6 H+ + 6 NO3 Al
+ 6 NO2 + 3 H2O
Ht NO2
Ht NO2
NO2 is toxic and brown; irritant and insoluble; to

bypass upper airway without any warning
irritation of the eyes or nasopharynx.[7] In the
moist mucoid environment of the lower
respiratory tract, NO2 dissolves and penetrates
the bronchiolar and alveolar membranes
generating nitric acid, and cause acute lung
injury.[8]
Teofilo L, LeeChiong Jr: Smoke inhalation injury. Postgrad Med J 1999;105.

Hajela R, Janigan DT, Landrigan PL, Boudreau SF, Sebastian S. Fatal pulmonary
edema due to nitric acid fume inhalation in three pulpmill workers. Chest
1990;97:4879.
Severe pulmonary sequelae due to inhalation of NO2:

(1) immediate fatalities from very high concentrations
(2) delayed effects occurring within 48 hours, and
(3) mild immediate effects followed by a short recovery period,
but culminating in pneumonia (NIOSH, 1976; Hamilton and
Hardy, 1974).
Inhalation of gases from nitric acid can be extremely dangerous
because they do not invoke a violent protective cough reflex such
as occurs with chlorine and ammonia.[3]
Determination of Acute Reference Exposure Levels for Airborne

Toxicants Nitric acid 3 March 1999 C-244. CAS Registry. Number:
7697-37-2.
X QUANG ARDS
PHU PHOI TON THNG
February 10, 2004
109
X QUANG ARDS
PHU PHOI TON THNG
Thi gian:
0-12 giX quang ngc bnh thng.
12-24 giPhu phoi mo ke cho ra
hnh m mau knh uc.
24-48 giong ac cac chum phe
nang,rai rac chu yeu ngoai bien.
Khong co TDMP neu khong kem boi
nhiem phoi.
February 10, 2004
110
X QUANG ARDS
PHU PHOI TON THNG
Thi gian:
5-7 ngayPhu phoi bien mat t t.
ong ac tng vung.
> 7 ngayX hoa mo ke.
February 10, 2004
111
X QUANG ARDS
PHU PHOI TON THNG
Chan oan phan biet vi Phu phoi

cap bang:
o ap suat mao manh phoi bt
(PCWP) < 12mmHg.
Hut dch t phe quan
(ARDS:protein > 50g/l.)
February 10, 2004
112
X QUANG ARDS
PHU PHOI TON THNG
MENDELSONS SYNDROME
-Florid bilateral pulmonary edema
secondary to aspiration of gastric
contents.
-Appearing within 24 hours of the

incident.
-The mortality is high.
February 10, 2004
113
X QUANG ARDS
PHU PHOI TON THNG
ARDS in a patient who

sustained severe injuries in a
road traffic accident.
-Peripheral air-space
consolidation with air
bronchograms.
-Normal heart size.
February 10, 2004
114
X QUANG ARDS
PHU PHOI TON THNG
-Diffuse air-space
consolidation with air
bronchograms.
-Normal heart size.
February 10, 2004
115
X QUANG ARDS
PHU PHOI TON THNG
consolidation.
February 10, 2004
116
X QUANG ARDS
PHU PHOI TON THNG
consolidation.
February 10, 2004
117
X QUANG ARDS
PHU PHOI TON THNG
-Consolidation with air bronchograms.

-Some ground-glass opacities.
February 10, 2004
118
X QUANG ARDS
PHU PHOI TON THNG
DAY 1
DAY 5
DAY 7
February 10, 2004
119
X QUANG ARDS
PHU PHOI TON THNG
DAY 3
SARS
February 10, 2004
DAY 5
120
TOM TAT
ALVEOLAR PULMONARY EDEMA
ADULT RESPIRATORY DISTRESS SYNDROME
-Left heart failure.

-Mitral valve disease.
-Renal failure.
-Overhydration.
-Drowning.
-Neurogenic.
-Postembolic.
-Sepsis.
-Hypotension (VietNam lung,DaNang
lung, shock lung).
-O2 toxicity.
-Noxious inhalation (includes cocaine).
-Aspiration.
-Embolism (air,fat,amniotic).
-Pancreatitis.
-Disseminated intravascular
coagulation.
-Virulent pneumonias.
February 10, 2004
121
TOM TAT
ALVEOLAR
PUL.EDEMA
ARDS
1.KERLEYS LINES
Often present.
Usually absent.
2.FISSURES
Thickened.
Normal.
3.EFFUSION
Frequent,especially Usually absent or

on the right side.
small.
4.PULMONARY VESSELS Redistribution.
Normal.
5.BRONCHIAL WALLS
Cuffing.
+/- Cuffing.
6.HEART SIZE
Enlarged.
Normal.
7.DISTRIBUTION
Perihilar.
Diffuse or peripheral.
8.VASCULAR PEDICLE
Wide.
Normal.
February 10, 2004
122
KET LUAN
ARDS
ALVEOLAR
PULMONARY
EDEMA
(-)
>30mmHg
<30g/l
Tot,de dieu tr.
February 10, 2004
1.Ton thng noi bao mao

mach,lien bao phe nang.
2.Ap lc mao mach phoi bt.

3.Dch trong phe nang co
protein.
4.Tien lng.
(+)
<12mmHg.
>50g/l
Xau,kho tri.
(T vong 50-70%)
123
XIN CAM N S CHU Y THEO DOI CUA QUY BAC S

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CHAN OAN HNH ANH

HOI CHNG PHE NANG

October 31, 2014

October 31, 2014

October 31, 2014

October 31, 2014

October 31, 2014

PHE NANG (ALVEOLUS)

October 31, 2014

TIEU THUY S CAP (PRIMARY LOBULE)

Tieu thuy s cap la n v chc nang nho

October 31, 2014

CHUM PHE NANG (ACINUS)

Chum phe nang (acinus) bao gom tat ca cac

October 31, 2014

CHUM PHE NANG (ACINUS)

October 31, 2014

TIEU THUY TH CAP MILLER (SECONDARY LOBULE)

ay la n v cau truc nho nhat cua phoi ma

October 31, 2014

TIEU THUY TH CAP MILLER

Truc cua tieu thuy th

October 31, 2014

TIEU THUY TH CAP MILLER

Mi phi c 5000 tiu thu

October 31, 2014

TIEU THUY TH CAP MILLER

Cac tui phe nang

8.Lo Kohn (Pore de Kohn).

TIEU THUY TH CAP MILLER

October 31, 2014

TIEU THUY TH CAP MILLER

October 31, 2014

TIEU THUY TH CAP MILLER

October 31, 2014

TIEU THUY TH CAP MILLER

LAT CAT DAY: THAY C

LAT CAT MONG: THAY C

TIEU THUY TH CAP MILLER

October 31, 2014

TIEU THUY TH CAP MILLER

TON THNG CHUM PHE NANG

TON THNG TOAN TIEU THUY TH

October 31, 2014

CAC DAU HIEU X QUANG

October 31, 2014

1/ Bong m co am o dch,b m nhoe

2/ Cac bong m co khuynh hng hoi tu.

3.Cac bong m co the he thong hoa.

VIEM PHOI THUY TREN (P)

A.J.Chandrasekhar,M.D.Chest X-ray Atlas.

3.Cac bong m co the he thong hoa.

VIEM PHOI PHAN THUY NGOAI THUY GIA (P)

Thu gia phi phi (Lat, F: phn thu bn = phn thu 4;

4.Cac bong m tu tap thanh hnh canh bm

4.Cac bong m tu tap thanh hnh canh bm.

Bat wing, butterfly patternPulmonary edema

Bnh thng cc ph qun trong phi khng thy c

VIEM PHOI (Co air bronchogram)

VIEM PHOI (Co air bronchogram)

October 31, 2014

Air Bronchograms: Alveolar cell carcinoma

Alveolar cell carcinoma

Alveolar cell carcinoma