loculated pleural fluid - Azienda Ospedaliera S.Camillo

RUOLO dell’IMAGING nelle PLEURO‐POLMONITI
BATTERICHE
Stefania Ianniello
UOC Radiologia DEA e Cardioscienze
Az. Osp. San Camillo‐Forlanini
PLEUROPOLMONITI
Il processo inizia alla periferia ed è a base pleurica,
può complicarsi con versamento pleurico
versamento parapneumonico
PLEUROPOLMONITE
PLEUROPOLMONITE da S. PNEUMONIAE più frequente 6 mesi – 5 anni
responsabile anche di otiti e meningiti nei primi mesi di vita
BTS guidelines for the management of pleural infection in children 2005
Stages of pleural infection:
EXUDATIVE 24-48 h
simple parapneumonic effusion
FIBRINOPURULENT 7-10 days
fibrin in the pleural space
septations and loculations
COMPLICATED
PARAPNEUMONIC EFFUSION
PARAPNEUMONIC EFFUSION:
pleural fluid collection in association with
underlying pneumonia
EMPYEMA: pus in the pleural space
overt pus EMPIEMA
spontaneous healing
ORGANIZED 2-4 weeks
thick and non-elastic
pleural membranes (peel)
prevent lung re-expansion
BTS guidelines for the management of pleural infection in children 2005
Hogan 2008
chronic empyema
PEDIATRIC EMPYEMA
US is a central investigation in the management of
pediatric empyema
•
•
•
•
•
portable
easy to perform
non invasive
no ionizing radiation
dynamic assessment of the chest
•
•
differentiation of pleural fluid from consolidation
demonstration of fibrinous septations
within pleural collections
extimation of the effusion size
•
guide to chest drain placement
•
Jaffe Thorax 2008
PLEUROPOLMONITI
When there is a ‘‘white out’’ it is not always
possible to differentiate solid underlying severe
lung collapse / consolidation from a large effusion.
Ultrasound must be used
to confirm the presence
of a pleural fluid collection.
US consente di valutare il versamento, anche minimo
BTS guidelines for the management of pleural infection in children 2005
PLEUROPOLMONITI
US consente di valutare e quantificare il versamento
la struttura anecogena (trasudato)
corpuscolata (essudato)
le sepimentazioni / loculazioni (depositi di fibrina)
i segni di organizzazione
Ultrasound will not predict those patients who will fail with chest
drain and fibrinolytics alone and subsequently require surgery
Ramnath 1998, Donnelly 2005, Durand 2005, Coley 2005, Jaffé 2005
BTS guidelines for the management of pleural infection in children 2005
PLEUROPOLMONITI
Fibrinous septations and organization
are better visualised using US than CT scans.
BTS guidelines for the management of pleural infection in children 2005
PLEUROPOLMONITI e CT
Chest CT scans should not be performed routinely.
CT scanning with CE:
-loculated pleural fluid
-airway abnormalities
(endobronchial obstruction)
-parenchymal abnormalities (lung abscess)
-mediastinal pathology
-failure to aspirate pleural fluid
failing medical management
-immunocompromised children
-surgery planning
BTS guidelines for the management of pleural infection in children 2005
PLEURO-POLMONITE con EVOLUZIONE ASCESSUALE
EMPIEMA PLEURICO SACCATO
CT scanning with CE:
-loculated pleural fluid
-airway abnormalities
-lung abscess
-mediastinal pathology
-failure to aspirate pleural fluid
/ failing medical management
-immunocompromised children
-surgery planning
BTS guidelines for the management of pleural infection in children 2005
Chest CT scans should not be performed routinely.
CT is most valuable in evaluating
the parenchymal disease
CT EVALUATION OF
PULMONARY PARENCHYMAL CHANGES
•
SIMPLE COLLAPSE or CONSOLIDATION: homogeneous opacification
and enhancement with/without air bronchograms or with fluid filled airways
•
PNEUMATOCOELES: tubular or cystic areas of air density with thin or
imperceptible walls with no evidence of necrotizing pneumonia
•
NECROTIZING PNEUMONIA: ill defined areas of poorly enhancing lung
comprising more than half of consolidated lung
•
CAVITARY NECROSIS: necrotizing pneumonia containing irregular areas of
air density
•
PULMONARY ABSCESS: well defined area of intrapulmonary fluid density or
cavity with air fluid level, with thick (>2mm) enhancing wall
Jaffe Thorax 2008
PLEUROPOLMONITI: CT
CONSOLIDATION
homogeneous opacification
with air bronchograms
CT scanning with CE:
-loculated pleural fluid
-airway abnormalities
- parenchymal abnormalities
-mediastinal pathology
-failure to aspirate pleural fluid
failing medical management
-immunocompromised children
Jaffe Thorax 2008
CT is most valuable in evaluating
the parenchymal disease
BTS guidelines for the management of pleural infection in children 2005
Hogan 2008
PLEUROPOLMONITI:CT
CONSOLIDATION
homogeneous opacification
with air bronchograms
-mediastinal adenopathy
Jaffe Thorax 2008
BTS guidelines for the management of pleural infection in children 2005
PLEUROPOLMONITI:CT
NECROTIZING PNEUMONIA
ill defined areas of poorly enhancing lung
(thrombotic occlusion of alveolar capillaries)
BTS guidelines for the management of pleural infection in children 2005
CT is more sensitive than X-ray for
detecting parenchymal disease
Jaffe Thorax 2008
PLEUROPOLMONITI: CT
CT is more sensitive than X-ray
for detecting cavitary necrosis
CAVITARY NECROSIS
necrotizing pneumonia containing irregular
air density areas with air-fluid levels.
The necrotic tissue liquefies and forms fluid filled
cavities, which may fill with air when necrotic fluid
is expectorated via bronchial communications
Prognosis is better than that of adults
Jaffe Thorax 2008
BTS guidelines for the management of pleural infection in children 2005
Hoffer 1999
POLMONITI: COMPLICANZE
VERSAMENTO PLEURICO 36-57%
EMPIEMA 15-20%
essudativo
24-48 h
fibrino-purulento 7-10 g
organizzativo
2-4 sett
POLMONITE NECROTIZZANTE
ASCESSO
Hogan 2008
PNEUMATOCELE
ASCESSO POLMONARE
CT scanning with CE:
-loculated pleural fluid
-airway abnormalities
(endobronchial obstruction)
-parenchymal abnormalities (lung abscess)
-mediastinal pathology
-failure to aspirate pleural fluid
failing medical management
-immunocompromised children
BTS guidelines for the management of pleural infection in children 2005