{"id":5976,"date":"2016-09-08T11:53:32","date_gmt":"2016-09-08T11:53:32","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5976"},"modified":"2016-09-08T11:53:32","modified_gmt":"2016-09-08T11:53:32","slug":"transplantul-pulmonar-bolile-pulmonare-cronice","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/transplantul-pulmonar-bolile-pulmonare-cronice\/","title":{"rendered":"Transplantul pulmonar \u00een bolile pulmonare cronice"},"content":{"rendered":"<p style=\"text-align: justify\">\n<p style=\"text-align: justify\">De c\u00e2nd a fost efectuat cu success pentru prima dat\u0103 \u00een anul 1983 la Toronto, transplantul pulmonar este tot mai r\u0103sp\u00e2ndit \u00een lume \u0219i a devenit un tratament de sine st\u0103t\u0103tor pentru pacien\u021bii a c\u0103ror pl\u0103m\u00e2ni sunt \u00een stare de epuizare sever\u0103 fiind responsabili de o suferin\u0163\u0103 major\u0103 \u00een via\u0163a cotidian\u0103. Multe lucruri s-au descoperit de la \u00eenceputul acestei c\u0103l\u0103torii \u00een cei 30 de ani de istorie, cel mai important pilon fiind testele fiziologiei respiratorii care au devenit tot mai relevante \u0219i fiabile. Testele func\u0163ionale ale respira\u021biei ne permit \u0219i o mai bun\u0103 evaluare a bolii pulmonare de baz\u0103.<\/p>\n<p style=\"text-align: justify\">Actualmente testele respiratorii, precum volumul expirator maxim per secund\u0103 (VEMS), \u0219i capacitatea vital\u0103 for\u021bat\u0103 sunt investiga\u021biile esen\u021biale \u00een evaluarea unui pacient pentru un transplant pulmonar, dar de asemenea \u0219i pentru monitorizarea bunei func\u021bion\u0103ri a allogrefei pulmonare.\u00a0 Dup\u0103 transplant, modific\u0103rile spirometrice sunt cheia \u00een detectarea sindromului de reject cu poten\u021bial vital \u0219i \u00een special al temutului sindrom de bron\u0219iolit\u0103 obliterant\u0103 (BOS). \u00cenc\u0103 se cerceteaz\u0103 noi metode de investiga\u021bie care s\u0103 detecteze mai repede acest BOS. \u00a0Asigurarea unor investiga\u0163ii care s\u0103 ofere sensibilitate \u0219i specificitate mare nu au fost g\u0103site. Acest lucru ram\u00e2ne \u00eenc\u0103 un subiect deschis \u0219i de mare interes pentru cercetare.<\/p>\n<p style=\"text-align: justify\"><span style=\"color: #0000ff\">Evaluarea pacien\u021bilor care necesit\u0103 transplant pulmonar<\/span><\/p>\n<p style=\"text-align: justify\">Primele criterii de unde se porne\u0219te pentru un transplant pulmonar sunt reprezentate de o boal\u0103 pulmonar\u0103 cu tratament maximal, prognoz\u0103\u00a0 de supravie\u021buire de maxim 2 ani \u0219i o calitate a vie\u021bii foarte slab\u0103. M\u0103surarea func\u021biei pulmonare \u0219i mai important stabilirea declinului acesteia sunt folosite pentru a determina momentul optim pentru stabilirea necesit\u0103\u021bii unui transplant, evaluarea, punerea pe lista de a\u0219teptare \u0219i stabilirea priorit\u0103\u021bii \u00een list\u0103. Testele efectuate pentru evaluarea severit\u0103\u021bii bolii de baz\u0103 pot s\u0103 difere \u00eens\u0103 \u0219i \u00een func\u021bie de patologia de baz\u0103 care duce la necesitatea unui transplant pulmonar. Dintre aceste boli cele mai importante sunt fibroza chistic\u0103, fibroza pulmonar\u0103 idiopatic\u0103, hipertensiunea pulmonar\u0103 idiopatic\u0103 \u0219i BPOC. Este de asemenea foarte important s\u0103 se stabileasc\u0103 din timp dimensiunea pl\u0103m\u00e2nilor precum \u0219i compatibilitatea imunologic\u0103. De astfel\u00a0 trebuie cunoscute \u00een\u0103l\u021bimea, grupa sanguin\u0103 \u0219i sensibiliz\u0103rile anterioare. Alegerea momentului optim pentru \u00eenrolarea unui pacient pe lista de a\u0219teptare activ\u0103, \u00een condi\u021biile \u00een care donatorii sunt tot mai pu\u021bini, r\u0103mane problema cea mai mare care trebuie adresat\u0103.<\/p>\n<p style=\"text-align: justify\"><span style=\"color: #0000ff\"><a href=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/trasnplantul-pulmonar.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5979 alignright\" src=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/trasnplantul-pulmonar.jpg\" alt=\"trasnplantul-pulmonar\" width=\"248\" height=\"345\" \/><\/a>Compatibilitatea dimensiunilor pl\u0103m\u00e2nilor donator-receptor<\/span><\/p>\n<p style=\"text-align: justify\"><strong>\u00a0<\/strong>Potrivirea relativ\u0103 a dimensiunii pl\u0103m\u00e2nilor dintre donator \u0219i receptor este foarte important\u0103 at\u00e2t pentru perioada imediat\u0103 de dup\u0103 transplantul pulmonar, c\u00e2t \u0219i mai t\u00e2rziu. Dimensionarea se realizeaz\u0103 prin m\u0103sur\u0103tori pe radiografii, \u00een\u0103l\u021bimea indivizilor \u0219i capacitatea pulmonar\u0103 total\u0103 (CPT), ultima a \u00eembun\u0103t\u0103\u021bit compatibilitatea dar a ajutat \u00een decizia unui transplant pulmonar total sau doar lobar. Subdimensionarea pl\u0103m\u00e2nilor poate duce la \u201c\u00eentindere\u201d vascular\u0103 dup\u0103 ce pl\u0103m\u00e2nul se supradestinde pentru a umple spa\u021biul r\u0103mas rezult\u00e2nd edem pulmonar, drenaj pleural trenant sau chiar restric\u021bie pulmonar\u0103 pe termen lung. De cealalt\u0103 parte \u00eens\u0103 supradimensionarea pl\u0103m\u00e2nilor poate duce la dificult\u0103\u021bi \u00een \u00eenchiderea toracelui\u00a0 sau complica\u021bii postoperatorii precum atelectazia sau compresiunea c\u0103ilor aeriene. Cu toate acestea, s-ar p\u0103rea c\u0103 supradimensionarea poate avea \u0219i anumite beneficii precum flux aerian peste normal \u0219i aparent este asociat cu o mai bun\u0103 supravie\u021buire pe termen lung.<\/p>\n<p style=\"text-align: justify\">De la \u00eenceputul transplantului pulmonar se cunosc mai multe entit\u0103\u021bi de allo-reject, \u00eens\u0103 \u00een ultimii ani aceste a\u0219a-numite \u201dsindroame\u201d sunt tot mai bine conturate, fiecare av\u00e2nd simptomatologie \u0219i modific\u0103ri distincte de fiziologie a respira\u021biei.<\/p>\n<p style=\"text-align: justify\"><strong>\u00a0<em>Rejectul acut de allogref\u0103<\/em><\/strong><\/p>\n<p style=\"text-align: justify\">Rejectul celular acut de pl\u0103m\u00e2n presupune inflama\u021bia vaselor de s\u00e2nge din allogref\u0103. Este asociat\u0103 cu disfunc\u021bie de parenchim menifestat\u0103 prin deteriorare spirometric\u0103 acut\u0103, transfer gazos sc\u0103zut \u0219i sc\u0103derea toleran\u021bei la efort. O sc\u0103dere cu &gt;10% a VEMS-ului cre\u0219te riscul de a dezvolta rejectul cronic. Cu tratamentele imunosupresoare de ultim\u0103 genera\u021bie \u00eens\u0103 rejectul acut este tot mai rar \u00eent\u00e2lnit, iar pacien\u021bii sunt sf\u0103tui\u021bi s\u0103 \u00ee\u021bi efectueze spirometrii la domiciliu pentru identificarea eventualelor modific\u0103ri.<\/p>\n<p style=\"text-align: justify\"><strong><em>Rejectul cronic sau Sindromul de Bron\u0219iolit\u0103 Obliterant\u0103<\/em><\/strong><\/p>\n<p style=\"text-align: justify\">BOS este definit ca o disfunc\u021bie ventilatorie obstructiv\u0103 ireversibil\u0103 f\u0103r\u0103 o cauz\u0103 evident\u0103. Evolu\u021bia \u0219i progresul acestui sindrom pot \u00eembr\u0103ca multe forme de la agravare acut\u0103 a func\u021biei pulmonare p\u00e2n\u0103 la una cu evolu\u021bie lent\u0103 a disfunc\u021biei ventilatorii cu pierdere intermitent\u0103 a acesteia \u0219i perioade lungi \u00een platou de stabilitate func\u021bional\u0103.\u00a0 Din p\u0103cate, din momentul instal\u0103rii BOS supravie\u021buirea la 3 ani scade p\u00e2n\u0103 la 50%. Clasificarea se face pe baza VEMS pierdut fa\u021b\u0103 de valoarea de referin\u021b\u0103 (2 cele mai bune valori postoperatorii la distan\u021b\u0103 de cel pu\u021bin 3 s\u0103pt\u0103m\u00e2ni), valori reprezentate \u00een tabelul I.<\/p>\n<p style=\"text-align: justify\">\n<p style=\"text-align: justify\">Tabelul I<\/p>\n<table width=\"331\">\n<tbody>\n<tr>\n<td width=\"127\">BOS 0<\/td>\n<td width=\"204\">VEMS &gt; 90% \u0219i<\/p>\n<table>\n<tbody>\n<tr>\n<td width=\"254\">\n<table width=\"100%\">\n<tbody>\n<tr>\n<td>Fa\u021b\u0103 de valoarea<\/p>\n<p>de referin\u021b\u0103<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>FEF<sub>25-72 <\/sub>&gt;75<\/td>\n<\/tr>\n<tr>\n<td width=\"127\">BOS 0p<\/td>\n<td width=\"204\">VEMS 81-90% sau\/\u0219i<\/p>\n<p>FEF<sub>25-72 <\/sub>&lt;= 75%<\/td>\n<\/tr>\n<tr>\n<td width=\"127\">BOS I<\/td>\n<td width=\"204\">VEMS 66-80%<\/td>\n<\/tr>\n<tr>\n<td width=\"127\">BOS II<\/td>\n<td width=\"204\">VEMS 51-65%<\/td>\n<\/tr>\n<tr>\n<td width=\"127\">BOS III<\/td>\n<td width=\"204\">VEMS &lt; 50%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify\"><span style=\"color: #ff0000\">Concluzii<\/span><\/p>\n<ul>\n<li style=\"text-align: justify\">\u00a0De\u0219i transplantul pulmonar este un tratament acceptat pentru pacien\u021bii afla\u021bi \u00een stadiu terminal al unei boli pulmonare cronice, r\u0103m\u00e2ne tosu\u0219i o procedur\u0103 chirurgical\u0103 extrem de complex\u0103, care implic\u0103 morbiditate \u0219i mortalitate semnificativ\u0103. Pl\u0103m\u00e2nii transplanta\u021bi sus\u021bin via\u021ba imediat dup\u0103 opera\u021bie, \u00eens\u0103 abia dup\u0103 mai multe luni ajung la capacitate maxim\u0103.<\/li>\n<li style=\"text-align: justify\">\u00a0Cu toate c\u0103 func\u021bia pulmonar\u0103 se men\u021bine stabil\u0103 \u00een timp, mai mult de 50% din pacien\u021bi dezvolt\u0103 o form\u0103 de reject de organ \u00een primii 5 ani.<\/li>\n<li style=\"text-align: justify\">\u00a0Spirometria r\u0103m\u00e2ne un pilon central, ieftin, repetabil \u0219i u\u0219or de efectuat pentru evaluarea pacien\u021bilor cu transplant pulmonar pentru detectarea din timp a disfunc\u021biei de allogref\u0103.<\/li>\n<\/ul>\n<figure id=\"attachment_5978\" aria-describedby=\"caption-attachment-5978\" style=\"width: 184px\" class=\"wp-caption alignleft\"><a href=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/poza-autor.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5978 \" src=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/poza-autor-204x300.jpg\" alt=\"Prof. Dr. Monica POP, medic primar penumologie, \u0218ef Clinic\u0103, Clinica de Pneumologie Leon Danielo Cluj-Napoca\" width=\"184\" height=\"271\" srcset=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/poza-autor-204x300.jpg 204w, https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2016\/09\/poza-autor.jpg 301w\" sizes=\"auto, (max-width: 184px) 100vw, 184px\" \/><\/a><figcaption id=\"caption-attachment-5978\" class=\"wp-caption-text\"><em>Prof. Dr. Monica POP, medic primar penumologie, \u0218ef Clinic\u0103, Clinica de Pneumologie Leon Danielo Cluj-Napoca<\/em><\/figcaption><\/figure>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>De c\u00e2nd a fost efectuat cu success pentru prima dat\u0103 \u00een anul 1983 la Toronto, transplantul pulmonar este tot mai r\u0103sp\u00e2ndit \u00een lume \u0219i a devenit un tratament de sine [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":5981,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[564],"tags":[],"class_list":["post-5976","post","type-post","status-publish","format-standard","has-post-thumbnail","category-pneumologie"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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