呼吸病培训班课件：胸腔积液

胸腔积液胸膜腔的解剖 圆锥状 第一肋上2-3cm，锁骨内1/3，胸锁乳突肌后 下颈部外伤，上腔静脉导管，淋巴结活检 40um,5层正常生理液体和细胞成分0.26mL/kg白细胞1000-2500mL，巨噬细胞单核细胞和 淋巴细胞是主要成分胸膜灌洗安全，并非所 有胸膜疾病都有胸腔积液发生机制正常病理生理Intrapleural pressure is lower than the interstitial pressure of either of the pleural tissues.This pressure difference constitutes a gradient for liquid movement into,but not out of,the pleural space.The pleural membranes are leaky to liquid and protein and provide little resistance to protein movement.The entry of pleural fluid is normally slow and is compatible with known interstitial flow rates,about 0.5 mL hourly in a grown person.Most liquid exits the pleural space by bulk flow,not by diffusion.This is evident because the protein concentration of pleural effusions does not change as the effusion is absorbed.The major exit of liquid and protein is via the parietal pleural stomata(412 m diameter)and the pleural lymphatics.These lymphatics have a large capacity for absorption increasing up to 30 times the baseline exit rate and thereby resist effusion formation.疾病状态病理生理Most effusions develop from both an increase in the entry rate of liquid into the pleural space and a decrease in the maximal exit rate of liquid from the pleural space.Lymphatic function can be altered by inflammation,infection,fibrosis,or malignancy.A resulting decrease in exit rate can remain clinically silent until it becomes less than the entry rate or until the entry rate increases due to another condition,thereby leading to an effusion.Over time,the lymphatic clearance rate may be able to increase,for example,by increases in stomata number or size or by increases in lymphatic contractility.Nonetheless,lymphatic capacity constitutes a finite limit in the ability of the pleural space to remove liquid.Excess interstitial fluid from other parts of the body can travel toward and accumulate in the pleural space due to its subatmospheric pressure,leaky borders,and high capacitance.胸腔积液的最初评估胸腔积液的特别评估有诊断意义的评估Pleural TB Pleural TB is the second most common form of extra-pulmonary TB.In TB endemic countries,pleural TB is one of the most common causes of unilateral pleural effusions.The number of TB bacilli in the pleural fluid in TB pleuritis is typically very low.Symptoms are heterogeneous and do not differentiate TB pleuritis from other illnesses.Pleural effusions due to TB are usually unilateral associated with some parenchymal abnormalities.The pleural fluid analysis typically is lymphocyte predominant with low mesothelial cells and is exudative with elevated total protein,elevated LDH,and low glucose.The sensitivity of nucleic acid amplification testing on the pleural fluid is also limited.Adenosine deaminase and unstimulated interferon-gamma are useful biomarkers for the evaluation of pleural TB with good sensitivity although somewhat limited specificity.The gold standard for the diagnosis of pleural TB is a pleural biopsy with tissue AFB smear,AFB culture,and pathology examination to evaluate for caseating granulomas.Antimicrobial treatment for pleural TB is the same standard regimen as recommended for pulmonary TB.Unless a TB empyema is present,surgical drainage of a TB pleural effusion is not needed.肺炎旁胸腔积液恶性胸腔积液病理学是金标准25%无症状CT或PET-CT确诊渗出液，少数漏出液，淋巴细胞为主闭式胸膜活检术，B超或CT引导下内科胸腔镜检查术：诊断和胸膜固定5%恶性肿瘤患者胸腔积液为肿瘤旁PE肋间置管引流及胸膜固定术 10-14F，滑石粉2.5g10g，博来霉素 肺完全复张且引流量150ml/d参考文献 施焕中，张予辉.2014年恶性胸腔积液诊断与治疗专家共识解读 陈闽江，柳涛，蔡柏蔷.2010年英国胸科协会胸腔疾病指南：成人胸腔感染的诊治简介.国际呼吸杂志,2011,31(12):881-886.The text of pleural diseases.Third Edition.