胸腔积液诊断与治疗

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,DiagnosisandManagementofPleuralEffusions,呼吸内科：徐作军,2002,，,4,，,PUMC,1,Diagnosis of Pleural Effusions,2,Chest Radiograph,Pleural Fluid as the Only Abnormality With Primary Disease in the Chest,Bilateral Effusions,Diseases Below the Diaphragm,Interstitial Lung Disease,Pulmonary Nodules,3,1. Pleural Fluid as the Only Abnormality With Primary Disease in the Chest,infections,tuberculous and viral pleurisy,malignancy,cancer, non-Hodgkins lymphoma, and leukemia,pulmonary embolism,drug-induced lung disease,benign asbestos pleural effusion (BAPE),lymphatic abnormalities,chylothorax and yellow nail syndrome,uremic pleurisy,constrictive pericarditis,hypothyroidism,4,2.Bilateral Effusions,transudative effusions,congestive heart failure,nephrotic syndrome,hypoalbuminemia,peritoneal dialysis,constrictive pericarditis,exudative effusions,malignancy (extrapulmonic primary carcinomas, lymphoma),lupus pleuritis,yellow nail syndrome,5,3.Diseases Below the Diaphragm,transudates,hepatic hydrothorax,nephrotic syndrome,urinothorax,peritoneal dialysis,exudates,pancreatic disease,chylous ascites,subphrenic abscess,splenic abscess or infarction,6,4.Interstitial Lung Disease,congestive heart failure,rheumatoid arthritis,asbestos-induced disease (BAPE and asbestosis),lymphangitic carcinomatosis,Lymphangioleiomyomatosis,viral and mycoplasma pneumonias,Waldenstrms macroglobulinemia,sarcoidosis,Pneumocystis carinii pneumonia,7,5.Pulmonary Nodules,most common causes,metastatic carcinoma from a nonlung primary tumor.,Less common causes,Wegeners ranulomatosis,rheumatoid arthritis,septic emboli,sarcoidosis,tularemia,8,Value of Pleural Fluid Analysis,In a prospective study of 78 patients with new-onset pleural effusion,a definitive diagnosis was established by the initial pleural fluid analysis in 25% ,a presumptive diagnosis in 55%,with the remaining 20% having a nondiagnostic pleural fluid analysis. (excluding possible diagnoses),9,Value of Pleural Fluid Analysis,the initial pleural fluid analysis is either definitively or presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of cases.,10,Diagnoses that can be definitively,empyema (pus),malignancy,tuberculous,fungal,lupus pleuritis (lupus erythematosus cells),chylothorax (triglycerides 110 mg/dL or presence of chylomicrons),hemothorax (pleural fluid/blood hematocrit 0.5),urinothorax (pleural fluid/serum creatinine 1.0),peritoneal dialysis (total protein 0.5 g/dl and glucose 200 to 400 mg/dL),esophageal rupture (increased salivary amylase and pH ,0.5,pleural fluid LDH/serum LDH,0.6,pleural fluid LDH more than two-thirds normal upper limit for serum,any one of the above values makes it highly likely that the effusion is exudative.,12,Exudates Vs Transudates(2),pleural fluid LDH suggests an exudate and the pleural fluid/serum protein ratio suggests a transudate, malignancy or an effusion secondary to Pneumocystis carinii pneumonia should be considered.,It is important to remember that no laboratory test is 100% sensitive and specific and prethoracentesis diagnosis and clinical judgment must be used in the interpretation of pleural fluid analysis.,13,Pleural Fluid NucleatedCell Count(1),rarely helpful,in establishing a definitive diagnosis. however, it may provide useful information., 50,000/mL, it usually represents pleural space bacterial infection (typically empyema).,between 25,000 and 50,000/mL are usually seen only with uncomplicated parapneumonic effusions, acute pancreatitis and acute pulmonary infarction.,14,Pleural Fluid NucleatedCell Count(2),exudate,pleural fluid with,a lymphocyte count of 80%,of the total nucleated cells includes,tuberculous pleurisy, chylothorax, lymphoma, yellow nail syndrome, chronic rheumatoid pleurisy, sarcoidosis, trapped lung, and acute lung rejection.,15,eosinophilia,( 10% of the total nucleated cells are eosinophils),most commonly,pneumothorax and hemothorax,BAPE, pulmonary embolism with infarction, previous thoracentesis, parasitic disease (paragonimiasis), fungal disease, drug-induced lung disease , Hodgkins lymphoma, carcinoma.,The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.,16,Pleural Fluid pH and Glucose(1),pleural fluid pH 7.30, normal blood pH, exudative effusion,empyema, complicated parapneumonic effusion, chronic rheumatoid pleurisy, esophageal rupture, malignancy, tuberculous pleurisy, and lupus pleuritis,17,Pleural Fluid pH and Glucose(2),fluid glucose 60 mg/dL or pleural fluid/serum glucose 0.5 , exudate , low pleural fluid pH.,Urinothorax, most commonly caused by obstructive uropathy, is the only cause of a low pH transudate.,Empyema and rheumatoid pleurisy are the only effusions that can present,with glucose concentrations of 0 mg/dL,18,Pleural Fluid pH and Glucose(3),A pleural fluid pH 600mg/L,葡萄糖,30g/L,胸液血清,0.5,30g/L,胸液血清,1.018,50%,1000/ml,200IU/L,胸液血清,0.6,200IU/L,胸液血清,0.6,LDH,7.4,PH,多变,0.5,2,胸水,/,血清,LDH0.6,3,胸水,LDH,血清,LDH,2/3血清LDH,查体、胸片、,CT,、,B超等,进一步检查,22,胸腔积液的诊断程序,渗出液,测胸水淀粉,酶、Glu 、细胞学、细胞分类、培养、染色检查、结核标志物检查,Glu 7.27,38,Malignant Pleural Effusions(9),Cytologic examination and pleural biopsy,is high in malignant effusions with a pH of 7.30,Pleurodesis tends to be unsuccessful when the pH is low,because the lung may be trapped by tumor or fibrosis or because the tumor burden prevents the chemical agent from initiating mesothelial cell injury that initiates the inflammatory cascade that leads to fibrosis. Furthermore, tumor and fibrosis on the pleural surface may block submesothelial fibroblast migration into the coagulable pleural fluid, preventing collagen deposition.,39,Malignant Pleural Effusions(10),Adenocarcinoma of the lung is the most common malignancy causing an amylase-rich pleural effusion, followed by adenocarcinoma of the ovary. These tumors produce an ectopic salivary-like isoamylase.,A salivary-rich amylase effusion occurring in the absence of esophageal perforation has a high likelihood of being malignant.,40,结核性与肿瘤性胸水的鉴别,65ug/ml,65ug/ml,1,溶菌酶活力,胸水血液,LDH2,增高,LDH4,、,5,增高,LDH,同工酶,多,7.40,多,7.30,PH,大量间皮细胞,淋巴细胞为主,细胞类型,多为大量,生长快,多为中、少量,胸液量,（）,（）,PPD,试验,中、老年多见,青、少年多见,年龄,肿瘤性,结核性,41,结核性与肿瘤性胸水的鉴别,效果不佳,反应较好,抗,TB,治疗,肿瘤组织,结核肉芽肿,胸膜活检,1g/L,类粘蛋白,700ng/ml,20ug/L,1,20ug/L,1,CEA,胸水血液,45u/L,45u/L,1,腺苷脱氨酶,胸水血液,肿瘤性,结核性,42,Parapneumonic Effusions: Pathophysiology, Diagnosis, and Management,43,Incidence and Definitions,1 million persons in the United States developing parapneumonic effusions yearly.,Parapneumonic effusions (pleural fluids associated with pneumonia) are most often free-flowing effusions that resolve spontaneously with antibiotic therapy directed at the pneumonia(,uncomplicated effusions,.),Pleural fluids that require drainage of the pleural space for resolution of the febrile response have been termed,complicated effusions,.,Empyema,: the end stage of a complicated parapneumonic effusion (empyema thoracis).,44,Pathophysiology,（,1,）,a sterile, PMN-predominant exudate,pH is 7.30, the glucose is 60 mg/dL, and the lactate dehydrogenase (LDH) is 7.30,on admission virtually always predicted a good outcome with appropriate antibiotic treatment only.,pH of 7.10,predicted that pleural space drainage was necessary to resolve pleural sepsis,pH between 7.30 and 7.10,at admission had either complicated or uncomplicated effusions; these patients require careful clinical monitoring with further diagnostic testing (repeat thoracentesis, contrast CT scan) before an informed management decision is made.,49,Diagnosis(4),A recent meta-analysis found pleural fluid pH to have the highest diagnostic accuracy in identifying complicated parapneumonic effusions. Pleural fluid pH decision thresholds varied between 7.21 and 7.29 depending on cost-prevalence considerations,Current data support treatment with antibiotics and observation in patients with pH values between 7.21 and 7.29. Clinical parameters, repeat pleural fluid analysis, and contrast chest CT should determine management.,50,Management(1),Antibiotics,There is little difference in penetration of the penicillins and cephalosporins into empyemas and uninfected parapneumonic fluids. Drugs that show excellent pleural penetration include aztreonam, clindamycin, ciprofloxacin, cephalothin, and penicillin,Aminoglycosides may be inactivated or have poorer penetration into empyemas than uncomplicated parapneumonic effusions.,oral clindamycin or penicillin should be continued for the duration of treatment once parenteral antibiotics are discontinued. (a few weeks ),51,Management(2),Chest Tubes,Image-guided Percutaneous Catheters,Intrapleural Fibrinolytics,Thoracoscopy,Empyemectomy/Decortication and Open Drainage,52,