胸腔积液诊断与治疗ppt课件

DiagnosisandManagementofPleuralEffusions 1 DiagnosisofPleuralEffusions 2 3 ChestRadiograph PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules 4 1 PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChest infectionstuberculousandviralpleurisymalignancycancer non Hodgkin slymphoma andleukemiapulmonaryembolismdrug inducedlungdisease benignasbestospleuraleffusion BAPE lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism 5 2 BilateralEffusions transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditis exudativeeffusionsmalignancy extrapulmonicprimarycarcinomas lymphoma lupuspleuritisyellownailsyndrome 6 3 DiseasesBelowtheDiaphragm transudateshepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysis exudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction 7 4 InterstitialLungDisease congestiveheartfailurerheumatoidarthritisasbestos induceddisease BAPEandasbestosis lymphangiticcarcinomatosis LymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenstr m smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia 8 5 PulmonaryNodules mostcommoncausesmetastaticcarcinomafromanonlungprimarytumor LesscommoncausesWegener sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia 9 ValueofPleuralFluidAnalysis Inaprospectivestudyof78patientswithnew onsetpleuraleffusion adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25 apresumptivediagnosisin55 withtheremaining20 havinganondiagnosticpleuralfluidanalysis excludingpossiblediagnoses 10 ValueofPleuralFluidAnalysis theinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80 ofpatientsandisvaluableclinicallyinabout90 ofcases 11 Diagnosesthatcanbedefinitively empyema pus malignancytuberculousfungallupuspleuritis lupuserythematosuscells chylothorax triglycerides 110mg dLorpresenceofchylomicrons hemothorax pleuralfluid bloodhematocrit 0 5 urinothorax pleuralfluid serumcreatinine 1 0 peritonealdialysis totalprotein 0 5g dlandglucose200to400mg dL esophagealrupture increasedsalivaryamylaseandpH 7 00 rheumatoidpleurisy pleuralfluidcytology extravascularmigrationofacentralvenouscatheter highglucoselevelorpleuralfluidsimulatingtheinfusate 12 ExudatesVsTransudates 1 exudativepleuralfluidprotein serumprotein 0 5pleuralfluidLDH serumLDH 0 6pleuralfluidLDHmorethantwo thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative 13 ExudatesVsTransudates 2 pleuralfluidLDHsuggestsanexudateandthepleuralfluid serumproteinratiosuggestsatransudate malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered Itisimportanttorememberthatnolaboratorytestis100 sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis 14 PleuralFluidNucleatedCellCount 1 rarelyhelpfulinestablishingadefinitivediagnosis however itmayprovideusefulinformation 50 000 mL itusuallyrepresentspleuralspacebacterialinfection typicallyempyema between25 000and50 000 mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions acutepancreatitisandacutepulmonaryinfarction 15 PleuralFluidNucleatedCellCount 2 exudatepleuralfluidwithalymphocytecountof 80 ofthetotalnucleatedcellsincludestuberculouspleurisy chylothorax lymphoma yellownailsyndrome chronicrheumatoidpleurisy sarcoidosis trappedlung andacutelungrejection 16 eosinophilia 10 ofthetotalnucleatedcellsareeosinophils mostcommonlypneumothoraxandhemothorax BAPE pulmonaryembolismwithinfarction previousthoracentesis parasiticdisease paragonimiasis fungaldisease drug inducedlungdisease Hodgkin slymphoma carcinoma Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions 17 PleuralFluidpHandGlucose 1 pleuralfluidpH 7 30 normalbloodpH exudativeeffusionempyema complicatedparapneumoniceffusion chronicrheumatoidpleurisy esophagealrupture malignancy tuberculouspleurisy andlupuspleuritis 18 PleuralFluidpHandGlucose 2 fluidglucose 60mg dLorpleuralfluid serumglucose 0 5 exudate lowpleuralfluidpH Urinothorax mostcommonlycausedbyobstructiveuropathy istheonlycauseofalowpHtransudate Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresentwithglucoseconcentrationsof0mg dL 19 PleuralFluidpHandGlucose 3 ApleuralfluidpH1 000U L upperlimitofnormalofserum200IU L 20 漏出液渗出液鉴别 21 漏出液渗出液鉴别 22 胸腔积液的诊断程序 胸腔积液 都不符合 漏出液 诊断性胸腔穿刺测胸水蛋白及LDH 符合1条及以上 渗出液 治疗原发病 心衰 肾病等 1胸水 血清蛋白 0 52胸水 血清LDH 0 63胸水LDH 血清LDH 2 3血清LDH 查体 胸片 CT B超等 进一步检查 23 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 60mg dl恶性胸水细菌感染类风湿性 淀粉酶升高食管破裂胰腺炎性恶性胸水 不能诊断 24 考虑肺栓塞 CT 灌注扫描检查 否 治疗肺栓塞 否 结核标志物 抗结核治疗 症状是否改善 考虑行胸腔镜检查或开胸胸膜活检 观察 是 是 CommonDiseasesAssociatedWithPleuralEffusions 25 CongestiveHeartFailure 26 27 CongestiveHeartFailure 1 history orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure usualchestradiograph cardiomegaly bilateralpleuraleffusions rightgreaterthanleft andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing interstitialoralveolarinfiltrates orKerley Blines 28 CongestiveHeartFailure 2 diagnosticthoracentesisfever pleuriticchestpain aunilateraleffusion alefteffusiongreaterthentherighteffusion effusionsofdisparatesize andaPaO2inconsistentwiththeclinicalpresentation 29 CongestiveHeartFailure 2 diagnosticthoracentesisthetypicalpresentation thoracentesiscanbewithheldwhileobservingtheresponsetotreatment Ifresponseisnotappropriate diagnosticthoracentesisshouldbeperformed Acutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudate MalignantPleuralEffusions 30 31 MalignantPleuralEffusions 1 Dyspneaisthemostcommonpresentingsymptom followedbycough Ofpatientspresentingwithamassivepleuraleffusion approximatelytwothirdswillhavemalignancy Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion theeffusionisusuallycausedbyacarcinomathatisnotalungprimary 32 MalignantPleuralEffusions 2 Whenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift lungcanceristhemostlikelycause usuallysquamouscellcarcinomainvolvingthemainstembronchus otherdiagnoses afixedmediastinumfrommalignantlymphnodes malignantmesothelioma andparenchymaltumorinvasion 33 MalignantPleuralEffusions 3 Bilateraleffusionswithanormalheartsizemalignancy 50 Theother50 transudativeeffusions hepatichydrothorax nephroticsyndrome severehypoalbuminemia andconstrictivepericarditis exudates lupuspleuritis esophagealrupture andtuberculouspleurisy rareexceptinHIV positivepatients 34 MalignantPleuralEffusions 4 Lungandbreast themostcommoncauses about65 ofcases Ovarianandgastriccancer thetwonextmostcommoncarcinomas 6to10 ofcases Lymphoma about10 ofcases Lessthan10 ofmalignanteffusionshaveanunknownprimarytumoratthetimeofdiagnosis 35 MalignantPleuralEffusions 5 Malignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease particularlycongestiveheartfailure butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion 36 MalignantPleuralEffusions 6 ThepleuralfluidglucoseandthepHarelowinabout30 ofpatientsThelowglucoseisgenerallyintherangeof30to50mg dLandthepHintherangeof7 05to7 29 10and14 ofpatientsareamylase richsalivaryoriginThepleuralfluid to serumratioofamylaseinmalignancyisintherangeof5 1 muchlowerthaninpancreaticdisease 37 MalignantPleuralEffusions 7 FindingalowpleuralfluidpH 7 30 38 MalignantPleuralEffusions 8 However ameta analysisofmorethan400patientswithmalignanteffusionsdemonstratedthat evenwhenthepHwasintherangeof6 70to7 26 46 ofthepatientswerestillaliveat3monthsfromthetimeofinitialpleuralfluidanalysis Furthermore 65 ofpatientsinthelowestquartileofpH 6 70to7 26 hadsuccessfulpleurodesis comparedwith88 ofpatientswhohadapHof 7 27 39 MalignantPleuralEffusions 9 CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof 7 30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis Furthermore tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid preventingcollagendeposition 40 MalignantPleuralEffusions 10 Adenocarcinomaofthelungisthemostcommonmalignancycausinganamylase richpleuraleffusion followedbyadenocarcinomaoftheovary Thesetumorsproduceanectopicsalivary likeisoamylase Asalivary richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant 41 结核性与肿瘤性胸水的鉴别 42 结核性与肿瘤性胸水的鉴别 ParapneumonicEffusions Pathophysiology Diagnosis andManagement 43 44 IncidenceandDefinitions 1millionpersonsintheUnitedStatesdevelopingparapneumoniceffusionsyearly Parapneumoniceffusions pleuralfluidsassociatedwithpneumonia aremostoftenfree flowingeffusionsthatresolvespontaneouslywithantibiotictherapydirectedatthepneumonia uncomplicatedeffusions Pleuralfluidsthatrequiredrainageofthepleuralspaceforresolutionofthefebrileresponsehavebeentermed complicated effusions Empyema theendstageofacomplicatedparapneumoniceffusion empyemathoracis 45 Pathophysiology 1 asterile PMN predominantexudatepHis 7 30 theglucoseis 60mg dL andthelactatedehydrogenase LDH is 500U L canbetreatedsuccessfullywithantibioticswithouttheneedforpleuralspacedrainagebacterialinvasion fibrinopurulentstagefindingapositiveGram sstainandculturesignifiesbacterialpersistencecharacterizedbyanincreasednumberofPMNs afallinpleuralfluidpHandglucose andanincreaseinpleuralfluidLDH antibioticsalonemaybeeffective butlater pleuralspacedrainageisusuallyrequired 46 Pathophysiology 2 organizational empyemastageasinglecavityormultipleloculationsUntreatedempyemararelyresolvesspontaneouslyempyemaalwaysrequiredrainageforresolutionofpleuralsepsisTherationaleforeffectivemanagementistoidentifythepathophysiologicstageandintervenetimelyandappropriatelytopreventprogressiontoempyema 47 Diagnosis 1 Unfortunately differentiatinghigh fromlow riskpatientsclinicallyisproblematic asthereisnodifferenceatpresentationinage peripheralleukocytecount peaktemperature incidenceofpleuriticchestpain orextentofpneumonia 48 Diagnosis 2 Pleuralfluidanalysisisarelativelyinexpensiveandusefuldiagnostictesttoidentifythestageofaparapneumoniceffusionandtoguidetherapy ApositiveGram sstain eveninnonpurulentfluid impliesanadvancedstageofdiseaseandsuggeststheneedforimmediatedrainageThepleuralfluidproteinconcentration nucleatedcellcount orpercentageofPMNscannotdifferentiateacomplicatedfromuncomplicatedeffusion 49 Diagnosis 3 pH1 000U LindicatedacomplicatedparapneumoniceffusionthatrequireddrainagepHof 7 30onadmissionvirtuallyalwayspredictedagoodoutcomewithappropriateantibiotictreatmentonly pHof 7 10predictedthatpleuralspacedrainagewasnecessarytoresolvepleuralsepsispHbetween7 30and7 10atadmissionhadeithercomplicatedoruncomplicatedeffusions thesepatientsrequirecarefulclinicalmonitoringwithfurtherdiagnostictesting repeatthoracentesis contrastCTscan beforeaninformedmanagementdecisionismade 50 Diagnosis 4 Arecentmeta analysisfoundpleuralfluidpHtohavethehighestdiagnosticaccuracyinidentifyingcomplicatedparapneumoniceffusions PleuralfluidpHdecisionthresholdsvariedbetween7 21and7 29dependingoncost prevalenceconsiderationsCurrentdatasupporttreatmentwithantibioticsandobservationinpatientswithpHvaluesbetween7 21and7 29 Clinicalparameters repeatpleuralfluidanalysis andcontrastchestCTshoulddeterminemanagement 51 Management 1 AntibioticsThereislittledifferenceinpenetrationofthepenicillinsandcephalosporinsintoempyemasanduninfectedparapneumonicfluids Drugsthatshowexcellentpleuralpenetrationincludeaztreonam clindamycin ciprofloxacin cephalothin andpenicillinAminoglycosidesmaybeinactivatedorhavepoorerpenetrationintoempyemasthanuncomplicatedparapneumoniceffusions oralclindamycinorpenicillinshouldbecontinuedforthedurationoftreatmentonceparenteralantibioticsarediscontinued afewweeks 52 Management 2 ChestTubesImage guidedPercutaneousCathetersIntrapleuralFibrinolyticsThoracoscopyEmpyemectomy DecorticationandOpenDrainage