1、胸腔積液診斷與治療1Diagnosis and Management of Pleural Effusions呼吸內(nèi)科：徐作軍呼吸內(nèi)科：徐作軍2002，4，PUMC胸腔積液診斷與治療2Diagnosis of Pleural Effusions胸腔積液診斷與治療3Chest RadiographPleural Fluid as the Only Abnormality With Primary Disease in the ChestBilateral EffusionsDiseases Below the DiaphragmInterstitial Lung DiseasePulmonary

2、 Nodules胸腔積液診斷與治療41. 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 c

3、hylothorax and yellow nail syndrome uremic pleurisy constrictive pericarditis hypothyroidism胸腔積液診斷與治療52.Bilateral Effusions transudative effusions congestive heart failure nephrotic syndrome hypoalbuminemia peritoneal dialysis constrictive pericarditis exudative effusions malignancy (extrapulmonic p

4、rimary carcinomas, lymphoma) lupus pleuritis yellow nail syndrome胸腔積液診斷與治療63.Diseases Below the Diaphragm transudates hepatic hydrothorax nephrotic syndrome urinothorax peritoneal dialysis exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction胸腔積液診斷與治療74.Interst

5、itial 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胸腔積液診斷與治療85.Pulmonary Nodules m

6、ost common causes metastatic carcinoma from a nonlung primary tumor. Less common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia胸腔積液診斷與治療9Value of Pleural Fluid Analysis In a prospective study of 78 patients with new-onset pleural effusion, a definitive diagnos

7、is 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)胸腔積液診斷與治療10Value of Pleural Fluid Analysis the initial pleural fluid analysis is either definitively o

8、r presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of cases.胸腔積液診斷與治療11Diagnoses that can be definitively empyema (pus) malignancy tuberculous fungal lupus pleuritis (lupus erythematosus cells) chylothorax (triglycerides 110 mg/dL or presence of chylomicrons) hemot

9、horax (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 0.5pleural fluid LDH/serum LDH 0.6pleural fluid LDH more than two-thirds normal

10、upper limit for serumany one of the above values makes it highly likely that the effusion is exudative. 胸腔積液診斷與治療13Exudates 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 car

11、inii pneumonia should be considered. It is important to remember that no laboratory test i s 1 0 0 % s e n s i t i v e a n d s p e c i f i c a n d prethoracentesis diagnosis and clinical judgment must be used in the interpretation of pleural fluid analysis.胸腔積液診斷與治療14Pleural Fluid NucleatedCell Coun

12、t(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 pancrea

13、titis and acute pulmonary infarction.胸腔積液診斷與治療15Pleural 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, a

14、nd acute lung rejection.胸腔積液診斷與治療16 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 l

15、ymphoma, carcinoma. The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.胸腔積液診斷與治療17Pleural Fluid pH and Glucose(1) pleural fluid pH 7.30, normal blood pH, exudative effusion empyema, complicated parapneumonic effusion, chronic rheumatoid pl

16、eurisy, esophageal rupture, malignancy, tuberculous pleurisy, and lupus pleuritis胸腔積液診斷與治療18Pleural 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 lo

17、w pH transudate. Empyema and rheumatoid pleurisy are the only effusions that can present with glucose concentrations of 0 mg/dL胸腔積液診斷與治療19Pleural Fluid pH and Glucose(3) A pleural fluid pH 7.00 is usually seen only with empyema, whether it be parapneumonic or associated with esophageal rupture. Comp

18、licated parapneumonic effusion/empyema, rheumatoid pleurisy, and pleural paragonimiasis are the only effusions with the triad of a pH 7.30, a glucose 1,000 U/L (upper limit of normal of serum 200 IU/L).胸腔積液診斷與治療20漏出液滲出液鑒別漏出液滲出液鑒別可變可變,常常600mg/L 600mg/L葡萄糖葡萄糖30g/L胸液血清胸液血清0.530g/L胸液血清胸液血清1.01850%1000/m

19、l200IU/L胸液血清0.6200IU/L胸液血清0.6LDH7.4PH 多變0.52 胸水胸水/血清血清LDH0.63 胸水胸水LDH血清血清LDH2/3血清血清LDH查體、胸片、查體、胸片、CT、B超等超等進一步檢查進一步檢查胸腔積液診斷與治療23胸腔積液的診斷程序胸腔積液的診斷程序滲出液滲出液測胸水淀粉酶、測胸水淀粉酶、Glu 、細胞、細胞學、細胞分類、培養(yǎng)、染色學、細胞分類、培養(yǎng)、染色檢查、結(jié)核標志物檢查檢查、結(jié)核標志物檢查Glu60mg/dl惡性胸水惡性胸水細菌感染細菌感染類風濕性類風濕性淀粉酶升高淀粉酶升高食管破裂食管破裂胰腺炎性胰腺炎性惡性胸水惡性胸水不能診斷不能診斷?胸腔積液

20、診斷與治療24考慮肺栓塞考慮肺栓塞（CT、灌注掃描檢查）、灌注掃描檢查）否否治療肺栓塞治療肺栓塞否否結(jié)核標志物結(jié)核標志物抗結(jié)核治療抗結(jié)核治療癥狀是否改善癥狀是否改善考慮行胸腔鏡檢查考慮行胸腔鏡檢查或開胸胸膜活檢或開胸胸膜活檢觀觀 察察（）（）（）（）是是是是胸腔積液診斷與治療25Common Diseases Associated With Pleural Effusions胸腔積液診斷與治療26Congestive Heart Failure胸腔積液診斷與治療27Congestive Heart Failure(1) history : orthopnea and paroxysmal no

21、cturnal dyspnea typical of left ventricular failure. usual chest radiograph : cardiomegaly, bilateral pleural effusions (right greater than left), and evidence of pulmonary edema as demonstrated by peribronchial cuffing, interstitial or alveolar infiltrates, or Kerley-B lines胸腔積液診斷與治療28Congestive He

22、art Failure(2) diagnostic thoracentesis fever, pleuritic chest pain, a unilateral effusion, a left effusion greater then the right effusion, effusions of disparate size, and a PaO2 inconsistent with the clinical presentation. 胸腔積液診斷與治療29Congestive Heart Failure(2) diagnostic thoracentesis the typica

23、l presentation, thoracentesis can be withheld while observing the response to treatment. If response is not appropriate, diagnostic thoracentesis should be performed. Acute diuresis can transform a transudative congestive heart failure fluid into a pseudoexudate胸腔積液診斷與治療30Malignant Pleural Effusions

24、胸腔積液診斷與治療31Malignant Pleural Effusions(1) Dyspnea is the most common presenting symptom, followed by cough. Of patients presenting with a massive pleural effusion, approximately two thirds will have malignancy. When there is contralateral mediastinal shift with a large or massive effusion, the effus

25、ion is usually caused by a carcinoma that is not a lung primary. 胸腔積液診斷與治療32Malignant Pleural Effusions(2) When there is a large or complete opacification of the hemithorax without contralateral shift or ipsilateral shift, lung cancer is the most likely cause, usually squamous cell carcinoma involvi

26、ng the mainstem bronchus; other diagnoses : a fixed mediastinum from malignant lymph nodes, malignant mesothelioma, and parenchymal tumor invasion. 胸腔積液診斷與治療33Malignant Pleural Effusions(3) Bilateral effusions with a normal heart size malignancy (50%) The other 50% transudative effusions: hepatic hy

27、drothorax, nephrotic syndrome, severe hypoalbuminemia, and constrictive pericarditis, exudates :lupus pleuritis, esophageal rupture, and tuberculous pleurisy (rare except in HIV-positive patients).胸腔積液診斷與治療34Malignant Pleural Effusions(4) Lung and breast : the most common causes (about 65% of cases)

28、; Ovarian and gastric cancer: the two next most common carcinomas ( 6 to 10% of cases). Lymphoma : (about 10% of cases) Less than 10% of malignant effusions have an unknown primary tumor at the time of diagnosis.胸腔積液診斷與治療35Malignant Pleural Effusions(5) Malignant pleural effusions are typically exud

29、ative but on rare occasion can be transudative. Transudative malignant effusions are most commonly caused by concomitant disease, particularly congestive heart failure, but also may be due to early lymphatic obstruction and endobronchial obstruction producing an atelectatic effusion.胸腔積液診斷與治療36Malig

30、nant Pleural Effusions(6) The pleural fluid glucose and the pH are low in about 30% of patients The low glucose is generally in the range of 30 to 50 mg/dL and the pH in the range of 7.05 to 7.29. 10 and 14% of patients are amylase-rich salivary origin The pleural fluidto-serum ratio of amylase in m

31、alignancy is in the range of 5:1, much lower than in pancreatic disease胸腔積液診斷與治療37Malignant Pleural Effusions(7) Finding a low pleural fluid pH ( 7.30.胸腔積液診斷與治療38Malignant Pleural Effusions(8) However, a meta-analysis of more than 400 patients with malignant effusions demonstrated that, even when th

32、e pH was in the range of 6.70 to 7.26, 46% of the patients were still alive at 3 months from the time of initial pleural fluid analysis. Furthermore, 65% of patients in the lowest quartile of pH (6.70 to 7.26) had successful pleurodesis, compared with 88% of patients who had a pH of 7.27胸腔積液診斷與治療39M

33、alignant 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

34、 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.胸腔積液診斷與治療40Malignant Pleural Effusions(10) A

35、denocarcinoma 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 likeliho

36、od of being malignant.胸腔積液診斷與治療41結(jié)核性與腫瘤性胸水的鑒別 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7.30PH大量間皮細胞淋巴細胞為主細胞類型多為大量,生長快多為中、少量胸液量 （） （）PPD試驗中、老年多見青、少年多見年齡 腫瘤性 結(jié)核性胸腔積液診斷與治療42結(jié)核性與腫瘤性胸水的鑒別 效果不佳 反應(yīng)較好抗TB治療 腫瘤組織 結(jié)核肉芽腫胸膜活檢 1g/L類粘蛋白 700ng/ml 20ug/L 1 20ug/L 1CEA胸水血液 45u/L 45u/L 1腺苷脫氨酶胸水血液 腫瘤性 結(jié)核性胸腔積

37、液診斷與治療43Parapneumonic Effusions: Pathophysiology, Diagnosis, and Management胸腔積液診斷與治療44Incidence 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 t

38、hat 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 effusi

39、on (empyema thoracis).胸腔積液診斷與治療45Pathophysiology（1） a sterile, PMN-predominant exudate pH is 7.30, the glucose is 60 mg/dL, and the lactate dehydrogenase (LDH) is 500 U/L. can be treated successfully with antibiotics without the need for pleural space drainage bacterial invasion/fibrinopurulent stag

40、e finding a positive Grams stain and culture signifies bacterial persistence characterized by an increased number of PMNs, a fall in pleural fluid pH and glucose, and an increase in pleural fluid LDH. antibiotics alone may be effective; but later, pleural space drainage is usually required胸腔積液診斷與治療4

41、6Pathophysiology（2） organizational/empyema stage a single cavity or multiple loculations Untreated empyema rarely resolves spontaneously empyema always require drainage for resolution of pleural sepsis The rationale for effective management is to identify the pathophysiologic stage and intervene tim

42、ely and appropriately to prevent progression to empyema胸腔積液診斷與治療47Diagnosis(1) Unfortunately, differentiating high- from low-risk patients clinically is problematic, as there is no difference at presentation in age, peripheral leukocyte count, peak temperature, incidence of pleuritic chest pain, or

43、extent of pneumonia. 胸腔積液診斷與治療48Diagnosis(2) Pleural fluid analysis is a relatively inexpensive and useful diagnostic test to identify the stage of a parapneumonic effusion and to guide therapy. A positive Grams stain, even in nonpurulent fluid, implies an advanced stage of disease and suggests the

44、need for immediate drainage The pleural fluid protein concentration, nucleated cell count, or percentage of PMNs cannot differentiate a complicated from uncomplicated effusion. 胸腔積液診斷與治療49Diagnosis(3) pH 7.00, a glucose 1,000 U/L indicated a complicated parapneumonic effusion that required drainage pH of 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 necessar