胸腔积液诊断与治疗.ppt

1,Diagnosis and Management of Pleural Effusions,呼吸内科：徐作军 2019，4，PUMC,2,Diagnosis of Pleural Effusions,3,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,4,1. 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,5,2.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,6,3.Diseases Below the Diaphragm,transudates hepatic hydrothorax nephrotic syndrome urinothorax peritoneal dialysis,exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction,7,4.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,8,5.Pulmonary Nodules,most common causes metastatic carcinoma from a nonlung primary tumor.,Less common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia,9,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),10,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.,11,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 7.00) rheumatoid pleurisy (pleural fluid cytology) extravascular migration of a central venous catheter (high glucose level or pleural fluid simulating the infusate).,12,Exudates Vs Transudates(1),exudative pleural fluid protein/serum protein 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.,13,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.,14,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.,15,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.,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 lymphoma, carcinoma. The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.,17,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,18,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,19,Pleural Fluid pH and Glucose(3),A pleural fluid pH 1,000 U/L (upper limit of normal of serum 200 IU/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0.5 2 胸水/血清LDH0.6 3 胸水LDH血清LDH2/3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,Glu60mg/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,25,Common Diseases Associated With Pleural Effusions,26,Congestive Heart Failure,27,Congestive Heart Failure(1),history : orthopnea and paroxysmal nocturnal 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,28,Congestive Heart 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.,29,Congestive Heart Failure(2),diagnostic thoracentesis the typical 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,30,Malignant Pleural Effusions,31,Malignant 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 effusion is usually caused by a carcinoma that is not a lung primary.,32,Malignant 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 involving the mainstem bronchus; other diagnoses : a fixed mediastinum from malignant lymph nodes, malignant mesothelioma, and parenchymal tumor invasion.,33,Malignant Pleural Effusions(3),Bilateral effusions with a normal heart size malignancy (50%) The other 50% transudative effusions: hepatic hydrothorax, nephrotic syndrome, severe hypoalbuminemia, and constrictive pericarditis, exudates :lupus pleuritis, esophageal rupture, and tuberculous pleurisy (rare except in HIV-positive patients).,34,Malignant Pleural Effusions(4),Lung and breast : the most common causes (about 65% of cases); 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.,35,Malignant Pleural Effusions(5),Malignant pleural effusions are typically exudative 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.,36,Malignant 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 malignancy is in the range of 5:1, much lower than in pancreatic disease,37,Malignant Pleural Effusions(7),Finding a low pleural fluid pH ( 7.30.,38,Malignant Pleural Effusions(8),However, a meta-analysis of more than 400 patients with malignant effusions demonstrated that, even when the 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 7.27,39,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.,40,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.,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,43,Parapneumonic Effusions: Pathophysiology, Diagnosis, and Management,44,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).,45,Pathophysiology（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 stage 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,46,Pathophysiology（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 timely and appropriately to prevent progression to empyema,47,Diagnosis(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 extent of pneumonia.,48,Diagnosis(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 need for immediate drainage The pleural fluid protein concentration, nucleated cell count, or percentage of PMNs cannot differentiate a complicated from uncomplicated effusion.,49,Diagnosis(3),pH 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 necessary to resolve pleural sepsis pH between 7.30 and 7.10 at a