胸膜疾病英文版pptpleural disease.ppt

1、Respiratory Medicine,Rui Zheng（郑锐），M.D. , Ph.D. SHENG JING HOSPITAL CHINA MEDICAL UNIVERSITY,Male, 70 year old with an 80-pack-year history of smoking and a history of coronary heart disease. He was suffered from increasing shortness of breath for 1 week. And he also had chest pain on the right side

2、 that worsens with deep inspiration. He was afebrile,Chest examination revealed dullness to percussion, the absence of fremitus, and diminished breath sounds on the right side. No distended neck veins, no peripheral edema was observed. The chest radiograph was showed as picture,Pleural Diseases,Pleu

3、ral effusion,Pleural Space,Visceral Pleura attached to lungs. Parietal Pleura attached to chest wall. Pleural space 5-15 mL of fluid secreted by the pleural cells. Minimizes friction as the two pleural surfaces glide over each other during inspiration and expiration,Lets review,Lung,Rib cage,Viscera

4、l Pleura,Parietal Pleura,Pleural Space,Pleural effusion transport,Development of Pleural Effusion,pulmonary capillary hydrostatic pressure (CHF, constrictive pericarditis) transudate plasma oncotic pressure (hypoalbuminemia, liver cirrhosis) pleural membrane permeability exudate (pneumonia, TB, CTD，

5、malignancy, PE) lymphatic obstruction (malignancy) trauma (esophagus,thoracic duct rupture,Symptom,Dyspnea (most common) Mild, non-productive cough Severe cough with sputum or blood Pneumonia vs. bronchial lesion Constant chest pain Cancerous invasion of chest wall Pleuritic chest pain PE vs. inflam

6、matory pleural effusion,Physical Examination,Mediastinal shift away from the effusion Decreased tactile fremitus Dullness to percussion Decreased breath sounds Pleural friction rub,Chest X-Ray,Fluid in X-ray seen as a dense, white shadow with a concave upper edge (fluid level) anterior rib(2,Ultraso

7、nography,Ultrasonographic guidance is indicated if difficulty is encountered in obtaining pleural fluid or if the effusion is small to perform thoracentesis,Thoracentesis,A needle is inserted into the chest wall to remove the collection of fluid Determines the type of fluid (transudate or exudate,Pl

8、eural fluid analysis,Appearance, Specific gravity, Protein content, Cell counts, Glucose, LDH , Adenisine deaminase (ADA), Gram stain and culture, Cytologic examination, etc,Pleural fluid analysis,Appearance Colour yellow, Bloody, chocalate,milky, black specific gravity1.0161.018, 1.018 CloudyTRIG l

9、evel 1.21mmol/L= chylothorax Putrid odor stain and culture = infection? Transudate vs Exudate,Cells,Transudate: 500106/L, Pyothorax: WBC10000 106/L PMN -Acute inflammation lymphocyte mostTB or tumor eosinophile granulocyte - parasitic infection or CTD RBC 5000106/L malignant tumor or TB haematothora

10、x10000106/Lwound, tumor or PE malignant -tumour cell SLElupus cell,pH,Normal: 7.6 pH decrease pH7.35:SLE, malignant effusion,Protein,Exudate30g/L，pleural fluid/serum 0.5. Transudate30g/L，Rivalta test negative,Glucose,The level in normal PF is similar to that in serum Pyothorax, RF, SLE, TB and malig

11、nant PF 3.35mmol/L,Adipoid,Chylothoraxcloudy, Sudan staining red, triglyeride1.21mmol/L，cholesterol is normal. Pseudochylothoraxlight yellow or brown, containing Cholesterol crystal cells like lymphocytes, red blood cells. cholesterol 26mmol/L，triglyeride is normal,Enzymes,Exudate: lactic acid dehyd

12、rogenase (LDH)200uL， PFSerum0.6. LDH500U/Lmalignant or infective. Amylase -acute pancreatitis, tumor. Isoenzyme -tumor。 Adenosine deaminase (ADA) 45UL-TB,Tumor markers,CEA: 20g/L, PF/Serum1 CA125,CA199, et al,Pathogen,Smear or culture tuberculous pleurisy: M TB positive rate is about 20 %. Chocolate

13、-color effusion should examine Amoeba trophozoite by microscope,Biopsy of pleura,To find tumor, TB, and other diseases Contraindication: pyothorax or hemorrhagic tendency radiation therapy at the biopsy location if confirmed malignant pleural mesothelioma,Bronchoscope,Haemoptysis Suspect airway obst

14、ruction,Diagnosis,3 steps 1. to determine pleural effusion existing or not 2. to determine transudate or Exudate 3. to find the causes of pleural effusion,Transudate Exudate Apperance light yellow yellow, purulent Specific gravity 1.018 Coagulability unable able Revalta test negative positive Protei

15、n content 30g/L P. To serum 0.5 LDH 200 I U / L P. To s 0.6 Cell count 50010 6 / L Differential cell Lymphocyte Different,diagnosis,Lights Criteria,Pleural fluid is exudate if one or more: Pleural fluid protein:serum protein 0.5 Pleural fluid LDH:serum LDH 0.6 Pleural fluid LDH 2/3 upper limit ln se

16、rum LDH,Transudate,Hepatic hydrothorax. Nephritic syndrome. Congestive heart failure. Hypoproteinemia,Exudate,Cell count Neutrophil predominate acute process (pneumonia, PE) - Lymphocytic predominate chronic process (Cancer, TB,) Culture/stain- infected fluid Glucose- low level (60mg/dl)(pneumonia,

17、CA) Cytology- malignancy pH- parapneumonic 7.2 -must drain fluid malignant 7.2 poor prognosis,Malignant Effusions,Clinical features suggestive of malignacy: Symptoms 1mo, absence of fever, blood-tinged fluid, chest CT suggesting malignancy Lung breast lymphoma/leukemia metastatic adenocarcinoma posi

18、tive cytology 70% Lymphoma 25-50% Mesothelioma 10% Squamous Cell Carcinoma 20% Pleural fluid: bloody, lymphocytic, decreased glucose and pH, cytology,Treatment,The most important method is to cure the cause of pleural effusion,Tuberculous pleurisy,general treatment: rest, nutritional support, sympto

19、matic treatment thoracentesis Note: 700ml at the first time，1000ml afterwards re-expansion pulmonary edema pleura reaction Usually there is no need to inject antituberculosis drugs into thoracic cavity。 Antituberculosis therapy Glucocorticoid,Malignant pleura effusion,primary disease therapy Thorace

20、ntesis continuing closed drainage Chemical pleurodesis surgery,Parapneumonia pleural effusion and pyothorax,basic therapy: Thoracentesis and tube thoracostomy Antibiotics Rinsing the pleural cavity with 2 % NaHCO3 or normal saline repeatly. surgery general treatment,male, 70 year old with an 80-pack

21、-year history of smoking and a history of coronary heart disease. He was suffered from increasing shortness of breath for 1 week. And he also had chest pain on the right side that worsens with deep inspiration. He was afebrile,Case 1,Chest examination revealed dullness to percussion, the absence of

22、fremitus, and diminished breath sounds on the right side. No distended neck veins, no peripheral edema was observed. The chest radiograph was showed as picture,What shall we do next? The pleural fluid test result: total cells: 570106/L, lymphocyte 59%, protein 36g/L, Rivalta test(+), serum protein 6

23、2g/L,what kind of pleural effusion was it,diagnostic thoracentesis Exudate,Male, 32 years old. Chief complaint: Fever and fatigue for one month, dyspnea after movement for one week. Physical examination: T 38.5C, trachea toward the right, the plump contour of the left lower chest, decreased fremitus

24、 and breath sound as well as dullness by percussion at the left lower chest, no rub feeling,Case 2,Questions: 1. What kinds of laboratory examination should be done? 2. Should thoracentesis be done? If yes, what should be cautious? What kinds of examination should be done in pleural effusion? 3. if

25、the diagnosis is tuberculous pleural effusion, how about therapy,Pneumothorax,Pneumo”- gas “Thorax” chest cavity Air accumulation in the pleural space with secondary lung collapse,Definition,Sources,Visceral pleura Ruptured esophagus Chest wall defect Gas-forming organisms,52,Classification of Pneum

26、othorax,Spontaneous Primary Secondary COPD Infection Neoplasm Catamenial Miscellaneous,Traumatic Blunt Penetrating Iatrogenic Inadvertent Diagnostic Therapeutic,Primary Spontaneous Pneumothorax,Pt. with unknown lung disease. a rupture of a bulla in the lung. Most often tall, thin men between 20 and

27、40 years old,Secondary Spontaneous Pneumothorax,occurs in pt. with known lung disease most often COPD Other lung diseases commonly assoc. with Tuberculosis Pneumonia Asthma cystic fibrosis lung cancer Often severe & life threatening,Emphysema of the Lung -Solitary giant bulla, RLL,Closure pneumothor

28、ax Unclosure pneumothorax Tension pneumothorax,Clinical classification,Closure pneumothorax,Air enters the pleural cavity via lungs blunt chest trauma Car crash Fall Crushing chest injury,Unclosure pneumothorax,Open Pneumothorax Air enters pleural cavity via outside A free communication between the

29、exterior and the pleural space as through an open wound,Tension pneumothorax,a piece of tissue forms a one-way valve that allows air to enter the pleural cavity but not to escape, overpressure can build up with every breath,Tension pneumothorax,air accumulates in the pleural space with each breath.

30、The remorseless increase in intrathoracic pressure massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels cardiovascular collapse,Clinical Manifestations (all types,Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion Hyper resonan

31、ce or tympany Breath sounds diminished Absent,Respiratory distress O2 Sats decreased Tachypnea Tachycardia Restlessness/ Anxiety,S&S Tension pneumothorax,i cardiac output Hypotension Tachycardia (compensatory) Tachypnea Mediastinal shift and tracheal deviation To the unaffected side Cardiac arrest D

32、istended neck veins,Dx exam and tests,Chest x-ray ABGs Initial PaCO2 Decreased respiratory alkalosis Later ABGs Hypoxemia Hypercapnia Acidosis,Imaging,Plain Radiographs Upright PA on inspiration Detect other pathologies: pneumonia, cardiac, etc. Partially collapsed lung Tension Pneumothorax Trachea and mediastinum deviate contralaterally Ipsilateral depressed hemi-diaphragm Chest CT Not routine Only to assess the need for surgery (thoracotomy,Diagnosis,Unstable patient Thoracentesis Rapid release of air Vital signs stabilize rapidly,Stable pa