胸膜渗出诊疗课件

DiagnosisandManagementofPleuralEffusions

Causeofpleuraleffusionsamirrorofsystemicdisease.DiseaseaffectingvirtuallyanyorgancanresultinapleuraleffusionCauseofpleuraleffusionschestdiseaseorgansbelowthediaphragmsplenicinfarctionsystemicdiseasessystemiclupuserythematosusdiseasesofthelymphaticsystemyellownailsyndromePathophysiologyofPleuralFluidAccumulationdecreasedlymphaticdrainagemalignancymovementfromtheperitonealspacehepatichydrothoraxthoracicductrupturechylothorax iatrogenicextravascularmigrationofcentralvenouscatheterSymptomsatPresentationAwarenessofthesymptomsandsignsofspecificdiseasesinpatientswhopresentwithpleuraleffusionsmaybehelpfulinnarrowingthedifferentialdiagnosisoftheexudativeeffusion.postcardiacinjurysyndrome,lupuspleuritis,andmalignantmesotheliomausuallyaresymptomaticatpresentationwithapleuraleffusion.SymptomsatPresentationabout75%ofpatientswithcarcinomatousmalignanteffusions,50%ofpatientswithrheumatoidpleurisy,lessthanhalfofthepatientswithbenignasbestospleuraleffusion(BAPE)ChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodulesBilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndromeInterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenström'smacroglobulinemiasarcoidosisPneumocystiscariniipneumoniaResolutionofPleuralEffusionpulmonaryembolismwithoutaradiographicinfarction(consolidation)7to10days;whenaradiographicinfarctionispresent,2to3weeks.acutepancreatitiswillresolveasthepancreaticinflammationsubsides,typicallywithin1to2weeks.Withcontinuedhemodialysis,auremicpleuraleffusionresolvesin4to6weeksResolutionofPleuralEffusionPersistenceoftheuremiceffusionsuggeststhateitheratrappedlungorfibrothoraxhasdeveloped,whichcanbesuccessfullytreatedwithdecortication.Atuberculouspleuraleffusionhasaspontaneousresolutionrateof4to16weeks29ResolutionofPleuralEffusionRheumatoidpleuraleffusionshaveatypicalresolutiontimeof4to6months,witharangeofafewweeksto9months.BAPEeffusionstypicallyresolvein3to4months,withsomepersistingfor>1yearandsomeresolvingin<1month.ResolutionofPleuralEffusionEffusionsthatpersistfor>1yearhavealimiteddifferentialdiagnosistrappedlungyellownailsyndrome,lymphangiectasia,Noonan'ssyndrome(chylothorax),rarely,rheumatoidpleurisy,BAPE,andmalignancyValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)Diagnosesthatcanbedefinitivelyempyema(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).ExudatesVsTransudatesexudativepleuralfluid/serumproteinratioof>0.5pleuralfluidLDHof>0.45between0.67and0.80oftheupperlimitofnormalofserumLDHpleuralfluidcholesterol>45mg/dLor>60mg/dL.anyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.PleuralFluidNucleatedCellCountrarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.<500/mL,thefluidisusuallyatransudate>50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.PleuralFluidNucleatedCellCountexudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.PleuralFluidpHandGlucosepleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritisPleuralFluidpHandGlucosefluidglucose<60mg/dLorpleuralfluid/serumglucose<0.5,exudate,lowpleuralfluidpH.Urinothorax,mostcommonlycausedbyobstructiveuropathy,istheonlycauseofalowpHtransudate.Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresent

withglucoseconcentrationsof0mg/dLPleuralFluidpHandGlucoseApleuralfluidpH<7.00isusuallyseenonlywithempyema,whetheritbeparapneumonicorassociatedwithesophagealrupture.Complicatedparapneumoniceffusion/empyema,rheumatoidpleurisy,andpleuralparagonimiasisaretheonlyeffusionswiththetriadofapH<7.30,aglucose<60mg/dL,andanLDH>1,000U/L(upperlimitofnormalofserum200IU/L).CongestiveHeartFailurehistory:orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure.usualchestradiograph:cardiomegaly,bilateralpleuraleffusions(rightgreaterthanleft),andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing,interstitialoralveolarinfiltrates,orKerley-BlinesCongestiveHeartFailurediagnosticthoracentesis

fever,pleuriticchestpain,aunilateraleffusion,alefteffusiongreaterthentherighteffusion,effusionsofdisparatesize,andaPaO2inconsistentwiththeclinicalpresentation.CongestiveHeartFailurediagnosticthoracentesis

thetypicalpresentation,thoracentesiscanbewithheldwhileobservingtheresponsetotreatment.Ifresponseisnotappropriate,diagnosticthoracentesisshouldbeperformed.AcutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudateHepaticHydrothoraxresultswhenasciticfluidmovesalongapressuregradientthroughcongenitaldiaphragmaticdefectsthathavebeenopenedbyincreasedperitonealpressureinapproximately5%ofpatientswithclinicalascitesbutcanresultevenintheabsenceofclinicalascites.mostcommonlyright-sidedbutmaybeunilateralontheleft(15%)orbilateral(15%).HepaticHydrothoraxApresumptivediagnosiscanbeestablishedintheappropriateclinicalsettingbydemonstratingthatpleuralandasciticfluidcharacteristicsaresimilar.Foradefinitivediagnosis,aradionuclidestudyshouldbeperformed.Radionuclideappearinginthechestwithin1to2hfollowinginjectionintotheasciticfluidconfirmsthediagnosis.Managementofhepatichydrothoraxincludes

sodiumrestriction,diuretictherapyandintermittenttherapeuticthoracentesis.Refractoryeffusions:transjugularintrahepaticportalsystemicshuntorvideo-assistedthoracoscopicsurgeryrepairofthediaphragmaticdefectandpleurodesisinpatientswithareasonableexpectedsurvivalwhocantolerateasurgicalprocedure.ManagementofhepatichydrothoraxChesttubedrainage

iscontraindicatedinhepatichydrothorax,asitcausesproteinandlymphocytedepletionandcancauseaniatrogenicempyema,precipitaterenalfailure,andbeasourceofcontinuousfluidleakthroughthethoracostomysite.AtelectaticeffusionsAtelectasiscausesasmalltransudativepleuraleffusionduetoadecreaseinpleuralpressurecommonlyfoundinpatientsinICUsbutcanalsooccurwhenlungcancerobstructsamainstemorlobarbronchus,withpulmonaryembolismwithoutinfarction,andanycauseoflowerchestorupperabdominalpain.Mostatelectaticeffusionsaresmallinvolumeandresolvequicklywhentheatelectasisresolves.NephroticSyndromePatientswithnephroticsyndromehaveanestimated20%prevalenceofsmallbilateralpleuraleffusions,whichhaveatendencytobesubpulmonicinlocation.Thepresenceofalargevolumeofpleuralfluid,aunilateraleffusion,effusionsofdisparatesize,pleuriticchestpainoracutedyspnea,oranexudate,hemorrhage,orneutrophilpredominanceonpleuralfluidanalysisshouldpromptanimmediateevaluationforpulmonarythromboembolicdisease.MalignantPleuralEffusionsDyspneaisthemostcommonpresentingsymptom,followedbycough.Ofpatientspresentingwithamassivepleuraleffusion,approximatelytwothirdswillhavemalignancy.Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion,theeffusionisusuallycausedbyacarcinomathatisnotalungprimary.MalignantPleuralEffusionsWhenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift,lungcanceristhemostlikelycause,usuallysquamouscellcarcinomainvolvingthemainstembronchus;otherdiagnoses:afixedmediastinumfrommalignantlymphnodes,malignantmesothelioma,andparenchymaltumorinvasion.MalignantPleuralEffusionsBilateraleffusionswithanormalheartsizemalignancy(50%)Theother50%transudativeeffusions:hepatichydrothorax,nephroticsyndrome,severehypoalbuminemia,andconstrictivepericarditis,exudates:lupuspleuritis,esophagealrupture,andtuberculouspleurisy(rareexceptinHIV-positivepatients).MalignantPleuralEffusionsLungandbreast:themostcommoncauses(about65%ofcases);Ovarianandgastriccancer:thetwonextmostcommoncarcinomas(6to10%ofcases).Lymphoma:(about10%ofcases)Lessthan10%ofmalignanteffusionshaveanunknownprimarytumoratthetimeofdiagnosis.Paramalignanteffusionsareeffusionsassociatedwithaknownmalignancybutmalignantcellscannotbedemonstratedinpleuralfluidorpleuraltissue.Lymphaticobstructionandincreasedcapillarypermeabilitycausedbycytokinesareimportantmechanismscausingpleuralfluidformation.Endobronchialobstructionresultinginpneumoniaandaparapneumoniceffusionandatelectasiswithatransudativeeffusionalsoarecausesofaparamalignanteffusion.Pulmonaryembolism,superiorvenacavasyndrome,chylothorax,radiationtherapy,drugreactions,andseverehypoalbuminemiaalsocancauseparamalignanteffusions.MalignantPleuralEffusionsMalignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative.Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease,particularlycongestiveheartfailure,butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion.MalignantPleuralEffusionsThepleuralfluidglucoseandthepHarelowinabout30%ofpatientsThelowglucoseisgenerallyintherangeof30to50mg/dLandthepHintherangeof7.05to7.29.10and14%ofpatientsareamylase-richsalivaryoriginThepleuralfluid–to-serumratioofamylaseinmalignancyisintherangeof5:1,muchlowerthaninpancreaticdiseaseMalignantPleuralEffusionsFindingalowpleuralfluidpH(<7.30)inmalignantpleuraleffusionsisassociatedwithapoorerprognosis,ahigherpositiveyieldformalignantcellsoncytologyandpleuralbiopsy,andlesssuccesswithchemicalpleurodesisthanwhenthepHis>7.30.MalignantPleuralEffusionsHowever,ameta-analysisofmorethan400patientswithmalignanteffusionsdemonstratedthat,evenwhenthepHwasintherangeof6.70to7.26,46%ofthepatientswerestillaliveat3monthsfromthetimeofinitialpleuralfluidanalysis.Furthermore,65%ofpatientsinthelowestquartileofpH(6.70to7.26)hadsuccessfulpleurodesis,comparedwith88%ofpatientswhohadapHof>7.27MalignantPleuralEffusionsCytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof<7.30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis.Furthermore,tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid,preventingcollagendeposition.MalignantPleuralEffusionsAdenocarcinomaofthelungisthemostcommonmalignancycausinganamylase-richpleuraleffusion,followedbyadenocarcinomaoftheovary.Thesetumorsproduceanectopicsalivary-likeisoamylase.Asalivary-richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant.PulmonaryEmbolismPleuraleffusionsarefoundinapproximately40%ofpatientswithapulmonaryembolism.virtuallyalwayslessthanathirdofahemithorax,presentontheinitialchestradiograph,andunilateral.theexudativeeffusionsareduetopulmonaryischemia/infarction;andthetransudatesarecausedbyatelectasissecondarytochestpain.PulmonaryEmbolismanunlikelycauseforapleuraleffusionalargeormassiveeffusion,bilateraleffusions,effusionsdelayedinonset>24hfromtimeofpresentation,increaseinthesizeoftheeffusionafter72h,andeffusionsunaccompaniedbyipsilateralchestpain.PulmonaryEmbolismPleuraleffusionsthatincreaseafter3dayswithadocumentedpulmonaryembolismsuggestthefollowingdiagnoses:recurrentembolization,aninfectedpulmonaryinfarction,anotherdiagnosissuchaspneumonia,orspontaneoushemothoraxwithheparintherapy.PulmonaryEmbolismsmallandunilateralonsetoccurssoonaftertheinitialsymptoms.tendtoreachtheirmaximumsizewithinafewdays.PulmonaryEmbolismPulmonaryinfarctionsareassociatedwithlargerhemorrhagicpleuraleffusionsthatresolvemoreslowlythaneffusionswithoutinfarction,whicharesmallerandserous.Ipsilateralchestpainoccursinvirtuallyallpatientswithpleuraleffusionsfrompulmonaryembolism.Effusionsthataredelayedinonsetorincreaseinsizelaterinthecoursetendtobeassociatedwithrecurrentembolism,secondaryinfectionoranotherdiagnosis.TuberculousPleuralEffusionThemostcommonsymptomsarefever(86%),cough(80%),andchestpain(75%)smalltomoderateinsize,andaparenchymalinfiltrateisseenin<50%ofpatientsonastandardchestradiograph.Approximately80%ofpatientswillhaveasubpleuralinfiltrateidentifiedonCT.PPD:negativeupto30%classicpleuralfluidanalysisintuberculouspleurisyLymphocytes:90to95%inacutetuberculouspleurisyandtuberculousempyema,tein:4to5g/dLpH:<7.40andis<7.30inapproximately20%ofcases.Glucose:similartoserumglucoseinmostcasesandis<60mg/dLin20%.unlikely:mesothelial>10%cellsandpleuralfluideosinophilia.Thenucleatedcellcountisgenerally<5,000/mL.Diagnostictestintuberculouspleurisypercutaneouspleuralbiopsy:thegreatestsensitivitypleuraltissueculture:sensitivityfrom55to85%,andpleuraltissuehistologyfrom50to85%.Theaveragesensitivityofpleuralfluidcultureis30%withthepleuralfluidacid-fastbacillismearbeingpositivein<10%ofpatients.Whencombinedwithsputumanalysis,adiagnosisshouldbeestablishedin80to90%ofpatientsManagement6-monthregimenofisoniazidandrifampinwithpyrazinamideforthefirst2months,orwith6monthsofisoniazidandrifampinaloneinareaswithalowpercentageofisoniazidresistance.PatientswithHIVinfectionmayrequirelongertreatment.Untreatedpatientswithtuberculouspleurisyhavea65%chanceofdevelopingpulmonaryorextrapulmonarytuberculosisintheensuing5years.Theadministrationofcorticosteroidscanresultinmorerapidlysisoffeverandresolutionoftheeffusion;however,itprobablydoesnotaffectpleuralfibrosis.RheumatoidPleurisymostcommonlyinmalepatientswithactivearticulardiseaseandrheumatoidnodules.Themostcommontimeofonsetiswithinthefirst5yearsfollowingdiagnosis.However,rheumatoideffusionscanappear3yearsbeforeor>20yearsafterdiagnosisisestablished.RheumatoidPleurisymaybeturbid,haveayellow-greentint,orappeartocontaindebris.Nucleatedcellcountsvaryfrom100cells/mLinchroniceffusionsto15,000/mLinacuterheumatoidpleurisy.Neutrophilspredominateintheacutediseaseandlymphocytesinthechronicform.RheumatoidPleurisyThepleuralfluidtotalproteincanbeashighas7g/dL.Chronicrheumatoidpleurisyhastheclassictriadofaglucoselevelof<30mg/dL,anLDHof>1,000IU/L,andapHof7.00;acuteeffusionsusuallywillnothavethetriadRheumatoidPleurisyDefinitivediagnosisofrheumatoidpleurisycanbemadebycytologicexamination.Thepatternofroundorovalgiantmultinucleatedcells,largeelongated"tadpole"-or"comet"-shapedcells,andabackgroundofgranularnecroticmaterialisconsideredspecificforrheumatoidpleurisy.TrappedLungoccurswhenafibrousmembranecoversthevisceralpleura,preventinglungexpansion.Causesoftrappedlungincludeempyema,rheumatoidpleurisy,malignancy,uremicpleuritis,BAPE,hemothorax,coronaryarterybypassgraft,andpneumothoraxtherapyfortuberculosis.Theeffusionrecursrapidlyfollowingthoracentesistothepre-thoracentesisvolumeTheunilateralpleuraleffusioncanvaryfromsmalltolarge,dependingupontheextentoftrappedlung.TrappedLungThefluidisserousandistypicallyborderlinebetweenatransudateandexudateIftheinflammationisremote,t