胸腔积液诊疗和治疗专业知识讲座专家讲座

DiagnosisandManagementofPleuralEffusions1胸腔积液诊疗和治疗专业知识讲座第1页DiagnosisofPleuralEffusions2胸腔积液诊疗和治疗专业知识讲座第2页ChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules3胸腔积液诊疗和治疗专业知识讲座第3页1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralpleurisymalignancycancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolismdrug-inducedlungdiseasebenignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism4胸腔积液诊疗和治疗专业知识讲座第4页2.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome5胸腔积液诊疗和治疗专业知识讲座第5页3.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction6胸腔积液诊疗和治疗专业知识讲座第6页4.InterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenström'smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia7胸腔积液诊疗和治疗专业知识讲座第7页5.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia8胸腔积液诊疗和治疗专业知识讲座第8页ValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)9胸腔积液诊疗和治疗专业知识讲座第9页ValueofPleuralFluidAnalysistheinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.10胸腔积液诊疗和治疗专业知识讲座第10页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).11胸腔积液诊疗和治疗专业知识讲座第11页ExudatesVsTransudates(1)exudativepleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.12胸腔积液诊疗和治疗专业知识讲座第12页ExudatesVsTransudates(2)pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.13胸腔积液诊疗和治疗专业知识讲座第13页PleuralFluidNucleatedCellCount(1)rarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.<500/mL,thefluidisusuallyatransudate>50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.14胸腔积液诊疗和治疗专业知识讲座第14页PleuralFluidNucleatedCellCount(2)exudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.15胸腔积液诊疗和治疗专业知识讲座第15页eosinophilia(>10%ofthetotalnucleatedcellsareeosinophils)mostcommonlypneumothoraxandhemothorax,BAPE,pulmonaryembolismwithinfarction,previousthoracentesis,parasiticdisease(paragonimiasis),fungaldisease,drug-inducedlungdisease,Hodgkin'slymphoma,carcinoma.

Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions.16胸腔积液诊疗和治疗专业知识讲座第16页PleuralFluidpHandGlucose(1)pleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis17胸腔积液诊疗和治疗专业知识讲座第17页PleuralFluidpHandGlucose(2)fluidglucose<60mg/dLorpleuralfluid/serumglucose<0.5,exudate,lowpleuralfluidpH.

Urinothorax,mostcommonlycausedbyobstructiveuropathy,istheonlycauseofalowpHtransudate.Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresent

withglucoseconcentrationsof0mg/dL18胸腔积液诊疗和治疗专业知识讲座第18页PleuralFluidpHandGlucose(3)ApleuralfluidpH<7.00isusuallyseenonlywithempyema,whetheritbeparapneumonicorassociatedwithesophagealrupture.Complicatedparapneumoniceffusion/empyema,rheumatoidpleurisy,andpleuralparagonimiasisaretheonlyeffusionswiththetriadofapH<7.30,aglucose<60mg/dL,andanLDH>1,000U/L(upperlimitofnormalofserum200IU/L).19胸腔积液诊疗和治疗专业知识讲座第19页漏出液渗出液判别可变,常600mg/L

>600mg/L葡萄糖>30g/L胸液／血清>0.5<30g/L胸液／血清<0.5蛋白（＋）（－）Rivalta自凝不凝凝固>1.018<1.015比重色深,混浊,或血性淡黄，透明外观渗出液漏出液20胸腔积液诊疗和治疗专业知识讲座第20页漏出液渗出液判别急性期常>50%<50%PMN>1000/ml<1000/mlWBC>200IU/L胸液／血清>0.6<200IU/L胸液／血清<0.6LDH<6.8—7.2>7.4PH多变<5000/mlRBC渗出液漏出液21胸腔积液诊疗和治疗专业知识讲座第21页胸腔积液诊疗程序胸腔积液都不符合：漏出液诊疗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超等深入检验22胸腔积液诊疗和治疗专业知识讲座第22页胸腔积液诊疗程序渗出液测胸水淀粉酶、Glu、细胞学、细胞分类、培养、染色检验、结核标志物检验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疗????23胸腔积液诊疗和治疗专业知识讲座第23页考虑肺栓塞（CT、灌注扫描检验）否治疗肺栓塞否结核标志物抗结核治疗症状是否改进考虑行胸腔镜检验或开胸胸膜活检观察（＋）（－）是是24胸腔积液诊疗和治疗专业知识讲座第24页CommonDiseasesAssociatedWithPleuralEffusions25胸腔积液诊疗和治疗专业知识讲座第25页CongestiveHeartFailure26胸腔积液诊疗和治疗专业知识讲座第26页CongestiveHeartFailure(1)history:orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure.usualchestradiograph:cardiomegaly,bilateralpleuraleffusions(rightgreaterthanleft),andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing,interstitialoralveolarinfiltrates,orKerley-Blines27胸腔积液诊疗和治疗专业知识讲座第27页CongestiveHeartFailure(2)diagnosticthoracentesis

fever,pleuriticchestpain,aunilateraleffusion,alefteffusiongreaterthentherighteffusion,effusionsofdisparatesize,andaPaO2inconsistentwiththeclinicalpresentation.28胸腔积液诊疗和治疗专业知识讲座第28页CongestiveHeartFailure(2)diagnosticthoracentesis

thetypicalpresentation,thoracentesiscanbewithheldwhileobservingtheresponsetotreatment.Ifresponseisnotappropriate,diagnosticthoracentesisshouldbeperformed.Acutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudate29胸腔积液诊疗和治疗专业知识讲座第29页MalignantPleuralEffusions30胸腔积液诊疗和治疗专业知识讲座第30页MalignantPleuralEffusions(1)Dyspneaisthemostcommonpresentingsymptom,followedbycough.Ofpatientspresentingwithamassivepleuraleffusion,approximatelytwothirdswillhavemalignancy.Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion,theeffusionisusuallycausedbyacarcinomathatisnotalungprimary.31胸腔积液诊疗和治疗专业知识讲座第31页MalignantPleuralEffusions(2)Whenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift,lungcanceristhemostlikelycause,usuallysquamouscellcarcinomainvolvingthemainstembronchus;otherdiagnoses:afixedmediastinumfrommalignantlymphnodes,malignantmesothelioma,andparenchymaltumorinvasion.32胸腔积液诊疗和治疗专业知识讲座第32页MalignantPleuralEffusions(3)Bilateraleffusionswithanormalheartsizemalignancy(50%)Theother50%transudativeeffusions:hepatichydrothorax,nephroticsyndrome,severehypoalbuminemia,andconstrictivepericarditis,exudates:lupuspleuritis,esophagealrupture,andtuberculouspleurisy(rareexceptinHIV-positivepatients).33胸腔积液诊疗和治疗专业知识讲座第33页MalignantPleuralEffusions(4)Lungandbreast:themostcommoncauses(about65%ofcases);Ovarianandgastriccancer:thetwonextmostcommoncarcinomas(6to10%ofcases).Lymphoma:(about10%ofcases)Lessthan10%ofmalignanteffusionshaveanunknownprimarytumoratthetimeofdiagnosis.34胸腔积液诊疗和治疗专业知识讲座第34页MalignantPleuralEffusions(5)Malignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative.Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease,particularlycongestiveheartfailure,butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion.35胸腔积液诊疗和治疗专业知识讲座第35页MalignantPleuralEffusions(6)ThepleuralfluidglucoseandthepHarelowinabout30%ofpatientsThelowglucoseisgenerallyintherangeof30to50mg/dLandthepHintherangeof7.05to7.29.10and14%ofpatientsareamylase-richsalivaryoriginThepleuralfluid–to-serumratioofamylaseinmalignancyisintherangeof5:1,muchlowerthaninpancreaticdisease36胸腔积液诊疗和治疗专业知识讲座第36页MalignantPleuralEffusions(7)FindingalowpleuralfluidpH(<7.30)inmalignantpleuraleffusionsisassociatedwithapoorerprognosis,ahigherpositiveyieldformalignantcellsoncytologyandpleuralbiopsy,andlesssuccesswithchemicalpleurodesisthanwhenthepHis>7.30.37胸腔积液诊疗和治疗专业知识讲座第37页MalignantPleuralEffusions(8)However,ameta-analysisofmorethan400patientswithmalignanteffusionsdemonstratedthat,evenwhenthepHwasintherangeof6.70to7.26,46%ofthepatientswerestillaliveat3monthsfromthetimeofinitialpleuralfluidanalysis.Furthermore,65%ofpatientsinthelowestquartileofpH(6.70to7.26)hadsuccessfulpleurodesis,comparedwith88%ofpatientswhohadapHof>7.2738胸腔积液诊疗和治疗专业知识讲座第38页MalignantPleuralEffusions(9)CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof<7.30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis.Furthermore,tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid,preventingcollagendeposition.39胸腔积液诊疗和治疗专业知识讲座第39页MalignantPleuralEffusions(10)Adenocarcinomaofthelungisthemostcommonmalignancycausinganamylase-richpleuraleffusion,followedbyadenocarcinomaoftheovary.Thesetumorsproduceanectopicsalivary-likeisoamylase.Asalivary-richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant.40胸腔积液诊疗和治疗专业知识讲座第40页结核性与肿瘤性胸水判别<65ug/ml<1>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大量间皮细胞淋巴细胞为主细胞类型多为大量,生长快多为中、少许胸液量（－）（＋）PPD试验中、老年多见青、少年多见年纪肿瘤性结核性41胸腔积液诊疗和治疗专业知识讲座第41页结核性与肿瘤性胸水判别效果不佳反应很好抗TB治疗肿瘤组织结核肉芽肿胸膜活检<1g/L>1g/L类粘蛋白>700ng/ml<700ng/ml铁蛋白>20ug/L>1<20ug/L<1CEA胸水／血液<45u/L<1>45u/L>1腺苷脱氨酶胸水／血液肿瘤性结核性42胸腔积液诊疗和治疗专业知识讲座第42页ParapneumonicEffusions:Pathophysiology,Diagnosis,andManagement43胸腔积液诊疗和治疗专业知识讲座第43页IncidenceandDefinitions1millionpersonsintheUnitedStatesdevelopingparapneumoniceffusionsyearly.Parapneumoniceffusions(pleuralfluidsassociatedwithpneumonia)aremostoftenfree-flowingeffusionsthatresolvespontaneouslywithantibiotictherapydirectedatthepneumonia(uncomplicatedeffusions.)Pleuralfluidsthatrequiredrainageofthepleuralspaceforresolutionofthefebrileresponsehavebeentermed"complicated"effusions.Empyema:theendstageofacomplicatedparapneumoniceffusion(empyemathoracis).44胸腔积液诊疗和治疗专业知识讲座第44页Pathophysiology（1）asterile,PMN-predominantexudatepHis>7.30,theglucoseis>60mg/dL,andthelactatedehydrogenase(LDH)is<500U/L.canbetreatedsuccessfullywithantibioticswithouttheneedforpleuralspacedrainagebacterialinvasion/fibrinopurulentstagefindingapositiveGram'sstainandculturesignifiesbacterialpersistencecharacterizedbyanincreasednumberofPMNs,afallinpleuralfluidpHandglucose,andanincreaseinpleuralfluidLDH.antibioticsalonemaybeeffective;butlater,pleuralspacedrainageisusuallyrequired45胸腔积液诊疗和治疗专业知识讲座第45页Pathophysiology（2）organizational/empyemastageasinglecavityormultipleloculationsUntreatedempyemararelyresolvesspontaneouslyempyemaalwaysrequiredrainageforresolutionofpleuralsepsisTherationaleforeffectivemanagementistoidentifythepathophysiologicstageandintervenetimelyandappropriatelytopreventprogressiontoempyema46胸腔积液诊疗和治疗专业知识讲座第46页Diagnosis(1)Unfortunately,differentiatinghigh-fromlow-riskpatientsclinicallyisproblematic,asthereisnodifferenceatpresentationinage,peripheralleukocytecount,peaktemperature,incidenceofpleuriticchestpain,orextentofpneumonia.47胸腔积液诊疗和治疗专业知识讲座第47页Diagnosis(2)Pleuralfluidanalysisisarelativelyinexpensiveandusefuldiagnostictesttoidentifythestageofaparapneumoniceffusionandtoguidetherapy.ApositiveGram'sstain,eveninnonpurulentfluid,impliesanadvancedstageofdiseaseandsuggeststheneedforimmediatedrainageThepleuralfluidproteinconcentration,nucleatedcellcount,orpercentageofPMNs

cannotdifferentiateacomplicatedfromuncomplicatedeffusion.48胸腔积液诊疗和治疗专业知识讲座第48页Diagnosis(3)pH<7.00,aglucose<40mg/dL,andanLDH>1,000U/LindicatedacomplicatedparapneumoniceffusionthatrequireddrainagepHof>7.30onadmissionvirtuallyalwayspredictedagoodoutcomewithapp