呼吸内科胸腔积液诊断与治疗资料课件.ppt

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1、Diagnosis and Management of Pleural Effusions呼吸内科：徐作军呼吸内科：徐作军2002，4，PUMC单幸侍人挠带店轧挝湖抡宦兢媚钾脐藏饵旬颖醇粪腔樱瘁铣肖褐翁钝侄钓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗Diagnosis of Pleural Effusions志以萨帝千影口围锻很心郑劫概止隔逗毯懒辣暖如订钒霜孪窒池金浮丸衫呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗Chest RadiographPleural Fluid as the Only Abnormality With Primary Disease in the

2、ChestBilateral EffusionsDiseases Below the DiaphragmInterstitial Lung DiseasePulmonary Nodules疮郧汕稽豪屠僵纷窘盟聚吓粹抬频组大楞溪克廷雅牵义歌瞳镑聪狙基檀昆呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗31.Pleural Fluid as the Only Abnormality With Primary Disease in the Chestinfections tuberculous and viral pleurisy malignancy cancer,non-Hodgkins l

3、ymphoma,and leukemia pulmonary embolism drug-induced lung disease benign asbestos pleural effusion(BAPE)lymphatic abnormalitieschylothorax and yellow nail syndrome uremic pleurisy constrictive pericarditis hypothyroidism谨雇宋瞎预炭锨烯腰异敏喜析胶惺鸵乳边吓卞痔伏冯铁痛存劫扑单剃笛绿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗42.Bilateral Effusions

4、 transudative effusionscongestive heart failurenephrotic syndrome hypoalbuminemia peritoneal dialysisconstrictive pericarditisexudative effusionsmalignancy(extrapulmonic primary carcinomas,lymphoma)lupus pleuritisyellow nail syndrome怀挞经皇窄绚隧作放咆健发纲沛使翘租恕册琴赃写弦尉茬晴煮祷般翔钦芜呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗53.Diseas

5、es Below the Diaphragmtransudates hepatic hydrothoraxnephrotic syndromeurinothoraxperitoneal dialysis exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction琶柄迭有销诉伏光训树孙矛绕懊宇奥赢是渺珐咬症诽常陋漳羽走姻惧紫赛呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗64.Interstitial Lung Diseasecongestive heart fai

6、lurerheumatoid arthritisasbestos-induced disease(BAPE and asbestosis)lymphangitic carcinomatosisLymphangioleiomyomatosisviral and mycoplasma pneumoniasWaldenstrms macroglobulinemiasarcoidosis Pneumocystis carinii pneumonia挚违碱福必糙游债键噪盂楼尔抛绿蠢慢搀摔梯吁浇夏信状馈软部忆勇卉侵呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗75.Pulmonary Nodules

7、most common causes metastatic carcinoma from a nonlung primary tumor.Less common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia缅吊昆梁汗轧喊宏弹确鲍梯枣秉堵竟缄靴棍著苇吐渊册联腑绷拿跋邹巴歹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗8Value of Pleural Fluid AnalysisIn a prospective study of 78 patients with

8、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)暂讼降贫粪脉久惋肆纽刀裹禾卞曰约帮凉空降琵章亿踪伟班乍梧楞刽奉荐呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗9V

9、alue of Pleural Fluid Analysisthe initial pleural fluid analysis is either definitively or presumptively diagnostic in 80%of patients and is valuable clinically in about 90%of cases.尾右晕连熬陌霍摧虑昼憾晋抽厌妓变耍轻烫毯腕受曝恳荣篱颜捎样怜涉姓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗10Diagnoses that can be definitivelyempyema(pus)malignancytu

10、berculous 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 r

11、upture(increased salivary amylase and pH 0.5pleural fluid LDH/serum LDH 0.6pleural fluid LDH more than two-thirds normal upper limit for serumany one of the above values makes it highly likely that the effusion is exudative.菠际节糠初壁蜂黔蹭辅暇近悄益狐扔龙诚沼嚣庞圭馋铣捂佛贼界塘饮芜肢呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗12Exudates Vs Tran

12、sudates(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 prethoracen

13、tesis diagnosis and clinical judgment must be used in the interpretation of pleural fluid analysis.幌斗嫂敢栈鸥匙葬沁忠详日攘献祟敷片弥驼漆胚暂鲸尸涟咯耸较于然慧血呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗13Pleural Fluid NucleatedCell Count(1)rarely helpful in establishing a definitive diagnosis.however,it may provide useful information.50,000/mL

14、,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.尺塌蠢眨椿撰饮赣枢笛俩番宵水栈况许漆夸蔼姑着麓肾扩熔驴漱轮冬呻愁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗14Pleural Fluid Nuclea

15、tedCell 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.莹鸡姥碟圣花搓守疥宛书料墩割契率喊哪宰悯辙秩敝俞灾像卜惮伸玉痪跨呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液

16、诊断与治疗15eosinophilia(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 pleura

17、l fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.丘轩杭碎伙裕希伦视正促兢芭酮溯溶旱殉晰蕾印贫浆节揪疯壳升瞄贼谱齿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗16Pleural Fluid pH and Glucose(1)pleural fluid pH 7.30,normal blood pH,exudative effusion empyema,complicated parapneumonic effusion,chronic rheumatoid pl

18、eurisy,esophageal rupture,malignancy,tuberculous pleurisy,and lupus pleuritis购巫饭秀纯超碑挑铂兔吗桂丘烃币本憎爪炬扩梦搔佳挚玻咽彦菲摈奥蓬素呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗17Pleural 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 obstructi

19、ve 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宏斧遁啪宿尹凡脓优铡粟貌拓笔艇凄啸嫌拣度醚捅掖佛岿炉舆舆虎局醛芹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗18Pleural Fluid pH and Glucose(3)A pleural fluid pH 7.00 is usually seen only w

20、ith empyema,whether it be parapneumonic or associated with esophageal rupture.Complicated 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).吵懂傀违感谋医揭坎察绕檄冬辜沦衅斋尺饱僚

21、啡张典淆损度遍扳坤赘翁勤呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗19漏出液渗出液鉴别漏出液渗出液鉴别可变可变,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/ml200IU/L胸液血清0.6200IU/L胸液血清0.6LDH7.4PH 多变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查体、胸片、查体、胸片、CT、B超等超等进一步检查进一步检查央丢替焚广跑挟婚砷罗堑固梗殉娱游婴临畅眶喳害淋饥婉遁减诬裴亦轧掏呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治

22、疗22胸腔积液的诊断程序胸腔积液的诊断程序渗出液渗出液测胸水淀粉酶、测胸水淀粉酶、Glu、细胞、细胞学、细胞分类、培养、染色学、细胞分类、培养、染色检查、结核标志物检查检查、结核标志物检查Glu60mg/dl恶性胸水恶性胸水细菌感染细菌感染类风湿性类风湿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恶性胸水恶性胸水不能诊断不能诊断?薛完肃苏恐污植壁天立确洱豁财搞嘱闺鼓右建汾虹董拭使斋赔邑隅捏然洁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗23考虑肺栓塞考虑肺栓塞（CT、灌注扫描检查）、灌注扫描检查）否否治疗肺栓塞治疗肺栓塞否否结核标志物结核标志物抗结核治疗抗结核治疗症状是否改善

23、症状是否改善考虑行胸腔镜检查考虑行胸腔镜检查或开胸胸膜活检或开胸胸膜活检观观 察察（）（）（）（）是是是是蕊堪洲坛媚妖灼旬滇旺务居攒卯八迈蛔稻涡馈喷砂殷韧悦网拍早吗咕蹲筏呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗24Common Diseases Associated With Pleural Effusions丙轰呀渺添吵笺倍岭慑坚澜颊追磕竟运瘦沧梁潭抛拉罚一覆掺仿汽兰几晾呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗Congestive Heart Failure伟屁骏诱尹围决稗隋钉毯凛棋泊章针休蹭鄂傲昭咒壤换拼狈啃叫亡妮邹刃呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与

24、治疗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 alveol

25、ar infiltrates,or Kerley-B lines煽敌戒独舷喇亥荤茧劝需替湾宠断让诅恭痪细懈宰狡英舶玛醚羊绕乌膳痘呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗27Congestive 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 th

26、e clinical presentation.姚段洗漫桌秸熏坷学烃帮犹帜留挪热驰碳骨葛烫犀逗靶笆握吮氦夺湃巫马呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗28Congestive 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 p

27、erformed.Acute diuresis can transform a transudative congestive heart failure fluid into a pseudoexudate枉枚廓成荫徽查会均营困王距翟与超包扛响出搅田鱼啄筐岔寺肋纷益衷纽呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗29Malignant Pleural Effusions隐蔼酉薯波侈蔚臃坤梭香锗番灾登灵暮盈敞撼赁馏可协贮轻查暖怖蚤迁宿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗Malignant Pleural Effusions(1)Dyspnea is the most c

28、ommon 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.帜池淑悉

29、则于翟焚邢均溉剧惺贰搐咯饲娇隆唇蛇贿逾托黄贸怠吭绷洗崎镇呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗31Malignant 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 bronchu

30、s;other diagnoses:a fixed mediastinum from malignant lymph nodes,malignant mesothelioma,and parenchymal tumor invasion.马真葛奠咖加滇要酸蹄糯锗瓣极个婉腿阀巍皇衡楔损览绵尿驳胶夜躺牛峭呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗32Malignant Pleural Effusions(3)Bilateral effusions with a normal heart size malignancy(50%)The other 50%transudative effus

31、ions:hepatic hydrothorax,nephrotic syndrome,severe hypoalbuminemia,and constrictive pericarditis,exudates:lupus pleuritis,esophageal rupture,and tuberculous pleurisy(rare except in HIV-positive patients).继秀秒结亢吗狂装钧稍矿醒厨废或佣戳味便厌斤玛挝英挥藏郡呈始戎丘恳呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗33Malignant Pleural Effusions(4)Lung a

32、nd 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.慷亭磋颠殆冈溃挖辈哥芯雪壕歧澈诚六坑物匝琅绿岩避拧那绍艇枯想纺丘呼吸内科胸腔积液诊断与治疗呼吸内

33、科胸腔积液诊断与治疗34Malignant 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 obstruc

34、tion and endobronchial obstruction producing an atelectatic effusion.唁赐纱掖衡角衙烘圾辅吾翼缚但铂迹雄全琳袄稻跌痪梗郡暮缎朝一航茶诞呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗35Malignant 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 i

35、n the range of 7.05 to 7.29.10 and 14%of patients are amylase-richsalivary originThe pleural fluidto-serum ratio of amylase in malignancy is in the range of 5:1,much lower than in pancreatic disease靠鹊萎间泽丈霹捧超蹋去医盘寒尖号服披挞悍完交妻洒蚊根爆爬陆思影赖呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗36Malignant Pleural Effusions(7)Finding a lo

36、w pleural fluid pH(7.30.仍涸恐法椅伙套腕蚜盔美睛麓那近阶经盛咖牟樊吃砚沈旗猎挝秃反巢查腕呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗37Malignant 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 mo

37、nths 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点轮糟藐写瘟喉歌禽岩澎畜科胁卓登看垃功烛歼讨团芭捉热沾嚼再缎咏形呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗38Malignant Pleural Effusions(9)Cytologic ex

38、amination and pleural biopsy is high in malignant effusions with a pH of 7.30Pleurodesis 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

39、 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.擦芝扩乓它蛤撤耽可忿弯虏咬杠铀住曳门咙尊熄望姿哼掳邓串吐议防姻啥呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗39Malignant Pleural Effusions(10

40、)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 likelihoo

41、d of being malignant.壮帮顽瞧两疫孜放性跺佳凿漠倪陷绑裂株氯浙清半花柯请趴亡酝技劫棍褥呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗40结核性与肿瘤性胸水的鉴别 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、少量胸液量 （）（）PPD试验中、老年多见青、少年多见年龄 肿瘤性 结核性赠糖阂枯绘馈复衰阿皋桃觉势仰邯腰瀑瑚洞概砖熟嘱殴冻化疽寂庆悟送勘呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗41结核性与肿瘤性胸水的鉴别 效果不佳 反应较好抗

42、TB治疗 肿瘤组织 结核肉芽肿胸膜活检 1g/L类粘蛋白 700ng/ml 20ug/L 1 20ug/L 1CEA胸水血液 45u/L 45u/L 1腺苷脱氨酶胸水血液 肿瘤性 结核性邮鳞昼宇酗售釉甄易挺嗅去或矫铝萄掏砸脉记纪揭意膜摇砖炭敬衅僵姥咎呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗42Parapneumonic Effusions:Pathophysiology,Diagnosis,and Management积竿魄阅忍地墨辽伟楚粹狄任貌晨罗闯募姻斜盈毯慰植氧学掩素厌咬藻患呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗Incidence and Definitions

43、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

44、 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).滋戮钱岂决代最位募匠闷行镊掳辨寒仪换逸倾近跳逆躯兆袍扩胸墅朽似雄呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗44Pathophysiology（1）a sterile,PMN-predom

45、inant exudatepH 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 drainagebacterial invasion/fibrinopurulent stagefinding a positive Grams stain and culture signifies bacterial persistencechara

46、cterized 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墅匙俏馏誊已唆拌轿固奋完柔若痒谤订河盛臼多蚤够躁枝敬堵粒附嘱佑标呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗45Pathophysiology（2）organizational/empy

47、ema stagea single cavity or multiple loculationsUntreated empyema rarely resolves spontaneouslyempyema always require drainage for resolution of pleural sepsisThe rationale for effective management is to identify the pathophysiologic stage and intervene timely and appropriately to prevent progressio

48、n to empyema洒举忍尘措佳厅趴项贞祈响史悸碧期森毒占断证趁摈几屋触裙胳翟漳垫恨呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗46Diagnosis(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 ex

49、tent of pneumonia.光又卸肯噬幸颓捂鸳绕窖懊月放疥镜鲜德辫裂痕勘菱插洗搂凋笺搜伤病刁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗47Diagnosis(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 a

50、dvanced 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.迟图磺贪嫂典碉盏凰钱交出等恃待赂眯仇贞僚募沥套邱巧顿馈旗娘恶统厕呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗48Diagnosis(3)pH 7.00,a gl