胸腔积液ppt课件.ppt

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1、 胸腔积液胸腔积液 pleural effusion大连医科大学附属第一医院消化wgjDefinitionv 正正常常胸胸腔腔内内有有微微量量液液体体起起润润滑滑作作用用。其其产生与吸收处于动态平衡。产生与吸收处于动态平衡。v 当当产产生生增增加加或或吸吸收收减减少少，胸胸膜膜腔腔内内液液体体积聚，便形成积聚，便形成胸腔积液。胸腔积液。vGeneral Considerations:Pleural fluid is formed in the normal individual mostly on the parietal pleural surface at the rate of abou

2、t 0.1mL/kg body weight/h.nAbsorption of fluid occurs mostly through visceral pleural capillaries,while protein is recovered through parietal pleural lymphatics.The resultant homeostasis leaves 5-15mL of fluid normally present in the pleural space.nThe five major types of pleural effusion are transud

3、ates,exudates,empyema,hemorrhagic pleural effusion or hemothorax,and or chyliform effusion.胸腔积液产生与吸收的机制 胸腔内负压(5)胸腔内胶体渗透压(8 cm H2O)淋巴回流 毛细血管胶体渗透压 毛细血管静水压30cm H2O 34cm H2O 11cm H2O 壁层胸膜脏层胸膜 液体渗出压力梯度（5830）349cm H2O 液体再吸收压力梯度34（5811）10cm H2O 胸膜腔胸膜腔（体循环cap）（进入）（肺循环cap）（吸收）n壁层胸膜液体进入胸膜腔压力梯度：壁层胸膜液体进入胸膜腔压力梯度

4、：9 9cmHcmH2 2O On 毛细血管静水压毛细血管静水压 3030cmHcmH2 2O On 胸膜腔负压胸膜腔负压 5 5cmHcmH2 2O On 胸膜腔胶体渗透压胸膜腔胶体渗透压 8 8cmHcmH2 2O On 毛细血管胶体渗透压毛细血管胶体渗透压3434cmHcmH2 2O On脏层胸膜液体从胸膜腔回收压力梯度：脏层胸膜液体从胸膜腔回收压力梯度：1010cmHcmH2 2O On毛细血管静水压毛细血管静水压 1111cmHcmH2 2O On 胸膜腔负压胸膜腔负压 5 5cmHcmH2 2O On 胸膜腔胶体渗透压胸膜腔胶体渗透压 8 8cmHcmH2 2O On 毛细血管胶体

5、渗透压毛细血管胶体渗透压3434cmHcmH2 2O On 淋巴回流。淋巴回流。n胸腔积液的形成：胸腔积液的形成：n 上述胸液滤出和再吸收压力梯度失衡或胸膜面积变化上述胸液滤出和再吸收压力梯度失衡或胸膜面积变化n 淋巴管引流受影响淋巴管引流受影响【Pathogenesy】一一、毛毛细细血血管管静静水水压压增增高高：充充血血性性心心衰衰、缩缩窄窄性性心包炎等心包炎等体循环或肺循环静水压增加。漏出液为主体循环或肺循环静水压增加。漏出液为主二二、毛毛细细血血管管通通透透性性增增加加：胸胸膜膜炎炎症症、胸胸膜膜肿肿瘤瘤、全身性疾病等。渗出液（胸水胶渗压升高）全身性疾病等。渗出液（胸水胶渗压升高）三三、

6、血血浆浆胶胶体体渗渗透透压压降降低低：低低蛋蛋白白血血症症：肝肝硬硬化化、肾病综合征。漏出液肾病综合征。漏出液四、淋巴管引流障碍：癌症淋巴管阻塞。渗出液四、淋巴管引流障碍：癌症淋巴管阻塞。渗出液五五、损损伤伤所所致致胸胸腔腔内内出出血血：外外伤伤，主主A A瘤瘤破破裂裂；血性、脓性、乳糜性均属渗出液。血性、脓性、乳糜性均属渗出液。n主要病因和积液性质：参见讲义 P144 表2131Essentials of DiagnosisnAsymptomatic in many cases;pleurtic chest pain if pleuritis is present;dyspnea if ef

7、fusion is large.nDecreased tactile fremitus;dullness to percussion;distant breath sounds;egophony if effusion is large.nRadiographic evidence of pleural effusion.nDiagnostic findings on thoracentesis.【Clinical Manifestation】n症状症状n胸痛：大量积液时，气急加重，胸痛消失。胸痛：大量积液时，气急加重，胸痛消失。PleuriticPleuritic chest pain an

8、d dry cough chest pain and dry coughn呼吸困难：呼吸困难：300-500300-500mlml Small Small pleural pleural effusions effusions are are usually usually asymptomaticasymptomatic,whereas large pleural effusions may cause whereas large pleural effusions may cause dyspneadyspnean体征体征（1）：n气管移位：大量胸水可伴气管、纵隔移向健侧。气管移位：大量胸

9、水可伴气管、纵隔移向健侧。n呼吸动度减弱呼吸动度减弱n叩浊音，叩浊音，n呼吸音降低，胸膜摩擦音。呼吸音降低，胸膜摩擦音。n体征体征（2）Physical findings are absent if less than 200-300mL of pleural fluid is present.Signs consistent with a larger pleural effusion include decrease in tactile fremitus,dullness to percussion,and diminution of breath sounds over the eff

10、usion.n原发病的症状、体征原发病的症状、体征：结核中毒症状，结核中毒症状，恶液质，恶液质，体循环瘀血表现。体循环瘀血表现。影象诊断（影象诊断（imageimage）（）（1 1）1、胸液胸液0.30.50.30.5L L时，肋隔角变纯；时，肋隔角变纯；About 250mL of pleural fluid must be present before About 250mL of pleural fluid must be present before effusion can be detected on conventional erect effusion can be dete

11、cted on conventional erect posteroanterior posteroanterior chest radiograph.chest radiograph.2 2、更多的积液可见液性曲线（外高、内低的弧形上缘）、更多的积液可见液性曲线（外高、内低的弧形上缘）,随体位变化。随体位变化。3 3、液气胸时可见液平面。、液气胸时可见液平面。4 4、局限性积液（包裹性胸腔积液）：叶间积液、肺底积、局限性积液（包裹性胸腔积液）：叶间积液、肺底积液。液。5、积液量的判断：积液量的判断：2 2、4 4前肋前肋影象诊断（影象诊断（imageimage）（）（2 2）6 6、单侧大量

12、积液：、单侧大量积液：CaCa、TBTB、其他。其他。Massive pleural effusion(Massive pleural effusion(opacification opacification of an of an entire entire hemithoraxhemithorax)is commonly caused by)is commonly caused by cancer but has been observed in tuberculosis cancer but has been observed in tuberculosis and other dise

13、ases.and other diseases.CT检查少量积液少量积液:CT scanning is sensitive in the detection of small amounts of pleural fluid.包裹性胸腔积液包裹性胸腔积液肺肺内内、纵纵隔隔、胸胸膜膜的的病病变变：如肺内肿瘤，胸膜间皮瘤等。超声检查：定位(用于局限性胸水或者粘连分隔胸水的诊治）、鉴别胸腔积液或胸膜肥厚 Ultrasound is useful to locate loculated or small effusions.【laboratory findings】Diagnostic thorace

14、ntesis should be performed whenever a pleural effusion is detected and no cause for the effusion is clinically apparent.常规检查：常规检查：v外观外观：淡黄色、草黄色、血性、黄脓性淡黄色、草黄色、血性、黄脓性 巧克力样乳白色、黑、绿色巧克力样乳白色、黑、绿色v细胞：细胞：红细胞：红细胞：白细胞：白细胞：生化检查生化检查vpH：n结核性、肺炎并胸腔积液、类风湿结核性、肺炎并胸腔积液、类风湿7.30n脓胸脓胸7.0n肿瘤性、肿瘤性、SLE 7.35v蛋白质蛋白质:v葡萄糖:（胸液

15、血糖）结核性、肺炎并胸腔积液、类风湿、少数肿瘤性结核性、肺炎并胸腔积液、类风湿、少数肿瘤性 、脓胸、脓胸3.353.35，类风湿、脓胸可，类风湿、脓胸可1.101.10 肿瘤性、漏出液肿瘤性、漏出液 3.353.35mmolmmol/L/Lv类脂：乳糜胸：甘油三脂乳糜胸：甘油三脂，苏丹三染色（苏丹三染色（+）外伤、肿瘤、寄生虫外伤、肿瘤、寄生虫胸导管压迫破裂所致胸导管压迫破裂所致假性乳糜胸：胆固醇假性乳糜胸：胆固醇 苏丹三染色（苏丹三染色（-）见于结核性类风湿、癌性、肝硬化等见于结核性类风湿、癌性、肝硬化等酶学酶学vADA（腺苷脱氨酶）：腺苷脱氨酶）：45 结核肺炎结核肺炎 ca性、风湿性性、

16、风湿性80um/L,恶性恶性1015ug/L或胸液/血清CEA1，提示恶性胸水 CEA20ug/L，胸液/血CEA1诊断恶性胸水的敏感性和特异性均超过90。vCA（血清糖链肿瘤相关抗原）：胸水中血清 CA50 20u/ml，考虑恶性胸水vCEA、CA50、CA125、CA19-9 等联合测试诊断恶性胸水，有利于提高敏感性和特异性。细胞学检查细胞学检查v瘤瘤细胞：细胞：恶性胸水约恶性胸水约4080可检出恶性细胞，多次可检出恶性细胞，多次检查可提高阳性率。检查可提高阳性率。vDNA：应用应用DNA流式细胞分析仪免疫组织化学分别检流式细胞分析仪免疫组织化学分别检出胸液中细胞出胸液中细胞DNA含量和恶

17、性肿瘤细胞重要相含量和恶性肿瘤细胞重要相关抗原，用于诊断恶性胸水，与细胞学检查联关抗原，用于诊断恶性胸水，与细胞学检查联合可显著提高敏感性。合可显著提高敏感性。v间皮细胞：非结核性间皮细胞：非结核性5；结核性；结核性1%病原学检查病原学检查n离心沉淀物：可行普通细菌、真菌、结核分枝杆菌等培养；涂片革兰染色或抗酸染色分别查找普通细菌、真菌、结核分枝杆菌。n胸液有时需行厌氧菌培养、寄生虫检测。组织学检查组织学检查nClosed pleural biopsy with a Cope or Abrams needle should be considered whenever malignancy o

18、r tuberculosis is considered in the differential diagnosis of a pleural effusion that is unexplained after routine studies and thoracentesis.nOpen pleural biopsy is sometimes required to establish the diagnosis of pleural malignancy and is especially indicated for the diagnosis of malignant pleural

19、mesothelioma.n胸膜活检：ca、TB阳性率 3070n胸腔镜或纤支镜代胸腔镜：阳性率 75-98 良、恶性胸腔积液的鉴别诊断良、恶性胸腔积液的鉴别诊断n（见下页）【treatment】(1)Treatment should address both the disease causing the pleural effusion and the effusion itself.Transudative pleural effusions generally respond to treatment of the underlying condition;therapeutic th

20、oracentesis is indicated only if massive effusion causes dyspnea.一、结核性胸膜炎一、结核性胸膜炎1、抗结核治疗、抗结核治疗【treatment】(2)2、胸腔穿刺、胸腔穿刺：n 诊断性穿刺：诊断性穿刺：n 治治疗疗性性穿穿刺刺：1000ml/次次，抽抽液液速速度度不不易易过过快快，以以防防复复张张后后肺肺水水肿肿和和循循环环障障碍碍。抽抽液液过过程程中中如如有有胸胸膜膜反反应应，应应立立即即停停止止抽抽液液，使使患患者者平平卧卧位位，必必要要时时皮皮下下注注射射0.1%肾肾上上腺腺素素0.5ml，密密切切观观察察病病情情，防止休

21、克。防止休克。3、糖皮质激素的应用、糖皮质激素的应用 在抗痨基础上加用皮质在抗痨基础上加用皮质激素，强的松激素，强的松2530mg/日，渐减量，一般日，渐减量，一般疗程为疗程为46个周。个周。二、恶性胸腔积液恶性胸腔积液(1)1、反复胸腔穿刺抽液。反复胸腔穿刺抽液。In cancer patients with malignant pleural effusion,the pleural surface is directly invaded by malignant cells In such cases the tumor causing the effusion is unresecta

22、ble.2、全身化疗或局部化疗、全身化疗或局部化疗 经全身化疗，约经全身化疗，约1/3病人胸水消失。病人胸水消失。将将胸胸水水排排空空，经经引引流流管管注注入入抗抗肿肿瘤瘤药药物物，如如DDP、5FU等，既杀癌细胞又引起胸膜粘连。等，既杀癌细胞又引起胸膜粘连。胸胸膜膜腔腔注注入入生生物物免免疫疫调调节节剂剂：IL2、干干扰扰素素、cp、沙培林沙培林OK43、LAK细胞等。细胞等。恶性胸腔积液恶性胸腔积液(2)3、胸膜粘连术、胸膜粘连术 Chemical pleurodesis(obliteration of the pleural space by producing fibrous adhe

23、sion between the visceral and the parietal pleura)is advised for selected patients with symptomatic malignant pleural effusion who fail to respond to chemotherapy or mediastinal radiation or who are not candidates for these forms of therapy.采采用用四四环环素素（2g)、滑滑石石粉粉（5g)、多多西西环环素素等等粘粘连连剂剂，使使胸膜腔闭锁阻止积液复发。胸膜

24、腔闭锁阻止积液复发。三、化脓性胸腔积液（脓胸）（1）n炎性胸水：有以下情况需插管引流 (1)the fluid resembles frank pus or bacteria are seen on Gram stain,(2)pleural fluid glucose is 40mg/dL (3)pleural fluid pH is 7.2n有包裹积液？：A parapneumonic effusion that does not respond to drainage within 24 hours may have become loculated.nB超定位：In such case

25、s,ultrasound examination is required to guide placement of an additional chest tube in the proper location.n手术：Open surgical drainage may be necessary if these measures are ineffective.三、化脓性胸腔积液（脓胸）（2）n病原体：金葡菌、厌氧菌、G-杆菌、TB菌、放线菌n急性期：全身和胸腔内给药 胸穿、肋间切开引流 2NaHCO3 冲洗 注入抗生素或抗痨药（结核性）n慢性期：胸膜增厚、肺被包裹不能张开，影响心肺功 能胸膜剥脱术 支气管胸膜瘘瘘管结扎、胸廓改形术 营养支持、纠正电介质及酸碱失衡ThanksThanks！