胸腔积液的定义课件

胸腔积液pleuraleffusionDefinition正常胸腔内有微量液体起润滑作用。其产生与吸收处于动态平衡。当产生增加或吸收减少，胸膜腔内液体积聚，便形成胸腔积液。GeneralConsiderations:Pleuralfluidisformedinthenormalindividualmostlyontheparietalpleuralsurfaceattherateofabout0.1mL/kgbodyweight/h.Absorptionoffluidoccursmostlythroughvisceralpleuralcapillaries,whileproteinisrecoveredthroughparietalpleurallymphatics.Theresultanthomeostasisleaves5-15mLoffluidnormallypresentinthepleuralspace.Thefivemajortypesofpleuraleffusionaretransudates,exudates,empyema,hemorrhagicpleuraleffusionorhemothorax,andorchyliformeffusion.壁层胸膜液体进入胸膜腔压力梯度：9cmH2O毛细血管静水压30cmH2O胸膜腔负压5cmH2O胸膜腔胶体渗透压8cmH2O毛细血管胶体渗透压34cmH2O脏层胸膜液体从胸膜腔回收压力梯度：10cmH2O毛细血管静水压11cmH2O胸膜腔负压5cmH2O胸膜腔胶体渗透压8cmH2O毛细血管胶体渗透压34cmH2O淋巴回流。胸腔积液的形成：上述胸液滤出和再吸收压力梯度失衡或胸膜面积变化淋巴管引流受影响【Pathogenesy】一、毛细血管静水压增高：充血性心衰、缩窄性心包炎等→体循环或肺循环静水压增加。漏出液为主二、毛细血管通透性增加：胸膜炎症、胸膜肿瘤、全身性疾病等。渗出液（胸水胶渗压升高）三、血浆胶体渗透压降低：低蛋白血症：肝硬化、肾病综合征。漏出液四、淋巴管引流障碍：癌症淋巴管阻塞。渗出液五、损伤所致胸腔内出血：外伤，主A瘤破裂；血性、脓性、乳糜性均属渗出液。主要病因和积液性质：参见讲义P144表2－13－1EssentialsofDiagnosisAsymptomaticinmanycases;pleurticchestpainifpleuritisispresent;dyspneaifeffusionislarge.Decreasedtactilefremitus;dullnesstopercussion;distantbreathsounds;egophonyifeffusionislarge.Radiographicevidenceofpleuraleffusion.Diagnosticfindingsonthoracentesis.体征（2）

Physicalfindingsareabsentiflessthan200-300mLofpleuralfluidispresent.Signsconsistentwithalargerpleuraleffusionincludedecreaseintactilefremitus,dullnesstopercussion,anddiminutionofbreathsoundsovertheeffusion.原发病的症状、体征：结核中毒症状，恶液质，体循环瘀血表现。影象诊断（image）（2）6、单侧大量积液：Ca、TB、其他。Massivepleuraleffusion(opacificationofanentirehemithorax)iscommonlycausedbycancerbuthasbeenobservedintuberculosisandotherdiseases.【laboratoryfindings】Diagnostic

thoracentesisshouldbeperformedwheneverapleuraleffusionisdetectedandnocausefortheeffusionisclinicallyapparent.常规检查：外观：淡黄色、草黄色、血性、黄脓性巧克力样乳白色、黑、绿色细胞：红细胞：白细胞：生化检查pH：结核性、肺炎并胸腔积液、类风湿＜7.30脓胸＜7.0肿瘤性、SLE＞7.35蛋白质:酶学ADA（腺苷脱氨酶）：＞45

结核＞肺炎

ca性、风湿性<45u/LLDH：＞500，见于化脓性、恶性NSE（神经烯醇化酶）：ca性增高溶菌酶：肺炎＞结核

TB>80um/L,恶性<65CEA(癌胚抗原）：CEA>10－15ug/L或胸液/血清CEA>1，提示恶性胸水CEA>20ug/L，胸液/血CEA>1诊断恶性胸水的敏感性和特异性均超过90％。CA（血清糖链肿瘤相关抗原）：胸水中>血清CA50>20u/ml，考虑恶性胸水CEA、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。病原学检查离心沉淀物：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。胸液有时需行厌氧菌培养、寄生虫检测。组织学检查ClosedpleuralbiopsywithaCopeorAbramsneedleshouldbeconsideredwhenevermalignancyortuberculosisisconsideredinthedifferentialdiagnosisofapleuraleffusionthatisunexplainedafterroutinestudiesandthoracentesis.Openpleuralbiopsyissometimesrequiredtoestablishthediagnosisofpleuralmalignancyandisespeciallyindicatedforthediagnosisofmalignantpleuralmesothelioma.胸膜活检：ca、TB阳性率30－70％胸腔镜或纤支镜代胸腔镜：阳性率75-98％【treatment】(1)Treatmentshouldaddressboththediseasecausingthepleuraleffusionandtheeffusionitself.Transudativepleuraleffusionsgenerallyrespondtotreatmentoftheunderlyingcondition;therapeuticthoracentesisisindicatedonlyifmassiveeffusioncausesdyspnea.一、结核性胸膜炎1、抗结核治疗

【treatment】(2)2、胸腔穿刺：

诊断性穿刺：治疗性穿刺：<1000ml/次，抽液速度不易过快，以防复张后肺水肿和循环障碍。抽液过程中如有胸膜反应，应立即停止抽液，使患者平卧位，必要时皮下注射0.1%肾上腺素0.5ml，密切观察病情，防止休克。3、糖皮质激素的应用

在抗痨基础上加用皮质激素，强的松25~30mg/日，渐减量，一般疗程为4~6个周。

恶性胸腔积液(2)3、胸膜粘连术

Chemicalpleurodesis(obliterationofthepleuralspacebyproducingfibrousadhesionbetweenthevisceralandtheparietalpleura)isadvisedforselectedpatientswithsymptomaticmalignantpleuraleffusionwhofailtorespondtochemotherapyormediastinalradiationorwhoarenotcandidatesfortheseformsoftherapy.采用四环素（<2g)、滑石粉（<5g)、多西环素等粘连剂，使胸膜腔闭锁阻止积液复发。三、化脓性胸腔积液（脓胸）（1）炎性胸水：有以下情况需插管引流(1)thefluidresemblesfrankpusorbacteriaareseenonGramstain,(2)pleuralfluidglucoseis<40mg/dL(3)pleuralfluidpHis<7.2有包裹积液？：Aparapneumoniceffusionthatdoesnotrespondtodrainagewithin24hoursmayhavebecomeloculated.B超定位：Insuchcases,ultrasoundexaminationisrequiredtoguideplacementofanadditionalchesttubeintheproperlocation.手术：Opensurgicaldrainagemaybenecessaryifthesemeasuresareineffective.三、化脓性