胸腔积液的定义PPT课件.pptVIP

,胸腔积液pleuraleffusion,Definition,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.,胸腔积液产生与吸收的机制,30cmH2O,34cmH2O,11cmH2O,壁层胸膜,脏层胸膜,液体渗出压力梯度（5830）349cmH2O,液体再吸收压力梯度34（5811）10cmH2O,胸膜腔,（体循环cap）（进入）,（肺循环cap）（吸收）,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2131,EssentialsofDiagnosis,Asymptomaticinmanycases;pleurticchestpainifpleuritisispresent;dyspneaifeffusionislarge.Decreasedtactilefremitus;dullnesstopercussion;distantbreathsounds;egophonyifeffusionislarge.Radiographicevidenceofpleuraleffusion.Diagnosticfindingsonthoracentesis.,【ClinicalManifestation】,症状胸痛：大量积液时，气急加重，胸痛消失。Pleuriticchestpainanddrycough呼吸困难：300-500mlSmallpleuraleffusionsareusuallyasymptomatic,whereaslargepleuraleffusionsmaycausedyspnea体征（1）：气管移位：大量胸水可伴气管、纵隔移向健侧。呼吸动度减弱叩浊音，呼吸音降低，胸膜摩擦音。,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）（1）,1、胸液0.30.5L时，肋隔角变纯；About250mLofpleuralfluidmustbepresentbeforeeffusioncanbedetectedonconventionalerectposteroanteriorchestradiograph.2、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。3、液气胸时可见液平面。4、局限性积液（包裹性胸腔积液）：叶间积液、肺底积液。5、积液量的判断：2、4前肋,影象诊断（image）（2）,6、单侧大量积液：Ca、TB、其他。Massivepleuraleffusion(opacificationofanentirehemithorax)iscommonlycausedbycancerbuthasbeenobservedintuberculosisandotherdiseases.,CT检查,少量积液:CTscanningissensitiveinthedetectionofsmallamountsofpleuralfluid.包裹性胸腔积液肺内、纵隔、胸膜的病变：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Ultrasoundisusefultolocateloculatedorsmalleffusions.,【laboratoryfindings】,Diagnosticthoracentesisshouldbeperformedwheneverapleuraleffusionisdetectedandnocausefortheeffusionisclinicallyapparent.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、SLE7.35蛋白质:,葡萄糖:（胸液血糖）结核性、肺炎并胸腔积液、类风湿、少数肿瘤性、脓胸3.35，类风湿、脓胸可1，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。CA（血清糖链肿瘤相关抗原）：胸水中血清CA5020u/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。,细胞学检查,瘤细胞：恶性胸水约4080可检出恶性细胞，多次检查可提高阳性率。DNA：应用DNA流式细胞分析仪免疫组织化学分别检出胸液中细胞DNA含量和恶性肿瘤细胞重要相关抗原，用于诊断恶性胸水，与细胞学检查联合可显著提高敏感性。间皮细胞：非结核性5；结核性1%,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3070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,（见下页）,【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2530mg/日，渐减量，一般疗程为46个周。,二、恶性胸腔积液(1),1、反复胸腔穿刺抽液。Incancerpatientswithmalignantpleuraleffusion,thepleuralsurfaceisdirectlyinvadedbymalignantcellsInsuchcasesthetumorcausingtheeffusionisunresectable.2、全身化疗或局部化疗经全身化疗，约1/3病人胸水消失。将胸水排空，经引流管注入抗肿瘤药物，如DDP、5FU等，既杀癌细胞又引起胸膜粘连。胸膜腔注入生物免疫调节剂：IL2、干扰素、cp、沙培林OK43、LAK细胞等。,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)pleuralfluidglucoseis40mg/dL(3)pleuralfluidpHis7.2有包裹积液？：Aparapneumoniceffusionthatdoesnotrespondtodrainagewithin24hoursmayhavebecomeloculated.B超定位：Insuchcases,ultrasoundexaminationisrequiredtoguideplacementofanadditional