胸腔积液诊断与治疗

Diagnosis and Management of Pleural Effusions,呼吸内科：徐作军2002，4，PUMC,Diagnosis of Pleural Effusions,3,Chest Radiograph,Pleural Fluid as the Only Abnormality With Primary Disease in the ChestBilateral EffusionsDiseases Below the DiaphragmInterstitial Lung DiseasePulmonary Nodules,4,1. Pleural Fluid as the Only Abnormality With Primary Disease in the Chest,infections tuberculous and viral pleurisy malignancy cancer, non-Hodgkins lymphoma, and leukemia pulmonary embolism drug-induced lung disease,benign asbestos pleural effusion (BAPE) lymphatic abnormalitieschylothorax and yellow nail syndrome uremic pleurisy constrictive pericarditis hypothyroidism,5,2.Bilateral Effusions,transudative effusionscongestive heart failurenephrotic syndrome hypoalbuminemia peritoneal dialysisconstrictive pericarditis,exudative effusionsmalignancy (extrapulmonic primary carcinomas, lymphoma)lupus pleuritisyellow nail syndrome,6,3.Diseases Below the Diaphragm,transudates hepatic hydrothoraxnephrotic syndromeurinothoraxperitoneal dialysis,exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction,7,4.Interstitial Lung Disease,congestive heart failurerheumatoid arthritisasbestos-induced disease (BAPE and asbestosis)lymphangitic carcinomatosis,Lymphangioleiomyomatosisviral and mycoplasma pneumoniasWaldenstrms macroglobulinemiasarcoidosis Pneumocystis carinii pneumonia,8,5.Pulmonary Nodules,most common causes metastatic carcinoma from a nonlung primary tumor.,Less common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia,9,Value of Pleural Fluid Analysis,In a prospective study of 78 patients with 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),10,Value of Pleural Fluid Analysis,the initial pleural fluid analysis is either definitively or presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of cases.,11,Diagnoses that can be definitively,empyema (pus)malignancytuberculous 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 rupture (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.,13,Exudates Vs Transudates(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 prethoracentesis diagnosis and clinical judgment must be used in the interpretation of pleural fluid analysis.,14,Pleural Fluid NucleatedCell Count(1),rarely helpful in establishing a definitive diagnosis. however, it may provide useful information. 50,000/mL, 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.,15,Pleural Fluid NucleatedCell 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.,16,eosinophilia ( 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 pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.,17,Pleural Fluid pH and Glucose(1),pleural fluid pH 7.30, normal blood pH, exudative effusion empyema, complicated parapneumonic effusion, chronic rheumatoid pleurisy, esophageal rupture, malignancy, tuberculous pleurisy, and lupus pleuritis,18,Pleural Fluid pH and Glucose(2),fluid glucose 60 mg/dL or pleural fluid/serum glucose 0.52 胸水/血清LDH0.63 胸水LDH血清LDH2/3血清LDH,查体、胸片、CT、B超等,进一步检查,23,胸腔积液的诊断程序,渗出液,测胸水淀粉酶、Glu 、细胞学、细胞分类、培养、染色检查、结核标志物检查,Glu 7.27,39,Malignant Pleural Effusions(9),Cytologic examination and pleural biopsy is high in malignant effusions with a pH of 7.30, the glucose is 60 mg/dL, and the lactate dehydrogenase (LDH) is 7.30 on admission virtually always predicted a good outcome with appropriate antibiotic treatment only. pH of 7.10 predicted that pleural space drainage was necessary to resolve pleural sepsis pH between 7.30 and 7.10 at admission had either complicated or uncomplicated effusions; these patients require careful clinical monitoring with further diagnostic testing (repeat thoracentesis, contrast CT scan) before an informed management decision is made.,50,Diagnosis(4),A recent meta-analysis found pleural fluid pH to have the highest diagnostic accuracy in identifying complicated parapneumonic effusions. Pleural fluid pH decision thresholds varied between 7.21 and 7.29 depending on cost-prevalence considerations Current data support treatment with antibiotics and observation in patients with pH values between 7.21 and 7.29. Clinical parameters, repeat pleural fluid analysis, and contrast chest CT should determine management.,51,Management(1),Antibiotics There is little