第二篇-第十一章-结核性胸膜炎.ppt

,结核性胸膜炎（TuberculousPleuralEffusion）,第二篇呼吸系统疾病,赵建平,学时数：1学时,第十一章,讲授目的和要求,1.掌握结核性胸膜炎的诊断及鉴别诊断。2.掌握结核性胸膜炎的治疗原则。,讲授主要内容,概述病因和发病机制病理临床表现实验室和其他检查诊断标准鉴别诊断治疗,Anatomy：解剖学：Visceralpleura脏层胸膜Parietalpleura壁层胸膜Latentspace潜在腔隙,概述,I.Etiology:Mycobacteriumtuberculosis病因：结核分枝杆菌,病因和发病机制,DiscoveredbyDr.Kochin1882由Dr.Koch于1882年发现Acid-fast抗酸染色性,Pathogenesis:twotheories发病机制：两种学说Delayedhypersensitivereaction迟发性高敏反应Pleuralinfection胸膜感染,1.Pleuralcongestionwithcellinfiltration,unilateralinmostcases.胸膜充血，细胞浸润，多数病例累及单侧胸膜,病理,Intheearlystage,polymorphspredominate.早期以多型核细胞为主Typically,lymphocytespredominate.典型表现以淋巴细胞为主2.Tuberculousnodules结核结节3.Exudativeeffusion渗出液,临床表现,Symptoms症状Age,oftenseeninyoungpeople,butalsoinelderlypeople1.年龄，多见于年轻人，但也可见于老年人Fever,typically3738C,butcanbe39C2.发热，典型者37-38C，但也有39C者,Chestpain,moreseverewhenthereisonlylittlefluid.3.胸痛，胸水少时明显Breathlessness,whenthereisalotoffluid.4.气短，胸水多时明显,Physicalsigns体征Inspection:fullnessofchestintheinvolvedside.1.视诊：患侧胸廓饱满2.Palpation:tracheashiftstotheotherside,weaknessofvocalfremitus.2.触诊：气管向健侧移位，触觉语颤减低,3.Percussion:dullnessintheinvolvedside.3.叩诊：患侧实音4.Auscultation:disappearanceofbreathingsound4.听诊：患侧呼吸音消失,实验室和其他检查,1.ChestX-ray胸片Fluidisvisibleonlywhenmorethan300ml.胸水超过300ml时胸片可以发现CTisneededinafewcases.少数病例需做CT,Pericardialeffusion心包积液,2.Ultrasonicexamination超声检查MoreaccuratethanX-rays.诊断胸水比X线准确Canprovidevitalinformationforthoracentesis.能为胸腔穿刺术提供关键资料,3.Thoracentesisandfluidexamination-essential胸腔穿刺术诊断的关键,(1)Fluidroutine-exudate胸水常规渗出液specificgravity1.018;比重1.018WBC500/cmm,predominatedbypolymorphsatearlystageandlymphocyteslater白细胞计数500/cmm,早期以多型核细胞为主，以后以淋巴细胞为主protein3gram/dl蛋白含量3gram/dl,(2)Acid-faststainingforacid-fastbacilli(notsensitive).(2)抗酸染色（不敏感）(3)Culturefortuberculousbacilli(timeconsuming).(3)结核杆菌培养（费时间）(4)Others:cultureforbacteria,cytologicalexam,etc.(4)其他：细菌培养，细胞学检查，等等,4.Pleuralneedlebiopsy-tub.granuloma4.胸膜活检发现结核结节5.Others:Eos.count,liverfunction,immunoglobulin,5.其他检查：血嗜酸细胞计数，肝功能，免疫球蛋白，等等,symptoms+physicalsigns+fluidexam.症状体征胸水检查retrospective,exclusive.回顾性，排他性,诊断标准,Istherepleuraleffusion?有无胸水？Isittransudateorexudate?胸水是漏出液还是渗出液？Whatisthespecificetiology?胸水的病因是什么？,鉴别诊断,Transudate漏出液1.Heartdiseases心脏病2.Kidneydiseases肾脏病3.Liverdiseases肝脏病4.Malnutrition营养不良5.Endocrinediseases内分泌疾病,Exudate渗出液1.tumorousdiseases1.肿瘤类疾病2.bacterialinfectionempyemapurulentfluidreactivepleuralfluid2.细菌感染脓胸脓性胸水反应性胸水,3.connectivetissuediseases3.结缔组织疾病4.parasiteinfection,suchasparagonimiasis4.寄生虫感染，如肺吸虫病5.Others5.其他,anti-tuberculouschemotherapy1.抗结核病化疗Inthesamewayaspul.Tuberculosis与肺结核相同,治疗,Keys关键Initiatetreatmentasearlyaspossible早期Usemultipledrugregimen联合Useadequatedosage适量Givemedicinesinaregularbases规律Treatpatientslong