胸腔积液诊断与治疗.ppt

1,DiagnosisandManagementofPleuralEffusions,呼吸内科：徐作军2002，4，PUMC,2,DiagnosisofPleuralEffusions,3,ChestRadiograph,PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules,4,1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChest,infectionstuberculousandviralpleurisymalignancycancer,non-Hodgkinslymphoma,andleukemiapulmonaryembolismdrug-inducedlungdisease,benignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism,5,2.BilateralEffusions,transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditis,exudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome,6,3.DiseasesBelowtheDiaphragm,transudateshepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysis,exudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction,7,4.InterstitialLungDisease,congestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosis,LymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenstrmsmacroglobulinemiasarcoidosisPneumocystiscariniipneumonia,8,5.PulmonaryNodules,mostcommoncausesmetastaticcarcinomafromanonlungprimarytumor.,LesscommoncausesWegenersranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia,9,ValueofPleuralFluidAnalysis,Inaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses),10,ValueofPleuralFluidAnalysis,theinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.,11,Diagnosesthatcanbedefinitively,empyema(pus)malignancytuberculousfungallupuspleuritis(lupuserythematosuscells)chylothorax(triglycerides110mg/dLorpresenceofchylomicrons)hemothorax(pleuralfluid/bloodhematocrit0.5)urinothorax(pleuralfluid/serumcreatinine1.0),peritonealdialysis(totalprotein0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.,13,ExudatesVsTransudates(2),pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.,14,PleuralFluidNucleatedCellCount(1),rarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.,15,PleuralFluidNucleatedCellCount(2),exudatepleuralfluidwithalymphocytecountof80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.,16,eosinophilia(10%ofthetotalnucleatedcellsareeosinophils)mostcommonlypneumothoraxandhemothorax,BAPE,pulmonaryembolismwithinfarction,previousthoracentesis,parasiticdisease(paragonimiasis),fungaldisease,drug-inducedlungdisease,Hodgkinslymphoma,carcinoma.Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions.,17,PleuralFluidpHandGlucose(1),pleuralfluidpH7.30,normalbloodpH,exudativeeffusionempyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis,18,PleuralFluidpHandGlucose(2),fluidglucose0.63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,Glu7.27,39,MalignantPleuralEffusions(9),CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof7.30,theglucoseis60mg/dL,andthelactatedehydrogenase(LDH)is7.30onadmissionvirtuallyalwayspredictedagoodoutcomewithappropriateantibiotictreatmentonly.pHof7.10predictedthatpleuralspacedrainagewasnecessarytoresolvepleuralsepsispHbetween7.30and7.10atadmissionhadeithercomplicatedoruncomplicatedeffusions;thesepatientsrequirecarefulclinicalmonitoringwithfurtherdiagnostictesting(repeatthoracentesis,contrastCTscan)beforeaninformedmanagementdecisionismade.,50,Diagnosis(4),Arecentmeta-analysisfoundpleuralfluidpHtohavethehighestdiagnosticaccuracyinidentifyingcomplicatedparapneumoniceffusions.PleuralfluidpHdecisionthresholdsvariedbetween7.21and7.29dependingoncost-prevalenceconsiderationsCurrentdatasupporttreatmentwithantibioticsandobservationinpatientswithpHvaluesbetween7.21and7.29.Clinicalparameters,repeatpleuralfluidanalysis,andcontrastchestCTshoulddeterminemanagement.,51,Management(1),AntibioticsThereislittledifferenceinpenetrationofthepenicillinsandcephalosporinsintoempyemasanduninfectedparapneumonicfluids.Drugsthatshowexcellentpleuralpenetrationincludeaztreonam,clindamycin,ciprofloxacin,cephalothin,andpenicillinAminoglycosidesmaybeinactivatedorhavepoorerpenetrationintoempyemasthanuncomplicatedparapne