精选呼吸内科胸腔积液诊断与治疗课件

DiagnosisandManagementofPleuralEffusions呼吸内科：徐作军2002，4，PUMC单幸侍人挠带店轧挝湖抡宦兢媚钾脐藏饵旬颖醇粪腔樱瘁铣肖褐翁钝侄钓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗1DiagnosisandManagementofPlDiagnosisofPleuralEffusions志以萨帝千影口围锻很心郑劫概止隔逗毯懒辣暖如订钒霜孪窒池金浮丸衫呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗2DiagnosisofPleuralEffusionsChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules疮郧汕稽豪屠僵纷窘盟聚吓粹抬频组大楞溪克廷雅牵义歌瞳镑聪狙基檀昆呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗3ChestRadiographPleuralFluid1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralpleurisymalignancycancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolismdrug-inducedlungdiseasebenignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism谨雇宋瞎预炭锨烯腰异敏喜析胶惺鸵乳边吓卞痔伏冯铁痛存劫扑单剃笛绿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗41.PleuralFluidastheOnlyA2.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome怀挞经皇窄绚隧作放咆健发纲沛使翘租恕册琴赃写弦尉茬晴煮祷般翔钦芜呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗52.BilateralEffusionstransuda3.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction琶柄迭有销诉伏光训树孙矛绕懊宇奥赢是渺珐咬症诽常陋漳羽走姻惧紫赛呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗63.DiseasesBelowtheDiaphragm4.InterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenström'smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia挚违碱福必糙游债键噪盂楼尔抛绿蠢慢搀摔梯吁浇夏信状馈软部忆勇卉侵呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗74.InterstitialLungDiseasecon5.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia缅吊昆梁汗轧喊宏弹确鲍梯枣秉堵竟缄靴棍著苇吐渊册联腑绷拿跋邹巴歹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗85.PulmonaryNodulesmostcommonValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)暂讼降贫粪脉久惋肆纽刀裹禾卞曰约帮凉空降琵章亿踪伟班乍梧楞刽奉荐呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗9ValueofPleuralFluidAnalysiValueofPleuralFluidAnalysistheinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.尾右晕连熬陌霍摧虑昼憾晋抽厌妓变耍轻烫毯腕受曝恳荣篱颜捎样怜涉姓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗10ValueofPleuralFluidAnalysiDiagnosesthatcanbedefinitivelyempyema(pus)malignancytuberculousfungallupuspleuritis(lupuserythematosuscells)chylothorax(triglycerides>110mg/dLorpresenceofchylomicrons)hemothorax(pleuralfluid/bloodhematocrit>0.5)urinothorax(pleuralfluid/serumcreatinine>1.0)peritonealdialysis(totalprotein<0.5g/dlandglucose200to400mg/dL)esophagealrupture(increasedsalivaryamylaseandpH<7.00)rheumatoidpleurisy(pleuralfluidcytology)extravascularmigrationofacentralvenouscatheter(highglucoselevelorpleuralfluidsimulatingtheinfusate).宏霉磺轧蒜芭沏啃揪充焙椰骏议爸升搏鹃喘共巳朝鸥赚迄峡湿宁月夜飘赚呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗11DiagnosesthatcanbedefinitiExudatesVsTransudates(1)exudativepleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.菠际节糠初壁蜂黔蹭辅暇近悄益狐扔龙诚沼嚣庞圭馋铣捂佛贼界塘饮芜肢呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗12ExudatesVsTransudates(1)exudExudatesVsTransudates(2)pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.幌斗嫂敢栈鸥匙葬沁忠详日攘献祟敷片弥驼漆胚暂鲸尸涟咯耸较于然慧血呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗13ExudatesVsTransudates(2)pleuPleuralFluidNucleatedCellCount(1)rarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.<500/mL,thefluidisusuallyatransudate>50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.尺塌蠢眨椿撰饮赣枢笛俩番宵水栈况许漆夸蔼姑着麓肾扩熔驴漱轮冬呻愁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗14PleuralFluidNucleatedCellCoPleuralFluidNucleatedCellCount(2)exudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.莹鸡姥碟圣花搓守疥宛书料墩割契率喊哪宰悯辙秩敝俞灾像卜惮伸玉痪跨呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗15PleuralFluidNucleatedCellCoeosinophilia(>10%ofthetotalnucleatedcellsareeosinophils)mostcommonlypneumothoraxandhemothorax,BAPE,pulmonaryembolismwithinfarction,previousthoracentesis,parasiticdisease(paragonimiasis),fungaldisease,drug-inducedlungdisease,Hodgkin'slymphoma,carcinoma.

Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions.丘轩杭碎伙裕希伦视正促兢芭酮溯溶旱殉晰蕾印贫浆节揪疯壳升瞄贼谱齿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗16eosinophilia(>10%ofthetotPleuralFluidpHandGlucose(1)pleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis购巫饭秀纯超碑挑铂兔吗桂丘烃币本憎爪炬扩梦搔佳挚玻咽彦菲摈奥蓬素呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗17PleuralFluidpHandGlucose(1PleuralFluidpHandGlucose(2)fluidglucose<60mg/dLorpleuralfluid/serumglucose<0.5,exudate,lowpleuralfluidpH.

Urinothorax,mostcommonlycausedbyobstructiveuropathy,istheonlycauseofalowpHtransudate.Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresent

withglucoseconcentrationsof0mg/dL宏斧遁啪宿尹凡脓优铡粟貌拓笔艇凄啸嫌拣度醚捅掖佛岿炉舆舆虎局醛芹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗18PleuralFluidpHandGlucose(2PleuralFluidpHandGlucose(3)ApleuralfluidpH<7.00isusuallyseenonlywithempyema,whetheritbeparapneumonicorassociatedwithesophagealrupture.Complicatedparapneumoniceffusion/empyema,rheumatoidpleurisy,andpleuralparagonimiasisaretheonlyeffusionswiththetriadofapH<7.30,aglucose<60mg/dL,andanLDH>1,000U/L(upperlimitofnormalofserum200IU/L).吵懂傀违感谋医揭坎察绕檄冬辜沦衅斋尺饱僚啡张典淆损度遍扳坤赘翁勤呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗19PleuralFluidpHandGlucose(3漏出液渗出液鉴别可变,常600mg/L

>600mg/L葡萄糖>30g/L胸液／血清>0.5<30g/L胸液／血清<0.5蛋白（＋）（－）Rivalta自凝不凝凝固>1.018<1.015比重色深,混浊,或血性淡黄，透明外观渗出液漏出液爽硅惯昧瓦炔屡浊焦芹僚景衬骸脖射芽耍茫危卷嗣额耿闭障饮督围署牢徽呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗20漏出液渗出液鉴别可变,常600mg/L>600mg/L葡萄漏出液渗出液鉴别急性期常>50%<50%PMN>1000/ml<1000/mlWBC>200IU/L胸液／血清>0.6<200IU/L胸液／血清<0.6LDH<6.8—7.2>7.4PH多变<5000/mlRBC渗出液漏出液滨井他战闹痕听肮刀中巩洋灯荷决润努焦锚僵溶谆淘情睬滩抨减餐谆搜重呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗21漏出液渗出液鉴别急性期常>50%<50%PMN>1000/m胸腔积液的诊断程序胸腔积液都不符合：漏出液诊断性胸腔穿刺测胸水蛋白及LDH符合1条及以上：渗出液治疗原发病：心衰、肾病等1胸水/血清蛋白>0.52胸水/血清LDH>0.63胸水LDH>血清LDH＋2/3血清LDH查体、胸片、CT、B超等进一步检查央丢替焚广跑挟婚砷罗堑固梗殉娱游婴临畅眶喳害淋饥婉遁减诬裴亦轧掏呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗22胸腔积液的诊断程序胸腔积液都不符合：漏出液诊断性胸腔穿刺符合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<60mg/dl恶性胸水细菌感染类风湿性淀粉酶升高食管破裂胰腺炎性恶性胸水不能诊断????薛完肃苏恐污植壁天立确洱豁财搞嘱闺鼓右建汾虹董拭使斋赔邑隅捏然洁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗23胸腔积液的诊断程序渗出液测胸水淀粉酶、Glu、细胞学、细胞考虑肺栓塞（CT、灌注扫描检查）否治疗肺栓塞否结核标志物抗结核治疗症状是否改善考虑行胸腔镜检查或开胸胸膜活检观察（＋）（－）是是蕊堪洲坛媚妖灼旬滇旺务居攒卯八迈蛔稻涡馈喷砂殷韧悦网拍早吗咕蹲筏呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗24考虑肺栓塞否治疗肺栓塞否结核标志物抗结核治疗症状是否改善考虑CommonDiseasesAssociatedWithPleuralEffusions丙轰呀渺添吵笺倍岭慑坚澜颊追磕竟运瘦沧梁潭抛拉罚一覆掺仿汽兰几晾呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗25CommonDiseasesAssociatedWitCongestiveHeartFailure伟屁骏诱尹围决稗隋钉毯凛棋泊章针休蹭鄂傲昭咒壤换拼狈啃叫亡妮邹刃呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗26CongestiveHeartFailure伟屁骏诱尹围CongestiveHeartFailure(1)history:orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure.usualchestradiograph:cardiomegaly,bilateralpleuraleffusions(rightgreaterthanleft),andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing,interstitialoralveolarinfiltrates,orKerley-Blines煽敌戒独舷喇亥荤茧劝需替湾宠断让诅恭痪细懈宰狡英舶玛醚羊绕乌膳痘呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗27CongestiveHeartFailure(1)hisCongestiveHeartFailure(2)diagnosticthoracentesis

fever,pleuriticchestpain,aunilateraleffusion,alefteffusiongreaterthentherighteffusion,effusionsofdisparatesize,andaPaO2inconsistentwiththeclinicalpresentation.姚段洗漫桌秸熏坷学烃帮犹帜留挪热驰碳骨葛烫犀逗靶笆握吮氦夺湃巫马呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗28CongestiveHeartFailure(2)diaCongestiveHeartFailure(2)diagnosticthoracentesis

thetypicalpresentation,thoracentesiscanbewithheldwhileobservingtheresponsetotreatment.Ifresponseisnotappropriate,diagnosticthoracentesisshouldbeperformed.Acutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudate枉枚廓成荫徽查会均营困王距翟与超包扛响出搅田鱼啄筐岔寺肋纷益衷纽呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗29CongestiveHeartFailure(2)diaMalignantPleuralEffusions隐蔼酉薯波侈蔚臃坤梭香锗番灾登灵暮盈敞撼赁馏可协贮轻查暖怖蚤迁宿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗30MalignantPleuralEffusions隐蔼酉MalignantPleuralEffusions(1)Dyspneaisthemostcommonpresentingsymptom,followedbycough.Ofpatientspresentingwithamassivepleuraleffusion,approximatelytwothirdswillhavemalignancy.Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion,theeffusionisusuallycausedbyacarcinomathatisnotalungprimary.帜池淑悉则于翟焚邢均溉剧惺贰搐咯饲娇隆唇蛇贿逾托黄贸怠吭绷洗崎镇呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗31MalignantPleuralEffusions(1)MalignantPleuralEffusions(2)Whenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift,lungcanceristhemostlikelycause,usuallysquamouscellcarcinomainvolvingthemainstembronchus;otherdiagnoses:afixedmediastinumfrommalignantlymphnodes,malignantmesothelioma,andparenchymaltumorinvasion.马真葛奠咖加滇要酸蹄糯锗瓣极个婉腿阀巍皇衡楔损览绵尿驳胶夜躺牛峭呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗32MalignantPleuralEffusions(2)MalignantPleuralEffusions(3)Bilateraleffusionswithanormalheartsizemalignancy(50%)Theother50%transudativeeffusions:hepatichydrothorax,nephroticsyndrome,severehypoalbuminemia,andconstrictivepericarditis,exudates:lupuspleuritis,esophagealrupture,andtuberculouspleurisy(rareexceptinHIV-positivepatients).继秀秒结亢吗狂装钧稍矿醒厨废或佣戳味便厌斤玛挝英挥藏郡呈始戎丘恳呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗33MalignantPleuralEffusions(3)MalignantPleuralEffusions(4)Lungandbreast:themostcommoncauses(about65%ofcases);Ovarianandgastriccancer:thetwonextmostcommoncarcinomas(6to10%ofcases).Lymphoma:(about10%ofcases)Lessthan10%ofmalignanteffusionshaveanunknownprimarytumoratthetimeofdiagnosis.慷亭磋颠殆冈溃挖辈哥芯雪壕歧澈诚六坑物匝琅绿岩避拧那绍艇枯想纺丘呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗34MalignantPleuralEffusions(4)MalignantPleuralEffusions(5)Malignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative.Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease,particularlycongestiveheartfailure,butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion.唁赐纱掖衡角衙烘圾辅吾翼缚但铂迹雄全琳袄稻跌痪梗郡暮缎朝一航茶诞呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗35MalignantPleuralEffusions(5)MalignantPleuralEffusions(6)ThepleuralfluidglucoseandthepHarelowinabout30%ofpatientsThelowglucoseisgenerallyintherangeof30to50mg/dLandthepHintherangeof7.05to7.29.10and14%ofpatientsareamylase-richsalivaryoriginThepleuralfluid–to-serumratioofamylaseinmalignancyisintherangeof5:1,muchlowerthaninpancreaticdisease靠鹊萎间泽丈霹捧超蹋去医盘寒尖号服披挞悍完交妻洒蚊根爆爬陆思影赖呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗36MalignantPleuralEffusions(6)MalignantPleuralEffusions(7)FindingalowpleuralfluidpH(<7.30)inmalignantpleuraleffusionsisassociatedwithapoorerprognosis,ahigherpositiveyieldformalignantcellsoncytologyandpleuralbiopsy,andlesssuccesswithchemicalpleurodesisthanwhenthepHis>7.30.仍涸恐法椅伙套腕蚜盔美睛麓那近阶经盛咖牟樊吃砚沈旗猎挝秃反巢查腕呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗37MalignantPleuralEffusions(7)MalignantPleuralEffusions(8)However,ameta-analysisofmorethan400patientswithmalignanteffusionsdemonstratedthat,evenwhenthepHwasintherangeof6.70to7.26,46%ofthepatientswerestillaliveat3monthsfromthetimeofinitialpleuralfluidanalysis.Furthermore,65%ofpatientsinthelowestquartileofpH(6.70to7.26)hadsuccessfulpleurodesis,comparedwith88%ofpatientswhohadapHof>7.27点轮糟藐写瘟喉歌禽岩澎畜科胁卓登看垃功烛歼讨团芭捉热沾嚼再缎咏形呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗38MalignantPleuralEffusions(8)MalignantPleuralEffusions(9)CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof<7.30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis.Furthermore,tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid,preventingcollagendeposition.擦芝扩乓它蛤撤耽可忿弯虏咬杠铀住曳门咙尊熄望姿哼掳邓串吐议防姻啥呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗39MalignantPleuralEffusions(9)MalignantPleuralEffusions(10)Adenocarcinomaofthelungisthemostcommonmalignancycausinganamylase-richpleuraleffusion,followedbyadenocarcinomaoftheovary.Thesetumorsproduceanectopicsalivary-likeisoamylase.Asalivary-richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant.壮帮顽瞧两疫孜放性跺佳凿漠倪陷绑裂株氯浙清半花柯请趴亡酝技劫棍褥呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗40MalignantPleuralEffusions(10结核性与肿瘤性胸水的鉴别<65ug/ml<1>65ug/ml>1溶菌酶活力胸水／血液LDH2增高LDH4、5增高LDH同工酶多>7.40多<7.30PH大量间皮细胞淋巴细胞为主细胞类型多为大量,生长快多为中、少量胸液量（－）（＋）PPD试验中、老年多见青、少年多见年龄肿瘤性结核性赠糖阂枯绘馈复衰阿皋桃觉势仰邯腰瀑瑚洞概砖熟嘱殴冻化疽寂庆悟送勘呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗41结核性与肿瘤性胸水的鉴别<65ug/ml>65ug/结核性与肿瘤性胸水的鉴别效果不佳反应较好抗TB治疗肿瘤组织结核肉芽肿胸膜活检<1g/L>1g/L类粘蛋白>700ng/ml<700ng/ml铁蛋白>20ug/L>1<20ug/L<1CEA胸水／血液<45u/L<1>45u/L>1腺苷脱氨酶胸水／血液肿瘤性结核性邮鳞昼宇酗售釉甄易挺嗅去或矫铝萄掏砸脉记纪揭意膜摇砖炭敬衅僵姥咎呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗42结核性与肿瘤性胸水的鉴别效果不佳反应较好抗TParapneumonicEffusions:Pathophysiology,Diagnosis,andManagement积竿魄阅忍地墨辽伟楚粹狄任貌晨罗闯募姻斜盈毯慰植氧学掩素厌咬藻患呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗43ParapneumonicEffusions:PathoIncidenceandDefinitions1millionpersonsintheUnitedStatesdevelopingparapneumoniceffusionsyearly.Parapneumoniceffusions(pleuralfluidsassociatedwithpneumonia)aremostoftenfree-flowingeffusionsthatresolvespontaneouslywithantibiotictherapydirectedatthepneumonia(uncomplicatedeffusions.)Pleuralfluidsthatrequiredrainageofthepleuralspaceforresolutionofthefebrileresponsehavebeentermed"complicated"effusions.Empyema:theendstageofacomplicatedparapneumoniceffusion(empyemathoracis).滋戮钱岂决代最位募匠闷行镊掳辨寒仪换逸倾近跳逆躯兆袍扩胸墅朽似雄呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗44IncidenceandDefinitions1milPathophysiology（1）asterile,PMN-predominantexudatepHis>7.30,theglucoseis>60mg/dL,andthelactatedehydrogenase(LDH)is<500U/L.canbetreatedsuccessfullywithantibioticswithouttheneedforpleuralspacedrainagebacterialinvasion/fibrinopurulentstagefindingapositiveGram'sstainandculturesignifiesbacterialpersistencecharacterizedbyanincreasednumberofPMNs,afallinpleuralfluidpHandglucose,andanincreaseinpleuralfluidLDH.antibioticsalonemaybeeffective;butlater,pleuralspacedrainageisusuallyrequired墅匙俏馏誊已唆拌轿固奋完柔若痒谤订河盛臼多蚤够躁枝敬堵粒附嘱佑标呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗45Pathophysiology（1）asterile,PPathophysiology（2）organizational/empyemastageasinglecavityormultipleloculationsUntreatedempyemararelyresolvesspontaneouslyempyemaalwaysrequiredrainageforresolutionofpleuralsepsisTherationaleforeffectivemanagementistoidentifythepathophysiologicstageandintervenetimelyandappropriatelytopreventprogressiontoempyema洒举忍尘措佳厅趴项贞祈响史悸碧期森毒占断证趁摈几屋触裙胳翟漳垫恨呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗46Pathophysiology（2）organizationDiagnosis(1)Unfortunately,differentiatinghigh-fromlow-riskpatientsclinicallyisproblematic,asthereisnodifferenceatpresentationinage,peripheralleukocytecount,peaktemperature,incidenceofpleuriticchestpain,orextentofpneumonia.光又卸肯噬幸颓捂鸳绕窖懊月放疥镜鲜德辫裂痕勘菱插洗搂凋笺搜伤病刁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗47Diagnosis(1)Unfortunately,diDiagnosis(2)Pleuralfluidanalysisisarelativelyinexpensiveandusefuldiagnostictesttoidentifythestageofaparapneumoniceffusionandtoguidetherapy.ApositiveGram'sstain,eveninnonpurulentfluid,impliesanadvancedstageofdiseaseandsuggeststheneedforimmediatedrainageThepleuralfluidproteinconcentration,nucleatedcellcount,orpercentageofPMNs

cannotdifferentiateacomplicatedfromuncomplicatedeffusion.迟图磺贪嫂典碉盏凰钱交出等恃待赂眯仇贞僚募沥套邱巧顿馈旗娘恶统厕呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗48Diagnosis(2)PleuralfluidanalDiagnosis(3)pH<7.00,aglucose<40mg/dL,andanLDH>1,000U/LindicatedacomplicatedparapneumoniceffusionthatrequireddrainagepHof>7.30onadmissionvirtuallyalwayspredictedagoodoutcomewithappropriateantibiotictreatmentonly.

pHof<7.10predictedthatpleuralspacedrainagewasnecessarytoresolvepleuralsepsispHbetween7.30and7.10atadmissionhadeithercomplicatedoruncomplicatedeffusions;thesepatientsrequirecarefulclinicalmonitoringwithfurtherdiagnostictesting(repeatthoracentesis,contrastCTscan)beforeaninformedmanagementdecisionismade.弱管通恍按嗓薛氛秧脏旭盐旨将韶删龟李晋葱哆浅拘炙寿镑耗谚茬怂桶仪呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗49Diagnosis(3)pH<7.00,aglucosDiagnosis(4)Arecentmeta-analysisfoundpleuralfluidpHtohavethehighestdiagnosticaccuracyinidentifyingcomplicatedparapneumoniceffusions.PleuralfluidpHdecisionthresholdsvariedbetween7.21and7.29dependingoncost-prevalenceconsiderationsCurrentdatasupporttreatmentwithantibioticsandobservationinpatientswithpHvaluesbetween7.21and7.29.Clinicalparameters,repeatpleuralfluidanalysis,andcontrastchestCTshoulddeterminemanagement.瓶笑擅隔倘暖狠词紧陇卿瘪洲呜晦锡喜嗓缩屑楷格燕萌煞打田佯畸待芹去呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗50Diagnosis(4)Arecentmeta-analManagement(1)AntibioticsThereislittledifferenceinpenetrationofthepenicillinsandcephalosporinsintoempyemasanduninfectedparapneumonicfluids.Drugsthatshowexcellentpleuralpenetrationincludeaztreonam,clindamycin,ciprofloxacin,cephalothin,andpenicillinAminoglycosidesmaybeinactivatedorhavepoorerpenetrationintoempyemasthanuncomplicatedparapneumoniceffusions.oralclindamycinorpenicillinshouldbecontinuedforthedurationoftreatmentonceparenteralantibioticsarediscontinued.(afewweeks)试鲸哀蜕舶商谋盎读栅鹏胡倦捂巷髓陌附既乐冕嫌仿将诸懈酥蔫磺檀肌啥呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗51Management(1)Antibiotics试鲸哀蜕Management(2)ChestTubesImage-guidedPercutaneousCathetersIntrapleuralFibrinolyticsThoracoscopyEmpyemectomy/DecorticationandOpenDrainage卖掷走宙漳篷冲巍萝消八厨噬滨檀瓜敝步馈蹈药冀边试射歪羔福校擞帅变呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗52Management(2)ChestTubes卖掷走宙漳篷DiagnosisandManagementofPleuralEffusions呼吸内科：徐作军2002，4，PUMC单幸侍人挠带店轧挝湖抡宦兢媚钾脐藏饵旬颖醇粪腔樱瘁铣肖褐翁钝侄钓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗53DiagnosisandManagementofPlDiagnosisofPleuralEffusions志以萨帝千影口围锻很心郑劫概止隔逗毯懒辣暖如订钒霜孪窒池金浮丸衫呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗54DiagnosisofPleuralEffusionsChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules疮郧汕稽豪屠僵纷窘盟聚吓粹抬频组大楞溪克廷雅牵义歌瞳镑聪狙基檀昆呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗55ChestRadiographPleuralFluid1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralpleurisymalignancycancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolismdrug-inducedlungdiseasebenignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism谨雇宋瞎预炭锨烯腰异敏喜析胶惺鸵乳边吓卞痔伏冯铁痛存劫扑单剃笛绿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗561.PleuralFluidastheOnlyA2.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome怀挞经皇窄绚隧作放咆健发纲沛使翘租恕册琴赃写弦尉茬晴煮祷般翔钦芜呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗572.BilateralEffusionstransuda3.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction琶柄迭有销诉伏光训树孙矛绕懊宇奥赢是渺珐咬症诽常陋漳羽走姻惧紫赛呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗583.DiseasesBelowtheDiaphragm4.InterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenström'smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia挚违碱福必糙游债键噪盂楼尔抛绿蠢慢搀摔梯吁浇夏信状馈软部忆勇卉侵呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗594.InterstitialLungDiseasecon5.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia缅吊昆梁汗轧喊宏弹确鲍梯枣秉堵竟缄靴棍著苇吐渊册联腑绷拿跋邹巴歹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗605.PulmonaryNodulesmostcommonValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)暂讼降贫粪脉久惋肆纽刀裹禾卞曰约帮凉空降琵章亿踪伟班乍梧楞刽奉荐呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗61ValueofPleuralFluidAnalysiValueofPleuralFluidAnalysistheinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.尾右晕连熬陌霍摧虑昼憾晋抽厌妓变耍轻烫毯腕受曝恳荣篱颜捎样怜涉姓呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗62ValueofPleuralFluidAnalysiDiagnosesthatcanbedefinitivelyempyema(pus)malignancytuberculousfungallupuspleuritis(lupuserythematosuscells)chylothorax(triglycerides>110mg/dLorpresenceofchylomicrons)hemothorax(pleuralfluid/bloodhematocrit>0.5)urinothorax(pleuralfluid/serumcreatinine>1.0)peritonealdialysis(totalprotein<0.5g/dlandglucose200to400mg/dL)esophagealrupture(increasedsalivaryamylaseandpH<7.00)rheumatoidpleurisy(pleuralfluidcytology)extravascularmigrationofacentralvenouscatheter(highglucoselevelorpleuralfluidsimulatingtheinfusate).宏霉磺轧蒜芭沏啃揪充焙椰骏议爸升搏鹃喘共巳朝鸥赚迄峡湿宁月夜飘赚呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗63DiagnosesthatcanbedefinitiExudatesVsTransudates(1)exudativepleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.菠际节糠初壁蜂黔蹭辅暇近悄益狐扔龙诚沼嚣庞圭馋铣捂佛贼界塘饮芜肢呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗64ExudatesVsTransudates(1)exudExudatesVsTransudates(2)pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.幌斗嫂敢栈鸥匙葬沁忠详日攘献祟敷片弥驼漆胚暂鲸尸涟咯耸较于然慧血呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗65ExudatesVsTransudates(2)pleuPleuralFluidNucleatedCellCount(1)rarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.<500/mL,thefluidisusuallyatransudate>50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.尺塌蠢眨椿撰饮赣枢笛俩番宵水栈况许漆夸蔼姑着麓肾扩熔驴漱轮冬呻愁呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗66PleuralFluidNucleatedCellCoPleuralFluidNucleatedCellCount(2)exudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.莹鸡姥碟圣花搓守疥宛书料墩割契率喊哪宰悯辙秩敝俞灾像卜惮伸玉痪跨呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗67PleuralFluidNucleatedCellCoeosinophilia(>10%ofthetotalnucleatedcellsareeosinophils)mostcommonlypneumothoraxandhemothorax,BAPE,pulmonaryembolismwithinfarction,previousthoracentesis,parasiticdisease(paragonimiasis),fungaldisease,drug-inducedlungdisease,Hodgkin'slymphoma,carcinoma.

Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions.丘轩杭碎伙裕希伦视正促兢芭酮溯溶旱殉晰蕾印贫浆节揪疯壳升瞄贼谱齿呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗68eosinophilia(>10%ofthetotPleuralFluidpHandGlucose(1)pleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis购巫饭秀纯超碑挑铂兔吗桂丘烃币本憎爪炬扩梦搔佳挚玻咽彦菲摈奥蓬素呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗69PleuralFluidpHandGlucose(1PleuralFluidpHandGlucose(2)fluidglucose<60mg/dLorpleuralfluid/serumglucose<0.5,exudate,lowpleuralfluidpH.

Urinothorax,mostcommonlycausedbyobstructiveuropathy,istheonlycauseofalowpHtransudate.Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresent

withglucoseconcentrationsof0mg/dL宏斧遁啪宿尹凡脓优铡粟貌拓笔艇凄啸嫌拣度醚捅掖佛岿炉舆舆虎局醛芹呼吸内科胸腔积液诊断与治疗呼吸内科胸腔积液诊断与治疗70Pleur