胸腔積液診療和治療專業(yè)知識培訓(xùn)培訓(xùn)課件

胸腔積液診療和治療專業(yè)知識培訓(xùn)DiagnosisofPleuralEffusions2胸腔積液診療和治療專業(yè)知識培訓(xùn)ChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules3胸腔積液診療和治療專業(yè)知識培訓(xùn)1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralpleurisymalignancycancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolismdrug-inducedlungdiseasebenignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism4胸腔積液診療和治療專業(yè)知識培訓(xùn)2.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome5胸腔積液診療和治療專業(yè)知識培訓(xùn)3.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction6胸腔積液診療和治療專業(yè)知識培訓(xùn)4.InterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenstr?m'smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia7胸腔積液診療和治療專業(yè)知識培訓(xùn)5.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia8胸腔積液診療和治療專業(yè)知識培訓(xùn)ValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)9胸腔積液診療和治療專業(yè)知識培訓(xùn)ValueofPleuralFluidAnalysistheinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.10胸腔積液診療和治療專業(yè)知識培訓(xùn)Diagnosesthatcanbedefinitivelyempyema(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).11胸腔積液診療和治療專業(yè)知識培訓(xùn)ExudatesVsTransudates(1)exudativepleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.12胸腔積液診療和治療專業(yè)知識培訓(xùn)ExudatesVsTransudates(2)pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.13胸腔積液診療和治療專業(yè)知識培訓(xùn)PleuralFluidNucleatedCellCount(1)rarelyhelpfulinestablishingadefinitivediagnosis.however,itmayprovideusefulinformation.<500/mL,thefluidisusuallyatransudate>50,000/mL,itusuallyrepresentspleuralspacebacterialinfection(typicallyempyema).between25,000and50,000/mLareusuallyseenonlywithuncomplicatedparapneumoniceffusions,acutepancreatitisandacutepulmonaryinfarction.14胸腔積液診療和治療專業(yè)知識培訓(xùn)PleuralFluidNucleatedCellCount(2)exudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.15胸腔積液診療和治療專業(yè)知識培訓(xùn)eosinophilia(>10%ofthetotalnucleatedcellsareeosinophils)mostcommonlypneumothoraxandhemothorax,BAPE,pulmonaryembolismwithinfarction,previousthoracentesis,parasiticdisease(paragonimiasis),fungaldisease,drug-inducedlungdisease,Hodgkin'slymphoma,carcinoma.

Theprevalenceofpleuralfluideosinophiliaissimilarincarcinomatousandnoncarcinomatouspleuraleffusions.16胸腔積液診療和治療專業(yè)知識培訓(xùn)PleuralFluidpHandGlucose(1)pleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis17胸腔積液診療和治療專業(yè)知識培訓(xùn)PleuralFluidpHandGlucose(2)fluidglucose<60mg/dLorpleuralfluid/serumglucose<0.5,exudate,lowpleuralfluidpH.

Urinothorax,mostcommonlycausedbyobstructiveuropathy,istheonlycauseofalowpHtransudate.Empyemaandrheumatoidpleurisyaretheonlyeffusionsthatcanpresent

withglucoseconcentrationsof0mg/dL18胸腔積液診療和治療專業(yè)知識培訓(xùn)PleuralFluidpHandGlucose(3)ApleuralfluidpH<7.00isusuallyseenonlywithempyema,whetheritbeparapneumonicorassociatedwithesophagealrupture.Complicatedparapneumoniceffusion/empyema,rheumatoidpleurisy,andpleuralparagonimiasisaretheonlyeffusionswiththetriadofapH<7.30,aglucose<60mg/dL,andanLDH>1,000U/L(upperlimitofnormalofserum200IU/L).19胸腔積液診療和治療專業(yè)知識培訓(xùn)漏出液滲出液鑒別可變,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,混濁,或血性淡黃，透明外觀滲出液漏出液20胸腔積液診療和治療專業(yè)知識培訓(xùn)漏出液滲出液鑒別急性期常>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多變<5000/mlRBC滲出液漏出液21胸腔積液診療和治療專業(yè)知識培訓(xùn)胸腔積液的診斷程序胸腔積液都不符合：漏出液診斷性胸腔穿刺測胸水蛋白及LDH符合1條及以上：滲出液治療原發(fā)?。盒乃?、腎病等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查體、胸片、CT、B超等進(jìn)一步檢查22胸腔積液診療和治療專業(yè)知識培訓(xùn)胸腔積液的診斷程序滲出液測胸水淀粉酶、Glu、細(xì)胞學(xué)、細(xì)胞分類、培養(yǎng)、染色檢查、結(jié)核標(biāo)志物檢查Glu<60mg/dl惡性胸水細(xì)菌感染類風(fēng)濕性淀粉酶升高食管破裂胰腺炎性惡性胸水不能診斷????23胸腔積液診療和治療專業(yè)知識培訓(xùn)考慮肺栓塞（CT、灌注掃描檢查）否治療肺栓塞否結(jié)核標(biāo)志物抗結(jié)核治療癥狀是否改善考慮行胸腔鏡檢查或開胸胸膜活檢觀察（＋）（－）是是24胸腔積液診療和治療專業(yè)知識培訓(xùn)CommonDiseasesAssociatedWithPleuralEffusions25胸腔積液診療和治療專業(yè)知識培訓(xùn)CongestiveHeartFailure26胸腔積液診療和治療專業(yè)知識培訓(xùn)CongestiveHeartFailure(1)history:orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure.usualchestradiograph:cardiomegaly,bilateralpleuraleffusions(rightgreaterthanleft),andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing,interstitialoralveolarinfiltrates,orKerley-Blines27胸腔積液診療和治療專業(yè)知識培訓(xùn)CongestiveHeartFailure(2)diagnosticthoracentesis

fever,pleuriticchestpain,aunilateraleffusion,alefteffusiongreaterthentherighteffusion,effusionsofdisparatesize,andaPaO2inconsistentwiththeclinicalpresentation.28胸腔積液診療和治療專業(yè)知識培訓(xùn)CongestiveHeartFailure(2)diagnosticthoracentesis

thetypicalpresentation,thoracentesiscanbewithheldwhileobservingtheresponsetotreatment.Ifresponseisnotappropriate,diagnosticthoracentesisshouldbeperformed.Acutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudate29胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions30胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(1)Dyspneaisthemostcommonpresentingsymptom,followedbycough.Ofpatientspresentingwithamassivepleuraleffusion,approximatelytwothirdswillhavemalignancy.Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion,theeffusionisusuallycausedbyacarcinomathatisnotalungprimary.31胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(2)Whenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift,lungcanceristhemostlikelycause,usuallysquamouscellcarcinomainvolvingthemainstembronchus;otherdiagnoses:afixedmediastinumfrommalignantlymphnodes,malignantmesothelioma,andparenchymaltumorinvasion.32胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(3)Bilateraleffusionswithanormalheartsizemalignancy(50%)Theother50%transudativeeffusions:hepatichydrothorax,nephroticsyndrome,severehypoalbuminemia,andconstrictivepericarditis,exudates:lupuspleuritis,esophagealrupture,andtuberculouspleurisy(rareexceptinHIV-positivepatients).33胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(4)Lungandbreast:themostcommoncauses(about65%ofcases);Ovarianandgastriccancer:thetwonextmostcommoncarcinomas(6to10%ofcases).Lymphoma:(about10%ofcases)Lessthan10%ofmalignanteffusionshaveanunknownprimarytumoratthetimeofdiagnosis.34胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(5)Malignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative.Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease,particularlycongestiveheartfailure,butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion.35胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(6)ThepleuralfluidglucoseandthepHarelowinabout30%ofpatientsThelowglucoseisgenerallyintherangeof30to50mg/dLandthepHintherangeof7.05to7.29.10and14%ofpatientsareamylase-richsalivaryoriginThepleuralfluid–to-serumratioofamylaseinmalignancyisintherangeof5:1,muchlowerthaninpancreaticdisease36胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(8)However,ameta-analysisofmorethan400patientswithmalignanteffusionsdemonstratedthat,evenwhenthepHwasintherangeof6.70to7.26,46%ofthepatientswerestillaliveat3monthsfromthetimeofinitialpleuralfluidanalysis.Furthermore,65%ofpatientsinthelowestquartileofpH(6.70to7.26)hadsuccessfulpleurodesis,comparedwith88%ofpatientswhohadapHof>7.2738胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(9)CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof<7.30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis.Furthermore,tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid,preventingcollagendeposition.39胸腔積液診療和治療專業(yè)知識培訓(xùn)MalignantPleuralEffusions(10)Adenocarcinomaofthelungisthemostcommonmalignancycausinganamylase-richpleuraleffusion,followedbyadenocarcinomaoftheovary.Thesetumorsproduceanectopicsalivary-likeisoamylase.Asalivary-richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant.40胸腔積液診療和治療專業(yè)知識培訓(xùn)結(jié)核性與腫瘤性胸水的鑒別<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大量間皮細(xì)胞淋巴細(xì)胞為主細(xì)胞類型多為大量,生長快多為中、少量胸液量（－）（＋）PPD試驗中、老年多見青、少年多見年齡腫瘤性結(jié)核性41胸腔積液診療和治療專業(yè)知識培訓(xùn)結(jié)核性與腫瘤性胸水的鑒別效果不佳反應(yīng)較好抗TB治療腫瘤組織結(jié)核肉芽腫胸膜活檢<1g/L>1g/L類粘蛋白>700ng/ml<700ng/ml鐵蛋白>20ug/L>1<20ug/L<1CEA胸水／血液<45u/L<1>45u/L>1腺苷脫氨酶胸水／血液腫瘤性結(jié)核性42胸腔積液診療和治療專業(yè)知識培訓(xùn)ParapneumonicEffusions:Pathophysiology,Diagnosis,andManagement43胸腔積液診療和治療專業(yè)知識培訓(xùn)IncidenceandDefinitions1millionpersonsintheUnitedStatesdevelopingparapneumoniceffusionsyearly.Parapneumoniceffusions(pleuralfluidsassociatedwithpneumonia)aremostoftenfree-flowingeffusionsthatresolvespontaneouslywithantibiotictherapydirectedatthepneumonia(uncomplicatedeffusions.)Pleuralfluidsthatrequiredrainageofthepleuralspaceforresolutionofthefebrileresponsehavebeentermed"complicated"effusions.Empyema:theendstageofacomplicatedparapneumoniceffusion(empyemathoracis).44胸腔積液診療和治療專業(yè)知識培訓(xùn)Pathophysiology（1）asterile,PMN-predominantexudatepHis>7.30,theglucoseis>60mg/dL,andthelactatedehydrogenase(LDH)is<500U/L.canbetreatedsuccessfullywithantibioticswithouttheneedforpleuralspacedrainagebacterialinvasion/fibrinopurulentstagefindingapositiveGram'sstainandculturesignifiesbacterialpersistencecharacterizedbyanincreasednumberofPMNs,afallinpleuralfluidpHandglucose,andanincreaseinpleuralfluidLDH.antibioticsalonemaybeeffective;butlater,pleuralspacedrainageisusuallyrequired45胸腔積液診療和治療專業(yè)知識培訓(xùn)Pathophysiology（2）organizational/empyemastageasinglecavityormultipleloculationsUntreatedempyemararelyresolvesspontaneouslyempyemaalwaysrequiredrainageforresolutionofpleuralsepsisTherationaleforeffectivemanagementistoidentifythepathophysiologicstageandintervenetimelyandappropriatelytopreventprogressiontoempyema46胸腔積液診療和治療專業(yè)知識培訓(xùn)Diagnosis(1)Unfortunately,differentiatinghigh-fromlow-riskpatientsclinicallyisproblematic,asthereisnodifferenceatpresentationinage,peripheralleukocytecount,peaktemperature,incidenceofpleuriticchestpain,orextentofpneumonia.47胸腔積液診療和治療專業(yè)知識培訓(xùn)Diagnosis(2)Pleuralfluidanalysisisarelativelyinexpensiveandusefuldiagnostictesttoidentifythestageofaparapneumoniceffusionandtoguidetherapy.ApositiveGram'sstain,eveninnonpurulentfluid,impliesanadvancedstageofdiseaseandsuggeststheneedforimmediatedrainageThepleuralfluidproteinconcentration,nucleatedcellcount,orpercentageofPMNs

cannotdifferentiateacomplicatedfromuncomplicatedeffusion.48胸腔積液診療和治療專業(yè)知識培訓(xùn)Diagnosis(3)pH<7.00,aglucose<40mg/dL,andanLDH>1,000U/LindicatedacomplicatedparapneumoniceffusionthatrequireddrainagepHof>7.30onadmissionvirtuallyalwayspredictedagoodoutcomewithappropriateantibiotictreatmentonly.

pH