胸腔積液總論

1、胸腔積液胸腔積液總論總論Pleural effusion胸膜腔功能胸膜腔功能n減少肺與胸壁的摩擦n肺的機械保護和支持n負壓調(diào)節(jié)心肺功能n肺內(nèi)水腫液的吸收(高靜水壓高滲透壓性肺水腫的25%由胸膜吸收)胸膜腔胸膜腔n兩層胸膜并不相互接觸n臟層胸膜無神經(jīng)纖維胸腔內(nèi)壓 n胸腔內(nèi)壓 肺彈性回縮力n功能 殘氣位 5CMH2On肺總量位-30CMH20 肺順應性下降,胸腔負壓增加n立位時胸膜腔壓力梯度每垂直下移1CM壓力增加0.5,而兩肺肺泡內(nèi)壓相同.肺內(nèi)通氣順序上肺區(qū)先進后出,下肺區(qū)后進先出,胸水形成傳統(tǒng) 正常人胸腔內(nèi)有315ml液體，人體每天胸膜腔可有0.51L液體通過。胸液中的蛋白質(zhì)主要經(jīng)由淋巴管進入

2、胸導管。新論 壁層胸膜緩慢產(chǎn)生，經(jīng)壁層胸膜間皮間2-12UM小孔，直接引流入淋巴管。每日100-200。 臟層胸膜對胸水產(chǎn)生吸收不起作用 。正常胸水0.3ml/kg,低滲,交換量0.15ml/kg/h,最大流量30ml/h由胸膜腔尖頂區(qū)壁層胸膜產(chǎn)生胸膜腔基底區(qū)橫膈縱膈壁層胸膜重吸收淋巴管微孔 單向活 作用胸液的濾過量超過胸膜最大淋巴流量時產(chǎn)生胸水胸腔積液量n0.30.5L時，X線僅見肋膈角變鈍；n少于0.3L時癥狀多不明顯；n若超過0.5L，患者漸感胸悶。機制胸液循環(huán)與有關壓力（胸液循環(huán)與有關壓力（cmH2O）關系示意圖關系示意圖34胸腔積液與吸收的機制病因?qū)W病因?qū)W一、胸膜毛細血管內(nèi)靜水壓增高

3、充血性心力衰竭縮窄性心包炎血容量增加上腔靜脈或奇靜脈受阻二、胸膜毛細血管通透性增加胸膜炎癥（結(jié)核病、肺炎）結(jié)締組織?。⊿LE、類風濕關節(jié)炎）胸膜腫瘤（惡性腫瘤轉(zhuǎn)移、間皮瘤）肺梗死膈下炎癥（膈下膿腫、肝膿腫、胰腺炎）三、胸膜毛細血管內(nèi)膠體滲透壓降低低蛋白血癥肝硬化腎病綜合征、急性腎小球腎炎粘液性水腫四、壁層胸膜淋巴引流障礙癌癥淋巴管阻塞發(fā)育性淋巴管引流異常五、損傷所致胸腔內(nèi)出血主動脈瘤破裂食管破裂胸導管破裂等產(chǎn)生血胸、膿胸、乳糜胸病因n惡性 45nCHF 12n感染 22 結(jié)核 10 細菌 9 病毒 1 真菌 1 膿胸1 寄生蟲 1 n肺栓 3 n肝變 2n膠原 1 n其它 5Frequency

4、 In the USPleural effusion affects 1.3 million individuals each yearcongestive heart failure, 500,000; bacterial pneumonia, 300,000 (uncomplicated, 270,000;complicated, 30,000);malignancy, 200,000pulmonary embolus, 150,000;cirrhosis with ascites, 50,000pancreatitis, 20,000collagen vascular disease,

5、6,000and tuberculosis, 2,500. Transudative pleural effusionCongestive heart failure (most common transudative effusion)Hepatic cirrhosis with and without ascites Nephrotic syndromePeritoneal dialysis/continuous ambulatory peritonealdialysisHypoproteinemia (eg, severe starvation)Glomerulonephritis Su

6、perior vena cava obstruction Fontan procedure Urinothorax Exudative pleural effusion Malignant disorders - Metastatic disease to the pleura or lungs, primary lung cancer, mesothelioma, Kaposi sarcoma, lymphoma, leukemiaInfectious diseases - Bacterial, fungal, parasitic, and viral infections; infecti

7、on with atypical organisms such as Mycoplasma, Rickettsiae, Chlamydia, Legionella GI diseases and conditions - Pancreatic disease (acute or chronic disease, pseudocyst, pancreatic abscess), Whipple disease, intraabdominal abscess (eg, subphrenic, intrasplenic, intrahepatic), esophageal perforation (

8、spontaneous/iatrogenic), abdominal surgery, diaphragmatic hernia, endoscopic variceal sclerotherapy Collagen vascular diseases - Rheumatoid arthritis, systemic lupus erythematosus, drug-induced lupus syndrome (procainamide, hydralazine, quinidine, isoniazid, phenytoin, tetracycline, penicillin, chlo

9、rpromazine), immunoblastic lymphadenopathy (angioimmunoblastic lymphadenopathy), Sj鰃ren syndrome, familial Mediterranean fever, Churg-Strauss syndrome, Wegener granulomatosisBenign asbestos effusion Meigs syndrome - Benign solid ovarian neoplasm associated with ascites and pleural effusion Drug-indu

10、ced primary pleural disease - Nitrofurantoin, dantrolene, methysergide, bromocriptine, amiodarone, procarbazine, methotrexate, ergonovine, ergotamine, oxprenolol, maleate, practolol, minoxidil, bleomycin, interleukin-2, propylthiouracil, isotretinoin, metronidazole, mitomycinInjury after cardiac sur

11、gery (Dressler syndrome) - Injury reported after cardiac surgery, pacemaker implantation, myocardial infarction, blunt chest trauma, angioplasty Uremic pleuritisYellow nail syndromeRuptured ectopic pregnancyElectrical burns pleural fluid with exudative or transudative characteristics Pulmonary embol

12、ismHypothyroidism Diuresed transudatePericardial disease (inflammatory or constrictive) AtelectasisTrapped lung (usually a borderline exudate)Sarcoidosis (usually an exudate)Amyloidosis Miscellaneous conditionsHemothoraxFollowing coronary artery bypass graft surgeryAfter lung or liver transplantMilk

13、 of calcium pleural effusion - Colloidal suspension of precipitated calcium saltsAcute respiratory distress syndromeSystemic cholesterol emboliIatrogenic misplacement of lines or tubes into the mediastinum or the pleural space - Insertion or reinsertion of percutaneous central venous catheter, infus

14、ion of enteral formula through misplaced nasogastric or nasoenteric feeding tubes, translumbar aortography Radiation pleuritis Necrotizing sarcoid granulomatosis Ovarian hyperstimulation syndrome Postpartum pleural effusion (immediate or delayed)Rupture of a silicone bag mammary prosthesisRupture of

15、 a benign germ cell tumor into the pleural space (eg, benign mediastinal teratoma) SyphilisEchinococcosis癥狀DyspneanDyspnea is the most common clinical symptom at presentation.nIt indicates a large effusion (usually not 500 mL).nIt is reported to occur in 50% of patients with malignant pleural effusi

16、ons.nHowever, other factors (eg, underlying lung disease, cardiac dysfunction, anemia) also may contribute to the development of dyspnea.Chest painnChest pain may be mild or severe; it typically is described as sharp or stabbing, is exacerbated with deep inspiration, and is pleuritic.nPain may be lo

17、calized to the chest wall or referred to the ipsilateral shoulder or upper abdomen (frequently seen with malignant mesothelioma), usually because of diaphragmatic involvement.nIt often diminishes in intensity as the pleural effusion increases in size.nChest pain signifies pleural irritation, which c

18、an aid in the diagnosis of the cause of the effusion, since most transudative effusions do not cause direct pleural irritation.檢查檢查診斷性胸腔穿刺n除非 10mm/CHF/雙側(cè)積液外觀漏出液透明清亮，不凝固，比重1.018。膿性胸液若為大腸桿菌或厭氧菌感染常有臭味。尿味是尿素胸;血性胸液呈程度不同的洗肉水樣或靜脈血樣；乳狀胸液為乳糜胸；巧克力色應考慮阿米巴肝膿腫破潰入胸腔的可能；黑色胸液可能為曲菌感染。渾濁胸水離心后上清液沉清,可能是膿性; 混濁可能是乳糜性pHnP

19、H7.3 感染性、類風關、食道破裂、腫瘤npH7.00者僅見于膿胸以及食管破裂所致n肺炎旁積液pH7.0，需引流n惡性pH7.0，提示細胞陽性率高，胸膜硬化可能無效，預后差。葡萄糖n漏出液與大多數(shù)滲出液葡萄糖含量正常；n3.35mmol/L惡性、類風關及結(jié)核性、化膿性胸腔積液。n風濕（）化膿（）最低n腫瘤很少降低下降提示累及廣泛。蛋白質(zhì)滲出液的蛋白含量，胸液/血清比值大于0.5。蛋白含量30g/L時，胸液比重約為1.018。漏出液蛋白含量較低（5%不會是結(jié)核 結(jié)核性胸液中常低于1。中性粒n50%,提示胸膜急性炎癥 肺炎旁、胰腺炎、肺栓塞中中性粒占優(yōu)，而腫瘤僅，結(jié)核。嗜酸細胞寄生蟲感染或結(jié)締組織

20、病時常增多占10-20%以上5%血氣胸，肺梗，過後性疾病炎癥，反復抽水，霉菌，石棉肺，藥物性惡性腫瘤亦是常見原因（嗜酸性積液）淋巴細胞n淋巴細胞為主提示慢性炎癥，為結(jié)核性或惡性；結(jié)核病90-95%，75%常為結(jié)核 n其它：0.5 腫瘤，淋巴瘤，慢性感染，類風關，黃甲S，結(jié)節(jié)病，乳糜胸病原n胸液涂片查找細菌及培養(yǎng)，有助于病原診斷。n結(jié)核性胸膜炎胸液沉淀后作結(jié)核菌培養(yǎng)，陽性率僅20n巧克力色膿液應鏡檢阿米巴滋養(yǎng)體。病原學n除膿胸，胸水不查TBn培養(yǎng)陽性率，涂片細胞學n惡性陽性率60%n轉(zhuǎn)移性腺癌70%,間皮瘤10%鱗癌20%淋巴瘤25-50%,肉瘤25%n流式細胞儀酶LDHn胸液LDH活性可反映胸

21、膜炎癥的程度，其值越高，表明炎癥越明顯。nLDH含量增高，大于200U/L，且胸液LDH/血清LDH比值大于0.6，提示為滲出液，nLDH 500U/L常提示為惡性腫瘤或胸液已并發(fā)細菌感染。n進行性增加提示炎癥加重，否則不必積極檢查CEAn惡性胸液中CEA水平升高較血清早且顯著。n20ng/ml,胸液/血漿1，應疑及惡性n有認為胸液CEA特異性90%，敏感性40%鐵蛋白n惡性胸液中鐵蛋白含量增高腺苷脫氨酶（ADA）nTB50% 敏感性94%，特異性能 0.90n 45% 排除結(jié)核性的敏感性和特異性100%胸液淀粉酶n食道破裂，急性胰腺炎，惡性腫瘤等。免疫學檢查n結(jié)核性與惡性胸腔積液時，T淋巴細

22、胞增高，尤以結(jié)核性胸膜炎為顯著可高達90，且以T4（CD+4）為主。n惡性胸腔積液中的T細胞功能受抑，其對自體腫瘤細胞的殺傷活性明顯較外周血淋巴細胞為低，提示惡性胸腔積液患者胸腔層局部免疫功能呈抑制狀態(tài)。n系統(tǒng)性紅斑狼瘡及類風濕關節(jié)炎引起的胸腔積液中補體C3、C4成分降低，且免疫復合物的含量增高。胸膜活檢n胸膜活檢針 Abrams Cope兩種n鑒別有無腫瘤（陽性率3975%,57%）及判定胸膜肉芽腫性病變（結(jié)核性7080%,75%）有一定幫助。n膿胸或有出血傾向者不宜作胸膜活檢。胸膜活檢n肉芽腫患者95%是結(jié)核性n其它原因真菌，結(jié)節(jié)病類風關FOBn有咳嗽咯血肺內(nèi)病變者胸腔鏡n病因診斷率95.

23、4%n惡性積液診斷率9396%超聲檢查滲出液與漏出液的鑒別1.外觀2.凝固性3.比重1.016 25%誤差4.蛋白定量 2.5-3.0 10%誤差5.Rivalta 滲出液占60% 漏出液30.8% 40%誤差6.細胞數(shù) 100-5007.PH8.糖 感染、風濕性積液尤低滲出液與漏出液n是診斷第一步n如是漏出液，排除CHF、肝硬化、肺栓塞，無需更多檢查，CHF不必抽胸水。Light標準1972年1.胸液LDH 正常血清上限之2/3 2.胸液LDH/血清LDH0.63.胸液蛋白/血清蛋白0.5 1個或以上則為滲出液, 鑒定滲出液98%的敏感,83%特異(漏出液可能誤為滲出)其它標準nRoth標準

24、胸水白蛋白血清蛋白1.2g/dlnHamm&Valdes 胸水膽固醇55mg/dlnMeiset 胸水膽紅素/血清膽紅素0.6滲出液滲出性胸液 1 結(jié)核性胸膜炎 2 癌性胸膜炎: 肺癌,胸膜間皮瘤,乳腺癌,淋巴瘤 3 肺炎伴發(fā)胸膜炎4 化膿性胸膜炎5 肺吸蟲腸膜炎 6 結(jié)締組織病胸膜炎： 風濕,類風濕,SLE7 乳糜性胸膜炎: 結(jié)核 絲蟲,外傷,縱隔瘤, 淋巴瘤 8 膽固醇性胸膜炎: 結(jié)核 糖尿病,梅毒,癌瘤 漏出性胸液 1 左心衰竭2 肝硬化 3 腎功能衰竭 4 低蛋白血癥 一側(cè)肺野密度增高1 一側(cè)全肺不張 2 一側(cè)全肺肺炎 3 廣泛胸膜增厚 肺硬變 4 彌漫性間皮瘤 5 巨大良性瘤 畸胎瘤

25、 6 損毀肺并胸膜增厚 Extrapleural sign原因 nExpanding Rib lesions nMetastasis nCallous nFracture with Hemorrhage nPlasmacytoma漿細胞瘤 nNeurofibroma nMesothelioma 間皮瘤nPlumbage 左側(cè)胸水特殊原因 unique considerations for left sided pleural effusion:nDissecting Aneurysm of Aorta nEsophageal rupture nSplenic disease nPericarditis nLV