胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座專(zhuān)家講座

DiagnosisandManagementofPleuralEffusions1胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第1頁(yè)DiagnosisofPleuralEffusions2胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第2頁(yè)ChestRadiographPleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestBilateralEffusionsDiseasesBelowtheDiaphragmInterstitialLungDiseasePulmonaryNodules3胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第3頁(yè)1.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralpleurisymalignancycancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolismdrug-inducedlungdiseasebenignasbestospleuraleffusion(BAPE)lymphaticabnormalitieschylothoraxandyellownailsyndromeuremicpleurisyconstrictivepericarditishypothyroidism4胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第4頁(yè)2.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome5胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第5頁(yè)3.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction6胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第6頁(yè)4.InterstitialLungDiseasecongestiveheartfailurerheumatoidarthritisasbestos-induceddisease(BAPEandasbestosis)lymphangiticcarcinomatosisLymphangioleiomyomatosisviralandmycoplasmapneumoniasWaldenstr?m'smacroglobulinemiasarcoidosisPneumocystiscariniipneumonia7胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第7頁(yè)5.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sranulomatosisrheumatoidarthritissepticembolisarcoidosistularemia8胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第8頁(yè)ValueofPleuralFluidAnalysisInaprospectivestudyof78patientswithnew-onsetpleuraleffusion,adefinitivediagnosiswasestablishedbytheinitialpleuralfluidanalysisin25%,apresumptivediagnosisin55%,withtheremaining20%havinganondiagnosticpleuralfluidanalysis.(excludingpossiblediagnoses)9胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第9頁(yè)ValueofPleuralFluidAnalysistheinitialpleuralfluidanalysisiseitherdefinitivelyorpresumptivelydiagnosticin80%ofpatientsandisvaluableclinicallyinabout90%ofcases.10胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第10頁(yè)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(zhuān)業(yè)知識(shí)講座第11頁(yè)ExudatesVsTransudates(1)exudativepleuralfluidprotein/serumprotein>0.5pleuralfluidLDH/serumLDH>0.6pleuralfluidLDHmorethantwo-thirdsnormalupperlimitforserumanyoneoftheabovevaluesmakesithighlylikelythattheeffusionisexudative.12胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第12頁(yè)ExudatesVsTransudates(2)pleuralfluidLDHsuggestsanexudateandthepleuralfluid/serumproteinratiosuggestsatransudate,malignancyoraneffusionsecondarytoPneumocystiscariniipneumoniashouldbeconsidered.Itisimportanttorememberthatnolaboratorytestis100%sensitiveandspecificandprethoracentesisdiagnosisandclinicaljudgmentmustbeusedintheinterpretationofpleuralfluidanalysis.13胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第13頁(yè)P(yáng)leuralFluidNucleatedCellCount(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(zhuān)業(yè)知識(shí)講座第14頁(yè)P(yáng)leuralFluidNucleatedCellCount(2)exudatepleuralfluidwithalymphocytecountof>80%ofthetotalnucleatedcellsincludestuberculouspleurisy,chylothorax,lymphoma,yellownailsyndrome,chronicrheumatoidpleurisy,sarcoidosis,trappedlung,andacutelungrejection.15胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第15頁(yè)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(zhuān)業(yè)知識(shí)講座第16頁(yè)P(yáng)leuralFluidpHandGlucose(1)pleuralfluidpH<7.30,normalbloodpH,exudativeeffusion

empyema,complicatedparapneumoniceffusion,chronicrheumatoidpleurisy,esophagealrupture,malignancy,tuberculouspleurisy,andlupuspleuritis17胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第17頁(yè)P(yáng)leuralFluidpHandGlucose(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(zhuān)業(yè)知識(shí)講座第18頁(yè)P(yáng)leuralFluidpHandGlucose(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(zhuān)業(yè)知識(shí)講座第19頁(yè)漏出液滲出液判別可變,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(guān)滲出液漏出液20胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第20頁(yè)漏出液滲出液判別急性期常>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(zhuān)業(yè)知識(shí)講座第21頁(yè)胸腔積液診療程序胸腔積液都不符合：漏出液診療性胸腔穿刺測(cè)胸水蛋白及LDH符合1條及以上：滲出液治療原發(fā)?。盒乃ァ⒛I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超等深入檢驗(yàn)22胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第22頁(yè)胸腔積液診療程序滲出液測(cè)胸水淀粉酶、Glu、細(xì)胞學(xué)、細(xì)胞分類(lèi)、培養(yǎng)、染色檢驗(yàn)、結(jié)核標(biāo)志物檢驗(yàn)Glu<60mg/dl惡性胸水細(xì)菌感染類(lèi)風(fēng)濕性淀粉酶升高食管破裂胰腺炎性惡性胸水不能診療????23胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第23頁(yè)考慮肺栓塞（CT、灌注掃描檢驗(yàn)）否治療肺栓塞否結(jié)核標(biāo)志物抗結(jié)核治療癥狀是否改進(jìn)考慮行胸腔鏡檢驗(yàn)或開(kāi)胸胸膜活檢觀(guān)察（＋）（－）是是24胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第24頁(yè)CommonDiseasesAssociatedWithPleuralEffusions25胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第25頁(yè)CongestiveHeartFailure26胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第26頁(yè)CongestiveHeartFailure(1)history:orthopneaandparoxysmalnocturnaldyspneatypicalofleftventricularfailure.usualchestradiograph:cardiomegaly,bilateralpleuraleffusions(rightgreaterthanleft),andevidenceofpulmonaryedemaasdemonstratedbyperibronchialcuffing,interstitialoralveolarinfiltrates,orKerley-Blines27胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第27頁(yè)CongestiveHeartFailure(2)diagnosticthoracentesis

fever,pleuriticchestpain,aunilateraleffusion,alefteffusiongreaterthentherighteffusion,effusionsofdisparatesize,andaPaO2inconsistentwiththeclinicalpresentation.28胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第28頁(yè)CongestiveHeartFailure(2)diagnosticthoracentesis

thetypicalpresentation,thoracentesiscanbewithheldwhileobservingtheresponsetotreatment.Ifresponseisnotappropriate,diagnosticthoracentesisshouldbeperformed.Acutediuresiscantransformatransudativecongestiveheartfailurefluidintoapseudoexudate29胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第29頁(yè)MalignantPleuralEffusions30胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第30頁(yè)MalignantPleuralEffusions(1)Dyspneaisthemostcommonpresentingsymptom,followedbycough.Ofpatientspresentingwithamassivepleuraleffusion,approximatelytwothirdswillhavemalignancy.Whenthereiscontralateralmediastinalshiftwithalargeormassiveeffusion,theeffusionisusuallycausedbyacarcinomathatisnotalungprimary.31胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第31頁(yè)MalignantPleuralEffusions(2)Whenthereisalargeorcompleteopacificationofthehemithoraxwithoutcontralateralshiftoripsilateralshift,lungcanceristhemostlikelycause,usuallysquamouscellcarcinomainvolvingthemainstembronchus;otherdiagnoses:afixedmediastinumfrommalignantlymphnodes,malignantmesothelioma,andparenchymaltumorinvasion.32胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第32頁(yè)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(zhuān)業(yè)知識(shí)講座第33頁(yè)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(zhuān)業(yè)知識(shí)講座第34頁(yè)MalignantPleuralEffusions(5)Malignantpleuraleffusionsaretypicallyexudativebutonrareoccasioncanbetransudative.Transudativemalignanteffusionsaremostcommonlycausedbyconcomitantdisease,particularlycongestiveheartfailure,butalsomaybeduetoearlylymphaticobstructionandendobronchialobstructionproducinganatelectaticeffusion.35胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第35頁(yè)MalignantPleuralEffusions(6)ThepleuralfluidglucoseandthepHarelowinabout30%ofpatientsThelowglucoseisgenerallyintherangeof30to50mg/dLandthepHintherangeof7.05to7.29.10and14%ofpatientsareamylase-richsalivaryoriginThepleuralfluid–to-serumratioofamylaseinmalignancyisintherangeof5:1,muchlowerthaninpancreaticdisease36胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第36頁(yè)MalignantPleuralEffusions(7)FindingalowpleuralfluidpH(<7.30)inmalignantpleuraleffusionsisassociatedwithapoorerprognosis,ahigherpositiveyieldformalignantcellsoncytologyandpleuralbiopsy,andlesssuccesswithchemicalpleurodesisthanwhenthepHis>7.30.37胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第37頁(yè)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(zhuān)業(yè)知識(shí)講座第38頁(yè)MalignantPleuralEffusions(9)CytologicexaminationandpleuralbiopsyishighinmalignanteffusionswithapHof<7.30PleurodesistendstobeunsuccessfulwhenthepHislowbecausethelungmaybetrappedbytumororfibrosisorbecausethetumorburdenpreventsthechemicalagentfrominitiatingmesothelialcellinjurythatinitiatestheinflammatorycascadethatleadstofibrosis.Furthermore,tumorandfibrosisonthepleuralsurfacemayblocksubmesothelialfibroblastmigrationintothecoagulablepleuralfluid,preventingcollagendeposition.39胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第39頁(yè)MalignantPleuralEffusions(10)Adenocarcinomaofthelungisthemostcommonmalignancycausinganamylase-richpleuraleffusion,followedbyadenocarcinomaoftheovary.Thesetumorsproduceanectopicsalivary-likeisoamylase.Asalivary-richamylaseeffusionoccurringintheabsenceofesophagealperforationhasahighlikelihoodofbeingmalignant.40胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第40頁(yè)結(jié)核性與腫瘤性胸水判別<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(lèi)型多為大量,生長(zhǎng)快多為中、少許胸液量（－）（＋）PPD試驗(yàn)中、老年多見(jiàn)青、少年多見(jiàn)年紀(jì)腫瘤性結(jié)核性41胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第41頁(yè)結(jié)核性與腫瘤性胸水判別效果不佳反應(yīng)很好抗TB治療腫瘤組織結(jié)核肉芽腫胸膜活檢<1g/L>1g/L類(lèi)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(zhuān)業(yè)知識(shí)講座第42頁(yè)P(yáng)arapneumonicEffusions:Pathophysiology,Diagnosis,andManagement43胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第43頁(yè)IncidenceandDefinitions1millionpersonsintheUnitedStatesdevelopingparapneumoniceffusionsyearly.Parapneumoniceffusions(pleuralfluidsassociatedwithpneumonia)aremostoftenfree-flowingeffusionsthatresolvespontaneouslywithantibiotictherapydirectedatthepneumonia(uncomplicatedeffusions.)Pleuralfluidsthatrequiredrainageofthepleuralspaceforresolutionofthefebrileresponsehavebeentermed"complicated"effusions.Empyema:theendstageofacomplicatedparapneumoniceffusion(empyemathoracis).44胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第44頁(yè)P(yáng)athophysiology（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(zhuān)業(yè)知識(shí)講座第45頁(yè)P(yáng)athophysiology（2）organizational/empyemastageasinglecavityormultipleloculationsUntreatedempyemararelyresolvesspontaneouslyempyemaalwaysrequiredrainageforresolutionofpleuralsepsisTherationaleforeffectivemanagementistoidentifythepathophysiologicstageandintervenetimelyandappropriatelytopreventprogressiontoempyema46胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第46頁(yè)Diagnosis(1)Unfortunately,differentiatinghigh-fromlow-riskpatientsclinicallyisproblematic,asthereisnodifferenceatpresentationinage,peripheralleukocytecount,peaktemperature,incidenceofpleuriticchestpain,orextentofpneumonia.47胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第47頁(yè)Diagnosis(2)Pleuralfluidanalysisisarelativelyinexpensiveandusefuldiagnostictesttoidentifythestageofaparapneumoniceffusionandtoguidetherapy.ApositiveGram'sstain,eveninnonpurulentfluid,impliesanadvancedstageofdiseaseandsuggeststheneedforimmediatedrainageThepleuralfluidproteinconcentration,nucleatedcellcount,orpercentageofPMNs

cannotdifferentiateacomplicatedfromuncomplicatedeffusion.48胸腔積液診療和治療專(zhuān)業(yè)知識(shí)講座第48頁(yè)Diagnosis(3)pH<7.00,aglucose<40mg/dL,andanLDH>1,000U/LindicatedacomplicatedparapneumoniceffusionthatrequireddrainagepHof>7.30onadmissionvirtuallyalwayspredictedagoodoutcomewithapp