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1、Diagnosis and Management of Pleural Effusions呼吸内科：徐作军 2002，4，PUMC1Diagnosis of Pleural Effusions2Chest Radiograph Pleural Fluid as the Only Abnormality With Primary Disease in the Chest Bilateral Effusions Diseases Below the Diaphragm Interstitial Lung Disease Pulmonary Nodules31. Pleural Fluid as t
2、he Only Abnormality With Primary Disease in the Chest infections tuberculous and viral pleurisy malignancy cancer, non-Hodgkins lymphoma, and leukemia pulmonary embolism drug-induced lung disease benign asbestos pleural effusion (BAPE) lymphatic abnormalities chylothorax and yellow nail syndrome ure
3、mic pleurisy constrictive pericarditis hypothyroidism42.Bilateral Effusions transudative effusions congestive heart failure nephrotic syndrome hypoalbuminemia peritoneal dialysis constrictive pericarditis exudative effusions malignancy (extrapulmonic primary carcinomas, lymphoma) lupus pleuritis yel
4、low nail syndrome53.Diseases Below the Diaphragm transudates hepatic hydrothorax nephrotic syndrome urinothorax peritoneal dialysis exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction64.Interstitial Lung Disease congestive heart failure rheumatoid arthritis a
5、sbestos-induced disease (BAPE and asbestosis) lymphangitic carcinomatosis Lymphangioleiomyom atosis viral and mycoplasma pneumonias Waldenstrms macroglobulinemia sarcoidosis Pneumocystis carinii pneumonia75.Pulmonary Nodules most common causes metastatic carcinoma from a nonlung primary tumor. Less
6、common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia8Value of Pleural Fluid Analysis In a prospective study of 78 patients with new-onset pleural effusion, a definitive diagnosis was established by the initial pleural fluid analysis in 25% , a presumptive dia
7、gnosis in 55%, with the remaining 20% having a nondiagnostic pleural fluid analysis. (excluding possible diagnoses)9Value of Pleural Fluid Analysis the initial pleural fluid analysis is either definitively or presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of case
8、s.10Diagnoses that can be definitively empyema (pus) malignancy tuberculous fungal lupus pleuritis (lupus erythematosus cells) chylothorax (triglycerides 110 mg/dL or presence of chylomicrons) hemothorax (pleural fluid/blood hematocrit 0.5) urinothorax (pleural fluid/serum creatinine 1.0) peritoneal
9、 dialysis (total protein 0.5 pleural fluid LDH/serum LDH 0.6 pleural fluid LDH more than two-thirds normal upper limit for serum any one of the above values makes it highly likely that the effusion is exudative. 12Exudates Vs Transudates(2) pleural fluid LDH suggests an exudate and the pleural fluid
10、/serum protein ratio suggests a transudate, malignancy or an effusion secondary to Pneumocystis carinii pneumonia should be considered. It is important to remember that no laboratory test is 100% sensitive and specific and prethoracentesis diagnosis and clinical judgment must be used in the interpre
11、tation of pleural fluid analysis.13Pleural Fluid NucleatedCell Count(1) rarely helpful in establishing a definitive diagnosis. however, it may provide useful information. 50,000/mL, it usually represents pleural space bacterial infection (typically empyema). between 25,000 and 50,000/mL are usually
12、seen only with uncomplicated parapneumonic effusions, acute pancreatitis and acute pulmonary infarction.14Pleural Fluid NucleatedCell Count(2) exudate pleural fluid with a lymphocyte count of 80% of the total nucleated cells includes tuberculous pleurisy, chylothorax, lymphoma, yellow nail syndrome,
13、 chronic rheumatoid pleurisy, sarcoidosis, trapped lung, and acute lung rejection.15 eosinophilia ( 10% of the total nucleated cells are eosinophils) most commonly pneumothorax and hemothorax, BAPE, pulmonary embolism with infarction, previous thoracentesis, parasitic disease (paragonimiasis), funga
14、l disease, drug-induced lung disease , Hodgkins lymphoma, carcinoma. The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.16Pleural Fluid pH and Glucose(1) pleural fluid pH 1,000 U/L (upper limit of normal of serum 200 IU/L).19漏出液渗出液鉴别可变,常60
15、0mg/L 600mg/L葡萄糖30g/L 胸液血清0.51.01850%1000/ml200IU/L 胸液血清0.67.4PH多变0.5 2 胸水/血清LDH0.6 3 胸水LDH血清LDH2/3血清LDH查体、胸片、CT、B超等进一步检查22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 7.30.37Malignant Pleural Effusions(8) However, a meta-analysis of more than 400 patients with malignant effusions demonstrated that, even when the pH was in the range of 6.70 to 7.26, 46% of the patients were still alive at 3 months from the time of initial pleural fluid analysis. Furthermore, 65% of patients in the lowest quartile of pH (6.70 to 7.26) had successful pleurodesis, compared with 88% of patients
