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1、 胸腔积液pleural effusionDefinitionv 正常胸腔内有微量液体起润滑作用。其 产生与吸收处于动态平衡。v 当产生增加或吸收减少，胸膜腔内液体 积聚，便形成胸腔积液。vGeneral Considerations: Pleural fluid is formed in the normal individual mostly on the parietal pleural surface at the rate of about 0.1mL/kg body weight/h.nAbsorption of fluid occurs mostly through viscer
2、al pleural capillaries, while protein is recovered through parietal pleural lymphatics. The resultant homeostasis leaves 5-15mL of fluid normally present in the pleural space.nThe five major types of pleural effusion are transudates, exudates, empyema, hemorrhagic pleural effusion or hemothorax, and
3、 or chyliform effusion.胸腔积液产生与吸收的机制 胸腔内负压 (5)胸腔内胶体渗透压 (8 cm H2O ) 淋巴回流毛细血管胶体渗透压毛细血管静水压30cm H2O 34cm H2O 11cm H2O 壁层胸膜脏层胸膜液体渗出压力梯度（5830）349cm H2O 液体再吸收压力梯度34（5811）10cm H2O 胸膜腔（体循环cap ）（进入）（肺循环cap ）（吸收）n壁层胸膜液体进入胸膜腔压力梯度：9cmH2On 毛细血管静水压 30cmH2On 胸膜腔负压 5cmH2On 胸膜腔胶体渗透压 8cmH2On 毛细血管胶体渗透压34cmH2On脏层胸膜液体从胸膜腔
4、回收压力梯度：10cmH2On毛细血管静水压 11cmH2On 胸膜腔负压 5cmH2On 胸膜腔胶体渗透压 8cmH2On 毛细血管胶体渗透压34cmH2On 淋巴回流。n胸腔积液的形成：n 上述胸液滤出和再吸收压力梯度失衡或胸膜面积变化n 淋巴管引流受影响【Pathogenesy】一、毛细血管静水压增高：充血性心衰、缩窄性 心包炎等体循环或肺循环静水压增加。漏出液为主 二、毛细血管通透性增加：胸膜炎症、胸膜肿瘤 、全身性疾病等。渗出液（胸水胶渗压升高） 三、血浆胶体渗透压降低：低蛋白血症：肝硬化 、肾病综合征。漏出液 四、淋巴管引流障碍：癌症淋巴管阻塞。渗出液 五、损伤所致胸腔内出血：外伤
5、，主A瘤破裂； 血性、脓性、乳糜性均属渗出液。n主要病因和积液性质：参见讲义 P144 表2131Essentials of DiagnosisnAsymptomatic in many cases; pleurtic chest pain if pleuritis is present; dyspnea if effusion is large.nDecreased tactile fremitus; dullness to percussion; distant breath sounds; egophony if effusion is large.nRadiographic evide
6、nce of pleural effusion.nDiagnostic findings on thoracentesis.【Clinical Manifestation】n症状n胸痛：大量积液时，气急加重，胸痛消失。Pleuritic chest pain and dry coughn呼吸困难：300-500mlSmall pleural effusions are usually asymptomatic, whereas large pleural effusions may cause dyspnean体征（1）：n气管移位：大量胸水可伴气管、纵隔移向健侧。n呼吸动度减弱n叩浊音，n呼
7、吸音降低，胸膜摩擦音。n体征（2）Physical findings are absent if less than 200- 300mL of pleural fluid is present. Signs consistent with a larger pleural effusion include decrease in tactile fremitus, dullness to percussion, and diminution of breath sounds over the effusion.n原发病的症状、体征： 结核中毒症状， 恶液质， 体循环瘀血表现。影象诊断（ima
8、ge）（1）1、胸液0.30.5L时，肋隔角变纯；About 250mL of pleural fluid must be present before effusion can be detected on conventional erect posteroanterior chest radiograph. 2、更多的积液可见液性曲线（外高、内低的弧形上缘）, 随体位变化。 3、液气胸时可见液平面。 4、局限性积液（包裹性胸腔积液）：叶间积液、肺底积 液。 5、积液量的判断：2、4前肋影象诊断（image）（2）6、单侧大量积液：Ca、TB、其他。Massive pleural effu
9、sion (opacification of an entire hemithorax) is commonly caused by cancer but has been observed in tuberculosis and other diseases.CT检查少量积液:CT scanning is sensitive in the detection of small amounts of pleural fluid.包裹性胸腔积液肺内、纵隔、胸膜的病变：如肺内肿瘤，胸膜 间皮瘤等。超声检查：定位(用于局限性胸水或者粘 连分隔胸水的诊治）、鉴别胸腔积液或胸 膜肥厚Ultrasound
10、 is useful to locate loculated or small effusions.【laboratory findings】nDiagnostic thoracentesis should be performed whenever a pleural effusion is detected and no cause for the effusion is clinically apparent.n常规检查：v外观：淡黄色、草黄色、血性、黄脓性巧克力样乳白色、黑、绿色v细胞：红细胞：白细胞：生化检查vpH：n结核性、肺炎并胸腔积液、类风湿7.30n脓胸7.0n肿瘤性、SLE
11、 7.35v蛋白质:v葡萄糖: （胸液血糖） 结核性、肺炎并胸腔积液、类风湿、少数肿瘤性 、脓胸80um/L,恶性1015ug/L或胸液/血清CEA1，提示恶 性胸水CEA20ug/L，胸液/血CEA1诊断恶性胸水的 敏感性和特异性均超过90。vCA（血清糖链肿瘤相关抗原）：胸水中血清CA50 20u/ml，考虑恶性胸水vCEA、CA50 、CA125 、CA19-9 等联合测试诊断 恶性胸水，有利于提高敏感性和特异性。细胞学检查v瘤细胞：恶性胸水约4080可检出恶性细胞，多次 检查可提高阳性率。vDNA：应用DNA流式细胞分析仪免疫组织化学分别检 出胸液中细胞DNA含量和恶性肿瘤细胞重要相
12、关抗原，用于诊断恶性胸水，与细胞学检查联 合可显著提高敏感性。v间皮细胞：非结核性5；结核性1%病原学检查n离心沉淀物：可行普通细菌、真菌、结 核分枝杆菌等培养；涂片革兰染色或抗 酸染色分别查找普通细菌、真菌、结核 分枝杆菌。n胸液有时需行厌氧菌培养、寄生虫检测 。组织学检查nClosed pleural biopsy with a Cope or Abrams needle should be considered whenever malignancy or tuberculosis is considered in the differential diagnosis of a pleu
13、ral effusion that is unexplained after routine studies and thoracentesis.nOpen pleural biopsy is sometimes required to establish the diagnosis of pleural malignancy and is especially indicated for the diagnosis of malignant pleural mesothelioma.n胸膜活检：ca、TB阳性率 3070n胸腔镜或纤支镜代胸腔镜：阳性率 75-98良、恶性胸腔积液的鉴别诊断n
14、（见下页）【treatment】(1)Treatment should address both the disease causing the pleural effusion and the effusion itself.Transudative pleural effusions generally respond to treatment of the underlying condition; therapeutic thoracentesis is indicated only if massive effusion causes dyspnea. 一、结核性胸膜炎 1、抗结核治
15、疗 【treatment】(2)2、胸腔穿刺 ：n 诊断性穿刺：n 治疗性穿刺：1000ml/次，抽液速度不易过快 ，以防复张后肺水肿和循环障碍。抽液过程中如有 胸膜反应，应立即停止抽液，使患者平卧位，必要 时皮下注射0.1%肾上腺素0.5ml，密切观察病情 ，防止休克。3、糖皮质激素的应用 在抗痨基础上加用皮质 激素，强的松2530mg/日，渐减量，一般 疗程为46个周。 二、恶性胸腔积液(1)1、反复胸腔穿刺抽液。In cancer patients with malignant pleural effusion, the pleural surface is directly invad
16、ed by malignant cellsIn such cases the tumor causing the effusion is unresectable. 2、全身化疗或局部化疗经全身化疗，约1/3病人胸水消失。将胸水排空，经引流管注入抗肿瘤药物，如DDP、 5FU等，既杀癌细胞又引起胸膜粘连。胸膜腔注入生物免疫调节剂：IL2、干扰素、cp 、沙培林OK43、LAK细胞等。恶性胸腔积液(2)3、胸膜粘连术Chemical pleurodesis (obliteration of the pleural space by producing fibrous adhesion between the visceral and the parietal pleura)is advised for selected patients with symptomati
