1、Diagnosis and Management of Pleural Effusions呼吸内科：徐作军呼吸内科：徐作军2019，4，PUMC1Diagnosis of Pleural Effusions2Chest Radiograph?Pleural Fluid as the Only Abnormality With Primary Disease in the ChestBilateral Effusions?Diseases Below the DiaphragmInterstitial Lung DiseasePulmonary Nodules31.Pleural Fluid a
2、s the Only Abnormality With Primary Disease in the Chest?infections tuberculous and viral pleurisy?benign asbestos pleural effusion(BAPE)?lymphatic abnormalities chylothorax and yellow nail syndrome?malignancy cancer,non-Hodgkins lymphoma,and leukemia?pulmonary embolism?constrictive pericarditis?dru
3、g-induced lung disease?hypothyroidism4?uremic pleurisy2.Bilateral Effusions?transudative effusions?exudative effusions?congestive heart failure?nephrotic syndrome?malignancy(extrapulmonic primary carcinomas,lymphoma)?lupus pleuritis?yellow nail syndrome5?hypoalbuminemia?peritoneal dialysis?constrict
4、ive pericarditis3.Diseases Below the Diaphragm?transudates?exudates?hepatic hydrothorax?pancreatic disease?nephrotic syndrome?chylous ascites?urinothorax?subphrenic abscess?peritoneal dialysis?splenic abscess or infarction64.Interstitial Lung Disease?congestive heart failure?rheumatoid arthritis?asb
5、estos-induced disease(BAPE and asbestosis)?lymphangitic carcinomatosis?Lymphangioleiomyomatosis?viral and mycoplasma pneumonias?Waldenstr?ms macroglobulinemia?sarcoidosis?Pneumocystis carinii pneumonia75.Pulmonary Nodules?most common causes?metastatic carcinoma from a nonlung primary tumor.?Less com
6、mon 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 diagnos
7、is 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 cases.10Diag
8、noses that can be definitively?empyema(pus)malignancytuberculous 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 dialysis(total
9、 protein 0.5 g/dl and glucose 200 to 400 mg/dL)?esophageal rupture(increased salivary amylase and pH 0.5pleural fluid LDH/serum LDH 0.6pleural fluid LDH more than two-thirds normal upper limit for serumany one of the above values makes it highly likely that the effusion is exudative.12Exudates Vs Tr
10、ansudates(2)?pleural fluid LDH suggests an exudate and thepleuralfluid/serumproteinratiosuggestsatransudate,malignancy or an effusion secondary toPneumocystiscariniipneumoniashouldbeconsidered.?It is important to remember that no laboratory testis100%sensitiveandspecificandprethoracentesis diagnosis
11、 and clinical judgmentmust be used in the interpretation of pleural fluidanalysis.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 empyem
12、a).?between 25,000 and 50,000/mL are usually 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,ch
13、ylothorax,lymphoma,yellow nail syndrome,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 dis
14、ease(paragonimiasis),fungal 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 7.30,normal blood pH,exudative effusion?empyem
15、a,complicated parapneumonic effusion,chronic rheumatoid pleurisy,esophageal rupture,malignancy,tuberculous pleurisy,and lupus pleuritis17Pleural Fluid pH and Glucose(2)?fluid glucose 60 mg/dL or pleural fluid/serum glucose 0.5,exudate,low pleural fluid pH.?Urinothorax,most commonly caused by obstruc
16、tive uropathy,is the only cause of a low pH transudate.?Empyema and rheumatoid pleurisy are the only effusions that can present with glucose concentrations of 0 mg/dL18Pleural Fluid pH and Glucose(3)?A pleural fluid pH 7.00 is usually seen only with empyema,whether it be parapneumonic or associated
17、with esophageal rupture.?Complicated parapneumonic effusion/empyema,rheumatoid pleurisy,and pleural paragonimiasis are the only effusions with the triad of a pH 7.30,a glucose 1,000 U/L(upper limit of normal of serum 200 IU/L).19漏出液渗出液鉴别漏出液渗出液鉴别漏出液漏出液外观外观比重比重淡黄，透明1.018凝固凝固Rivalta蛋白蛋白不凝不凝（）（）30g/L胸液血
18、清胸液血清30g/L胸液血清胸液血清0.5葡萄糖葡萄糖600mg/L可变可变,常常600mg/L20漏出液渗出液鉴别漏出液渗出液鉴别漏出液WBCPMN1000/ml1000/ml急性期常50%多变RBCPHLDH7.4200IU/L胸液血清0.6200IU/L胸液血清0.621胸腔积液的诊断程序胸腔积液的诊断程序胸腔积液胸腔积液查体、胸片、查体、胸片、CT、B超等超等1 胸水胸水/血清蛋白血清蛋白0.52 胸水胸水/血清血清LDH0.63 胸水胸水LDH血清血清LDH2/3血清血清LDH诊断性胸腔穿刺诊断性胸腔穿刺测胸水蛋白及测胸水蛋白及LDH都不符合都不符合：漏出液：漏出液符合符合1条及以上
19、条及以上：渗出液：渗出液治疗原发病：心衰、肾病等治疗原发病：心衰、肾病等进一步检查进一步检查22胸腔积液的诊断程序胸腔积液的诊断程序渗出液渗出液测胸水淀粉酶、测胸水淀粉酶、Glu、细胞、细胞学、细胞分类、培养、染色学、细胞分类、培养、染色检查、结核标志物检查检查、结核标志物检查淀粉酶升高淀粉酶升高食管破裂食管破裂胰腺炎性胰腺炎性恶性胸水恶性胸水不能诊断不能诊断?Glu60mg/dl恶性胸水恶性胸水细菌感染细菌感染类风湿性类风湿性23否否考虑肺栓塞考虑肺栓塞（CT、灌注扫描检查）、灌注扫描检查）是是结核标志物结核标志物（）（）治疗肺栓塞治疗肺栓塞（）（）抗结核治疗抗结核治疗是是观观察察症状是否改
20、善症状是否改善否否考虑行胸腔镜检查考虑行胸腔镜检查或开胸胸膜活检或开胸胸膜活检24Common Diseases Associated With Pleural Effusions25Congestive Heart Failure26Congestive Heart Failure(1)?history:orthopnea and paroxysmal nocturnal dyspnea typical of left ventricular failure.?usual chest radiograph:cardiomegaly,bilateral pleural effusions(ri
21、ght greater than left),and evidence of pulmonary edema as demonstrated by peribronchial cuffing,interstitial or alveolar infiltrates,or Kerley-B lines27Congestive Heart Failure(2)?diagnostic thoracentesis fever,pleuritic chest pain,a unilateral effusion,a left effusion greater then the right effusio
22、n,effusions of disparate size,and a PaO2 inconsistent with the clinical presentation.28Congestive Heart Failure(2)?diagnostic thoracentesis the typical presentation,thoracentesis can be withheld while observing the response to treatment.If response is not appropriate,diagnostic thoracentesis should
23、be performed.Acute diuresis can transform a transudative congestive heart failure fluid into a pseudoexudate29Malignant Pleural Effusions30Malignant Pleural Effusions(1)?Dyspnea is the most common presenting symptom,followed by cough.?Of patients presenting with a massive pleural effusion,approximat
24、ely two thirds will have malignancy.?When there is contralateral mediastinal shift with a large or massive effusion,the effusion is usually caused by a carcinoma that is not a lung primary.31Malignant Pleural Effusions(2)?When there is a large or complete opacification of the hemithorax without cont
25、ralateral shift or ipsilateral shift,lung cancer is the most likely cause,usually squamous cell carcinoma involving the mainstem bronchus;other diagnoses:a fixed mediastinum from malignant lymph nodes,malignant mesothelioma,and parenchymal tumor invasion.32Malignant Pleural Effusions(3)?Bilateral ef
26、fusions with a normal heart size malignancy(50%)The other 50%?transudative effusions:hepatic hydrothorax,nephrotic syndrome,severe hypoalbuminemia,and constrictive pericarditis,?exudates:lupus pleuritis,esophageal rupture,and tuberculous pleurisy(rare except in HIV-positive patients).33Malignant Ple
27、ural Effusions(4)?Lung and breast:the most common causes(about 65%of cases);?Ovarian and gastric cancer:the two next most common carcinomas(6 to 10%of cases).?Lymphoma:(about 10%of cases)?Less than 10%of malignant effusions have an unknown primary tumor at the time of diagnosis.34Malignant Pleural E
28、ffusions(5)?Malignant pleural effusions are typically exudative but on rare occasion can be transudative.Transudative malignant effusions are most commonly caused by concomitant disease,particularly congestive heart failure,but also may be due to early lymphatic obstruction and endobronchial obstruc
29、tion producing an atelectatic effusion.35Malignant Pleural Effusions(6)?The pleural fluid glucose and the pH are low in about 30%of patients?The low glucose is generally in the range of 30 to 50 mg/dL and the pH in the range of 7.05 to 7.29.?10 and 14%of patients are amylase-rich salivary origin The
30、 pleural fluidto-serum ratio of amylase in malignancy is in the range of 5:1,much lower than in pancreatic disease36Malignant Pleural Effusions(7)?Finding a low pleural fluid pH(7.30.37Malignant Pleural Effusions(8)?However,a meta-analysis of more than 400 patients with malignant effusions demonstra
31、ted 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 who had a pH of 7.2
32、738Malignant Pleural Effusions(9)?Cytologic examination and pleural biopsy is high in malignant effusions with a pH of 7.30?Pleurodesis tends to be unsuccessful when the pH is low because the lung may be trapped by tumor or fibrosis or because the tumor burden prevents the chemical agent from initia
33、ting mesothelial cell injury that initiates the inflammatory cascade that leads to fibrosis.Furthermore,tumor and fibrosis on the pleural surface may block submesothelial fibroblast migration into the coagulable pleural fluid,preventing collagen deposition.39Malignant Pleural Effusions(10)?Adenocarc
34、inoma of the lung is the most common malignancy causing an amylase-rich pleural effusion,followed by adenocarcinoma of the ovary.These tumors produce an ectopic salivary-like isoamylase.?A salivary-rich amylase effusion occurring in the absence of esophageal perforation has a high likelihood of bein
35、g malignant.40结核性与肿瘤性胸水的鉴别结核性年龄青、少年多见PPD试验（）胸液量多为中、少量细胞类型淋巴细胞为主PH多65ug/ml胸水血液1肿瘤性中、老年多见（）多为大量,生长快大量间皮细胞多7.40LDH2增高65ug/ml45u/L120ug/L11g/L结核肉芽肿反应较好肿瘤性45u/L20ug/L1700ng/ml7.30,the glucose is 60 mg/dL,and the lactate dehydrogenase(LDH)is 500 U/L.can be treated successfully with antibiotics without the
36、 need for pleural space drainage?bacterial invasion/fibrinopurulent stage finding a positive Grams stain and culture signifies bacterial persistence characterized by an increased number of PMNs,a fall in pleural fluid pH and glucose,and an increase in pleural fluid LDH.antibiotics alone may be effec
37、tive;but later,pleural space drainage is usually required45Pathophysiology（2）?organizational/empyema stage a single cavity or multiple loculations Untreated empyema rarely resolves spontaneously empyema always require drainage for resolution of pleural sepsis?The rationale for effective management i
38、s to identify the pathophysiologic stage and intervene timely and appropriately to prevent progression to empyema46Diagnosis(1)?Unfortunately,differentiating high-from low-risk patients clinically is problematic,as there is no difference at presentation in age,peripheral leukocyte count,peak tempera
39、ture,incidence of pleuritic chest pain,or extent of pneumonia.47Diagnosis(2)?Pleural fluid analysis is a relatively inexpensive and useful diagnostic test to identify the stage of a parapneumonic effusion and to guide therapy.?A positive Grams stain,even in nonpurulent fluid,implies an advanced stag
40、e of disease and suggests the need for immediate drainage?The pleural fluid protein concentration,nucleated cell count,or percentage of PMNs cannot differentiate a complicated from uncomplicated effusion.48Diagnosis(3)?pH 7.00,a glucose 1,000 U/Lindicated a complicated parapneumonic effusion that re
41、quired drainage?pH of 7.30 on admission virtually always predicted a good outcome with appropriate antibiotic treatment only.?pH of 7.10 predicted that pleural space drainage was necessary to resolve pleural sepsis?pH between 7.30 and 7.10 at admission had either complicated or uncomplicated effusio
42、ns;these patients require careful clinical monitoring with further diagnostic testing(repeat thoracentesis,contrast CT scan)before an informed management decision is made.49Diagnosis(4)?A recent meta-analysis found pleural fluid pH to have the highest diagnostic accuracy in identifying complicated p
43、arapneumonic effusions.Pleural fluid pH decision thresholds varied between 7.21 and 7.29 depending on cost-prevalence considerations?Current data support treatment with antibiotics and observation in patients with pH values between 7.21 and 7.29.Clinical parameters,repeat pleural fluid analysis,and
44、contrast chest CT should determine management.50Management(1)?Antibiotics?There is little difference in penetration of the penicillins and cephalosporins into empyemas and uninfected parapneumonic fluids.Drugs that show excellent pleural penetration include aztreonam,clindamycin,ciprofloxacin,cephal
45、othin,and penicillin?Aminoglycosides may be inactivated or have poorer penetration into empyemas than uncomplicated parapneumonic effusions.?oral clindamycin or penicillin should be continued for the duration of treatment once parenteral antibiotics are discontinued.(a few weeks)51Management(2)?Chest TubesImage-guided Percutaneous CathetersIntrapleural FibrinolyticsThoracoscopyEmpyemectomy/DecorticationandOpenDrainage52
