《胸腔积液》课件.ppt

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1、,胸腔积液 pleural effusion,大连医科大学附属第一医院消化wgj,Definition,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。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。General 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.,Absorption of fluid occurs mostly t

2、hrough visceral pleural capillaries,while protein is recovered through parietal pleural lymphatics.The resultant homeostasis leaves 5-15mL of fluid normally present in the pleural space.The five major types of pleural effusion are transudates,exudates,empyema,hemorrhagic pleural effusion or hemothor

3、ax,and or chyliform effusion.,胸腔积液产生与吸收的机制,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）,壁层胸膜液体进入胸膜腔压力梯度：9cmH2O 毛细血管静水压 30cmH2O 胸膜腔负压 5cmH2O 胸膜腔胶体渗透压 8cmH2O 毛细血管胶体渗透压34cmH2O脏层胸膜液体从胸膜腔回收压力梯度：10cmH2O毛细血管静水压 11cmH2O 胸膜腔负压 5cmH2O 胸膜腔

4、胶体渗透压 8cmH2O 毛细血管胶体渗透压34cmH2O 淋巴回流。胸腔积液的形成：上述胸液滤出和再吸收压力梯度失衡或胸膜面积变化 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，主A瘤破裂；血性、脓性、乳糜性均属渗出液。,主要病因和积液性质：参见讲义 P144 表2131,Essentials

5、of Diagnosis,Asymptomatic in many cases;pleurtic chest pain if pleuritis is present;dyspnea if effusion is large.Decreased tactile fremitus;dullness to percussion;distant breath sounds;egophony if effusion is large.Radiographic evidence of pleural effusion.Diagnostic findings on thoracentesis.,【Clin

6、ical Manifestation】,症状胸痛：大量积液时，气急加重，胸痛消失。Pleuritic chest pain and dry cough呼吸困难：300-500ml Small pleural effusions are usually asymptomatic,whereas large pleural effusions may cause dyspnea体征（1）：气管移位：大量胸水可伴气管、纵隔移向健侧。呼吸动度减弱叩浊音，呼吸音降低，胸膜摩擦音。,体征（2）Physical findings are absent if less than 200-300mL of pl

7、eural 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.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（image）（1）,1、胸液0.30.5L时，肋隔角变纯；About 250mL of pleural fluid must be present before eff

8、usion 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 effusion(opacification of an entire hemithorax)is commonly caused by cancer but has been

9、 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 is useful to locate loculated or small effusions.,【laboratory findings】,Diagnostic th

10、oracentesis should be performed whenever a pleural effusion is detected and no cause for the effusion is clinically apparent.常规检查：外观：淡黄色、草黄色、血性、黄脓性 巧克力样乳白色、黑、绿色细胞：红细胞：白细胞：,生化检查,pH：结核性、肺炎并胸腔积液、类风湿7.30脓胸7.0肿瘤性、SLE 7.35蛋白质:,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3.35，类风湿、脓胸可1.10 肿瘤性、漏出液 3.35mmol/L类脂：乳糜胸：甘油三

11、脂，苏丹三染色（+）外伤、肿瘤、寄生虫胸导管压迫破裂所致假性乳糜胸：胆固醇 苏丹三染色（-）见于结核性类风湿、癌性、肝硬化等,酶学,ADA（腺苷脱氨酶）：45 结核肺炎 ca性、风湿性80um/L,恶性65,CEA(癌胚抗原）：CEA1015ug/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。CA（血清糖链肿瘤相关抗原）：胸水中血清 CA50 20u/ml，考虑恶性胸水CEA、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,瘤细胞：恶性胸水约4080可检出恶性细胞，多次检查可

12、提高阳性率。DNA：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。间皮细胞：非结核性5；结核性1%,病原学检查,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。胸液有时需行厌氧菌培养、寄生虫检测。,组织学检查,Closed pleural biopsy with a Cope or Abrams needle should be considered whenever malignancy or tuberculosis is con

13、sidered in the differential diagnosis of a pleural effusion that is unexplained after routine studies and thoracentesis.Open pleural biopsy is sometimes required to establish the diagnosis of pleural malignancy and is especially indicated for the diagnosis of malignant pleural mesothelioma.胸膜活检：ca、T

14、B阳性率 3070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,（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 ma

15、ssive effusion causes dyspnea.一、结核性胸膜炎1、抗结核治疗,【treatment】(2),2、胸腔穿刺：诊断性穿刺：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

16、 pleural surface is directly invaded by malignant cells In 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

17、by producing fibrous adhesion between the visceral and the parietal pleura)is advised for selected patients with symptomatic malignant pleural effusion who fail to respond to chemotherapy or mediastinal radiation or who are not candidates for these forms of therapy.采用四环素（2g)、滑石粉（5g)、多西环素等粘连剂，使胸膜腔闭锁阻

18、止积液复发。,三、化脓性胸腔积液（脓胸）（1）,炎性胸水：有以下情况需插管引流(1)the fluid resembles frank pus or bacteria are seen on Gram stain,(2)pleural fluid glucose is 40mg/dL(3)pleural fluid pH is 7.2有包裹积液？：A parapneumonic effusion that does not respond to drainage within 24 hours may have become loculated.B超定位：In such cases,ultra

19、sound examination is required to guide placement of an additional chest tube in the proper location.手术：Open surgical drainage may be necessary if these measures are ineffective.,三、化脓性胸腔积液（脓胸）（2）,病原体：金葡菌、厌氧菌、G-杆菌、TB菌、放线菌急性期：全身和胸腔内给药 胸穿、肋间切开引流 2NaHCO3 冲洗 注入抗生素或抗痨药（结核性）慢性期：胸膜增厚、肺被包裹不能张开，影响心肺功 能胸膜剥脱术 支气管胸膜瘘瘘管结扎、胸廓改形术 营养支持、纠正电介质及酸碱失衡,Thanks！,