胸膜疾病英文版pptpleural disea.ppt

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1、,Respiratory Medicine,Rui Zheng（郑锐），M.D.,Ph.D.SHENG JING HOSPITALCHINA MEDICAL UNIVERSITY,Male,70 year old with an 80-pack-year history of smoking and a history of coronary heart disease.He was suffered from increasing shortness of breath for 1 week.And he also had chest pain on the right side that

2、worsens with deep inspiration.He was afebrile.,Chest examination revealed dullness to percussion,the absence of fremitus,and diminished breath sounds on the right side.No distended neck veins,no peripheral edema was observed.The chest radiograph was showed as picture,Pleural Diseases,Pleural effusio

3、n,Pleural Space,Visceral Pleura attached to lungs.Parietal Pleura attached to chest wall.Pleural space5-15 mL of fluid secreted by the pleural cells.Minimizes friction as the two pleural surfaces glide over each other during inspiration and expiration.,Lets review,Lung,Rib cage,Visceral Pleura,Parie

4、tal Pleura,Pleural Space,Pleural effusion transport,Development of Pleural Effusion,pulmonary capillary hydrostatic pressure(CHF,constrictive pericarditis)transudate plasma oncotic pressure(hypoalbuminemia,liver cirrhosis)pleural membrane permeability exudate(pneumonia,TB,CTD，malignancy,PE)lymphatic

5、 obstruction(malignancy)trauma(esophagus,thoracic duct rupture),Symptom,Dyspnea(most common)Mild,non-productive coughSevere cough with sputum or bloodPneumonia vs.bronchial lesionConstant chest painCancerous invasion of chest wallPleuritic chest painPE vs.inflammatory pleural effusion,Physical Exami

6、nation,Mediastinal shift away from the effusion Decreased tactile fremitusDullness to percussionDecreased breath soundsPleural friction rub,Chest X-Ray,Fluid in X-ray seen as a dense,white shadow with a concave upper edge(fluid level)anterior rib(2),Ultrasonography,Ultrasonographic guidance is indic

7、ated if difficulty is encountered in obtaining pleural fluid or if the effusion is small to perform thoracentesis,Thoracentesis,A needle is inserted into the chest wall to remove the collection of fluid Determines the type of fluid(transudate or exudate),Pleural fluid analysis,Appearance,Specific gr

8、avity,Protein content,Cell counts,Glucose,LDH,Adenisine deaminase(ADA),Gram stain and culture,Cytologic examination,etc.,Pleural fluid analysis,AppearanceColour yellow,Bloody,chocalate,milky,blackspecific gravity1.0161.018,1.018CloudyTRIG level 1.21mmol/L=chylothoraxPutrid odor stain and culture=inf

9、ection?Transudate vs Exudate?,Cells,Transudate:500106/L,Pyothorax:WBC10000 106/L PMN-Acute inflammation lymphocyte mostTB or tumor eosinophile granulocyte-parasitic infection or CTD RBC 5000106/L malignant tumor or TB haematothorax10000106/Lwound,tumor or PE malignant-tumour cell SLElupus cell,pH,No

10、rmal:7.6pH decrease pH7.35:SLE,malignant effusion,Protein,Exudate30g/L，pleural fluid/serum 0.5.Transudate30g/L，Rivalta test negative.,Glucose,The level in normal PF is similar to that in serum Pyothorax,RF,SLE,TB and malignant PF 3.35mmol/L,Adipoid,Chylothoraxcloudy,Sudan staining red,triglyeride1.2

11、1mmol/L，cholesterol is normal.Pseudochylothoraxlight yellow or brown,containing Cholesterol crystal cells like lymphocytes,red blood cells.cholesterol 26mmol/L，triglyeride is normal.,Enzymes,Exudate:lactic acid dehydrogenase(LDH)200uL，PFSerum0.6.LDH500U/Lmalignant or infective.Amylase-acute pancreat

12、itis,tumor.Isoenzyme-tumor。Adenosine deaminase(ADA)45UL-TB.,Tumor markers,CEA:20g/L,PF/Serum1CA125,CA199,et al,Pathogen,Smear or culturetuberculous pleurisy:M TB positive rate is about 20%.Chocolate-color effusion should examine Amoeba trophozoite by microscope.,Biopsy of pleura,To find tumor,TB,and

13、 other diseases Contraindication:pyothorax or hemorrhagic tendencyradiation therapy at the biopsy location if confirmed malignant pleural mesothelioma,Bronchoscope,HaemoptysisSuspect airway obstruction,Diagnosis,3 steps 1.to determine pleural effusion existing or not 2.to determine transudate or Exu

14、date 3.to find the causes of pleural effusion,Transudate ExudateApperance light yellow yellow,purulent Specific gravity 1.018Coagulability unable ableRevalta test negative positiveProtein content 30g/LP.To serum 0.5LDH 200 I U/L P.To s 0.6Cell count 50010 6/LDifferential cell Lymphocyte Different,di

15、agnosis,Lights Criteria,Pleural fluid is exudate if one or more:Pleural fluid protein:serum protein 0.5Pleural fluid LDH:serum LDH 0.6Pleural fluid LDH 2/3 upper limit ln serum LDH,Transudate,Hepatic hydrothorax.Nephritic syndrome.Congestive heart failure.Hypoproteinemia.,Exudate,Cell count Neutroph

16、il predominate acute process(pneumonia,PE)-Lymphocytic predominate chronic process(Cancer,TB,)Culture/stain-infected fluidGlucose-low level(60mg/dl)(pneumonia,CA)Cytology-malignancypH-parapneumonic 7.2-must drain fluid malignant 7.2 poor prognosis,Malignant Effusions,Clinical features suggestive of

17、malignacy:Symptoms 1mo,absence of fever,blood-tinged fluid,chest CT suggesting malignancyLung breast lymphoma/leukemiametastatic adenocarcinoma positive cytology 70%Lymphoma 25-50%Mesothelioma 10%Squamous Cell Carcinoma 20%Pleural fluid:bloody,lymphocytic,decreased glucose and pH,cytology,Treatment,

18、The most important method is to cure the cause of pleural effusion.,Tuberculous pleurisy,general treatment:rest,nutritional support,symptomatic treatmentthoracentesis Note:700ml at the first time，1000ml afterwards re-expansion pulmonary edema pleura reactionUsually there is no need to inject antitub

19、erculosis drugs into thoracic cavity。Antituberculosis therapy Glucocorticoid,Malignant pleura effusion,primary disease therapyThoracentesis continuing closed drainageChemical pleurodesissurgery,Parapneumonia pleural effusion and pyothorax,basic therapy:Thoracentesis and tube thoracostomyAntibioticsR

20、insing the pleural cavity with 2%NaHCO3 or normal saline repeatly.surgerygeneral treatment,male,70 year old with an 80-pack-year history of smoking and a history of coronary heart disease.He was suffered from increasing shortness of breath for 1 week.And he also had chest pain on the right side that

21、 worsens with deep inspiration.He was afebrile.,Case 1,Chest examination revealed dullness to percussion,the absence of fremitus,and diminished breath sounds on the right side.No distended neck veins,no peripheral edema was observed.The chest radiograph was showed as picture,What shall we do next?Th

22、e pleural fluid test result:total cells:570106/L,lymphocyte 59%,protein 36g/L,Rivalta test(+),serum protein 62g/L,what kind of pleural effusion was it?,diagnostic thoracentesisExudate,Male,32 years old.Chief complaint:Fever and fatigue for one month,dyspnea after movement for one week.Physical exami

23、nation:T 38.5C,trachea toward the right,the plump contour of the left lower chest,decreased fremitus and breath sound as well as dullness by percussion at the left lower chest,no rub feeling.,Case 2,Questions:1.What kinds of laboratory examination should be done?2.Should thoracentesis be done?If yes

24、,what should be cautious?What kinds of examination should be done in pleural effusion?3.if the diagnosis is tuberculous pleural effusion,how about therapy?,Pneumothorax,“Pneumo”-gas“Thorax”chest cavity Air accumulation in the pleural space with secondary lung collapse,Definition,Sources,Visceral ple

25、uraRuptured esophagusChest wall defectGas-forming organisms,52,Classification of Pneumothorax,Spontaneous Primary Secondary COPD Infection Neoplasm Catamenial Miscellaneous,Traumatic Blunt PenetratingIatrogenic Inadvertent Diagnostic Therapeutic,Primary Spontaneous Pneumothorax,Pt.with unknown lung

26、disease.a rupture of a bulla in the lung.Most often tall,thin men between 20 and 40 years old.,Secondary Spontaneous Pneumothorax,occurs in pt.with known lung diseasemost often COPD Other lung diseases commonly assoc.withTuberculosisPneumoniaAsthmacystic fibrosislung cancerOften severe&life threaten

27、ing,Emphysema of the Lung-Solitary giant bulla,RLL,Closure pneumothorax Unclosure pneumothoraxTension pneumothorax,Clinical classification,Closure pneumothorax,Air enters the pleural cavity via lungsblunt chest traumaCar crashFallCrushing chest injury,Unclosure pneumothorax,Open PneumothoraxAir ente

28、rs pleural cavity via outsideA free communication between the exterior and the pleural space as through an open wound,Tension pneumothorax,a piece of tissue forms a one-way valve that allows air to enter the pleural cavity but not to escape,overpressure can build up with every breath,Tension pneumot

29、horax,air accumulates in the pleural space with each breath.The remorseless increase in intrathoracic pressure massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels cardiovascular collapse,Clinical Manifestations(all types),Sudden sharp chest painAsymmetrica

30、l chest expansiondyspneaCyanosisPercussionHyper resonance or tympany Breath soundsdiminishedAbsent,Respiratory distressO2 Satsdecreased TachypneaTachycardiaRestlessness/Anxiety,S&S Tension pneumothorax,i cardiac outputHypotensionTachycardia(compensatory)Tachypnea Mediastinal shift and tracheal devia

31、tionTo the unaffected side Cardiac arrestDistended neck veins,Dx exam and tests,Chest x-rayABGsInitial PaCO2Decreasedrespiratory alkalosisLater ABGsHypoxemiaHypercapniaAcidosis,Imaging,Plain RadiographsUpright PA on inspirationDetect other pathologies:pneumonia,cardiac,etc.Partially collapsed lungTe

32、nsion PneumothoraxTrachea and mediastinum deviate contralaterallyIpsilateral depressed hemi-diaphragmChest CTNot routineOnly to assess the need for surgery(thoracotomy),Diagnosis,Unstable patientThoracentesisRapid release of airVital signs stabilize rapidly,Stable patientCXRBe sure that pneumothorax

33、 is not expanding,Assessment of size,Differential diagnosis,Bronchial asthmaCOPDAcute myocardial infarctionAcute pulmonary embolismPulmonary blebs,COPDLung blebsubcutaneous emphysema,acute pulmonary embolism,Treatment,Tx:Small pneumothorax Spontaneous recoveryBed rest,40%oxygenresolve on its own in

34、1 to 2 weeksRemove with small bore needle inserted into the pleural space Second intercostal space,midclavicular line.No more than 1000ml,Treatment,Tx:Larger pneumothoraxChest tube Surgery repairPleurodesis“glue”Very painfulPrep with analgesicO2Surgery,Complication of Spontaneous Pneumothorax,Re-exp

35、ansion pulmonary edemaHemothoraxCutaneous emphysema and Pneumomediastinum,Case,A client who has been on a ventilator for two days experiences acute respiratory distress accompanied by distended neck veins.The best action of the nurse is to:hand ventilate the client.prepare for chest tube insertion.call the physician immediately.perform emergency chest decompression.,Congratulations!,You have successfully completely this tutorial!,