,Respiratory Medicine,Rui Zheng（郑锐），M.D. , Ph.D. SHENG JING HOSPITAL CHINA 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 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 effusion,Pleural Space,Visceral Pleura attached to lungs. Parietal Pleura attached to chest wall. Pleural space 5-15 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,Parietal 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 obstruction (malignancy)trauma (esophagus,thoracic duct rupture ),Symptom,Dyspnea (most common) Mild, non-productive cough Severe cough with sputum or blood Pneumonia vs. bronchial lesion Constant chest pain Cancerous invasion of chest wall Pleuritic chest pain PE vs. inflammatory pleural effusion,Physical Examination,Mediastinal shift away from the effusion Decreased tactile fremitus Dullness to percussion Decreased breath sounds Pleural 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 indicated 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 gravity, Protein content, Cell counts, Glucose, LDH ,Adenisine deaminase (ADA), Gram stain and culture, Cytologic examination, etc.,Pleural fluid analysis,Appearance Colour yellow, Bloody, chocalate,milky, black specific gravity 1.0161.018, 1.018 Cloudy TRIG level 1.21mmol/L= chylothorax Putrid odor stain and culture = infection?Transudate vs Exudate?,Cells,Transudate: 500106/L, Pyothorax: WBC10000 106/LPMN -Acute inflammationlymphocyte mostTB or tumoreosinophile granulocyte - parasitic infection or CTDRBC 5000106/L malignant tumor or TBhaematothorax10000106/Lwound, tumor or PEmalignant -tumour cellSLElupus cell,pH,Normal: 7.6 pH 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 1.21mmol/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 pancreatitis, tumor. Isoenzyme -tumor。 Adenosine deaminase (ADA) 45UL-TB.,Tumor markers,CEA: 20g/L, PF/Serum1 CA125,CA199, et al,Pathogen,Smear or culture tuberculous 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 other diseases Contraindication: pyothorax or hemorrhagic tendency radiation therapy at the biopsy location if confirmed malignant pleural mesothelioma,Bronchoscope,Haemoptysis Suspect airway obstruction,Diagnosis,3 steps1. to determine pleural effusion existing or not 2. to determine transudate or Exudate3. to find the causes of pleural effusion,Transudate Exudate Apperance light yellow yellow, purulent Specific gravity 1.018 Coagulability unable able Revalta test negative positive Protein content 30g/L P. To serum 0.5 LDH 200 I U / L P. To s 0.6 Cell count 50010 6 / L Differential cell Lymphocyte Different,diagnosis,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.,