Diagnosis and Management of Pleural Effusions呼吸内科：徐作军呼吸内科：徐作军2002，4，PUMC1Diagnosis of Pleural Effusions2Chest RadiographPleural Fluid as the Only Abnormality With Primary Disease in the ChestBilateral EffusionsDiseases Below the DiaphragmInterstitial Lung DiseasePulmonary Nodules31.Pleural Fluid as the Only Abnormality With Primary Disease in the Chestinfections tuberculous and viral pleurisy malignancy cancer,non-Hodgkins lymphoma,and leukemia pulmonary embolism drug-induced lung disease benign asbestos pleural effusion(BAPE)lymphatic abnormalitieschylothorax and yellow nail syndrome uremic pleurisy constrictive pericarditis hypothyroidism42.Bilateral Effusions transudative effusionscongestive heart failurenephrotic syndrome hypoalbuminemia peritoneal dialysisconstrictive pericarditisexudative effusionsmalignancy(extrapulmonic primary carcinomas,lymphoma)lupus pleuritisyellow nail syndrome53.Diseases Below the Diaphragmtransudates hepatic hydrothoraxnephrotic syndromeurinothoraxperitoneal dialysis exudates pancreatic disease chylous ascites subphrenic abscess splenic abscess or infarction64.Interstitial Lung Diseasecongestive heart failurerheumatoid arthritisasbestos-induced disease(BAPE and asbestosis)lymphangitic carcinomatosisLymphangioleiomyomatosisviral and mycoplasma pneumoniasWaldenstrms macroglobulinemiasarcoidosis Pneumocystis carinii pneumonia75.Pulmonary Nodulesmost common causes metastatic carcinoma from a nonlung primary tumor.Less common causes Wegeners ranulomatosis rheumatoid arthritis septic emboli sarcoidosis tularemia8Value of Pleural Fluid AnalysisIn 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 diagnosis in 55%,with the remaining 20%having a nondiagnostic pleural fluid analysis.(excluding possible diagnoses)9Value of Pleural Fluid Analysisthe initial pleural fluid analysis is either definitively or presumptively diagnostic in 80%of patients and is valuable clinically in about 90%of cases.10Diagnoses that can be definitivelyempyema(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 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 Transudates(2)pleural fluid LDH suggests an exudate and the pleural fluid/serum protein ratio suggests a transudate,malignancy or an effusion secondary to Pneumocystis carinii pneumonia should be considered.It is important to remember that no laboratory test is 100%sensitive and specific and prethoracentesis diagnosis and clinical judgment must be used in the interpretation of pleural fluid analysis.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 empyema).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,chylothorax,lymphoma,yellow nail syndrome,chronic rheumatoid pleurisy,sarcoidosis,trapped lung,and acute lung rejection.15eosinophilia(10%of the total nucleated cells are eosinophils)most commonly pneumothorax and hemothorax,BAPE,pulmonary embolism with infarction,previous thoracentesis,parasitic disease(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 empyema,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 obstructive 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 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