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 pleural fluid LDH/serum LDH pleural 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漏出液渗出液鉴别漏出液渗出液鉴别可变可变,常常600mg/L 600mg/L葡萄糖葡萄糖30g/L胸液血清胸液血清0.530g/L胸液血清胸液血清1.01850%1000/ml200IU/L胸液血清0.6200IU/L胸液血清0.6LDH7.4PH 多变血清血清LDH2/3血清血清LDH查体、胸片、查体、胸片、CT、B超等超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测胸水淀粉酶、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?23考虑肺栓塞考虑肺栓塞（CT、灌注扫描检查）灌注扫描检查）否否治疗肺栓塞治疗肺栓塞否否结核标志物结核标志物抗结核治疗抗结核治疗症状是否改善症状是否改善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观观 察察（）（）（）（）是是是是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 (right 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 effusion, 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 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, approximately 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 contralateral 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 effusions 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 Pleural 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 Effusions(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 obstruction 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-richsalivary originThe 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 demonstrated 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 pleurodesis38Malignant Pleural Effusions(9)Cytologic examination and pleural biopsyPleurodesis 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 initiating 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)Adenocarcinoma 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 being malignant.40结核性与肿瘤性胸水的鉴别 65ug/ml 65ug/ml 1溶菌酶活力胸水血液LDH2增高LDH4、5增高LDH同工酶多7.40多7.30PH大量间皮细胞淋巴细胞为主细胞类型多为大量,生长快多为中、少量胸液量 （） （）PPD试验中、老年多见青、少年多见年龄 肿瘤性 结核性41结核性与肿瘤性胸水的鉴别 效果不佳 反应较好抗TB治疗 肿瘤组织 结核肉芽肿胸膜活检 1g/L类粘蛋白 700ng/ml 20ug/L 1 20ug/L 1CEA胸水血液 45u/L 45u/L 1腺苷脱氨酶胸水血液 肿瘤性 结核性42Parapneumonic Effusions: Pathophysiology, Diagnosis, and Management43Incidence and Definitions1 million persons in the United States developing parapneumonic effusions yearly. Parapneumonic effusions (pleural fluids associated with pneumonia) are most often free-flowing effusions that resolve spontaneously with antibiotic therapy directed at the pneumonia(uncomplicated effusions.)Pleural fluids that require drainage of the pleural space for resolution of the febrile response have been termed complicated effusions.Empyema : the end stage of a complicated parapneumonic effusion (empyema thoracis).44Pathophysiology（1）a sterile, PMN-predominant exudatepH is 7.30, the glucose is 60 mg/dL, and the lactate dehydrogenase (LDH) is 500 U/L. can be treated successfully with antibiotics without the need for pleural space drainagebacterial invasion/fibrinopurulent stagefinding a positive Grams stain and culture signifies bacterial persistencecharacterized 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 effective; but later, pleural space drainage is usually required45Pathophysiology（2）organizational/empyema stagea single cavity or multiple loculationsUntreated empyema rarely resolves spontaneouslyempyema always require drainage for resolution of pleural sepsisThe rationale for effective management is 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 temperature, 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 stage 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/L indicated a complicated parapneumonic effusion that required drainage on admission virtually always predicted a good outcome with appropriate antibiotic treatment only. predicted that pleural space drainage was necessary to resolve pleural sepsis at admission had either complicated or uncomplicated effusions; 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 parapneumonic 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 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, cephalothin, and penicillinAminoglycosides 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/Decortication and Open Drainage 52