1、胸腔积液总论,Pleural effusion,胸膜腔功能,减少肺与胸壁的摩擦肺的机械保护和支持负压调节心肺功能肺内水肿液的吸收(高静水压高渗透压性肺水肿的25%由胸膜吸收),胸膜腔,两层胸膜并不相互接触脏层胸膜无神经纤维,胸腔内压,胸腔内压 肺弹性回缩力功能 残气位 5CMH2O肺总量位-30CMH20 肺顺应性下降,胸腔负压增加立位时胸膜腔压力梯度每垂直下移1CM压力增加0.5,而两肺肺泡内压相同.肺内通气顺序上肺区先进后出,下肺区后进先出,胸水形成,传统 正常人胸腔内有315ml液体，人体每天胸膜腔可有0.51L液体通过。胸液中的蛋白质主要经由淋巴管进入胸导管。新论 壁层胸膜缓慢产生，经
2、壁层胸膜间皮间2-12UM小孔，直接引流入淋巴管。每日100-200。 脏层胸膜对胸水产生吸收不起作用 。正常胸水0.3ml/kg,低渗,交换量0.15ml/kg/h,最大流量30ml/h由胸膜腔尖顶区壁层胸膜产生胸膜腔基底区横膈纵膈壁层胸膜重吸收淋巴管微孔 单向活 作用胸液的滤过量超过胸膜最大淋巴流量时产生胸水,胸腔积液量,0.30.5L时，X线仅见肋膈角变钝；少于0.3L时症状多不明显；若超过0.5L，患者渐感胸闷。,机制,胸液循环与有关压力（cmH2O）关系示意图,34,胸腔积液与吸收的机制,病因学,一、胸膜毛细血管内静水压增高,充血性心力衰竭缩窄性心包炎血容量增加上腔静脉或奇静脉受阻,
3、二、胸膜毛细血管通透性增加,胸膜炎症（结核病、肺炎）结缔组织病（SLE、类风湿关节炎）胸膜肿瘤（恶性肿瘤转移、间皮瘤）肺梗死膈下炎症（膈下脓肿、肝脓肿、胰腺炎）,三、胸膜毛细血管内胶体渗透压降低,低蛋白血症肝硬化肾病综合征、急性肾小球肾炎粘液性水肿,四、壁层胸膜淋巴引流障碍,癌症淋巴管阻塞发育性淋巴管引流异常,五、损伤所致胸腔内出血,主动脉瘤破裂食管破裂胸导管破裂等产生血胸、脓胸、乳糜胸,病因,恶性 45CHF 12感染 22 结核 10 细菌 9 病毒 1 真菌 1 脓胸1 寄生虫 1 肺栓 3 肝变 2胶原 1 其它 5,Frequency In the US,Pleural effusi
4、on affects 1.3 million individuals each yearcongestive heart failure, 500,000; bacterial pneumonia, 300,000 (uncomplicated, 270,000;complicated, 30,000);malignancy, 200,000pulmonary embolus, 150,000;cirrhosis with ascites, 50,000pancreatitis, 20,000collagen vascular disease, 6,000and tuberculosis, 2
5、,500.,Transudative pleural effusion,Congestive heart failure (most common transudative effusion)Hepatic cirrhosis with and without ascites Nephrotic syndromePeritoneal dialysis/continuous ambulatory peritonealdialysisHypoproteinemia (eg, severe starvation)Glomerulonephritis Superior vena cava obstru
6、ction Fontan procedure Urinothorax,Exudative pleural effusion,Malignant disorders - Metastatic disease to the pleura or lungs, primary lung cancer, mesothelioma, Kaposi sarcoma, lymphoma, leukemiaInfectious diseases - Bacterial, fungal, parasitic, and viral infections; infection with atypical organi
7、sms such as Mycoplasma, Rickettsiae, Chlamydia, Legionella GI diseases and conditions - Pancreatic disease (acute or chronic disease, pseudocyst, pancreatic abscess), Whipple disease, intraabdominal abscess (eg, subphrenic, intrasplenic, intrahepatic), esophageal perforation (spontaneous/iatrogenic)
8、, abdominal surgery, diaphragmatic hernia, endoscopic variceal sclerotherapy Collagen vascular diseases - Rheumatoid arthritis, systemic lupus erythematosus, drug-induced lupus syndrome (procainamide, hydralazine, quinidine, isoniazid, phenytoin, tetracycline, penicillin, chlorpromazine), immunoblas
9、tic lymphadenopathy (angioimmunoblastic lymphadenopathy), Sj鰃ren syndrome, familial Mediterranean fever, Churg-Strauss syndrome, Wegener granulomatosisBenign asbestos effusion Meigs syndrome - Benign solid ovarian neoplasm associated with ascites and pleural effusion Drug-induced primary pleural dis
10、ease - Nitrofurantoin, dantrolene, methysergide, bromocriptine, amiodarone, procarbazine, methotrexate, ergonovine, ergotamine, oxprenolol, maleate, practolol, minoxidil, bleomycin, interleukin-2, propylthiouracil, isotretinoin, metronidazole, mitomycinInjury after cardiac surgery (Dressler syndrome
11、) - Injury reported after cardiac surgery, pacemaker implantation, myocardial infarction, blunt chest trauma, angioplasty Uremic pleuritisYellow nail syndromeRuptured ectopic pregnancyElectrical burns,pleural fluid with exudative or transudative characteristics,Pulmonary embolismHypothyroidism Diure
12、sed transudatePericardial disease (inflammatory or constrictive) AtelectasisTrapped lung (usually a borderline exudate)Sarcoidosis (usually an exudate)Amyloidosis Miscellaneous conditionsHemothoraxFollowing coronary artery bypass graft surgeryAfter lung or liver transplantMilk of calcium pleural eff
13、usion - Colloidal suspension of precipitated calcium saltsAcute respiratory distress syndromeSystemic cholesterol emboliIatrogenic misplacement of lines or tubes into the mediastinum or the pleural space - Insertion or reinsertion of percutaneous central venous catheter, infusion of enteral formula
14、through misplaced nasogastric or nasoenteric feeding tubes, translumbar aortography Radiation pleuritis Necrotizing sarcoid granulomatosis Ovarian hyperstimulation syndrome Postpartum pleural effusion (immediate or delayed)Rupture of a silicone bag mammary prosthesisRupture of a benign germ cell tum
15、or into the pleural space (eg, benign mediastinal teratoma) SyphilisEchinococcosis,症状,Dyspnea,Dyspnea is the most common clinical symptom at presentation.It indicates a large effusion (usually not 500 mL).It is reported to occur in 50% of patients with malignant pleural effusions.However, other fact
16、ors (eg, underlying lung disease, cardiac dysfunction, anemia) also may contribute to the development of dyspnea.,Chest pain,Chest pain may be mild or severe; it typically is described as sharp or stabbing, is exacerbated with deep inspiration, and is pleuritic.Pain may be localized to the chest wal
17、l or referred to the ipsilateral shoulder or upper abdomen (frequently seen with malignant mesothelioma), usually because of diaphragmatic involvement.It often diminishes in intensity as the pleural effusion increases in size.Chest pain signifies pleural irritation, which can aid in the diagnosis of
18、 the cause of the effusion, since most transudative effusions do not cause direct pleural irritation.,检查,诊断性胸腔穿刺,除非 10mm/CHF/双侧积液,外观,漏出液透明清亮，不凝固，比重1.018。脓性胸液若为大肠杆菌或厌氧菌感染常有臭味。尿味是尿素胸;血性胸液呈程度不同的洗肉水样或静脉血样；乳状胸液为乳糜胸；巧克力色应考虑阿米巴肝脓肿破溃入胸腔的可能；黑色胸液可能为曲菌感染。浑浊胸水离心后上清液沉清,可能是脓性; 混浊可能是乳糜性,pH,PH7.3 感染性、类风关、食道破裂、肿瘤pH7
19、.00者仅见于脓胸以及食管破裂所致肺炎旁积液pH7.0，需引流恶性pH7.0，提示细胞阳性率高，胸膜硬化可能无效，预后差。,葡萄糖,漏出液与大多数渗出液葡萄糖含量正常；3.35mmol/L恶性、类风关及结核性、化脓性胸腔积液。风湿（）化脓（）最低肿瘤很少降低下降提示累及广泛。,蛋白质,渗出液的蛋白含量，胸液/血清比值大于0.5。蛋白含量30g/L时，胸液比重约为1.018。漏出液蛋白含量较低（5%不会是结核 结核性胸液中常低于1。,中性粒,50%,提示胸膜急性炎症 肺炎旁、胰腺炎、肺栓塞中中性粒占优，而肿瘤仅，结核。,嗜酸细胞,寄生虫感染或结缔组织病时常增多占10-20%以上5%血气胸，肺梗，
20、过後性疾病炎症，反复抽水，霉菌，石棉肺，药物性恶性肿瘤亦是常见原因（嗜酸性积液）,淋巴细胞,淋巴细胞为主提示慢性炎症，为结核性或恶性；结核病90-95%，75%常为结核 其它：0.5 肿瘤，淋巴瘤，慢性感染，类风关，黄甲S，结节病，乳糜胸,病原,胸液涂片查找细菌及培养，有助于病原诊断。结核性胸膜炎胸液沉淀后作结核菌培养，阳性率仅20巧克力色脓液应镜检阿米巴滋养体。,病原学,除脓胸，胸水不查TB培养阳性率，涂片,细胞学,恶性阳性率60%转移性腺癌70%,间皮瘤10%鳞癌20%淋巴瘤25-50%,肉瘤25%流式细胞仪,酶LDH,胸液LDH活性可反映胸膜炎症的程度，其值越高，表明炎症越明显。LDH含
21、量增高，大于200U/L，且胸液LDH/血清LDH比值大于0.6，提示为渗出液，LDH500U/L常提示为恶性肿瘤或胸液已并发细菌感染。进行性增加提示炎症加重，否则不必积极检查,CEA,恶性胸液中CEA水平升高较血清早且显著。20ng/ml,胸液/血浆1，应疑及恶性有认为胸液CEA特异性90%，敏感性40%,铁蛋白,恶性胸液中铁蛋白含量增高,腺苷脱氨酶（ADA）,TB50% 敏感性94%，特异性能 0.90 45% 排除结核性的敏感性和特异性100%,胸液淀粉酶,食道破裂，急性胰腺炎，恶性肿瘤等。,免疫学检查,结核性与恶性胸腔积液时，T淋巴细胞增高，尤以结核性胸膜炎为显著可高达90，且以T4（
22、CD+4）为主。恶性胸腔积液中的T细胞功能受抑，其对自体肿瘤细胞的杀伤活性明显较外周血淋巴细胞为低，提示恶性胸腔积液患者胸腔层局部免疫功能呈抑制状态。系统性红斑狼疮及类风湿关节炎引起的胸腔积液中补体C3、C4成分降低，且免疫复合物的含量增高。,胸膜活检,胸膜活检针 Abrams Cope两种鉴别有无肿瘤（阳性率3975%,57%）及判定胸膜肉芽肿性病变（结核性7080%,75%）有一定帮助。脓胸或有出血倾向者不宜作胸膜活检。,胸膜活检,肉芽肿患者95%是结核性其它原因真菌，结节病类风关,FOB,有咳嗽咯血肺内病变者,胸腔镜,病因诊断率95.4%恶性积液诊断率9396%,超声检查,渗出液与漏出液
23、的鉴别,外观凝固性比重1.016 25%误差蛋白定量 2.5-3.0 10%误差Rivalta 渗出液占60% 漏出液30.8% 40%误差细胞数 100-500PH糖 感染、风湿性积液尤低,渗出液与漏出液,是诊断第一步如是漏出液，排除CHF、肝硬化、肺栓塞，无需更多检查，CHF不必抽胸水。,Light标准1972年,1.胸液LDH 正常血清上限之2/3 2.胸液LDH/血清LDH0.63.胸液蛋白/血清蛋白0.5 1个或以上则为渗出液, 鉴定渗出液98%的敏感,83%特异(漏出液可能误为渗出),其它标准,Roth标准胸水白蛋白血清蛋白1.2g/dlHamm&Valdes 胸水胆固醇55mg/
24、dlMeiset 胸水胆红素/血清胆红素0.6渗出液,渗出性胸液,1 结核性胸膜炎 2 癌性胸膜炎: 肺癌,胸膜间皮瘤,乳腺癌,淋巴瘤 3 肺炎伴发胸膜炎4 化脓性胸膜炎5 肺吸虫肠膜炎 6 结缔组织病胸膜炎： 风湿,类风湿,SLE7 乳糜性胸膜炎: 结核 丝虫,外伤,纵隔瘤, 淋巴瘤 8 胆固醇性胸膜炎: 结核 糖尿病,梅毒,癌瘤,漏出性胸液,1 左心衰竭2 肝硬化 3 肾功能衰竭 4 低蛋白血症,一侧肺野密度增高,1 一侧全肺不张 2 一侧全肺肺炎 3 广泛胸膜增厚 肺硬变 4 弥漫性间皮瘤 5 巨大良性瘤 畸胎瘤 6 损毁肺并胸膜增厚,Extrapleural sign原因,Expand
25、ing Rib lesions Metastasis Callous Fracture with Hemorrhage Plasmacytoma浆细胞瘤 Neurofibroma Mesothelioma 间皮瘤Plumbage,左侧胸水特殊原因,unique considerations for left sided pleural effusion:Dissecting Aneurysm of Aorta Esophageal rupture Splenic disease Pericarditis LV aneurysm Internal mammary artery,气胸液气胸,X线上
26、鉴别积液性质时应注意,1.双侧积液：生理性积液、心力衰竭、肾炎时，一般量不多。 2. 横隔升高：胸腔积液与腹水并存时可使双侧横膈升高，多见于肾炎、肝硬化、恶性淋巴瘤、癌转移。 3.肺内病灶 4.肺不张和肿块 5.纵隔是否增宽 6.心影是否增大：心包积液与胸腔积液并存见于结核、败血症、恶性肿瘤转移和结缔组织疾病，心力衰竭。 7.胸膜结节阴影：胸膜间皮瘤和胸膜转移瘤 8. 肋骨破坏和骨折 9.动态变化：恶性淋巴瘤化疗后液体消失得快、但还可复发。结核性胸膜炎抗痨治疗有效。,肺底积液,膈肌胸膜炎 假膈肌-流动型 包裹型,X线特征1 右高1个肋间2 内1/3最高 3 左膈厚1CM4 患侧肺纹抬平密集4
27、变换体位5 B超,CT与胸片发现率比较,胸膜钙化 3 0胸膜斑 7 0 胸膜肥厚 7 3胸膜粘连 9 1 胸膜损害 20 4,CT,量 胸水量达15ml 可发现性质 不能区分 血胸CT值70-80，可以确诊分类 游离性 叶间积液 包裹性积液 液气胸,CT与良恶性胸膜增厚,恶性胸膜增厚常为结节状、纵隔性、壁层胸膜增厚、环绕型胸膜增厚，特异性为94、94、88、100，敏感性36-44%；CT确定最佳活检位置。,胸膜增厚,纤维蛋白沉着 肉芽增生 肿瘤 粉尘沉着结核性 纤维素性 脂肪石棉沉着 斑块间皮瘤 广泛,胸膜钙化,结核性化脓性 损伤性尘肺,风湿病积液的发生率,SLE 11.4-44% M:F=1:7.9 多F硬皮病 皮肌炎 重叠综合症 10%,积液发生率,肺栓 30-50%急性胰腺炎 20%膈下脓肿 80%肝内脓肿 20%腹部手术 49-6%,结核性胸水,40-59岁 占61%,恶性36.2% 60岁 占18%,恶性79.4%,恶性胸水,肺癌 48.6%乳癌 20.6%淋瘤 8.7%不明原因 6.9%以恶性胸水首诊 15%病程中出现胸水 50%,
