胸腔积液诊断与治疗(Diagnosis of Pleural Effusions).ppt
http://www.100md.com
参见附件(189KB)。
Diagnosis and Management of Pleural Effusions
Diagnosis of Pleural Effusions
Chest Radiograph
? Pleural Fluid as the Only Abnormality With Primary Disease in the Chest
? Bilateral Effusions
? Diseases Below the Diaphragm
? Interstitial Lung Disease
? Pulmonary Nodules
1. Pleural Fluid as the Only Abnormality With Primary Disease in the Chest
? infections
- tuberculous and viral pleurisy
?malignancy
- cancer, non-Hodgkin's lymphoma, and leukemia
?pulmonary embolism
?drug-induced lung disease
? benign asbestos pleural effusion (BAPE)
?lymphatic abnormalities
- chylothorax and yellow nail syndrome
?uremic pleurisy
?constrictive pericarditis
?hypothyroidism
2.Bilateral Effusions
?transudative effusions
? congestive heart failure
? nephrotic syndrome
?hypoalbuminemia
?peritoneal dialysis
? constrictive pericarditis
? exudative effusions
? malignancy (extrapulmonic primary carcinomas, lymphoma)
? lupus pleuritis
? yellow nail syndrome
3.Diseases Below the Diaphragm
? transudates
? hepatic hydrothorax
? nephrotic syndrome
? urinothorax
? peritonealdialysis
? exudates
?pancreatic disease
?chylous ascites
?subphrenic abscess
?splenic abscess or infarction
4.Interstitial Lung Disease
? congestive heart failure
? rheumatoid arthritis
? asbestos-induced disease (BAPE and asbestosis)
? lymphangitic carcinomatosis
? Lymphangioleiomyomatosis
? viral and mycoplasma pneumonias
? Waldenstr?m's macroglobulinemia
? sarcoidosis
?Pneumocystis carinii pneumonia
5.Pulmonary Nodules
? most commoncauses
? metastatic carcinoma from a nonlung primary tumor.
? Less common causes
?Wegener's ranulomatosis
?rheumatoid arthritis
?septic emboli
?sarcoidosis
?tularemia
Value of Pleural Fluid Analysis
? In 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)
Value of Pleural Fluid Analysis
? the initial pleural fluid analysis is either definitively or presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of cases.
Diagnoses that can be definitively
? empyema (pus)
? malignancy
? tuberculous
? 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 < 7.00)
? rheumatoid pleurisy (pleural fluid cytology)
? extravascular migration of a central venous catheter (high glucose level or pleural fluid simulating the infusate).
Exudates Vs Transudates(1)
? exudative
? pleural fluid protein/serum protein ?0.5
? pleural fluid LDH/serum LDH ?0.6
? pleural fluid LDH more than two-thirds normal upper limit for serum
? any one of the above values makes it highly likely that the effusion is exudative.
Exudates 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.
Pleural Fluid NucleatedCell Count(1)
? rarely helpful in establishing a definitive diagnosis. however, it may provide useful information.
? < 500/mL, the fluid is usually a transudate
?> 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.
Pleural 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.
? eosinophilia (> 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 , Hodgkin's lymphoma, carcinoma.
? The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.
Pleural 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 pleuritis
Pleural 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/dL
Pleural 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 < 60 mg/dL, and an LDH > 1,000 U/L (upper limit of normal of serum 200 IU/L).......（后略) ......
Diagnosis and Management of Pleural Effusions
Diagnosis of Pleural Effusions
Chest Radiograph
? Pleural Fluid as the Only Abnormality With Primary Disease in the Chest
? Bilateral Effusions
? Diseases Below the Diaphragm
? Interstitial Lung Disease
? Pulmonary Nodules
1. Pleural Fluid as the Only Abnormality With Primary Disease in the Chest
? infections
- tuberculous and viral pleurisy
?malignancy
- cancer, non-Hodgkin's lymphoma, and leukemia
?pulmonary embolism
?drug-induced lung disease
? benign asbestos pleural effusion (BAPE)
?lymphatic abnormalities
- chylothorax and yellow nail syndrome
?uremic pleurisy
?constrictive pericarditis
?hypothyroidism
2.Bilateral Effusions
?transudative effusions
? congestive heart failure
? nephrotic syndrome
?hypoalbuminemia
?peritoneal dialysis
? constrictive pericarditis
? exudative effusions
? malignancy (extrapulmonic primary carcinomas, lymphoma)
? lupus pleuritis
? yellow nail syndrome
3.Diseases Below the Diaphragm
? transudates
? hepatic hydrothorax
? nephrotic syndrome
? urinothorax
? peritonealdialysis
? exudates
?pancreatic disease
?chylous ascites
?subphrenic abscess
?splenic abscess or infarction
4.Interstitial Lung Disease
? congestive heart failure
? rheumatoid arthritis
? asbestos-induced disease (BAPE and asbestosis)
? lymphangitic carcinomatosis
? Lymphangioleiomyomatosis
? viral and mycoplasma pneumonias
? Waldenstr?m's macroglobulinemia
? sarcoidosis
?Pneumocystis carinii pneumonia
5.Pulmonary Nodules
? most commoncauses
? metastatic carcinoma from a nonlung primary tumor.
? Less common causes
?Wegener's ranulomatosis
?rheumatoid arthritis
?septic emboli
?sarcoidosis
?tularemia
Value of Pleural Fluid Analysis
? In 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)
Value of Pleural Fluid Analysis
? the initial pleural fluid analysis is either definitively or presumptively diagnostic in 80% of patients and is valuable clinically in about 90% of cases.
Diagnoses that can be definitively
? empyema (pus)
? malignancy
? tuberculous
? 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 < 7.00)
? rheumatoid pleurisy (pleural fluid cytology)
? extravascular migration of a central venous catheter (high glucose level or pleural fluid simulating the infusate).
Exudates Vs Transudates(1)
? exudative
? pleural fluid protein/serum protein ?0.5
? pleural fluid LDH/serum LDH ?0.6
? pleural fluid LDH more than two-thirds normal upper limit for serum
? any one of the above values makes it highly likely that the effusion is exudative.
Exudates 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.
Pleural Fluid NucleatedCell Count(1)
? rarely helpful in establishing a definitive diagnosis. however, it may provide useful information.
? < 500/mL, the fluid is usually a transudate
?> 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.
Pleural 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.
? eosinophilia (> 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 , Hodgkin's lymphoma, carcinoma.
? The prevalence of pleural fluid eosinophilia is similar in carcinomatous and noncarcinomatous pleural effusions.
Pleural 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 pleuritis
Pleural 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/dL
Pleural 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 < 60 mg/dL, and an LDH > 1,000 U/L (upper limit of normal of serum 200 IU/L).......（后略) ......
相关资料1：
- 下背痛的McKenzie力学诊断与治疗方法.pdf
- 《错骨缝的诊断与治疗》.田纪钧.扫描版.pdf
- 不稳定性心绞痛和非ST段抬高心肌梗死诊断与治疗指南.pdf
- 老年高血压诊断与治疗2008中国专家共识.pdf
- 肺血栓栓塞症的诊断与治疗指南（草案）.pdf
- 011肺血栓栓塞症的诊断与治疗指南(草案).pdf
- 甲状腺疾病危象的诊断与治疗.pdf
- 肺血栓栓塞症的诊断与治疗指南(草案).pdf
- 规范侵袭性肺真菌病的诊断与治疗.pdf
- 肺栓塞的诊断与治疗.pdf
- 急性肺栓塞诊断与治疗指南.pdf
- 《有毒化学物质中毒诊断与治疗》扫描版.pdf
- [脊柱疾病的现代诊断与治疗].扫描版.pdf
- 肌张力障碍诊断与治疗指南.pdf
- 隐睾的诊断与治疗.pdf