胸腔积液总论.

胸腔积液总论Pleuraleffusion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3～15ml液体，人体每天胸膜腔可有0.5～1L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0.3～0.5L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45CHF12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5FrequencyIntheUSPleuraleffusionaffects1.3millionindividualseachyearcongestiveheartfailure,500,000;bacterialpneumonia,300,000(uncomplicated,270,000;complicated,30,000);malignancy,200,000pulmonaryembolus,150,000;cirrhosiswithascites,50,000pancreatitis,20,000collagenvasculardisease,6,000andtuberculosis,2,500.TransudativepleuraleffusionCongestiveheartfailure(mostcommontransudativeeffusion)HepaticcirrhosiswithandwithoutascitesNephroticsyndromePeritonealdialysis/continuousambulatoryperitonealdialysisHypoproteinemia(eg,severestarvation)GlomerulonephritisSuperiorvenacavaobstructionFontanprocedureUrinothoraxExudativepleuraleffusionMalignantdisorders-Metastaticdiseasetothepleuraorlungs,primarylungcancer,mesothelioma,Kaposisarcoma,lymphoma,leukemiaInfectiousdiseases-Bacterial,fungal,parasitic,andviralinfections;infectionwithatypicalorganismssuchasMycoplasma,Rickettsiae,Chlamydia,LegionellaGIdiseasesandconditions-Pancreaticdisease(acuteorchronicdisease,pseudocyst,pancreaticabscess),Whippledisease,intraabdominalabscess(eg,subphrenic,intrasplenic,intrahepatic),esophagealperforation(spontaneous/iatrogenic),abdominalsurgery,diaphragmatichernia,endoscopicvaricealsclerotherapyCollagenvasculardiseases-Rheumatoidarthritis,systemiclupuserythematosus,drug-inducedlupussyndrome(procainamide,hydralazine,quinidine,isoniazid,phenytoin,tetracycline,penicillin,chlorpromazine),immunoblasticlymphadenopathy(angioimmunoblasticlymphadenopathy),Sj鰃rensyndrome,familialMediterraneanfever,Churg-Strausssyndrome,WegenergranulomatosisBenignasbestoseffusionMeigssyndrome-BenignsolidovarianneoplasmassociatedwithascitesandpleuraleffusionDrug-inducedprimarypleuraldisease-Nitrofurantoin,dantrolene,methysergide,bromocriptine,amiodarone,procarbazine,methotrexate,ergonovine,ergotamine,oxprenolol,maleate,practolol,minoxidil,bleomycin,interleukin-2,propylthiouracil,isotretinoin,metronidazole,mitomycinInjuryaftercardiacsurgery(Dresslersyndrome)-Injuryreportedaftercardiacsurgery,pacemakerimplantation,myocardialinfarction,bluntchesttrauma,angioplastyUremicpleuritisYellownailsyndromeRupturedectopicpregnancyElectricalburnspleuralfluidwithexudativeortransudativecharacteristicsPulmonaryembolismHypothyroidismDiuresedtransudatePericardialdisease(inflammatoryorconstrictive)AtelectasisTrappedlung(usuallyaborderlineexudate)Sarcoidosis(usuallyanexudate)AmyloidosisMiscellaneousconditionsHemothoraxFollowingcoronaryarterybypassgraftsurgeryAfterlungorlivertransplantMilkofcalciumpleuraleffusion-ColloidalsuspensionofprecipitatedcalciumsaltsAcuterespiratorydistresssyndromeSystemiccholesterolemboliIatrogenicmisplacementoflinesortubesintothemediastinumorthepleuralspace-Insertionorreinsertionofpercutaneouscentralvenouscatheter,infusionofenteralformulathroughmisplacednasogastricornasoentericfeedingtubes,translumbaraortographyRadiationpleuritisNecrotizingsarcoidgranulomatosisOvarianhyperstimulationsyndromePostpartumpleuraleffusion(immediateordelayed)RuptureofasiliconebagmammaryprosthesisRuptureofabenigngermcelltumorintothepleuralspace(eg,benignmediastinalteratoma)SyphilisEchinococcosis症状DyspneaDyspneaisthemostcommonclinicalsymptomatpresentation.Itindicatesalargeeffusion(usuallynot500mL).Itisreportedtooccurin50%ofpatientswithmalignantpleuraleffusions.However,otherfactors(eg,underlyinglungdisease,cardiacdysfunction,anemia)alsomaycontributetothedevelopmentofdyspnea.ChestpainChestpainmaybemildorsevere;ittypicallyisdescribedassharporstabbing,isexacerbatedwithdeepinspiration,andispleuritic.Painmaybelocalizedtothechestwallorreferredtotheipsilateralshoulderorupperabdomen(frequentlyseenwithmalignantmesothelioma),usuallybecauseofdiaphragmaticinvolvement.Itoftendiminishesinintensityasthepleuraleffusionincreasesinsize.Chestpainsignifiespleuralirritation,whichcanaidinthediagnosisofthecauseoftheeffusion,sincemosttransudativeeffusionsdonotcausedirectpleuralirritation.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1.016～1.018;渗出液则多呈草黄色稍混浊，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pH7.00者仅见于脓胸以及食管破裂所致肺炎旁积液pH7.２0，需引流恶性pH7.２0，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