新光吴火狮纪念医院胸腔内科.ppt

PLEURAL DISEASES 林鎮均 新光吳火獅紀念醫院胸腔內科 Introduction Pleural effusion Pneumothorax NON-MALIGNANT PLEURAL EFFUSION Transudate v.s. Exudate Transudate More than 150 mL of fluid is required to blunt the C-P angle on a lateral CXR CHF is the most common cause of transudative effusion CHF + nephritic syndrome + cirrhosis ? 90% of transudative effusion Nephrotic Syndrome / Hypoalbuminemia Nephrotic syndrome的病人，因為protein S從尿中流失，因此DVT和pulmonary embolism (PE) 的危險性也相對的增加 Nephrotic syndrome的病人若有單側且多量的PLE，要考慮PE PE的PLE通常為exudative，但有時也可能是transudative Liver Disease Ascites流入肋膜腔 ? hepatic hydrothorax Hypoalbuminemia 有時腹水會全部被吸入肋膜腔而導致腹腔內完全沒水 6%的腹水病患可能會有大量的PLE 70％在右側 Atelectasis /Lymphatic Obstruction 肺塌陷 肋膜腔內的壓力降低（更負）? PLE 肺張開後PLE會消失 淋巴管阻塞 最常見的原因是惡性腫瘤 必須和malignant PLE分辨 Malignant PLE?肋膜腔內有cancer cell Rare Causes Urinothorax: rupture of ureter ? fluid in the retroperitoneal space ? pleural space, Low pH in the PLE Iatrogenic: CVP Peritoneal dialysis Management Treatment of the underlying problem Diuretics can change a transudative effusion into an exudative effusions Thoracentasis快速引流1L?可能會發生reexpansion pulmonary edema，特別是在long-standing PLE或引流吸力太大時 Exudate Even small exudative effusions may be associated with pleuritic chest pain or referred shoulder pain The presence of a pleural friction rub with an effusion strongly suggests an exudative process. Diagnostic Procedure Step 1—check appearance of pleural fluid. Step 2—obtain chemistries, cell counts, cultures, and cytologies. Step 3—obtain other studies in selected individuals: pH, ANA, complement levels, rheumatoid factor, and lipid analysis… Step 4—perform percutaneous pleural biopsy Parapneumonic Effusion/Empyema Low WBC count, low LDH, normal glucose, pH 7.3, no demonstrable bacteria ?uncomplicated parapneumonic effusion With antibiotic use, pleural drainage usually unnecessary pH 7.2, glucose 40 mg/dl and LDH 1000 IU/l should be drained Parapneumonic Effusion/Empyema Empyema, as defined by gross pus or a positive Grams stain