Pleural effusion:
1. 先分exudate or transudate: Light's criteria
TP of effu/TP in serum > 0.5
LDH of effusion/LDH in serum > 0.6 --> sensitivity最高
LDH of effu > 2/3 ULN of serum LDH --> specificity最高
上述三者符合一個以上即可.
2. 怎樣的pleural effusion需要tapping?
在decubitus view or sono上>1cm的水就要tapping.
或是asymmetric,有fever, chest pain, failure to resolve的就要.
3. parapneumonic effusion: 分成uncomplicated/ complicated/ empyema
complicated (就是感染發炎還在進行的)以及empyema要draine
complicated在pleural fluid analysis上可見:
1) pH1000
這是因為細菌持續入侵-->neutrophil增兵攻擊,
雙方爭奪glucose (所以glucose
後來死掉的neutrophil溶解之後裡面的LDH跑出來(所以LDH>1000)
-->所以見到這樣的數值就要去drain
尤其是pH
drain的量每天不可超過1.5L,否則會pulmonary edema after rapid lung expansion and hypotension.
4. 上述的除了drain也要合併抗生素使用.在complicated case要加入cover anaerobics的Abx. 另外gentamicin可能無效因為在酸性的環境下無用.
empyema可用intrathoracic injection of streptokinase去把膿包的壁溶掉.
5. 對於undiagnosed pleural effusion:
勿忘survey of TB, malignancy, exposure hx of asbestoes, drug hx (nitrofuratoin, amiodarone), hepatic hydrothorax
可以取pleura biopsy送檢, bronchoscopy的檢查幫助不大除非病人有咳血, CXR上有airway deviation或是反正就是有大呼吸道的症狀和異常時才有用.
6. 簡易版的鑑別診斷:
|
exudate
|
transudate
|
| infection |
CHF |
| 胸內負壓增加 |
hepatic hydrothorax |
| connective tissue disease |
nephrotic |
| malignancy |
peritoneal dialysis |
| other inflammation |
hypoalbuminemia |
| endocrine |
constrictive pericarditis |
| lymphatic |
uremic |
| from abdomen |
|
多為exudate但也可以是transudate的: malignancy, PE, sarcoidosis, hypothyroid pleural effusion
7. hepatic hydrothorax:
簡單說,就是有liver cirrhosis, portal hypertension的病人
腹水從diagphram上的小洞跑到胸腔去了(通常是tendonous part of diagphragm),所以臨床上沒有明顯的腹水可是有很多胸水.
這樣的胸水是transudate不過成分上可以略為與胸水需別:
Characteristics of hepatic hydrothroax
| Location |
| Right side (85 percent) |
| Left side (13 percent) |
| Bilateral (2 percent) |
| Fluid |
| Cell count |
| Protein |
| Pleural fluid/serum total protein ratio |
| Pleural fluid/serum LDH ratio >0.6 |
| Pleural fluid/serum albumin gradient >1.1 |
| Pleural fluid/serum bilirubin ratio |
| pH >7.4 |
| Glucose level similar to that of serum |
鑑別方式可以用核醫在抽完胸水之後從腹腔打入99mTc-sulphur colloid or 99mTc-human serum albumin
然後看這些東西會不會跑到胸腔去
8. mesothelial cell的角色:
mesothelial cell是lining pleural cavity的細胞.正常情況下是可以出現在pleural effusion內.
如果完全沒有表示pleural diffuse injury or fibrin cotting.
TB不常出現mesothelial cell除非在疾病初期,所以exudate中出現>5% mesothelial cell可以exclude TB.
9.TB pleurisy: pleural effusion為serosanguinous, lymphocyte predominant, ADA(adenosine deaminase)>70, 另外skin tuberculin test (+).
pleural effusion應送AFB, TB culture, 無法確診時可以用PCR.
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