Conclusion There is 3 ~ 15 ml liquid in the chest cavity of normal people, which plays a lubricating role during respiratory exercise, but the amount of effusion in the chest cavity is not fixed. Even for normal people, 500 ~ 1000 ml of liquid is formed and absorbed every 24 hours. Intrapleural injection is reabsorbed from the venous end of capillaries, and the rest of the liquid is recovered from the lymphatic system to the blood, and filtration and absorption are in a dynamic balance. If this dynamic balance is destroyed by systemic or local lesions, pleural effusion will occur clinically because the liquid in pleural cavity is formed too fast or absorbed too slowly.
3 Diagnostic imaging diagnosis
When the amount of pleural effusion is 0.3~0.5L, only the costal diaphragm angle becomes dull on the X-ray film. More effusion appears as an outward upward arc-shaped upper edge (Figure 1). When lying down, the effusion spreads outward, which reduces the brightness of the whole lung field. There is liquid level in hydropneumothorax. When there is a large amount of effusion, the whole affected side is dark and the mediastinum moves towards the healthy side. The edge of effusion is usually smooth and full, confined between the lobes or between the lung and diaphragm. Ultrasonic examination is helpful for diagnosis.
Fig. 1 exudative pleurisy
B-ultrasound can find the mass covered by pleural effusion and assist the location of thoracic puncture. According to the density of pleural effusion, CT examination can indicate exudate, blood or pus, and can also show mediastinum, paratracheal lymph nodes, lung masses, pleural mesothelioma and intrathoracic metastases. CT examination of pleural lesions has high sensitivity and density resolution. It is easy to find a small amount of effusion that is difficult to show on X-ray plain film.
4 Treatment measures Pleural effusion is a part of systemic diseases in the chest, and etiological treatment is particularly important. After the cause is corrected, the leaked liquid can usually be absorbed. The common diseases of exudative pleurisy are tuberculosis, malignant tumor and pneumonia.
First, tuberculous pleurisy
Most patients are satisfied with the therapeutic effect of anti-tuberculosis drugs, and a small amount of pleural effusion generally does not need to be pumped or only diagnosed. Thoracic puncture is not only helpful for diagnosis, but also can reduce the pressure on lung, heart and blood vessels, improve breathing, prevent fibrin deposition and pleural thickening, and prevent lung function from being damaged. After the liquid is pumped out, the poisoning symptoms can be alleviated, and the body temperature drops, which is helpful to quickly restore the compressed lung. A large amount of pleural effusion is pumped 2 ~ 3 times a week until the pleural effusion is completely absorbed. The amount of liquid pumped each time should not exceed 65,438+0,000 ml. Too fast and too much liquid pumping can make the chest pressure drop sharply, leading to pulmonary edema or circulatory disorder. This kind of pulmonary edema after lung recruitment is quickly produced by pumping pleural fluid, which is characterized by severe cough, shortness of breath, coughing up a lot of foam-like sputum, turbid and moist rales in both lungs, decreased PaO2 _ 2, and signs of pulmonary edema on X-ray. Oxygen should be inhaled immediately, glucocorticoids and diuretics should be used as appropriate, water intake should be controlled, and the condition and acid-base balance should be closely monitored. In case of "pleural reaction", manifested as dizziness, cold sweat, palpitation, pallor, rapid pulse and chills in limbs, the patient should immediately stop moving and lie on his back, and if necessary, inject 0.5 ml of 0. 1% adrenaline subcutaneously, closely observe the condition, pay attention to blood pressure and prevent shock. In general, there is no need to inject drugs into the chest cavity after pleural effusion is pumped out.
Glucocorticoid can alleviate allergic and inflammatory reactions, improve toxic symptoms, accelerate the absorption of pleural effusion, and reduce sequelae such as pleural adhesion or pleural thickening. However, there are some adverse reactions or lead to the spread of tuberculosis, and the indications should be carefully grasped. Acute tuberculous exudative pleurisy with severe systemic toxic symptoms and excessive pleural effusion can be treated with anti-tuberculosis drugs and glucocorticoids, generally prednisone or prednisolone 25 ~ 30 mg/d, taken orally three times. When the body temperature is normal, the symptoms of systemic poisoning are relieved and subsided, and the pleural effusion is obviously reduced, the dose should be gradually closed or even stopped. The withdrawal speed should not be too fast, otherwise it is easy to rebound, and the general course of treatment is about 4 ~ 6 weeks.
Second, empyema
Empyema refers to the infectious inflammation of pleural cavity caused by various pathogenic microorganisms, accompanied by cloudy appearance and purulent pleural exudate. Bacteria are the most common pathogen of empyema. Most bacterial empyema is related to the failure to effectively control bacterial pleurisy. A few empyemas can be caused by tuberculosis or fungi, actinomycetes and Nocardia. At present, the most common pathogen in infectious pleural effusion is gram-negative bacilli, followed by staphylococcus aureus and pneumococcus. Pseudomonas such as Pseudomonas aeruginosa and Escherichia coli are common among gram-negative bacilli. Anaerobic bacteria as a common pathogen of empyema has also been widely confirmed. Empyema complicated with pneumonia is often a single bacterial infection. If it is lung abscess or bronchiectasis with empyema, it is mostly mixed bacterial infection. Fungal and gram-negative bacilli infections are very common among patients who use immunosuppressants.
Acute empyema usually manifests as high fever, exhaustion and chest pain. The treatment principle is to control infection, drain pleural effusion, promote lung recruitment and restore lung function. The pathogenic bacteria of empyema should be given effective antibacterial drugs as soon as possible, systemic and intrapleural administration. Drainage is the most basic treatment for empyema, and repeated aspiration or closed drainage is used. 2% sodium bicarbonate or normal saline can be used to wash the chest repeatedly, and then appropriate antibiotics and streptokinase can be injected to dilute the pus, which is beneficial to drainage. A few empyemas can be discharged by sealing bottles between ribs with boiling water. For patients with bronchopleural fistula, it is not advisable to flush the chest to avoid spreading bacteria.
Chronic empyema includes pleural thickening, thoracic collapse, chronic failure, clubbed fingers (toes) and so on. Surgical pleurodesis should be considered in the treatment. In addition, general supportive treatment is also very important, and foods with high energy, high protein and vitamins should be given. Correct water-electrolyte disorder and maintain acid-base balance, and transfuse a small amount of blood many times when necessary.
Third, malignant pleural effusion.
Malignant pleural effusion is mostly caused by the progress of malignant tumor, which is a common complication in the late stage of malignant tumor. For example, lung cancer with advanced pleural effusion. Imaging examination is helpful to understand the range of pulmonary and mediastinal lymph nodes. In view of the rapid growth and persistent existence of pleural effusion, which often leads to severe dyspnea or even death due to the compression of a large number of pleural effusion, it is necessary to puncture pleural effusion repeatedly, but repeated aspiration will cause excessive protein loss (1L pleural effusion contains 40g protein), which is very difficult to treat and the effect is not satisfactory. Therefore, it is of great significance to correctly diagnose malignant tumors and tissue types and carry out reasonable and effective treatment in time to relieve symptoms, relieve pain, improve quality of life and prolong life.
Systemic chemotherapy has a certain effect on pleural effusion caused by some small cell lung cancer. Local radiotherapy is feasible for patients with mediastinal lymph node metastasis. After aspiration of pleural effusion, intrathoracic injection of antineoplastic drugs, including adriamycin, cisplatin, fluorouracil, mitomycin, niclosamide and bleomycin, is a common treatment method, which is helpful to kill tumor cells, slow down the generation of pleural effusion and cause pleural adhesion. Intrapleural injection of biological immunomodulators, such as Corynebacterium parvum vaccine (CP), IL-2, interferon β, interferon γ, lymphokine activated killer cells (LAK cells) and tumor infiltrating lymphocytes (TIL), is a successful method to treat malignant pleural effusion in recent years, which can inhibit malignant tumor cells, enhance local infiltration and activity of lymphocytes, and make pleura adhere. In order to block the pleural cavity, we can use thoracic intubation to drain pleural effusion, and then inject pleural adhesive, such as tetracycline, erythromycin, talcum powder, etc., to make the two layers of pleura adhere to avoid the re-formation of pleural effusion. If a small amount of lidocaine and dexamethasone are injected at the same time, the adverse reactions such as pain and fever can be alleviated. Despite the above treatment, the prognosis of malignant pleural effusion is very poor.
5 Pathogenic laboratory examination:
First, the hydrostatic pressure in pleural capillaries increases.
Such as congestive heart failure, constrictive pericarditis, increased blood volume, obstruction of superior vena cava or azygos vein, leading to pleural effusion.
Second, pleural capillary permeability is increased.
Such as pleurisy (tuberculosis, pneumonia), connective tissue disease (systemic lupus erythematosus, rheumatoid arthritis), pleural tumor (malignant tumor metastasis, mesothelioma), lung infarction, subphrenic inflammation (subphrenic abscess, liver abscess, acute pancreatitis), etc. , produce pleural effusion.
Thirdly, the colloid osmotic pressure in pleural capillaries decreased.
Such as hypoproteinemia, liver cirrhosis, nephrotic syndrome, acute glomerulonephritis and mucinous edema.
Fourth, parietal pleura's lymphatic drainage disorder.
Cancer lymphatic obstruction, abnormal lymphatic drainage and so on. , produce pleural effusion.
Five, injury caused by intrathoracic hemorrhage
Rupture of aortic aneurysm, esophagus, thoracic duct, etc. , leading to hemothorax, empyema and chylothorax.
The main causes and properties of pleural effusion are shown in table 1.
Table 1 main causes and properties of pleural effusion
? Exudative exudate (serous or bloody) empyema, hemothorax and chylothorax infectious disease? Pleurisy (tuberculosis, various infections), subphrenic inflammatory tuberculosis, various pulmonary infections tuberculosis? Tumor, circulatory system disease, superior vena cava obstruction, congestive heart failure, constrictive pericarditis malignant tumor, pleural mesothelioma, lung infarction? Malignant tumor, ruptured hemangioma, hypoproteinemic nephrotic syndrome caused by pulmonary infarction, peritoneal dialysis of other diseases of liver cirrhosis, myxedema, drug allergy, radiation rheumatic fever, systemic lupus erythematosus, thoracic surgery, pneumothorax trauma, esophageal fistula, pneumothorax, traumatic purulent infection after thoracic puncture, rupture of thoracic duct caused by pneumothorax (with tearing pleural adhesion) trauma, and filariasis pleural effusion are the most common. Tuberculosis is especially common in young and middle-aged patients. Middle-aged and elderly patients with pleural effusion (especially bloody pleural effusion) should carefully consider the metastasis of malignant lesions and malignant tumors (such as lung cancer, breast cancer and lymphoma) to pleural or mediastinal lymph nodes, which may cause pleural effusion. Tumor involving pleura can increase its surface permeability, or lymphatic drainage is blocked, or obstructive pneumonia involving pleura can cause exudative pleural effusion. Occasionally, chylothorax is caused by obstruction of thoracic duct. Pericardial effusion is caused by pericardial involvement, or the increase of hydrostatic pressure in blood vessels due to obstruction of superior vena cava, or malnutrition and hypoproteinemia caused by malignant tumor. Pleural effusion can be leakage.
Pathogenesis and absorption of pleural effusion
The pleural cavity of healthy people is under negative pressure (average 5cmH2O,1cmh298 pa), and colloid osmotic pressure protein (8cmH2O) is contained in the pleural effusion. The accumulation and dissipation of pleural effusion are also closely related to osmotic pressure and hydrostatic pressure in pleural capillaries. Parietal pleura is supplied with blood by systemic circulation, and the capillary hydrostatic pressure is high (30cm H2O). The visceral pleura was supplied with blood by pulmonary circulation, and the vein was depressed (1 1cmH2O). The absorption rate of blood membrane in systemic circulation and pulmonary circulation is the same (Figure 1).
Fig. 1 schematic diagram of the relationship between thoracic water circulation and related pressure (cmH2O)
According to animal experiments, 0.5 ~ 1L liquid can pass through pleural cavity every day. Protein in pleural effusion mainly enters the thoracic duct through lymphatic vessels.
Pleural inflammation can increase the permeability of the tube wall, and more protein will enter the pleural cavity, which will increase the osmotic pressure of pleural effusion. Tumors can compress and block lymphatic drainage, leading to protein accumulation in pleural effusion, leading to pleural effusion. Portal vein cirrhosis often appears hypoproteinemia, and plasma colloid osmotic pressure decreases, which may lead to leakage. When there is ascites, it can also cause pleural effusion through the congenital defect of diaphragm or lymphatic vessels. Allergic diseases, autoimmune diseases, cardiovascular diseases or chest trauma may increase the possibility of pleural effusion.
Clinical manifestations, age, medical history, symptoms and signs are of reference value for diagnosis. Tuberculous pleurisy is more common in young people, often accompanied by fever; Patients over middle age should be alert to pleural metastasis caused by lung cancer. Inflammatory effusion is mostly exudative, often accompanied by chest pain and fever. Pleural effusion caused by heart failure is leakage. The right pleural effusion associated with liver abscess can be reactive pleurisy or empyema. When the amount of hydrops is less than 0.3L, the symptoms are not obvious. If it exceeds 0.5L, the patient gradually feels chest tightness. Local percussion dullness, decreased breathing sound. After the amount of effusion increased, the two pleura separated, no longer rubbing with breathing, chest pain gradually relieved, but dyspnea gradually aggravated; When there is a large amount of effusion, the mediastinal organs are compressed, and palpitation and dyspnea are more obvious.
8 auxiliary inspection 1. appear
The leakage liquid is transparent and clear, does not solidify after standing, and its specific gravity is: 1.0 18. Purulent pleural effusion often smells bad if it is infected with Escherichia coli or anaerobic bacteria. Hemorrhagic pleural effusion is characterized by different degrees of meat washing water samples or venous blood samples; The chylothorax is chylothorax; If the pleural effusion is chocolate, the possibility of amebic liver abscess protruding into the pleural cavity should be considered. Black pleural effusion may be Aspergillus infection.
Second, cells
There are a few mesothelial cells or lymphocytes in normal pleural effusion. When pleura is inflamed, various inflammatory cells and proliferative and degenerative mesothelial cells can be seen in pleural effusion. The number of cells in the leakage fluid is often less than 100× 106/L, mainly lymphocytes and mesothelial cells. White blood cells in exudate often exceed 500× 106/L/L, and the number of white blood cells in empyema exceeds 1000× 106/L, which indicates acute inflammation when neutrophils increase. Lymphocytes are mainly tuberculous or malignant; Eosinophils often increase when parasitic infections or connective tissue diseases occur. When the red blood cells in pleural effusion exceed 5× 109/L, they may be reddish, which is mostly caused by malignant tumor or tuberculosis. Blood vessels damaged by thoracic puncture can also cause bloody pleural effusion, which should be carefully identified. When the red blood cells exceed 100× 109/L, trauma, tumor or lung infarction should be considered. Malignant tumor cells can be found in about 60% of malignant pleural effusion, and repeated examination can improve the detection rate. Malignant tumor cells in pleural effusion often have the characteristics of enlarged nuclei, different sizes, nuclear aberration, deep nuclear staining, abnormal nuclear-cytoplasmic ratio and abnormal mitosis, so attention should be paid to differentiation. Mesothelial cells in pleural effusion are often deformed and easily misdiagnosed as tumor cells. There are more than 5% intermediate cells in non-tuberculous pleural effusion, and often less than 1% in tuberculous pleural effusion. When systemic lupus erythematosus complicated with pleural effusion, the antinuclear antibody titer in pleural effusion can reach more than 1: 160, and lupus cells are easy to find.
Third, pH
The pH value of tuberculous pleural effusion is usually
Fourth, pathogens.
Pleural fluid smear for bacteria and culture are helpful for pathogen diagnosis. The positive rate of tuberculous pleurisy after pleural effusion precipitation is only 20%, so the amoeba trophozoite should be examined microscopically in chocolate-colored pus.
Verb (abbreviation of verb) protein
The protein content of exudate and the ratio of pleural effusion to serum are greater than 0.5. When the content of protein is 30g/L, the specific gravity of pleural effusion is about 1.0 18 (the weight increases or decreases by 0.003 for every increase or decrease of 1g protein). The protein content of the leaked liquid is low (
Carcinoembryonic antigen (CEA): The level of CEA in malignant pleural effusion increased earlier and more significantly than that in serum. If the CEA value of pleural effusion is >: 15 ~ 15μ g/L or pleural effusion/serum CEA >；; 1, often suggesting malignant pleural effusion. The content of iron protein in malignant pleural effusion is increased, which may be accompanied by differential diagnosis reference. Combined detection of multiple markers can improve the positive detection rate.
Six, lipids
In chylothorax, the content of neutral fat and triglyceride in pleural effusion is higher (>: 4.52mmol/L), which is milky white and turbid, and Sudan ⅲ is red, but the cholesterol content is not high, which can be seen in the rupture of thoracic duct. "Chyloid" or cholesterin pleural effusion (cholesterol >: 2.59mmol/L) is related to the accumulation of cholesterol in old pleural effusion, which can be seen in old tuberculous pleurisy, malignant pleural effusion or cirrhosis, rheumatoid arthritis, etc. Cholesterol-containing pleural effusion contains high cholesterol, but the triglyceride is normal, which is light yellow or dark brown, containing cholesterol crystals, fat particles and a large number of denatured cells (lymphocytes and red blood cells).
Seven, glucose
The glucose content in normal human pleural effusion is similar to that in blood, and changes with the increase or decrease of blood sugar. The determination of glucose content in pleural effusion is helpful to distinguish the cause of pleural effusion. The glucose content of leakage fluid and most exudates is normal; The glucose content in tuberculous, malignant, rheumatoid arthritis and purulent pleural effusion can be
Eight, enzymes
The content of lactate dehydrogenase (LDH) in pleural effusion was higher than 200U/L, and the ratio of LDH in pleural effusion to serum LDH was higher than 0.6, suggesting that it was exudate. The activity of LDH in pleural effusion can reflect the degree of pleural inflammation. The higher the value, the more obvious the inflammation. LDH & gt？ 500U/L often suggests malignant tumor or bacterial infection in pleural effusion.
The elevation of amylase in pleural effusion can be seen in acute pancreatitis and malignant tumor. When acute pancreatitis is accompanied by pleural effusion, the content of amylase in pleural effusion is higher than that in serum. Some patients have severe chest pain and dyspnea, which may mask their abdominal symptoms. At this time, amylase in pleural effusion has increased, so clinical diagnosis should be paid attention to.
The content of adenosine deaminase (ADA) in lymphocytes is high. In tuberculous pleurisy, the number of lymphocytes increases obviously due to cellular immunity, so the ADA in pleural effusion can be higher than 100U/L (generally not more than 45U/L). It is highly sensitive to the diagnosis of tuberculous pleurisy.
Nine, immunological examination
With the development of cell biology and molecular biology, the immunological examination of pleural effusion has been paid attention to, which plays a certain role in differentiating benign from malignant pleural effusion, studying the pathogenesis of pleural effusion and developing biological treatment of pleural effusion in the future.
In tuberculous and malignant pleural effusion, T lymphocytes increase, especially tuberculous pleurisy, which can be as high as 90%, and T4(CD+4) is the main factor. The function of T cells in malignant pleural effusion was inhibited, and its killing activity to autologous tumor cells was significantly lower than that of peripheral blood lymphocytes, suggesting that the local immune function of thoracic layer in patients with malignant pleural effusion was inhibited. The components of complement C3 and C4 in pleural effusion caused by systemic lupus erythematosus and rheumatoid arthritis decreased, and the content of immune complex increased.
Pleural biopsy
Percutaneous pleural biopsy is helpful to distinguish whether there is tumor or not and to judge pleural granulomatous lesions. When tuberculosis is to be diagnosed, biopsy specimens can be used for tuberculosis culture in addition to pathological examination. Pleural biopsy is not suitable for empyema or bleeding tendency. Biopsy can be performed through thoracoscope if necessary.
ultrasonic examination
It can distinguish pleural effusion, pleural thickening and hydropneumothorax. It can provide more accurate location diagnosis for cystic effusion and contribute to pleural puncture and drainage.
9 Differential diagnosis of pleural effusion The amount of examination is large enough to determine the persistence of pleural effusion. Usually, exudate should look for systemic factors, which may be caused by systemic diseases other than pleural lesions. Differential diagnosis should pay attention to the sequence of onset, fever, fatigue, chest pain and other systemic or local lung and pleural symptoms. Dyspnea, supine, edema of lower limbs; Whether there is ascites or abdominal mass, superficial lymphadenopathy, joint or skin lesions, etc. Combined with the corresponding hemogram, chest X-ray, B-ultrasound, pleural effusion, tuberculin test, etc. Do pleural biopsy for comprehensive analysis if necessary.
In the diagnosis of pleural effusion, we should first distinguish exudation from leakage. The most common disease of exudative pleural effusion is tuberculous pleurisy, and most of them are young patients. The tuberculin test was positive, and no important findings were found except the signs of pleural effusion. Pleural effusion is grass yellow, mainly lymphocytes, and pleural biopsy has no special changes. Without effective anti-tuberculosis treatment, about 1/3 may have pulmonary or extrapulmonary tuberculosis after 5 years of follow-up. The leakage of pleural effusion may be related to left heart failure and hypoproteinemia.
Tuberculous and malignant pleural effusion often need careful differentiation. Both of them are common in clinic, but their treatment and prognosis are very different. Malignant pleural effusion caused by malignant tumor invading pleura is called malignant pleural effusion, which is mostly bloody, massive and growing rapidly, with pH; 500U/L, often caused by lung cancer and breast cancer metastasis to the pleura. Tuberculous pleurisy usually has fever, pH is lower than 7.3, ADA activity is significantly higher than that of pleural effusion caused by other reasons, and CEA and ferritin usually do not increase. If it is difficult to differentiate clinically, anti-tuberculosis treatment can be given, the condition can be monitored and the effect of chemotherapy can be followed up. The elderly patients with tuberculous pleurisy can have no fever, and tuberculin test is often negative, which should be paid attention to. If the test is negative and anti-tuberculosis chemotherapy is ineffective, it should still be considered as a tumor. Combined with cytological examination of pleural effusion, pleural biopsy, chest imaging (CT, MRI), fiberoptic bronchoscopy and thoracoscopy, it is helpful for further differentiation. The accuracy of CT scanning in the diagnosis of pleural effusion is that it can correctly distinguish pleural invasion or extensive metastasis of bronchial lung cancer, which is very important for the etiological diagnosis of malignant pleural effusion, the staging of lung cancer and the choice of scheme. MRI can supplement CT scanning in the diagnosis of pleural effusion, especially in the diagnosis of malignant pleural effusion, and its characteristics are obviously superior to CT. Pleural biopsy is simple, feasible and minimally invasive, and the positive diagnosis rate is 40% ~ 75%. The diagnostic rate of thoracoscope for malignant pleural effusion is the highest, which can reach 70% ~ 100%, providing basis for making treatment plan. Thoracoscopy can comprehensively examine the pleural cavity, observe the morphological characteristics, distribution range and the involvement of adjacent organs, and can perform multiple biopsies under direct vision, so the diagnosis rate is high and the clinical staging of tumors is accurate. Although the etiology of a few clinical pleural effusion is still difficult to determine through the above examination, if there are no special contraindications, thoracotomy can be considered.
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