Pleural effusions (가슴막삼출, 흉막삼출)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
KEYWORDS:
..The accumulation of fluid in the pleural space can result from
i. Increased hydrostatic pressure
(e.g., Congestive Heart Failure)
ii. Decreased oncotic pressure
(e.g., Nephritic syndrome with hypoalbuminemia)
iii. Increased capillary permeability (e.g., Pneumonia)
iv. Decreased lymphatic drainage
(e.g., Carcinoma, Tuberculosis)
v. Entry of fluid from a source outside the pleura
(e.g., Blood from trauma, Chyle from rupture of the thoracic duct, Crystalloid from
a misplaced central line)
< Causes of pleural effusion >
Transudate Exudate
CHF Cancer
Cirrhosis Pneumonia
Nephrotic synd. Pulmonary embolism
Pulmonary embolism Connective tissue disease (RA, SLE)
SVC obstruction Postsurgical state (abdominal surgery,
Myxedema coronary artery bypass)
GI disease (pancreatitis, esophageal rupture,
liver abscess)
1. Often asymptomatic
2. Dyspnea
3. Pleuritic chest pain
4. Dry cough
Pleural
effusions
Key symptoms
367
The Root of ambulatory care
1. Dullness to percussion
2. Decreased breath sounds
Key signs
Is there a substantial amount of pleural fluid
(>10mm thick on ultrasonography or decubitus radlography?)
Observation
Does patient have
congestive heart failure?
Are there asymptomatic pleural effusions,
chest pain, or fever?
Diuresis and observation
Thoracentesis If effusions persist for > 3days
1) Is the ratio of pleural-fluid protein to serum protein > 0.5?
2) Is the ratio of pleural-fluid LDH > 0.6?
3) Is the pleural-fluid LDH level > two thirds the upper limit of normal for serum?
Transudate : treat congestive heart fallure,
cirrhosis, nephrosis
Exudate : obtain total and differential cell count, glucose
level, cytologic analysis, and cultures
If effusion is lymphocytic, test for
marker of tuberculosis
If no cause is established, rule out pulmonary
embolus
Yes
Yes
Yes
No
No
No
No
Yes
Fig 1. Algorithm for the evaluation of patients with pleural effusion. Pulmonary embolism should be considered earlier in the evaluation
if there are clinical symptoms or signs suggesting this diagnosis. (LDH = lactate dehydrogenase.)
Key test
Pleural
effusions
1. Thoracentesis ( definitive ) : Thoracentesis fluid는 protein, lactate dehydrogenase,
cell count, culture, pH, cytology 등의 검사를 위해 즉각 검사실로 보내야 한다.
2. Chest X ray (lat. Decubitus)
Blunting of costophrenic angle : lateral > 25-50cc / PA > 150cc
▶ Chest PA & Right lateral decubitus : Right pleural effusion
▶ Chest PA : Right pleural effusion
▶ Chest PA & Contrast Chest CT : 좌측 흉강속에 대량의 흉수가 보이고, 심장과 대동맥은 우측으로
압배되어 보이며, CT에서는 좌측 늑흉막에 잇달아 산재성 흉막중피종이 보인다.
369
The Root of ambulatory care
3. Ultrasonography
Thoracentesis indication
..Presence of a clinically significant pleural effusion ( > 10mm thick on ultrasonography
or lateral decubitus radiography)
..In a patient with congestive heart failure
i. If the effusion is unilateral
ii. If the effusion persist for more than three years
iii. If ferile
Light’s criteria (one or more of the following three suggests the exudates)
I. Pleural fluid protein/serum protein > 0.5
II. Pleural fluid LDH/serum LDH > 0.6
III. Pleural fluid LDH > two-thirds of the normal upper limit for serum LDH level
Total and differential cell count
▶ A predodominant neurtophils ( >50%)
- parapeumonic effusion
- effusion secondary to pulmonary embolism/pancreatitis
▶ A predominant mononuclear cells
- chronic process
▶ A predominant small lymphocytes
- most likely tuberculosis or cancer
▶ Pleural-fluid eosinophilia ( >10% eosinophils)
- caused in about two thirds by blood or air in the pleural space
- uncommon in cancer or tuberculosis
Smear and cultres
▶ bacterial, AFB, fungal
Glucose level
Key treatments
Pleural
effusions
▶ < 60 mg/dl
- parapneumonic or a malignant effusion
Cytologic examination
▶ can be diagnostic for carcinoma, SLE (LE cells)
1. Treat underlying disease
2. Therapeutic thoracentesis
(if unstable patients with severe dyspnea)
Chest tube or surgical drainage Pleurodesis
..Removal of more than 1.5 liters of pleural fluid during a single thoracentesis is
associated with the risk of reexpansion pulmonary edema.
참고 문헌
가톨릭의과대학 내과학교실 : 흉막유출. in Current Principles and Clinical Practice of Internal Medicine. 서
울, 군자출판사, 2005, P 193-197
Linda L. Kuribayashi : Pleural Effusions, in Saunders Manual of Medical Practice, 2nd ed, Robert E.
Rakel(ed). Philadelphia, Saunders, 2000, P 226-228
염태형 : 흉막삼출, in 가정의학 임상편. 서울, 계측문화사, 2002, P 756-760
Mark S. Allen, M.D. : Pleural effusion and Emphyema thoracis, in Conn's Current Therapy 2004, Robert
E. Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004,P 258-260
Jae-Hyoung Cho, Ji-Hyeon Ju, Jeoung-Won Jang : Pleural Effusion, in Clinical Road Map of Internal
Medicine. Seoul, Panmun Book, 2005, P 52
성균관대학교의과대학 삼성서울병원내과 : Pleural Effusion. in Handbook of Internal Medicine, 2nd ed. 서
울, 군자출판사, 2004, P 323-333
대한결핵 및 호흡기학회 : 호흡기학. 서울, 군자출판사, 2004, P 658
성동욱 역 : 흉부 CT. 서울, 군자출판사. 2005, p 447