Pleural effusion and pleurisy in the elderly

Introduction to pleural effusion and pleurisy in the elderly Pleural effusion (pleural effusison) refers to the imbalance of fluid production and absorption in the pleural cavity. The amount of fluid produced exceeds the absorbed amount, which makes the liquid in the thoracic cavity exceed normal. It can be a passive leakage or an active exudation process. Elderly pleural effusion is a very common clinical syndrome, which can be caused by pathological changes in the pleura itself or by systemic diseases. It often coexists in other diseases, the onset is often more insidious, the symptoms are not typical, and it is easy to delay the diagnosis and treatment. It is important for the elderly patients with pleural effusion to remove fluid and relieve lung compression, but the active etiology and primary disease treatment are more important. Pleurisy is a pleural inflammation caused by various causes, and it is one of the main causes of pleural effusion. basic knowledge The proportion of illness: 0.005% Susceptible people: the elderly Mode of infection: non-infectious Complications: pneumothorax hemoptysis

Elder pleural effusion and the cause of pleurisy

(1) Causes of the disease

The etiology of senile pleural effusion is very complicated and can be roughly divided into three categories:

Leakage:

Common in cardiovascular diseases, such as heart failure, constrictive pericarditis, superior vena cava obstruction, etc.; liver and kidney disease with hypoproteinemia.

Exudation:

Common in infectious inflammation, such as tuberculosis, viruses, purulent bacteria, fungi, parasites, etc.; malignant tumors, including primary lung cancer, lung metastases, lymphoma and pleural mesothelioma; allergic inflammation, such as systemic Lupus erythematosus, rheumatoid arthritis, etc.; chemical inflammation, such as uremia.

Bloody:

Common in malignant tumors, pulmonary infarction, trauma and so on.

(two) pathogenesis

Dynamic balance of fluid in the thorax = filtration factor × [(mean capillary hydrostatic pressure - average capillary perfusion) - (plasma colloid osmotic pressure - capillary pericorporeal osmotic pressure)], under normal conditions, intrathoracic fluid from the pleura (mainly the parietal pleura) the arterial end of the capillaries, 80% to 90% of which is absorbed from the venous end of the capillaries, and the remainder is recovered by the lymphatic system, when the average capillary hydrostatic pressure rises, such as heart failure; When the plasma colloid osmotic pressure is reduced, such as chronic liver and kidney disease; or when the capillary colloid osmotic pressure rises, such as pleural inflammation increases capillary permeability and a large amount of protein extravasation, the above factors can cause the outflow of liquid in the thorax to exceed The pleural effusion is formed by the recovery, the malignant tumor erodes the blood vessels, the blood formation component and the leakage of the protein increase the osmotic pressure of the capillaries, and it may also press the lymphatic vessels to increase the average capillary hydrostatic pressure.

Elderly pleural effusion and pleurisy prevention

1. Older patients coexist with multiple diseases, affecting the absorption of pleural effusion, so it is very important to treat comorbidities.

2. The amount of pleural fluid should not be too much or too fast to avoid accidents.

Elderly pleural effusion and pleurisy complications Complications

The main complications are pneumothorax, subcutaneous emphysema, intrathoracic hemorrhage, infection, hemoptysis and so on.

Elderly pleural effusion and pleural inflammatory symptoms Common symptoms Respiratory pleural effusion breathing shallow slow chest tightness pleural effusion when chest pain heart failure hypoproteinemia trachea and mediastinum displacement tracheal mediastinum and heart...

The clinical manifestations of senile pleural effusion can be divided into two categories, one is the primary disease signs, and the other is the accumulation of hydraulic signs.

Symptoms and signs: The severity of compression symptoms depends on the speed of pleural effusion, the amount of fluid accumulation and the basic lung function. When the amount of fluid is <250ml, there may be no symptoms; medium or large effusions may show different degrees of convulsions. Chest tightness and difficulty breathing; patients with poorly growing pleural effusion or poor basic lung function, even if the amount of pleural effusion is small, there will be obvious symptoms. It is suspected that pleural effusions have more physical examinations, a small amount of effusion, especially a packaged product. Fluid, inter-leaf effusion, lung fundus, often no obvious signs, a large number of effusions in the affected side of the thorax full, respiratory movements weakened, effusion zone palpation fainting weakened or disappeared, percussion as a real sound, breathing Sound and speech conduction are weakened or disappeared. Careful examination above the effusion zone can often reveal increased tremors, percussive voiced sounds and tubular breath sounds, and tracheal and mediastinal shifts to the healthy side.

The diagnosis of senile pleural effusion can be divided into four steps.

Elderly pleural effusion and pleurisy examination

1. Routine examination includes appearance, specific gravity, coagulability, cell number and classification, protein detection, etc., the leakage liquid is mostly colorless or light yellow transparent liquid, placed not solidified, specific gravity <1.018, cell number <0.3×109/L Rivanta test negative, protein quantification 30g / L, pleural fluid protein / serum protein <0.5, glucose quantification > 3.3mmol / L; exudate is clear or turbid, color shades, can be grass yellow, brown yellow, Red, dark red, milky white, green, etc., easy to coagulate, specific gravity >1.018, cell number>0.3×109/L, positive for Rivanta test, protein quantitation>30g/L, pleural fluid protein/serum protein>0.5, glucose quantitation>3.3mmol /L.

2. Cytological examination of malignant cells found in pleural fluid is helpful for tumor diagnosis. The white blood cell counts of cancerous and tuberculous pleural effusion are mostly (0.5~2.5)×109/L, and purulent pleural effusion is >1×1010/L, white blood cell classification. Mononuclear cells are more common in tuberculosis or viral, and multinucleated cells are mainly seen in suppurative and early tuberculosis.

3. Bacteriological examination suspected purulent infection pleural smear staining or centrifugation of bacterial culture contributes to pathogenic diagnosis.

4. Other laboratory tests for pleural effusion

(1) pH: The pH of the normal intrathoracic fluid is 7.32 to 7.52. The pH of the leakage fluid and cancerous pleural effusion is generally in the normal range, and the inflammatory pleural effusion is often <7.2.

(2) Enzymatic examination:

1 pleural lysozyme (LZM)> 20mg / L, lysozyme pleural fluid / serum > 1.2 more suggestive of inflammatory, lysozyme pleural fluid / serum <1.0 is more suggestive of cancer.

2 pleural fluid adenosine deaminase (ADA)>50U/L is highly suggestive of tuberculosis, <45U/L can exclude tuberculosis; 3 pleural fluid lactate dehydrogenase (IDH) <200U prompts leakage, >200U is more prompt Exudate.

(3) Cytokine detection:

1 Interferon- (IFN-) was significantly elevated in tuberculous pleural effusion, cancerous patients decreased significantly, and rheumatoid arthritis disappeared. The sensitivity and specificity of this test were 90%.

2 Tumor necrosis factor (TNF) tuberculosis is elevated, and cancerous patients are decreased.

(4) Immunological testing:

1 pleural fluid carcinoembryonic antigen (CEA)> 20g / L, and pleural fluid / serum CEA > 1.0 to help malignant pleural effusion.

2 pleural fluid chain antigen 50 (CA50) > 20kU / L height suggests malignant possibility.

3 anti-tuberculosis antibody (anti-PPD-IgG) tuberculous pleural effusion anti-PPD-IgG was significantly higher than malignant pleural effusion.

The proportion and absolute number of CD3 and CD4 cells in tuberculous pleural effusion of 4T lymphocyte subsets were higher than those in peripheral blood, while the absolute numbers of CD3, CD4, CD8 and CD8 in malignant pleural effusion were significantly lower than those in peripheral blood.

5 Polymerase chain reaction (PCR) and nucleic acid probe technology have higher sensitivity and specificity for the diagnosis of tuberculous pleural effusion.

(5) Biotechnological examination: The presence of hyperdiploid and polyploid chromosomal cells in the pleural fluid suggests malignant pleural effusion; pleural cytochrome staining of pleural fluid cells also helps distinguish between benign and malignant cells.

5. X-ray chest

A small amount of effusion can only show that the affected side of the rib angle is blurred, dull or disappear; a moderate amount of effusion can be seen in the affected side of the lower chest, a uniform dense shadow, the upper edge is curved in the outer high and low inside; the affected side in the case of a large amount of fluid The chest has a uniform and dense shadow, the trachea and mediastinum are displaced to the opposite side, and the affected side is moved down. The enveloping effusion is a circular or semi-circular uniform dense shadow of varying sizes, with smooth and clear edges; The liquid has a sharp, uniform fusiform dense shadow on the lateral slice with the long axis and the interlobular fissure; the lung fundus is easily confused with the diaphragmatic elevation on the anteroposterior, and the diaphragmatic level can be seen in the lateral fluoroscopy or filming. Normal, pleural effusion is distributed along the lower chest wall. X-ray examination can not only diagnose effusion, but also contribute to the diagnosis of primary disease.

6. CT and MRI examination

CT and MRI have the characteristics of high resolution and two-dimensional image, which can distinguish between liquid and solid shadow. It can display small lesions or a small amount of effusion in the blind spot of X-ray film, which can be covered by pleural effusion. The shadow of the lungs also helps to distinguish the nature of the effusion.

7. Ultrasound examination

It is more sensitive to the detection of a small amount of pleural effusion than the X-ray and contributes to puncture positioning.

Diagnosis and diagnosis of pleural effusion and pleurisy in the elderly

Diagnostic criteria

The first step: to determine the presence or absence of pleural effusion, according to medical history, physical signs, combined with X-ray and ultrasound examination data, the diagnosis should generally be no problem.

The second step: to determine the pleural effusion is leakage or exudate, various scholars have proposed a variety of different leakage-exudate identification criteria, the first clinical use of pleural effusion routine examination "appearance, cell number, Rivalta test, sugar content And specific gravity to distinguish, but its sensitivity and specificity are not high, 1972 Light proposed diagnostic criteria for exudate, one of the following can be diagnosed:

1 pleural fluid lactate dehydrogenase (LDH) > 2/3 of the upper limit of normal serum LDH or >200U/L.

2 pleural fluid / serum LDH> 0.6.

3 pleural fluid / serum protein > 0.5, the sensitivity of the Lights standard is 98%, the specificity is 83%, because the standard is concise and reliable, it is used by most clinicians, it is worth noting that some treatment measures, such as Diuretics can increase the content of pleural fluid protein and LDH, and may cause the leakage liquid to be misjudged as exudate. If pleural fluid cholesterol is >1.43mmol/L or serum albumin-pleural fluid albumin 0.12g/ L as an auxiliary standard can prevent misdiagnosis.

The third step: the exudate should be further determined to be benign or malignant, especially in the middle and large amount, the fast-growing serum-blood pleural fluid should be alert to the possibility of malignancy, CA50, ADA, IFN-, CEA and cytology of pleural fluid. Examination and other methods are of great value in judging good and malignant. CT and MRI examination are beneficial to the discovery and qualitative differentiation of lung primary lesions. If necessary, pleural biopsy, cell brushing and thoracoscopic examination, elderly patients with pleural effusion are ordered. Leakage, especially in the absence of significant heart failure or hypoproteinemia, does not relax the alertness to the tumor.

The fourth step: combined with medical history, physical examination, imaging, laboratory and other special examination data to further clarify the diagnosis of primary disease.

Differential diagnosis

1. Leaky pleural effusion (thoracic water)

When congestive heart failure, nephrotic syndrome, cirrhosis and other forms of hypoproteinemia lead to decreased colloid osmotic pressure and water retention caused by pleural effusion; any cause of superior vena cava obstruction, leakage of pleural effusion; part of the cause of ascites Disease, pleural effusion caused by diaphragmatic lymphatic drainage into the thoracic cavity, clinical manifestations of cough, chest swelling, shortness of breath and primary disease, physical examination of pleural fluid, pleural effusion colorless and transparent, relative density <1.016, protein content Below 30g/L, the ratio of pleural fluid to serum protein is <0.5; lactic acid dehydrogenase in pleural fluid is less than 200U/L, lactate dehydrogenase ratio in pleural fluid and serum is <0.6; glucose content is similar to blood glucose; white blood cells in pleural fluid are often Below 1 × 109 / L, no pathogens.

2. Tuberculous pleural effusion

Tuberculous pleurisy is a highly allergic reaction to the protein components of tuberculosis. It is the result of primary infection of children and adolescents or secondary TB involving the pleura. Clinical onset can be more urgent, but also slow, with fever, chest pain, dry cough. At the same time, there are fatigue, weight loss, loss of appetite, night sweats and other symptoms of tuberculosis, dry pleurisy, chest pain with deep breathing and coughing, pleural friction sound is an important sign, with the increase of pleural effusion, patients gradually feel shortness of breath, chest The liquid is yellow or transparent, slightly turbid, and it is ground glass. The longer effusion can be dark yellow turbidity; the relative density of pleural fluid is often above 1.016, and the total number of white blood cells is often (1~2)×109/L. Neutrophils are predominant, with lymphocytes predominating in the chronic phase, mesothelial cells generally less than 1%; protein content above 25g/L; sugar content below 2.8mmol/L; lysozyme and adenosine in pleural fluid Acid deaminase increased; pleural smear and collecting bacteria are not easy to find tuberculosis, about one-third of the culture method, 1/2 case of pleural biopsy can be seen in cheese or non-cheese granulomatous tissue, when the pleura has inflammatory adhesions Can form a package Wrapped pleural effusion.

3. Malignant pleural effusion

The primary cancer is mainly lung cancer and breast cancer, followed by lymphoma, a few are ovarian cancer, gastric cancer, uterine tumor, etc. The direct mechanism of pleural effusion caused by tumor is pleural metastasis, which increases vascular permeability; pleural lymphatic drainage is blocked. Mediastinal lymph nodes obstruct lymphatic drainage; thoracic duct obstruction; bronchial obstruction reduces pleural pressure; pericardial involvement (increased vascular hydrostatic pressure, resulting in leakage), indirect mechanism of hypoproteinemia; obstructive pneumonia; pulmonary embolism and radiation therapy Complications, malignant pleural effusion in addition to many symptoms of the tumor itself, clinically often have shortness of breath, weight loss, chest pain, fatigue and anorexia, X-ray examination can be seen from a small amount to total chest effusion, when the amount of fluid is large, lung Tumors in the mediastinum and mediastinal lymph nodes are often difficult to identify. At this time, CT examination can show the lesions. Malignant pleural fluid is often bloody. It grows rapidly after pumping. The pleural fluid examination includes routine, cytology, carcinoembryonic antigen, etc. The cells are the basis for the diagnosis of malignant pleural effusion. Because the cancer is first located in the visceral pleura, and the parietal pleura may only be scattered, the positive rate of pleural biopsy is not high.

4. empyema

Purulent pleural effusion referred to as empyema, common disease due to pulmonary infection (such as pneumonia, lung abscess, bronchiectasis, tuberculosis, etc.) spread to the pleural cavity, adjacent infection (such as subarachnoid abscess) or sepsis, sepsis involving the pleura Cavity, can also be a complication of thoracic surgery, complication of chest wall penetrating injury, improper treatment of tuberculous pleurisy can become tuberculous empyema, clinical manifestations of acute onset, high fever, chills, difficulty breathing, chest pain and weight loss, Cough, cough and cyanosis, signs of pleural effusion, pleural fluid is purulent, anaerobic infection is odorous, the number of white blood cells in pleural fluid is above 2 × 109 / L, mainly neutrophils; chest There are pathogens in liquid culture. The culture should include aerobic and anaerobic, even tuberculosis culture; the pH and sugar content of the pleural fluid are reduced. X-ray examination shows pleural effusion or entrapped effusion. If there is bronchopleural fistula, then See the liquid level.

5. Chest breast

Broken or obstructed thoracic duct, causing chyle to overflow into the pleural cavity to form chylothorax, common causes of mediastinal lymph node tuberculosis or cancerous enlargement, malignant lymphoma, filarial granuloma, trauma or thoracic surgery, etc., clinically acute onset, There are signs of shortness of breath and pleural effusion. The pleural fluid is milky. After standing, there is an oil film on the surface. For example, ether can make the liquid clear and odorless. The specific gravity of the chyle solution is 1.012~1.025, and lymphocytes and red blood cells can be seen. White blood cells are alkaline pH 7.4 ~ 7.8; high protein content in pleural fluid, rich in neutral fat and triglyceride, higher than plasma, but lower than plasma, cholesterol / triacylglycerol ratio <1, can be used Radionuclide lymphangiography confirmed the presence of a fistula between the thoracic duct and the thoracic cavity.

Cholesterol pleurisy, sometimes tuberculous, rheumatoid arthritis or cancerous, old (more than 1 year) wrapped effusion can also be milky, with high cholesterol, visible scaly cholesterol crystals visible to the naked eye, excluding Fat globules or chylomicrons, microscopic examination showed a large number of degenerative cells and cholesterol crystals, the relative density of which was above 1.018, the mucin qualitative test was positive, and the chyle-like appearance was caused by the degeneration of pus cells, but not the true chyle After adding diethyl ether to shake, it is allowed to stand, the color is unchanged, and it is not transparent.

6. Pleural mesothelioma

It is a rare tumor originating from pleural mesothelial tissue or subpleural mesothelial tissue. It is divided into two types: localized pleural mesothelioma and diffuse malignant mesothelioma. The latter is often accompanied by serous, serous or blood pleural effusion. Liquid, the disease is more men, the age of onset is more than 40 to 60 years old, mainly for persistent chest dull pain and shortness of breath, symptoms gradually worsen, chest pain is not reduced by increased fluid; there is still fatigue, weight loss, hemoptysis Etc., the signs of late pleural effusion and pleural thickening are becoming more and more obvious. After invading the chest wall, a "frozen chest" can be formed. Although there is obvious pleural thickening without intercostal or chest wall depression, there is partial chest wall bulging, late, with blood. The rapid development of pleural effusion, the disease suddenly died of cachexia and respiratory failure, pleural fluid is mostly bloody, tumor cells found in pleural fluid can be confirmed, pleural biopsy and thoracoscopy pathological results can be confirmed, X-ray findings mainly for pleural effusion or not Regular pleural thickening, pleural thickening shadow sometimes "camel-like", CT manifested as irregular diffuse thickening of the pleura, nodular, a wide range.

7. Connective tissue disease complicated with pleurisy

Systemic lupus erythematosus, rheumatoid arthritis and other common, pleural effusion for unilateral or bilateral, mostly small to medium amount, often accompanied by other changes in the primary disease, systemic lupus erythematosus pleural effusion Grass yellow exudate, a small amount of blood or purulent, increased protein content, anti-nuclear antibodies can be positive, immunoglobulin increased, complement reduction, can find lupus cells; anti-tuberculosis and antibiotic treatment is ineffective, corticosteroids are effective, rheumatoid The pleural fluid is a slightly yellowish, green turbid liquid. It can also be chylorrhea or pseudo-chylorrhea. The protein content is high, often above 40g/L, and the fat and cholesterol levels are also increased. The concentration of lactic acid dehydrogenase in pleural fluid is higher than serum. The glucocorticol has a very low glucose content, and the glucose content of the pleural fluid does not increase with the increase of blood glucose after intravenous glucose. The concentration of complement in the pleural fluid is decreased, the rheumatoid factor is positive, and a specific class is found in the pleural fluid. Rheumatoid arthritis cells are a powerful basis for the diagnosis of this disease, pleural biopsy showed non-specific inflammation, and has little significance for diagnosis.

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