Pulmonary effusion

Introduction Hydronephrosis medicine is usually called pleural effusion. Water is accumulated outside the lungs. It can be caused by infection and inflammation (such as pneumonia, tuberculosis, etc. can be combined with pleural effusion), or it can be caused by some autoimmune diseases (such as : lupus erythematosus, and many lung diseases can be combined with pleural effusion. The symptoms of acute pulmonary hydrops may be just coughing, especially in the middle of the night, coughing, unable to lie flat, often mistaken for tracheal inflammation or cold and not paid attention. In fact, if you have difficulty breathing, shortness of breath, paroxysmalnocturnaldyspnea (PND), thopnea, or even sitting and sleeping, don't neglect the symptoms. These are all acute hydronephrosis. One of the clinical symptoms.

Cause

Common cause

Cough

It is the most common cause of hydronephrosis. Early cough can be very light, often a single cough, which is our common saying that half-sound cough, no dry cough, affecting the working life is not obvious. When the lesion progresses, the cough can be aggravated. When accompanied by endobronchial tuberculosis, the cough can be aggravated, and sometimes cough can occur. For patients with chronic illness, such as bronchial displacement, the trachea is pulled due to adhesion of the lesion, or When the bronchus is deformed by the surrounding lymph nodes, irritating cough can occur due to poor ventilation. This cough is like coughing and even difficulty breathing when eating food.

Cough

In the early stage of the onset, the cough is not obvious, or there is a small amount of white mucus sputum, but the amount of sputum increases when the lesion is enlarged or even if there is a cavity in the lung. In the case of other pathogenic bacteria infections, the amount of sputum will increase, and yellow purulent sputum may occur, and fever and chills may occur along with systemic symptoms.

3. Chest pain

Chest pain is also the main cause of hydronephrosis, but it is generally necessary to have chest pain when the lesion spreads to the pleura, especially to the parietal pleura. The wall pleura, the tuberculosis of the anterior thorax and lung, is the parietal pleura. Sometimes there is a hidden pain in the indefinite part, which is caused by the nerve reflex and is not affected by the lung breathing movement. If the site is fixed with stinging and aggravated with breathing and coughing, this indicates that inflammation is caused by the pleura. Some patients often feel pain in the shoulder or upper abdomen. This is likely that inflammation stimulates the diaphragm through the nerve reflex. To.

Main cause

The heart can be divided into left and right sides in function, each responsible for a different circulation path. The left heart is responsible for transporting blood through the aorta to the circulation of the whole body, and then flows back to the right heart through the superior and inferior vena cava, which is called the systemic circulation (also called the large circulation), and the right heart is responsible for transporting the blood to the lungs via the pulmonary artery. The pulmonary veins flow back to the left heart, called the pulmonary circulation (also called the small circulation). When the left heart fails, it will cause an increase in pulmonary venous pressure and cause lung water accumulation. If the induced factors are fast and urgent, it will cause acute pulmonary water accumulation. The treatment of hydronephrosis depends mainly on the cause of the disease. Common causes include hypertensive heart disease, coronary heart disease, aortic valve disease and mitral regurgitation. Arrhythmia, severe anemia and infusion L, can also cause pulmonary congestion and water accumulation.

There are many causes of hydronephrosis, such as high blood pressure, high blood pressure, liver disease, renal insufficiency, heart failure, etc., but the proportion of lung water caused by heart disease is higher. Heart disease causes the blood that has been transported to the whole body to stagnate in the heart. When the blood in the lungs wants to flow back to the heart, the backflow is blocked due to the pressure in the heart, causing the water in the blood to penetrate into the interstitial space and cause the lungs to change. Gas block, which in turn leads to water in the lungs. Treatment must of course be treated for the cause of hydronephrosis.

an examination

Related inspection

Chest CT examination chest B-thoracic MRI bronchography

First, the appearance

The leakage liquid is clear and clear, and it is not solidified after standing, and the specific gravity is <1.016~1.018. The exudate is mostly straw yellow and slightly turbid, with a specific gravity of >1.018. Purulent pleural fluid is often smelly if it is infected with E. coli or anaerobic bacteria. Bloody pleural effusions have different levels of washed meat or venous blood samples. The milky pleural effusion is chylothorax. If the pleural fluid is chocolate, consider the possibility that the amoebic abscess will break into the chest. Black pleural fluid may be infected with Aspergillus.

Second, the cell

There are a small number of mesothelial cells or lymphocytes in normal pleural effusion. When pleural inflammation occurs, various inflammatory cells and hyperplastic and degenerate mesothelial cells can be seen in the pleural fluid. The number of leaking cells is often less than 100 × 106 / L, mainly lymphocytes and mesothelial cells. The leukocytes of the exudate often exceed 500 × 106 / L. At the time of empyema, the white blood cells are as much as 1000×106/L or more. Neutrophils suggest acute inflammation, lymphocytes are mostly tuberculous or malignant, and eosinophils often increase in parasitic infections or connective tissue diseases. When the red blood cells in the pleural fluid exceed 5 × 109 / L, it may be light red, mostly caused by malignant tumors or tuberculosis.

Thoracic puncture damage to blood vessels can also cause bloody pleural fluid, which should be carefully identified. Trauma, tumor or pulmonary infarction should be considered when red blood cells exceed 100 × 109 / L. About 60% of malignant pleural fluid can be found in malignant tumor cells, and repeated examinations can increase the detection rate. Malignant tumor cells in pleural fluid often have nuclear enlargement and different sizes, nuclear aberrations, deep nuclear staining, abnormal nucleoplasmic ratio and abnormal mitotic division, which should be identified. The pleural fluid intermediate cells are often deformed and easily misdiagnosed as tumor cells. Non-tuberculous pleural fluid intermediate cells are more than 5%, and tuberculous pleural fluid is often less than 1%. When systemic lupus erythematosus is complicated by pleural effusion, the anti-nuclear antibody titer in the pleural fluid can reach above 1:160, and it is easy to find lupus cells.

Third, pH tuberculous pleural effusion

The pH is often <7.30, and the pH <7.00 is only seen in empyema and pleural effusion caused by esophageal rupture. The pH of the pleural fluid caused by acute pancreatitis is <7.30. If the pH is <7.40, malignant pleural fluid should be considered.

Fourth, the pathogen

Chest smears for bacteria and culture help pathogen diagnosis. Tuberculous pleurisy after pleural fluid deposition for tuberculosis culture, the positive rate is only 20%, chocolate pus should be microscopic examination of amoeba trophozoites.

Five, protein

The protein content of the exudate, pleural fluid / serum ratio greater than 0.5. When the protein content is 30 g/L, the specific gravity of the pleural fluid is about 1.018 (1 g per protein added and subtracted, so that it is increased or decreased by 0.003). The leakage protein content is low (<30g/L), mainly albumin, and the mucin test (Rivalta test) is negative. Carcinoembryonic antigen (CEA): Elevated CEA levels in malignant pleural fluid appear earlier and more pronounced than serum. If the CEA value of the pleural fluid is >15~15g/L or the pleural fluid/serum CEA>1, it is often suggested as malignant pleural effusion. Increased ferritin content in malignant pleural effusion may be a reference for differential diagnosis. Combined detection of multiple markers can increase the positive detection rate.

6. Lipids

In the chylothorax, the content of neutral fat and triglyceride in the pleural fluid is higher (>4.52mmol/L), which is milky and turbid. Sudan III is dyed red, but the cholesterol content is not high, which can be seen when the thoracic duct is ruptured. "Cigar-like" or cholesterol pleural effusion (cholesterol > 2.59mmol / L), associated with the accumulation of old effusion cholesterol, can be seen in old tuberculous pleurisy, malignant pleural effusion or cirrhosis, rheumatoid arthritis. Cholesterol pleural fluid contains high levels of cholesterol, but triglycerides are normal, pale yellow or dark brown, containing cholesterol crystals, fat particles and a large number of degenerative cells (lymphocytes, red blood cells).

Seven, glucose

The glucose content in the pleural fluid of normal people is similar to the glucose content in the blood, and changes with the rise and fall of blood glucose. Determination of glucocorticol content helps identify the cause of pleural effusion. The leachate and most exudates have normal glucose levels. The glucose content in tuberculous, malignant, rheumatoid arthritis and suppurative pleural effusion can be <3.35mmol/L. If the pleural lesions are widely distributed, it is difficult for glucose and acidic metabolites to penetrate the pleura, which may result in lower glucose content, suggesting that the tumor is extensively infiltrated, and the rate of malignant tumor cells in the pleural fluid is also high.

Eight, enzyme

The pleural fluid lactate dehydrogenase (LDH) content increased, greater than 200U / L, and pleural fluid LDH / serum LDH ratio greater than 0.6, suggesting that exudate, pleural fluid LDH activity can reflect the degree of pleural inflammation, the higher the value, It shows that the inflammation is more obvious. LDH>00U/L is often indicated as a malignant tumor or pleural fluid has been complicated by bacterial infection. Elevated pleural fluid amylase can be found in acute pancreatitis, malignant tumors, and the like. In acute pancreatitis with pleural effusion, amylase leakage causes the enzyme to be higher in serum than in serum. Some patients have severe chest pain and difficulty breathing, which may mask their abdominal symptoms. At this time, the pleural fluid amylase has increased, and clinical diagnosis should be noted. Adenosine deaminase (ADA) is high in lymphocytes. In tuberculous pleurisy, cytotoxicity is stimulated and lymphocytes increase significantly, so ADA in pleural fluid can be higher than 100 U/L (generally no more than 45 U/L). Its sensitivity in the diagnosis of tuberculous pleurisy is higher.

Nine, immunological examination

With the advancement of cell biology and molecular biology, immunological examination of pleural fluid has attracted attention. It plays a role in the identification of benign and malignant pleural fluids, the study of the pathogenesis of pleural effusion and the future development of pleural effusion. In tuberculous and malignant pleural effusions, T lymphocytes increased, especially in tuberculous pleurisy, which was up to 90%, and mainly T4 (CD+4). The T cell function in malignant pleural effusion is inhibited, and its cytotoxic activity against autologous tumor cells is significantly lower than that of peripheral blood lymphocytes, suggesting that the local immune function of the thoracic layer is inhibited in patients with malignant pleural effusion. In patients with systemic lupus erythematosus and rheumatoid arthritis, the contents of complement C3 and C4 in pleural effusion decreased, and the content of immune complexes increased.

Ten, pleural biopsy

Percutaneous pleural biopsy can help to identify the presence or absence of tumors and to determine pleural granulomatous lesions. When the tuberculosis is to be diagnosed, the biopsy specimen can be used for tuberculosis culture in addition to pathological examination. Patients with empyema or bleeding tendency should not be used for pleural biopsy. A biopsy can be performed via a thoracoscope if necessary. Ultrasound examination can identify pleural effusion, pleural thickening, liquid pneumothorax and so on. The cystic effusion can provide a more accurate positioning diagnosis, which is helpful for thoracic puncture drainage.

Differential diagnosis

First, tuberculous pleurisy

Most patients have satisfactory anti-tuberculosis drugs. A small amount of pleural fluid generally does not need to be pumped or only for diagnostic puncture. Thoracentesis can not only help diagnosis, but also relieve lung and heart and blood vessel pressure, improve breathing and prevent fibrin deposition. The pleura is thickened to protect the lungs from damage. After pumping, the symptoms of toxicity can be alleviated, and the body temperature drops, which helps to quickly re-expand the compressed lungs. A large number of pleural fluids are pumped 2 to 3 times a week until the pleural fluid is completely absorbed. Each time the amount of fluid should not exceed 1000ml, too fast, excessive pumping can cause a sudden drop in chest pressure, pulmonary edema or circulatory disorders. This kind of lung edema caused by lung re-expansion after chest pumping, manifested as cough, shortness of breath, cough, a lot of foamy sputum, double lungs full of turbid sound, PaO2 decreased, X-ray showed pulmonary edema.

Oxygen should be taken immediately, glucocorticoids and diuretics should be applied as appropriate to control the amount of water, and the condition and acid-base balance should be closely monitored. If a "pleural reaction" manifests as dizziness, cold sweat, palpitations, pale complexion, fine veins, and cold extremities during pumping, stop the fluid immediately and allow the patient to lie flat. If necessary, subcutaneously inject 0.1% adrenaline 0.5ml. Closely observe the condition, pay attention to blood pressure, and prevent shock. Under normal circumstances, after pumping the chest fluid, it is not necessary to inject drugs into the chest cavity. Glucocorticoids can reduce the body's allergic reactions and inflammatory reactions, improve the symptoms of toxicity, accelerate the absorption of pleural fluid, and reduce the sequelae of pleural adhesions or pleural thickening. However, there are certain adverse reactions or dissemination of tuberculosis, so the indications should be carefully controlled. Acute tuberculous exudative pleurisy with severe systemic toxicity symptoms and more pleural fluid. In the treatment of anti-tuberculosis drugs, glucocorticoids can be added, usually with prednisone or prednisolone 25-30 mg/d. 3 times orally. When the body temperature is normal, the symptoms of systemic toxicity are relieved, and the pleural fluid is significantly reduced, it should be gradually reduced or even stopped. The speed of stopping the drug should not be too fast, otherwise it is prone to rebound phenomenon. The general course of treatment is about 4 to 6 weeks.

Second, empyema

Empyema refers to inflamed infection of the pleural cavity caused by various pathogenic microorganisms, accompanied by opaque appearance and pleural exudate with pus-like characteristics. Bacteria are the most common pathogens of empyema. Most bacterial empyema is associated with inadequate control of bacterial pleurisy. A small number of empyema can be caused by tuberculosis or fungi, actinomycetes, nocardia, and the like. The most common pathogens in infectious pleural effusions are Gram-negative bacilli, followed by Staphylococcus aureus and pneumococci. Among Gram-negative bacilli, Pseudomonas aeruginosa and other Escherichia coli are more common. Anaerobic bacteria have also been widely confirmed as a common pathogen of empyema. A pus that is complicated by pneumonia is often a single infection. If it is a lung abscess or bronchiectasis and empyema, it is mostly mixed bacteria infection.

Among patients with immunosuppressants, fungal and Gram-negative bacilli infections are common. Acute empyema often manifests as high fever, state of consumption, chest pain and so on. The principle of treatment is to control infection, drain pleural effusion and promote lung recruitment and restore lung function. Apply effective antibacterial drugs to the pathogens of empyema as soon as possible, systemic and intrathoracic administration. Drainage is the most basic treatment for empyema, repeated pus or closed drainage. The chest cavity can be repeatedly washed with 2% sodium bicarbonate or normal saline, and then an appropriate amount of antibiotics and streptokinase can be injected to make the pus thin and easy to drain. A small number of empyema can be closed by drainage with intercostal water. For patients with bronchopleural palsy, it is not appropriate to flush the chest to avoid bacterial spread. Chronic empyema with pleural thickening, thoracic collapse, chronic consumption, clubbing (toe), etc., should consider surgical pleural stripping and other treatments. In addition, general supportive care is also very important, high-energy, high-protein and vitamin-containing foods should be given. Correct water and electrolyte disorders and maintain acid-base balance, if necessary, a small number of multiple blood transfusions.

Third, malignant pleural effusion

Malignant pleural effusion is mostly caused by the progression of malignant tumors. It is a common symptom of advanced malignant tumors. For example, lung cancer with pleural effusion is already advanced. Imaging studies can help to understand the extent of lesions in the lungs and mediastinal lymph nodes. In view of the rapid and persistent growth of pleural fluid, it is often caused by severe dyspnea caused by the compression of a large amount of effusion, and even death, so it is necessary to repeat the thoracic puncture, but repeated pumping can cause too much protein loss (1L pleural fluid containing protein) 40g), so the treatment is very tricky and the effect is not ideal. Therefore, correct diagnosis of malignant tumors and tissue types, timely and reasonable treatment, is important for relieving symptoms, alleviating pain, improving quality of life, and prolonging life. Systemic chemotherapy has a certain effect on pleural effusion caused by some small cell lung cancer. Local radiotherapy is feasible in patients with mediastinal lymph nodes.

After the pleural fluid is pumped, anti-tumor drugs including doxorubicin, cisplatin, fluorouracil, mitomycin, nitrocaine, bleomycin, etc. are injected into the thoracic cavity, which is a commonly used treatment method. It kills tumor cells, slows the production of pleural fluid, and can cause pleural adhesions. Intrathoracic injection of biological immunomodulators is a successful method for exploring malignant pleural effusions in recent years, such as Corynebacterium parvum vaccine (CP), IL-2, interferon beta, interferon gamma, lymphokine activated killer cells (LAK). Cells, tumor infiltrating lymphocytes (TIL), etc., can inhibit malignant tumor cells, enhance local infiltration and activity of lymphocytes, and cause pleural adhesions. In order to block the pleural cavity, the pleural fluid can be drained by thoracic cannula, and pleural adhesion agents, such as tetracycline, erythromycin, and talc, can be injected to cause adhesion of the two layers of pleura to avoid re-formation of the pleural fluid. Lidocaine and dexamethasone can alleviate adverse reactions such as pain and fever. Despite the above various treatments, the prognosis of malignant pleural effusion is poor.

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