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1、胸腔积液总论Pleuraleffusion胸膜腔功能减少肺与胸壁的摩擦肺的机械保护和支持负压调节心肺功能肺内水肿液的吸收(高静水压高渗透压性肺水肿的25%由胸膜吸收)胸膜腔两层胸膜并不相互接触脏层胸膜无神经纤维胸腔内压胸腔内压肺弹性回缩力功能残气位–5CMH2O肺总量位-30CMH20肺顺应性下降,胸腔负压增加立位时胸膜腔压力梯度每垂直下移1CM压力增加0.5,而两肺肺泡内压相同.肺内通气顺序上肺区先进后出,下肺区后进先出,胸水形成传统正常人胸腔内有3～15ml液体，人体每天胸膜腔可有0.5～1L液体通过。胸液中的蛋白质主要经由淋巴管进入胸导管。新论壁层胸膜缓慢产生，经壁层胸膜
2、间皮间2-12UM小孔，直接引流入淋巴管。每日100-200。脏层胸膜对胸水产生吸收不起作用。正常胸水0.3ml/kg,低渗,交换量0.15ml/kg/h,最大流量30ml/h由胸膜腔尖顶区壁层胸膜产生胸膜腔基底区横膈纵膈壁层胸膜重吸收淋巴管微孔单向活作用胸液的滤过量超过胸膜最大淋巴流量时产生胸水胸腔积液量0.3～0.5L时，X线仅见肋膈角变钝；少于0.3L时症状多不明显；若超过0.5L，患者渐感胸闷。机制胸液循环与有关压力（cmH2O）关系示意图34胸腔积液与吸收的机制病因学一、胸膜毛细血管内静水压增高充血性心力衰竭缩窄性心包炎血容量增加上腔静脉或奇静脉受阻二、胸膜毛细血管通
3、透性增加胸膜炎症（结核病、肺炎）结缔组织病（SLE、类风湿关节炎）胸膜肿瘤（恶性肿瘤转移、间皮瘤）肺梗死膈下炎症（膈下脓肿、肝脓肿、胰腺炎）三、胸膜毛细血管内胶体渗透压降低低蛋白血症肝硬化肾病综合征、急性肾小球肾炎粘液性水肿四、壁层胸膜淋巴引流障碍癌症淋巴管阻塞发育性淋巴管引流异常五、损伤所致胸腔内出血主动脉瘤破裂食管破裂胸导管破裂等产生血胸、脓胸、乳糜胸病因恶性45CHF12感染22结核10细菌9病毒1真菌<1脓胸1寄生虫<1肺栓3肝变2胶原1其它5FrequencyIntheUSPleuraleffusionaffects1.3millionindividualseachy
4、earcongestiveheartfailure,500,000;bacterialpneumonia,300,000(uncomplicated,270,000;complicated,30,000);malignancy,200,000pulmonaryembolus,150,000;cirrhosiswithascites,50,000pancreatitis,20,000collagenvasculardisease,6,000andtuberculosis,2,500.TransudativepleuraleffusionCongestiveheartfailure
5、(mostcommontransudativeeffusion) Hepaticcirrhosiswithandwithoutascites Nephroticsyndrome Peritonealdialysis/continuousambulatoryperitoneal dialysis Hypoproteinemia(eg,severestarvation) Glomerulonephritis Superiorvenacavaobstruction Fontanprocedure UrinothoraxExudativepleuraleffusionMalignant
6、disorders-Metastaticdiseasetothepleuraorlungs,primarylungcancer,mesothelioma,Kaposisarcoma,lymphoma,leukemia Infectiousdiseases-Bacterial,fungal,parasitic,andviralinfections;infectionwithatypicalorganismssuchasMycoplasma,Rickettsiae,Chlamydia,LegionellaGIdiseasesandconditions-Pancreaticdise
7、ase(acuteorchronicdisease,pseudocyst,pancreaticabscess),Whippledisease,intraabdominalabscess(eg,subphrenic,intrasplenic,intrahepatic),esophagealperforation(spontaneous/iatrogenic),abdominalsurgery,diaphragmatichernia,endoscopicvaricealsclerotherapy
