Pleural effusion examination

The serosal cavity of the human body has a pleural cavity, a pericardial cavity, a joint cavity, and a scrotal sheath cavity. Under normal conditions, there is a small amount of liquid in the cavity that acts as a lubricant. However, under pathological conditions, there may be a large amount of fluid in the cavity, called serosal effusion, such as pleural effusion, ascites, pericardial effusion, scrotal sheath and effusion. Due to the different causes of effusion, it can be divided into two types: leakage and exudate. The various components and properties are obviously different. Check the amount, appearance, pH, relative density, protein, glucose and microscopy of various effusions. The significance is to distinguish the nature of the effusion, find out the cause, and conduct diagnosis and treatment. Pleural effusion examination is suitable for pleural effusion, empyema, hemorrhagic symptoms or symptoms of poisoning, also used for diagnostic thoracentesis, also for local injection of chemotherapy drugs for tuberculous, cancerous and suppurative pleural effusion . Basic Information Specialist classification: Respiratory examination classification: chest and ascites examination Applicable gender: whether men and women apply fasting: not fasting Tips: routinely do platelet determination, clotting time, stereo X-ray chest and other examinations before pumping. The puncture site was selected according to the chest signs, X-ray, CT or B-ultrasound results. Normal value Normal people have a very small amount of liquid in the pleural cavity, about 1 ~ 20ml, for lubrication. Clinical significance 1. General traits 1 The general leakage liquid and most exudates are clear or grass green, flowing, and odorless. The specific gravity of the leakage liquid is mostly less than 1.015, and the exudate is greater than 1.018. Tuberculous pleural effusion is mostly grass yellow or dark yellow, a few are light red; bloody pleural effusion may be pale red blood, water washing, macroscopic blood (venous blood) due to different bleeding degree; purulent effusion Yellow purulent, anaerobic infection has a foul odor; amebic liver abscess ruptured chest cavity caused by pleural effusion is chocolate; milky white pleural fluid is chylothorax pleural fluid; bacillary effusion infected with aspergillus can be black Pleural fluid. 2 turbid, viscous, colored purulent fluid is suppurative pleural fluid. 3 odor is often caused by infection with E. coli or anaerobic bacteria. 4 yellow and transparent pleural effusion is common in tuberculosis, rheumatoid or connective tissue diseases. 5 bloody fluid is common in puncture injury, uniform non-condensable bloody pleural effusion is common in malignant tumors, acute tuberculosis and trauma. 6 The chyle chest fluid is white milky, and can not be precipitated by centrifugation, which can be distinguished from the clear liquid phase after centrifugation of suppurative pleural fluid. 7 colorless and transparent is generally leakage, common in congestive heart failure, cirrhosis, nephrotic syndrome, hypoproteinemia. 2, cell counting and classification (1) The number of nucleated cells in the cell count leakage solution is often less than 100×106/L; when the exudate is in the serum, the number of nucleated cells is (200-500)×106/L, when the serum is purulent or purulent It can be as high as tens of millions to tens of thousands × 106 / L. (2) Cell classification There are fewer cells in the leakage fluid, mainly mesodermal cells and lymphocytes from the serosa. More cells in the exudate 1 When the number of red blood cell red blood cells is 0.005×10 12 /L (0.5 million/mm 3 ) or less, there is no clinical significance, and 0.01×10 12 /L (10,000/mm 3 ) or more is meaningful. Gross blood pleural effusion shows malignant tumor, traumatic blood pneumothorax, pulmonary infarction, pleural tuberculosis and so on. The hematocrit (Ht) in the bloody pleural effusion is more than 50% of the peripheral blood. 2 increased white blood cell neutrophils, indicating acute inflammation from the lung parenchyma to the chest, more common in purulent bacterial infections, early acute tuberculosis infection or mixed infection. Lymphocytes are mainly found in chronic diseases such as malignant tumors, tuberculosis, and connective tissue diseases. Eosinophilia is more than 5% common in allergic or parasitic diseases, and can also be seen in infections, fungal pleurisy, tumors, or sequelae of blood pneumothorax. 3 mesothelial mesothelial cells usually account for more than 5% of the cells in the pleural effusion, but tuberculous pleurisy is often less than 1%. 3, bacteriological examination In recent years, the anaerobic bacteria of the pathogenic bacteria of the empyema have increased, and the Gram-positive cocci are Staphylococcus aureus and Streptococcus. Gram-negative bacilli are Pseudomonas aeruginosa and E. Mycobacterium tuberculosis culture is about 25% positive in tuberculous pleurisy. 4, biochemical inspection 1 The specific gravity of the specific gravity leakage liquid is mostly less than 1.015, and the exudate is greater than 1.018. 2 Protein is a necessary check for the identification of leakage and exudate, but protein has no correlation with disease. A protein of 30 g/L (3.0 g/dl) aids in the identification of leaks and exudates. The protein classification of pleural effusion is the same as serum, the albumin with small molecular weight is relatively increased, the immunoglobulin (IgG, IgM, IgA) of pleural effusion is lower than the serum value, and the pleural effusion IgE of paragonimiasis is not diagnosed. The value is higher than the serum and its diagnostic value is greater. 3 The glucose concentration in glucose pleural effusion changes in parallel with the serum glucose concentration. The glucose concentration in pleural fluid is lower than 3.33mmol/L (60mg/dl). It is found in tuberculosis, cancerous pleurisy, rheumatoid arthritis, pneumonia complicated with pleurisy. Wait. The concentration of glucose in pleural effusions of SLE (systemic lupus erythematosus) is in the normal range and is useful for the identification of rheumatoid arthritis. 4 Lactate dehydrogenase (LDH) is a necessary examination for the identification of leakage and exudate. The degree of inflammation of the pleura is generally parallel to the LDH value of pleural effusion. The LDH isoenzyme of exudative pleural effusion is usually high in type 4 and type 5, and about 1/3 of cancerous pleurisy is high in type 2. 5 amylase pleural effusion amylase concentration in the serum limit of the normal limit of the cupping network more common in pancreatitis, cancer pleurisy, esophageal rupture three diseases. 6 pH pleural effusion pH <7.20 is more common in pneumonia complicated by pleurisy, esophageal rupture, rheumatoid arthritis, tuberculous pleurisy, cancerous pleurisy, hemothorax, systemic lupus erythematosus. 7 Adenosine dehydrogenase (ADA) tuberculous pleurisy auxiliary diagnosis, ADA> 50U / L is mostly tuberculosis, hemolysis of cancerous pleural effusion also appeared in high values, must be identified. 8 The increase of triglyceride neutral fat in pleural effusion is greater than 4.52mmmol/L, while cholesterol contains normal chylothorax. 5, cancer cell examination The item that must be examined for the diagnosis of cancerous pleurisy, the positive rate of cancer cell diagnosis is 30-70%, and the negative does not completely deny the cancerous pleural effusion. Precautions 1. Regularly perform platelet measurement, clotting time, and stereo X-ray chest X-ray before pumping. 2. Select the puncture site according to the chest signs, X-ray, CT or B-ultrasound results. 3. Do a good job of explaining and explaining the work of the patient, and contact with concerns; for those who are nervous, they can give 10mg of diazepam or a static pain of 0.03g of codeine half an hour before surgery. 4. Prepare all kinds of instruments, medicines and tubes needed for the operation, and prepare the drainage tube for chest drainage. 5. The patient's reaction should be closely observed during the operation, such as dizziness, pale, sweating, palpitations, chest pressure or severe pain, fainting and other pleural reactions; or continuous cough, shortness of breath, cough foaming, etc. Immediately stop the pumping and subcutaneously inject 0.1% adrenaline from 0.3 to 0.5 ml. Or other symptomatic treatment. 6. A single pumping should not be too much, too fast, diagnostic liquid 50 ~ 100ml can be; decompression liquid, the first time does not exceed 600ml, after each time does not exceed 1000ml; such as empyema, try to pump each time net. 7. Strict aseptic operation, to prevent air from entering the chest during operation, and always maintain negative pressure in the chest. 8. Puncture below the 9th intercostal space should be avoided to avoid penetrating the diaphragm and damaging the abdominal organs. 9. When suspected of purulent infection, use sterile tube to retain the specimen according to the regulations; when sending tumor cells, at least 100ml of pleural fluid should be taken, and should be sent immediately to avoid autolysis of the cells and affect the results. Inspection process Puncture method to collect appropriate amount of pleural effusion specimens, immediately sent for inspection, the detection methods are microscopic examination and biochemical methods. Not suitable for the crowd Taboo population: normal healthy people should not do this check. Adverse reactions and risks 1. Infection: Pay attention to aseptic operation during thoracic puncture, pay attention to local cleaning after puncture, prevent water pollution and avoid infection. 2, bleeding: puncture needle damage to local blood vessels or tissue caused by local bleeding, should try to avoid puncture too deep, the needle speed is too fast.