Frank W
Klinik III, Pneumologie, Johanniterkrankenhaus im Fläming, Treuenbrietzen.
Pneumologie. 2004 Nov;58(11):777-90. doi: 10.1055/s-2004-830084.
Pleural effusion is a common pneumologic and interdisciplinary problem. Transudate/exsudate discrimination of the pleural fluid by thoracentesis remains the diagnostic basic algorithm. Regardless of a number of new markers, classical LIGHT's criteria comprising the pleural fluid protein- and LDH-values (or their serum ratio respectively) reveal the highest potency with an overall accuracy of 95 %. Expansion to cholesterol-determination (triplet test) may be helpful to identify transudates in indeterminate cases. The need for further local diagnostic evaluation is then usually restricted to exudates. Bacterial pleurisy, malignant and tuberculous effusion are the principal differential diagnoses. With the use of a variety of conventional biochemical, cytologic, immunologic and microbiologic investigations, thoracentesis will allow- or substantially narrow-diagnosis of exudates in about 70 %, with novel cell biological markers in some conditions up to 90 %. In bacterial pleurisy thoracentesis provides information directly relevant to management in terms of local interventions. It also constitutes a platform for more invasive imaging- or endoscopy-guided investigations with a focus on medical thoracoscopy (pleuroscopy). Blind needle biopsy is diagnostic in a range of 40 - 70 % both in malignancy and inflammatory disease, thoracoscopy may clarify exudative conditions in about 95 %. Thus malignancy may be specifically diagnosed in 97 % of cases, tuberculous effusion in virtually 100 %. The value of thoracoscopy is augmented by interventional options including complete evacuation of the pleural cavity, eventually followed by talc pleurodesis ("poudrage") in recurrent effusions or adhesiolysis, irrigation and fibrinolysis protocols in certain inflammatory conditions. These combined features as accomplished in local anesthesia on a remarkably high safety level characterise medical thoracoscopy as a gold standard tool for the management of pleural disease even in comparison to more elaborate surgical procedures.
胸腔积液是一个常见的肺病及跨学科问题。通过胸腔穿刺术对胸腔积液进行漏出液/渗出液鉴别仍然是诊断的基本算法。尽管有许多新的标志物，但包括胸腔积液蛋白和乳酸脱氢酶值（或其与血清的比值）的经典利氏标准显示出最高的效能，总体准确率为95%。扩展到胆固醇测定（三联试验）可能有助于在不确定的病例中识别漏出液。然后，进一步的局部诊断评估通常仅限于渗出液。细菌性胸膜炎、恶性和结核性胸腔积液是主要的鉴别诊断。通过使用各种传统的生化、细胞学、免疫学和微生物学检查，胸腔穿刺术将能够在约70%的病例中做出渗出液的诊断或大幅缩小诊断范围，在某些情况下，使用新型细胞生物学标志物可达90%。在细菌性胸膜炎中，胸腔穿刺术提供了与局部干预管理直接相关的信息。它还构成了一个平台，用于更具侵入性的影像学或内镜引导下的检查，重点是内科胸腔镜检查（胸膜镜检查）。盲针活检在恶性肿瘤和炎症性疾病中的诊断率为40%-70%，胸腔镜检查可在约95%的病例中明确渗出性疾病。因此，恶性肿瘤的特异性诊断率可达97%，结核性胸腔积液几乎可达100%。胸腔镜检查的价值因介入选择而增加，包括完全排空胸腔，对于复发性胸腔积液最终可进行滑石粉胸膜固定术（“喷粉法”），或在某些炎症情况下进行粘连松解、冲洗和纤维蛋白溶解方案。这些综合特征在局部麻醉下以非常高的安全水平实现，使内科胸腔镜检查成为胸膜疾病管理的金标准工具，即使与更复杂的外科手术相比也是如此。
