胸腔闭式引流并注入尿激酶治疗结核性包裹性胸腔积液的护理

结核性胸腔积液是我国常见的胸腔积液，约占渗出性胸腔积液的54.8％。如果处理不及时，胸腔中大量纤维蛋白沉着于胸腔的脏层和壁层，导致胸膜粘连，形成多层性包裹性胸腔积液。可发展为包裹性脓胸，出现广泛胸膜增厚致肺萎缩。我院对结核性纤维分隔型包裹性胸腔积液采用了全身抗结核治疗联合胸腔闭式引流并注入尿激酶，取得了满意的效果。现将护理报告如下。     

胸腔置管引流联合尿激酶在结核性包裹性胸腔积液治疗中的疗效分析

正结核性胸腔积液是结核分枝杆菌及其代谢产物进入处于高敏状态的胸膜腔引起的胸膜炎症[1-3]。由于结核性胸腔积液患者胸腔积液中含有丰富的纤维蛋白、白细胞等成份[4],若患者延误治疗或不配合治疗,使胸液中的纤维蛋白等成份附着在胸膜表面,极易产生包裹性胸腔积液,最终导致患侧肋间隙变窄、肺膨胀不全、胸廓畸形、胸膜增厚及钙化等病变,严重者可出现毁损肺,产生一系列严重后果。如何减少结核性包裹性胸腔积液相关并发症的发生,是呼吸科医     

超声引导下胸腔置管引流并注入尿激酶治疗结核性包裹胸腔积液的价值

结核性胸腔积液是一种渗出液,积液中富含大量蛋白,治疗不及时或不当,可导致包裹性胸腔积液,尤其是多房性包裹,常规治疗效果不佳,严重者可引起胸膜增厚粘连,肺膨胀受限.笔者对结核性胸膜炎导致包裹性胸腔积液者,在抗结核治疗的基础上加用尿激酶胸膜腔内注射后排液,治疗效果明显.     

尿激酶治疗结核性包裹性胸积液后外科手术治疗的疗效分析肖泽林 刘家杰 高健齐 连贵勇简

目的 探讨在结核性包裹性胸积液疾病治疗中如何选择胸腔内注入尿激酶与外科手术治疗.方法 分析我院651例诊断结核性包裹性胸积液病例,在入院后予常规抗痨治疗并予胸腔内注入尿激酶治疗,对有效组与效果不佳再转入外科行胸腔纤维板剥脱术治疗的手术组的疗效进行对比分析.结果 两组病例的发病病程、复发率比较无明显差异 （P〉0.05）,在体查及B超、CT检查、胸腔穿刺或置管后肺能否复张比较有明显差异（P＜0.05）.结论 在体查、B超和CT检查有阳性结果、胸腔穿刺或置管后肺不能复张的病例选择外科手术治疗效果较好,胸膜纤维板剥脱术仍是治疗胸膜增厚的结核性包裹性胸积液的有效方法.     

微创导管引流并尿激酶胸腔内注射在治疗包裹性胸腔积液中的应用及护理

包裹性胸腔积液临床较为常见,常规穿刺抽液效果较差,不及时处理可发展为包裹性脓胸,出现胸膜增厚、纤维胸、胸廓畸形等并发症。我院在常规治疗、对症及营养支持基础上,对包裹性胸腔积液患者行微创导管引流并尿激酶胸腔内注射治疗,取得满意效果,现报道如下：     

尿激酶治疗结核性包裹性胸积液后外科手术治疗的疗效分析

目的探讨在结核性包裹性胸积液疾病治疗中如何选择胸腔内注入尿激酶与外科手术治疗。方法分析我院651例诊断结核性包裹性胸积液病例,在入院后予常规抗痨治疗并予胸腔内注入尿激酶治疗,对有效组与效果不佳再转入外科行胸腔纤维板剥脱术治疗的手术组的疗效进行对比分析。结果两组病例的发病病程、复发率比较无明显差异(P0.05),在体查及B超、CT检查、胸腔穿刺或置管后肺能否复张比较有明显差异(P0.05)。结论在体查、B超和CT检查有阳性结果、胸腔穿刺或置管后肺不能复张的病例选择外科手术治疗效果较好,胸膜纤维板剥脱术仍是治疗胸膜增厚的结核性包裹性胸积液的有效方法。     

胸痛—低热—右侧胸腔巨大占位

患者男,71岁,因"右胸痛、咳嗽、消瘦1年,低热乏力 4个月"于2010年6 月 21 日入院.患者1年前无明显诱因出现右侧胸部间歇性隐痛,咳嗽,干咳为主,偶有少量白痰,消瘦明显(1年来体重下降约25 kg).近4个月出现低热,下午为主,体温37.4～37.8℃,伴乏力、食欲差 无咯血,无呼吸困难,无盗汗.外院胸腔B超示右侧胸腔内多发团块样回声.遂转至我院.既往史:患者50年前有右侧胸腔包裹性积液,考虑为结核性,当时不规则抗结核治疗,此后一直遗留有右侧胸腔包裹性积夜、胸膜增厚钙化,但自觉无明显不适,未行进一步治疗.2004年 12 月27 日 曾行X线胸片示右侧胸腔包裹性积液、胸膜增厚钙化(图1).2004年12月 28日胸部CT示右侧胸腔包裹性积液、胸膜增厚钙化(图 2 ～4).     

结核性胸膜炎胸腔介入治疗的应用

结核性胸腔积液在我国仍然是常见病、多发病，绝大部分病人通过规则的化疗、适当的抽胸液以及全身应用糖皮质激素等项常规方法的治疗，胸液能够吸收，获得临床治愈。但由于就诊时间较晚，治疗措施不适当，或者治疗措施还不够完善等项因素，不少的病例在治疗前就已经有胸膜增厚和包裹性积液，部分病例则在治疗过程中再形成胸膜增厚和包裹性积液。     

尿激酶治疗包裹性胸腔积液100例临床分析

目的探讨注射用尿激酶治疗包裹性胸腔积液的机理和方法。方法本文收集陕西省结核病防治院1999年至2011年间结核性包裹性胸腔积液100例,采取胸腔内注射尿激酶以观察消除纤维分隔的效果。结果 100例中,积液消退,肺膨胀良好70例,积液消退但还有少许粘连带21例,积液显著减少、胸膜增厚减轻不佳9例。结论尿激酶胸膜腔内注射治疗包裹性胸腔积液疗效确切。     

内科胸腔镜对结核性胸腔包裹积液的治疗及其安全性

结核性胸膜炎是呼吸系统疾病中的常见病,国内报道在新发肺结核患者中伴有结核性胸膜炎者占4.7%～17.6%[1],第三次全国结核病流行病学调查表明结核性胸膜炎患者占结核病患者总数的2.5%.对于结核性胸腔积液患者,除全身抗结核治疗外,局部治疗亦非常关键.胸腔积液治疗不及时、不恰当,可导致纤维蛋白沉积于脏、壁层胸膜表面,造成多房分隔,形成包裹性胸腔积液,严重者影响肺功能;而抗结核药物难以进入包裹腔内[2],使患者长期不愈,甚至需开胸手术才能解决.我们对32例结核性胸腔包裹积液患者,在局部麻醉下借助胸腔镜清理粘连带、剥脱纤维膜、消灭包裹腔,促进肺功能恢复,取得了良好的治疗效果.     

Streptokinase in a loculated pleural effusion. Effectiveness determined by site of instillation

A patient with a large loculated pleural effusion had streptokinase instilled into the loculation, and this was ineffective; however, when the same amount of streptokinase was instilled into the space around the loculation, there was rapid lysis of the loculation, resulting in the drainage of purulent fluid through the chest tube.     

Pleural fluid pH in parapneumonic effusions.

The pH and carbon dioxide tension were measured in 24 consecutive parapneumonic effusions, along with the leukocyte count, leukocytic differential count, and levels of glucose and protein. Three categories of parapneumonic effusions were characterized: (1) empyemas; (2) benign (nonloculated) effusions; and (3) loculated effusions. A pH greater than 7.30 was present in all ten benign effusions, and spontaneous resolution occurred in each case. All ten empyemas and the four loculated effusions had a pH less than 7.30. All four loculated effusions required drainage with a chest tube for resolution. The pH of the pleural fluid alone separated the empyemas and loculated effusions from benign effusions. The early separation of parapneumonic effusions on the basis of the pleural fluid appears useful. If the pH is greater than 7.30, a benign effusion is present, and spontaneous resolution is likely. If the pH is less than 7.30, loculation of the pleural space may occur regardless of whether the effusion fulfills the criteria for empyema.     

Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema

STUDY OBJECTIVES: To determine the predicting factors for outcome of tube thoracostomy in patients with complicated parapneumonic effusion (CPE) or empyema. DESIGN AND SETTINGS: Retrospective chart review over a 55-month period at a tertiary referred medical center. PATIENTS AND MEASUREMENTS: The medical charts of patients with empyema or CPE were reviewed. Data including age, gender, clinical symptoms, important underlying diseases, leukocyte count, duration of preadmission symptoms, interval from first procedure to second procedure, the time from first procedure to discharge (recovery time), the amount of effusion drained, administration of intrapleural streptokinase, chest tube size and position, loculation of pleural effusion, and characteristics and culture results of pleural effusion were recorded and compared between groups of patients with successful and failed outcome of tube thoracostomy drainage. RESULTS: One hundred twenty-one patients were selected for study. One hundred of these patients had received tube thoracostomy drainage with 53 successful outcomes and 47 failed outcomes of chest tube drainage. Nineteen patients received decortication directly, and the other two received antibiotics alone. Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. Multiple logistic regression analysis demonstrated that loculation and pleural effusion leukocyte count < or = 6,400/uL were the only independent predicting factors related to failure of tube thoracostomy drainage. CONCLUSIONS: Loculation and pleural effusion leukocyte count < or = 6,400/microL were independent predicting factors of poor outcome of tube thoracostomy drainage. These results suggest that if the initial attempt at chest tube drainage fails, early surgical intervention should be considered in good surgical candidates with loculated empyema or pleural effusion with leukocyte count < or = 6,400/microL.     

A study of loculated tuberculous pleural effusions treated with intrapleural urokinase

AIM: To assess the effect of intrapleural urokinase, vis-à-vis simple pleural drainage, on residual pleural thickening in a series of patients suffering from loculated tuberculous pleural effusion. PATIENTS AND METHOD: Twenty-nine patients (21 males and 8 females) with loculated pleural effusion were studied. These patients were randomly allocated to one of two groups: one group received intrapleural urokinase (n=12) and the other was treated by simple drainage with suction (n=17). The urokinase (125,000 UI) was administered into the pleural cavity via an intrathoracic tube. This procedure was repeated every 12h until the quantity of pleural fluid obtained was less than 50 cm3, at which point the intrathoracic tube was removed. RESULTS: In both groups, the biochemical analysis of the pleural fluid was an exudate and the fluid had a serous appearance. Pleural thickening when the drainage tube was removed was 8.09+/-3.36 mm for the group treated with urokinase, and 14.78+/-17.20mm (P>0.05) for the control group. Residual pleural thickening measured upon completion of medical treatment at 6 months was 1.45+/-0.89 mm for the group treated with urokinase and 7.47+/-10.95 mm for the control group (P<0.05). In the control group, only two patients presented over 10mm of residual pleural thickening. The mean quantity of fluid drained in the two groups was 1.487+/-711 ml for the patients with urokinase, and 795+/-519 ml for the control group (P<0.01). CONCLUSION: Our study shows that patients with loculated tuberculous pleural effusion treated with urokinase suffered less from residual pleural thickening, as measured after six months, than those treated by simple drainage. It is therefore suggested that the administration of intrapleural urokinase is a safe and effective treatment for those patients who drain a larger quantity of pleural fluid.     

山茛菪碱联合糖皮质激素治疗结核性胸膜炎

目的山莨菪碱（654-2）联合糖皮质激素治疗结核性胸膜炎疗效好,减少胸膜增厚。方法对照组治疗采用2HRZE（S）／4HR＋激素＋抽胸水,治疗组在此基础上胸腔注射山莨菪碱（654-2）。结果两组对比疗效,加用山莨菪碱（654-2）治疗,胸水吸收情况、胸膜增厚减轻均好于对照组。结论山莨菪碱联合激素可加速治疗结核性胸膜炎胸腔积液,减少胸膜增厚、粘连。     

Proinflammatory cytokines, transforming growth factor-beta1, and fibrinolytic enzymes in loculated and free-flowing pleural exudates

STUDY OBJECTIVES: To measure tumor necrosis factor (TNF) alpha, interleukin (IL) 1beta, and transforming growth factor (TGF) beta1 in loculated and free-flowing pleural effusions caused by malignancy, tuberculosis (TB), and pneumonia and their relationship with plasminogen activator inhibitor-type 1 (PAI-1) and tissue-type plasminogen activator (tPA) and to compare the differences between loculated and free-flowing effusions. DESIGN: A prospective study. PATIENTS AND METHODS: The effusion levels of TNF-alpha, IL-1beta, TGF-beta1, PAI-1, and tPA were measured in 29 patients with malignant effusions, 19 patients with TB, and 30 patients with parapneumonic effusions. Pleural effusions were divided into loculated and free-flowing groups by imaging studies. A group of 42 patients with loculated effusions was subdivided into primary and secondary loculation groups by chest ultrasonography. RESULTS: The median levels of TNF-alpha (87.0 pg/mL), IL-1beta (13.8 pg/mL), TGF-beta1 (10,952.9 pg/mL), PAI-1 (111.2 ng/mL), and lactate dehydrogenase (LDH) [498 IU/dL] in the loculated group were significantly higher than those in the free-flowing group (TNF-alpha, 15.0 pg/mL; IL-1beta, 2.9 pg/mL; TGF-beta1, 6,117.3 pg/mL; PAI-1, 61.5 ng/mL, and LDH, 266 IU/dL). In both the loculated and free-flowing effusions, the levels of TGF-beta1 correlated positively with those of TNF-alpha (r = 0.51 and p < 0.001 vs r = 0.42 and p < 0.05, respectively) and IL-1beta (r = 0.52 and p < 0.001 vs r = 0.49 and p < 0.01, respectively), and the values of PAI-1 correlated positively with those of TNF-alpha (r = 0.59 and p < 0.001 vs r = 0.55 and p < 0.001, respectively), IL-1beta (r = 0.35 and p < 0.05 vs r = 0.47 and p < 0.01, respectively), and TGF-beta1 (r = 0.53 and p < 0.001 vs r = 0.58 and p < 0.001, respectively). In contrast, the levels of tPA correlated negatively with those of TNF-alpha (r = -0.37, p < 0.05) and IL-1beta (r =-0.56, p < 0.001) in loculated effusions. Twenty-seven of 42 patients with loculated effusions were classified into a secondary loculation group, which, compared with the primary loculation group, had significantly higher median levels of effusion TNF-alpha (119.2 vs 14.2 pg/mL, respectively; p = 0.001), IL-1beta (33.3 vs 3.4 pg/mL, respectively; p < 0.001), TGF-beta1 (13,152.7 vs 7746.0 pg/mL, respectively; p = 0.041), and PAI-1 (114.9 vs 94.1 pg/mL, respectively; p = 0.019). CONCLUSION: Compared with free-flowing effusions, fibrinolytic activity was depressed in loculated effusions. A higher intensity of pleural inflammation in loculated effusions may enhance the release of TNF-alpha, IL-1beta, and TGF-beta1, which may subsequently increase the levels of PAI-1. The imbalance of PAI-1 and tPA in pleural spaces may lead to fibrin deposition and loculation of pleural effusions.     

胸腔置管引流并注入尿激酶治疗结核性胸腔包裹性积液的临床研究

目的探讨胸腔置管引流并注入尿激酶在治疗结核性包裹性胸膜炎的应用价值。方法 90例结核性包裹性胸膜炎病人作为研究对象,并随机分为A、B、C 3组,各30例;A组胸腔置管引流并注入尿激酶;B组胸穿抽液后注入尿激酶;C组单纯胸穿抽液;化疗方案等其它治疗方法相同。结果 A组在胸水消失时间、排液总量、胸膜厚度、肺功能FEV1%和FVC%改善方面均优于B组或C组。结论胸腔置管引流并注入尿激酶治疗结核包裹性积液引流彻底,安全有效,并发症少,能显著减轻胸膜肥厚,改善肺功能。     

Analysis of pleural effusions in acute pulmonary embolism: radiological and pleural fluid data from 230 patients

BACKGROUND AND OBJECTIVE: The aims of this study were to describe the frequency and radiographical characteristics of pleural effusions in a large population of patients with acute pulmonary embolism (PE) and characterize the pleural fluid biochemistry in those patients who underwent diagnostic thoracentesis. METHODS: This was a retrospective observational single-centre study. A total of 230 consecutive patients with a diagnosis of PE over a 9-year period were enrolled. Spiral CT pulmonary angiography (52%) and high-probability ventilation and perfusion scans (42%) were used as the main reference methods. RESULTS: Pleural effusions were observed in 32% and 47% of patients by CXR and CT, respectively. Typically, pleural effusions were small (90% occupied less than one third of the hemithorax) and unilateral (85%), but occasionally they reached more than a half of the hemithorax. On CT, 21% of pleural effusions showed loculation. In patients with loculated pleural fluid the diagnosis of PE had been delayed for a mean of 12.2 days after symptoms developed. The presence of pleural fluid was not related to infarction. Twenty-six of 93 (28%) patients with effusions on imaging underwent thoracentesis. All the fluids met Light's criteria for exudate, 58% contained erythrocyte counts >10,000/microL and 46% showed neutrophilic predominance. CONCLUSIONS: Small pleural effusions, mostly unsuitable for diagnostic thoracentesis, were present in about one third of patients with PE. All the pleural effusions due to PE were exudates. If PE diagnosis was delayed the pleural effusion tended to become loculated.     

The In Vitro Efficacy of Varidase Versus Streptokinase or Urokinase for Liquefying Thick Purulent Exudative Material from Loculated Empyema

Patients with loculated parapneumonic effusion or empyema are sometimes treated with streptokinase or urokinase in an attempt to facilitate pleural fluid drainage by liquefying the pleural exudate and destroying the fibrin membranes producing the loculation. This study evaluated the effectiveness of streptokinase, urokinase, and Varidase (the combination of streptokinase and streptodornase) in liquefying gummy, purulent, exudative material from loculated empyemas. An empyema was created by injecting 10⁸ Pasteurella multocida bacteria into the pleural space of New Zealand white rabbits. Twenty specimens, each containing 0.5 g of purulent material obtained 5 days after empyema induction, were placed in test tubes. Streptokinase (15,000 IU), urokinase (10,000 IU), Varidase (4,000–15,000 IU streptodornase + 15,000 IU streptokinase) or saline was added to five sets of four test tubes each. The amount of nonliquefied material that remained after incubation with the fibrinolytic agents was quantitated. Over the 6-h incubation period, the amount of nonliquefied material decreased from 0.5 g to 0.02 g in the Varidase group but never decreased to less than 0.4 g in any of the other three treatment groups. Liquefaction of thick pleural exudates from rabbits with empyema can be achieved with Varidase but not with streptokinase or urokinase. Accepted for publication: 20 September 1999     

The prognostic value of loculations in parapneumonic pleural effusions

Forty-eight patients with pleural effusions who had sonographically directed thoracocentesis were evaluated retrospectively for radiologic findings, pleural fluid chemistries, and outcome. Loculation was found to be a radiologic marker of diagnostic and prognostic significance. The presence of loculations correlated with exudative pleural fluid chemistries, but no radiologic finding was specific for empyema. "Extreme" pleural fluid chemistries were associated with loculation, but not with empyema. Patients with loculated effusions had larger effusions, longer hospitalizations, and more frequent tube thoracostomy procedures than patients with nonloculated effusions. Light's criteria for tube thoracostomy were found to be unreliable in patients with loculated parapneumonic effusions or in patients treated with prolonged antibiotic therapy prior to thoracocentesis.