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BS.CKI.

TRNH TRUNG TIN

THNH NGC MNG PHI THNH

NHU M PHI MNG PHI TNG

Tng lng dch trong khoang mng phi (>20ml) Trn dch mng phi chia lm 2 loi : (1) dch thm v (2)

dch tit
Trn dch mng phi l triu chng

CU TO MNG PHI (T NGOI VO TRONG)


1. H thng mch mu (nhnh M lin sn, M v trong) 2. Khoang k ngoi vi 3. Khoang mng phi (bao gm mng phi thnh v mng phi tng) c lt bi tb mng y

(mesothelial )
4. Nhu m phi 5. H thng mch mu trong nhu m phi (M ph qun, M phi)

Dch mng phi c to ra do chnh p trong khoang

mng phi vo t cc mao mch vng nh vi mt lng ~250ml/ngy, nhm bi trn 2 l mng phi khi di chuyn trong qu trnh h hp. Ngoi ra, dch mng

phi hp thu t di c honh ln hoc t trung tht


Dch mng phi c thi ra qua h thng bch huyt

tp trung vng nh
Trong mi khoang mng phi c ~ 20ml dch, to ra mt

lp mng dch dy 2-10mm

Th tch T bo/ mm3


Mesothelial cells Monocytes Lymphocytes PMNs

0.2 mL/kg 1000 5000


60% 30% 5% 5%

Protein LDH ng pH

1-2 g/dL <50% plasma level plasma level plasma level

Tng p lc thy tnh


Mao mch h thng: suy tim phi

Mao mch phi: suy tim tri Gim p lc keo ti vi mao mch (gim protein mu nh hi chng thn h, suy
dinh dng, x gan)

Gim p lc trong khoang mng phi (xp phi)

Tng tnh thm mao mch (vim mng phi)

Gim s dn lu ca mch bch huyt (u phi, TDMP cn vim phi) Thm dch t khoang mng bng qua nhng khe h ca c honh hoc

qua nhng mch bch huyt xuyn c honh (bng bng, thm phn phc mc,
hi chng Meig)

Tng dch trong khoang k phi Tn thng mch mu thnh ngc Tn thng ng ngc

40% nguyn nhn do tim 60% khc


Bnh l phi (Pneumonia) (48%) U c tnh (Malignancy) (24%) Thuyn tc phi (Pulmonary embolism) (18%) X gan (Cirrhosis ) (6%)

Khi tit dch t, khong 200 300 ml, ngi bnh hi au bn c

trn dch, khng kh th, vn nm nga, u thp c, nhng c khuynh hng nm nghing v bn lnh trnh au .
Khi lng nc trung bnh, khong 700-800ml ti 1500 ngi

ln, th c kh th nh, v ngi bnh phi nm nghing v bn


au.
Khi lng dch nhiu, tnh trng kh th ni bt, ngi bnh

phi ngi dy th nhanh, nng.

Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Volume 42, Issue 07, July 2006

DCH THM
C CH
TNG P LC THY TNH GIM P LC KEO

DCH TIT
VIM NHIM

MU SC T BO
T TRNG Protein Protein [DCH] Protein [MU] Albumin LDH LDH [DCH] LDH [MU] Cholesterol

TRONG HNG CU
< 1.012 < 3 g/dL < 0.5 > 1.2 g/dL < 200 UI < 0.6 hoc < < 45 mg/dL

C BCH CU (+++)
> 1.020 > 3 g/dL > 0.5 < 1.2 g/dL > 200 UI > 0.6 hoc > > 45 mg/dL

Protein [DCH MP]/ protein [MU] > 0.5


Protein [DCH MP] > 2.9 g/dL

LDH [DCH MP] /LDH [MU] > 0.6


LDH [DCH MP] > 0.45 gii hn trn

Albumin [MU] - Albumin [DCH MP] < 1.2

Cholesterol [DCH MP] > 45 mg/dL


Chest 2003; 121: 1916-1920

DCH THM

DCH TIT
Vim mng phi (lao, vi khun, virus, k sinh
trng)

Suy tim huyt X gan Hi chng thn h

K di cn mng phi (K ph qun phi, K v,


lymphoma)

K nguyn pht mng phi (mesothelioma)

BNH L

Gim protid mu Thm phn phc mc Tc tnh mch ch trn Ph nim Hi chng Meigs

Thuyn tc phi
Chn thng Bnh l Collagen (SLE, RA) Do thuc

Ure mu
Hi chng Dressler (hi chng vim nhim c
tim sau m mng ngoi tim st, au ngc kiu mng phi, trn dch mng tim)

Triu chng c nng


au ngc: c th au nhiu, kiu mng phi , c th ch au

tc kh chu mt bn lng ngc. Nu c au ngc chng t l thnh mng phi b vim hoc b kch thch v gi y l

TDMP dch tit. Tuy nhin cng c th khng c cm gic au


ngc, ch pht hin tnh c khi chp x quang phi thng qui
Ho khan: t nhin hoc khi thay i t th, c th c m nu

c vim nhu m phi km theo


Kh th: thng xut hin khi c TDMP lng nhiu

Hi chng ba gim
Rung thanh gim G c R ro ph nang gim

Triu chng thc th

Nhn: lng ngc bn trn dch c th hi phng, km di ng


S: rung thanh gim hoc mt bn trn dch G: c bn trn dch Nghe: r ro ph nang gim hoc mt bn trn dch
Tuy nhin hi chng ba gim cn gp trong:
Dy dnh mng phi Xp phi do tc nghn ph qun

i th ca dch chc d : lng , mu , trong, qunh ca dch. Xt nghim sinh ho: nh lng m (protein), LDH (lactat

dehydrogenase), glucose, pH
m t bo trong dch mng phi

Vi trng: nhum gram, nhum tm vi trng lao, cy tm vi trng thng

hoc vi trng lao


Cellblock (ng khi t bo): ly khong 100 ml dch mng phi gi xt

nghim t bo hc
Hct nu nghi ng trn mu mng phi

History and physical exam are critical


Dyspnea, cough and pleuritic chest pain are common
Fever: pneumonia, empyema, tuberculosis (Tb) Hemoptysis: lung cancer, PE, or Tb Weight Loss: Malignancy, Tb, or lung abscess Chest Exam
Dullness to percussion Decreased breath sounds

Signs
Orthopnea, jvd, or peripheral edema (CHF) Unilateral extremity swelling (PE) Ascites (hepatic hydrothorax or Meigs)

History
Chest trauma (hemothorax) Abdominal surgery (post-op effusion) Post CABG surgery (Dresslers syndrome)

Nu lng dch < 100 ml: khng thy bt thng trn phim

thng ln phim nghing


Nu lng dch t 100 ml 250 ml, thng ch thy m

gc sn honh pha sau trn phim nghing


Nu lng dch t 250 500 ml: thy c m gc sn

honh bn ngoi trn phim thng

Nu hnh nh xquang m 1/3 di phi: lng dch

khong 1 L 1,5 lt, c ng cong Damoiseau nu dch cn chy t do.


Nu hnh nh x quang m na di phi: lng dch

khong 2 lt.
Nu hnh nh x quang m ton b mt bn phi: lng

dch khong 3,5 4 lt.

Siu m xc nh v tr dch mng phi


Siu m c vai tr quan

trng trong vic xc nh v


tr chc d dch mng phi nht l TDMP khu tr

hoc lng t

CT scan ngc: cho php phn tch hnh nh mng phi, nhu m phi, lp dch
mng phi m xquang thng qui v siu m khng pht hin

Hnh nh trn dch a mng

Soi ph qun
Ho ra mu

Du hiu tc nghn ph qun


Bt thng nhu m phi. Soi ph qun kim tra

Ni soi mng phi:

Ch nh khi trn dch mng phi nghi ng c tnh khng c chn on

BN X Quang ngc nghi c bnh l mng phi

M/t gc sn honh

Khng

Khng nghi TDMP

X Quang ngc nm nghing, CT ngc hoc siu m ngc B dy dch > 10mm

Khng
Theo di

c
Chc d mng phi chun on
C 1 trong cc tiu chun sau: - m DMP/HT > 0.5% - LTH DMP/HT> 0.6% - LTH DMP >2/3 tr s cao nht ca LDH bnh thng/HT

Khng
Dch thm

c
C kh nng l dch tuyn BN c suy tim sung huyt hoc s gan

Khng
Dch tit

Khng

c
m HT- m DMP> 3.1 g/dL

iu tr suy tim sung huyt, x gan, HC thn h

Tinh cht DMP ng trong DMP Phn tch t bo Cc markers Lao trong DMP.

Mu sc DMP Het DMP Het > 1 % Het < 1 % Mu khng ng k

C mu?

Dch duc?

Khng C
Phn tch sinh ha

Ung th Thuyn tc ph Chn thng lng ngc

Xem phn trn ca dch sau ly tm


c

Trong

Het > 20 %

C
Trn mu mng phi Xem xt t ng dn lu

Trn dng cht mng phi (chylothorax) hoc gi trn dng cht mng phi (psendochylothorax) Xem cn lng DMP Tinh th cholesterol Gi trn dng cht mng ph

Khng
Tryglycerider DMP 50-100 mg/dL > 100 mg/dL Trn dng cht MP

< 50 mg/dL

Phn tch Lipoprotein

khng

chylomicrons

m tnh
Phn tch dch mng phi

T bo hc DMP (cellblock)

Dng tnh
Trn dch mng phi c tnh

Lymphocyte u th BC a nhn u th Bnh l MP cp Thm nhim nhu m phi

Lao

Bnh l MP mn tnh
ADA / y- interferon / sinh thit mng phi / cy tm VT lao CT ngc cn quang

Dng tnh

C
Khc m m

khng
S hoc CT bng

m tnh + lm sng ph hp lao

m tnh

m tnh
BN ci thin

iu tr th lao

C
TDMP cn vim phi

khng
CT ngc cn quang

Dng tnh
Bnh l tiu ha

Dng tnh
Thuyn tc phi

khng
Cn nhc ni soi mng phi Xem xeta nhng ca TDMP him nh HC dessler Bnh cao keo Mesothelioma Bnh do nm v KST

C
Theo di

TDMP do suy tim


Nguyn nhn thng nht ca TDMP dch thm l suy tht tri Chc d nn thc hin khi TDMP ch mt bn hoc TDMP hai bn nhng vi lng dch khng tng xng nhau, khi bnh nhn c st hoc khi c au ngc kiu mng phi, kho st xem y l dch thm hay dch tit iu tr tt nht bng li tiu. Nu dch vn tn ti d dng li tiu, cn thc hin chc d mng phi chn on

TDMP do bnh l gan


TDMP xy ra khong 5% bnh nhn b x gan c bng bng. C

ch chnh l s di chuyn trc tip ca dch mng bng vo khoang mng phi qua nhng l nh ca c honh
TDMP thng bn phi v thng vi lng nhiu c th gy

kh th nng

Trn dch mng phi cn vim phi


TDMP cn vim phi l bin chng ca vim phi do vi khun, p xe phi, hoc gin ph qun. Bnh nhn b vim phi do vi khun hiu kh km trn dch mng phi thng c bnh cnh lm

sng st cao, au ngc, khc m c v tng bch cu mu.


Bnh nhn b nhim trng k kh thng c bnh cnh lm sng bn cp vi st cn, tng nhanh

bch cu, thiu mu nh, v c yu t nguy c ht dch vo trong phi.


Ngay khi vim phi c chn on, cn xem c TDMP km theo hay khng. chng t c

TDMP t do cn chp phim x quang nm nghing, CT scan lng ngc hoc siu m. Nu lng
dch t do c b dy > 10 mm, cn thc hin chc d mng phi iu tr.

Trn dch mng phi do lao


Thng c st, st cn, kh th v/hoc au ngc kiu mng phi. Dch mng phi l dch tit vi thnh phn lymphocyte nh chim u th ADA (adenosine deaminase) > 40 IU/L, Interferon > 140 pg/mL, hoc PCR tm vi trng lao Chn on cng c th da trn cy dch mng phi, sinh thit mng phi bng kim hoc ni soi mng phi

Trn dch mng phi th pht do ung th


Nguyn nhn thng gp ca TDMP dch tit.
Ung th phi, ung th v v lymphoma chim khong 75

Chn on thng da vo xt nghim t bo hc dch mng phi

Nu kt qu t bo hc ban u m tnh, khi ni soi mng phi l th thut tt nht nu vn nghi ng nhiu l trn dch c tnh. Khi ni soi mng phi, cn thc hin th thut co xc mng phi gy dnh mng phi. Nu khng c dng c ni soi mng phi, cn thc hin sinh thit mng phi bng kim

Trn dch mng phi th pht do ung th


Bnh nhn b TDMP c tnh c iu tr triu chng l ch yu, v khi c trn

dch chng t bnh lan trn v hu ht cc bnh l c tnh khi gy TDMP u khng th cha lnh bng ha tr

Nu bnh nhn c kh th lm nh hng n cht lng cuc sng v nu kh th gim khi chc tho bt dch mng phi, khi cn thc hin mt trong cc th thut sau y: (1) t mt catheter nh lu li, hoc (2) t ng dn lu mng phi v lm dnh mng phi bng cht gy dnh nh doxycycline 500 mg

Mesothelioma
Mesothelioma c tnh l khi u nguyn pht ca t bo trung m mng phi;

hu ht c lin quan n vic tip xc vi asbestos (amiante)


Bnh nhn b mesothelioma thng c au ngc v kh th

X quang ngc cho thy c TDMP, dy mng phi lan ta, v na lng ngc bn trn dch xp xung

Thng thng cn ni soi v sinh thit mng phi chn on

au ngc nn c iu tr bng dn xut phin v kh th iu tr bng oxy v/hoc dn xut phin

Trn dch mng phi do thuyn tc phi


Chn on thng d b st trong chn on phn bit mt bnh nhn b

TDMP l thuyn tc phi. Kh th l triu chng thng gp nht. Dch mng phi lun l dch tit
Chn on da trn CT scan hoc chp ng mch phi
iu tr cng ging nh iu tr thuyn tc phi. Nu dch mng phi gia tng

sau khi dng khng ng, c l bnh nhn b thuyn tc mi hoc b bin chng khc nh trn mu mng phi hoc nhim trng mng phi

TDMP dng chp


Trn dch mng phi dng chp xy ra khi ng ngc b v v dng chp tch

t trong khoang mng phi


Nguyn nhn chnh l do chn thng nhng cng c th do nhng khi u

trong trung tht


Chc d mng phi thy c dch c nh sa, v phn tch sinh ha c

triglyceride > 1,2 mmol/L (110 mg/dL)


Bnh nhn TDMP dng chp nhng khng c chn thng r rt nn c

chp bch huyt (lymphangiogram) v CT scan trung tht nh gi cc hch trung tht

Trn mu mng phi


Khi chc d mng phi c mu, cn thc hin Hct ca dch mng phi. Nu

Hct > 1/2 ca Hct trong mu l c trn mu mng phi. Hu ht nhng trng hp trn mu mng phi l do chn thng, cc nguyn nhn khc l v mch

mu hoc ung th
Hu ht nhng bnh nhn trn mu mng phi phi c t dn lu mng

phi. Nu trn mu mng phi do rch mng phi, khi hai l mng phi p li

c th lm cm mu. Nu mu mng phi chy qua ng sonde > 200 ml/gi,


cn xem xt ni soi mng phi hoc m lng ngc

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