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Management of Pleural Spacedisease

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Management of Pleural Spacedisease 0 Collective review Management of pleural spacedisease พญ.ปริญญา ปริญญาณัฏฐ์ รศ.นพ.วรวิทย์ จิตติถาวร Collective review Management of pleural space disease Content Page Pleural space 1 Parapneumonic pleural effusions. 2 Primary spontaneous pneumothorax 14 1 Management of pleural space disease เรียบเรียงโดย พญ.ปริญญา ปริญญาณัฏฐ์ อาจารย์ที'ปรึกษา รศ.นพ.วรวิทย์ จิตติถาวร Pleural space หมายถึง พื3นที'ระหวางเยื'อหุ้มปอดทั่ 3ง 2 ชั3น คือ visceral pleura and parietal pleuraโดย pleural space ด้านขวาและซ้ายก3นด้วยั mediastinum(1)ภายในประกอบด้วย pleural fluid ที'ผลิตจาก mesothelial cellsโดยปกติจะมีความหนาประมาณ 10 µmเพื'อช่วยหล่อลื'นในการขยับของปอดระหวางการหายใจ(2)่ รูปที' 1: pleural space Pleural space disease เป็นความผิดปกติที'เกิดขึ3นบริเวณ pleural space ประกอบด้วย(1,3) 1. Pleural effusionเป็นภาวะที'พบได้บอยของpleural่ diseaseถ้าจําแนกจากลักษณะของ pleural fluid โดย Light’s criteria จะแบงเป็น่ Transudate effusions และ EXudate effusions ซึ'งถ้ามีลักษณะดังตอไปนี่ 3 1 ข้อจะจําแนกในกลุ่ม EXudate effusionsคือ อัตราส่วนของโปรตีนใน Pleural fluid ตอโปรตีนในเลือด่ มากกวา่ 0.5หรืออัตราส่วนของ lactate dehydrogenase (LDH)ใน Pleural fluid ตอLDHในเลือดมากกว่ า่ 0.6 หรือ LDH ในPleural fluid มากกวาค่ าปกติของ่ LDH ในเลือด 1.67 เทา่ 2 1.1 Transudate effusionsมีสาเหตุจากหัวใจล้มเหลว, ตับแข็ง, โรคไต (nephrotic syndrome) ภาวะระดับ albuminในเลือดตํ'า, Fluid retention/overload, Pulmonary embolism, Lobar collapse และMeigs’ syndrome 1.2 EXudate effusionsมีสาเหตุจากมะเร็ง การติดเชื3อ โรคหลอดเลือดและเนื3อเยื'อเกี'ยวพัน (Collagen-Vascular Disease related),abdominal and Gastrointestinal Disease–related, ChylothoraX, uremia, sarcoidosis, หลังการผาตัดหลอดเลือดหัวใจ่ ฉายแสง และ อุบัติเหตุ 2. PneumothoraXเป็นภาวะที'มีลมอยูในช่ ่องเยื'อหุ้มปอด โดยแบงตามสาเหตุได้ดังนี่ 3 2.1 Spontaneous แบงเป็น่ - Primaryspontaneous pneumothoraX(ไมมีสาเหตุ)่ - Secondary spontaneous pneumothoraX ลมรั'วในช่องปอดที'เกิดขึ3นเองโดยมีสาเหตุได้ จากโรคถุงลมโปร่งพอง, Bullous disease, Cystic fibrosis,Pneumocystis−related, Congenital cysts, idiopathic pulmonary fibrosis, Pulmonary embolism - Catamenial - Neonatal 2.2 Traumatic 2.3 Iatrogenic 2.4 other 3 HemothoraXเป็นภาวะที'มีเลือดในช่องหุ้มปอด โดยส่วนมากมักเกิดในผู้ป่วยอุบัติเหตุต่อบริเวณทรวงอก หรืออาจเกิดตามหลังการผาตัด่ 4 Pleurisy เป็นภาวะการอักเสบของเยื'อหุ้มปอด ในที'นี3จะกล่าวถึงภาวะที'พบบอยและศัลยแพทย์ทั่ วไปมีบทบาทในการร' ่วมรักษา คือ Paraneumonic pleural effusion และ Primaryspontaneous pneumothoraX Parapneumonic pleural effusions Parapneumonic effusionsมีการกล่าวถึงครั3งแรกในสมัยอียิปต์3000 ปีก่อนคริสตกาลเป็นสาเหตุที'พบได้ บอยถึง่ 1ใน 3 ของpleural disease มีอุบัติการณ์เพิ'มมากขึ3นเรื'อยๆ โดยพบวาผู้ป่วยที'มีปอดติดเชื่ 3อร้อยละ 57 จะมี pleural effusion เกิดขึ3น โดย pleural effusion บางส่วนสามารถหายได้เอง แตบางส่ ่วนกลายเป็น empyema thoracisซึ'งทําให้มีอัตราตายร้อยละ 1-40 ซึ'งขึ3นกบหลายปัจจัยั เช่น โรคร่วมของผู้ป่วย (comorbid disease), immunocompromised patients วิธีการรักษา และ ความล่าช้าในการเปลี'ยนแผนการรักษา(3–7) 3 จากการรายงานของ Nick A. Maskell ในปี 2006 พบวา่ ผู้ป่วยที'ติดเชื3อจากบ้าน (community acquiredpleural infection) เชื3อที'เป็นสาเหตุส่วนใหญ่คือ Gram-positive aerobic organisms โดยพบ Streptococcus spp. ร้อยละ 52, Staphylococcus aureus ร้อยละ 25ส่วนเชื3อ Gram-negative organisms (ร้อยละ 9) และ anaerobes (ร้อยละ 20) พบได้น้อยกวาส่ ่วนผู้ป่วยที'ติดเชื3อจากในโรงพยาบาล (Hosp ital-acquired pleural infection)พบเชื3อดื3อยามากขึ3น โดยพบ Staphylococci MRSA ร้อยละ 25MSSA ร้อยละ 10 ส่วน Gram-negative aerobes ร้อยละ 17 และ Anaerobes ร้อยละ8 ดังแสดงในตารางที' 1(8) ตารางที'1:เชื3อที'ตรวจพบใน parapneumonic effusion s จําแนกเป็น community acquired และ Hospital-acquired pleural infection Parapneumonic effusions สามารถแบงได้่ 3 ระยะโดยแยกกนจากระยะเวลาั (รูปที' 2) ลักษณะที'ตรวจ พบจาก imaging และ pleural fluid (ตารางที' 2) คือ 1. Simple eXudate หรือ Sterile eXudate หรือ Simple parapneumonic effusion 2. Fibrinopurulent stage หรือ Empyema หรือ Complicated parapneumonic effusion 4 3. organising stage หรือ Scar tissue (pleural peel) formation รูปที' 2: ช่วงเวลาในการเกิดแตละระยะของ่ Empyema thoracis 5 How to management รูปที' 3 : Algorithm for management pleural infection 6 อาการ อาการแสดงและผลตรวจเพิ'มเติม ที'สงสัย pleural infection คือ ผู้ป่วยที'มีปอดอักเสบติดเชื3อ ร่วมกบั อัตราเต้นหัวใจ (HR) ความดันโลหิต (BP) ไมดีขึ่ 3นใน 2 วัน และ ไข้ อัตราการหายใจ (RR) ความเข้มข้น ของออกซิเจนในเลือด (Spo2) ไมดีขึ่ 3นใน 3 วัน hemoculture found organism หรือ มีผลเลือดดังตอไปนี่ 3 2 ใน 3 ข้อ - Albumin < 30 g/L - CRP > 100 mg/L - Platelet count > 400 000 /L - Na < 130 mmol/L - Intravenous drug abuse(8–10) Investigation หากสงสัยวาผู้ป่วย่ pleural infection ให้ส่ง Chest X-ray (CXR) PA view เพื'อดู pleural effusion แต่ หากไมชัดเจนอาจส่ ่ง lateral view หรือทํา ultrasound ซึ'งสามารถเห็น pleural fluid ปริมาณน้อยๆได้แล้ว ยัง สามารถดูloculated pleural effusionได้อีกด้วยโดยสังเกตจากAnechoicpleural collections(ร้อยละ 19),Hyperechoic without septae(ร้อยละ14), Hyperechoic with septae (ร้อยละ67) และ Diaphragm immobilization(11–13)ส่วน CT scan พิจารณาส่งในกรณีที'สงสัยวามีพยาธิสภาพของอวัยวะอื'นร่ ่วมด้วย เช่น หลอดอาหารทะลุ หรือ เนื3องอกหลอดลม เป็นต้น โดย CT scan ใน empyema มีลักษณะดังนี3(11,14,15) - collectionเป็นรูปเลนส์ไมมีขอบแยกจากเนื่ 3อปอด กดเบียดเนื3อปอด - Split pleura’ sign : visceral and parietal pleural enhanmentบงบอกถึงการอักเสบของ่ pleura พบในผู้ป่วยทุกราย - Pleural thickness ซึ'งพบใน empyema ร้อยละ 92 แตจะไม่ ่พบใน simple parapneumonic effusion - Thickening of eXtrapleural fat พบได้ร้อยละ 76 - Mediastinal lymph nodes ขนาด<2 cm MRI ไมได้มีประโยชน์เหนือกว่ า่ CT แต่อาจส่งตรวจ MRI ในกรณีที'ผู้ป่วยแพ้สารทึบรังสี ผู้ป่วยอายุ น้อย หรือ ผู้ป่วยตั3งครรภ์(9) 7 (a) (b) (c) (d) (e) (f) รูปที' 4 : CXR และ CT scan ในผู้ป่วย pleural infection (a)= CXR simple parapneumonic effusion, (b)=CT scan simple parapneumonic effusion (16) , (c)=CXR fibropurulent phase ( elevated diaphragm with loculation of the left pleural space)(12), (d)= CT scanfibropurulent phase ( loculation and septation) (12) , (e)= CXR organizing stage, (f)= CT scan organizing stage 8 Pleural fluid examination พิจารณาส่งในกรณีต่อไปนี3 - Pleuraleffusionหนา > 10 mm ร่วมกบผู้ป่วยมีsepsisั และมีประวัติปอดอักเสบติดเชื3อ มีการบาดเจ็บตอทรวงอก่ (Chest trauma)หรือเคยผาตัด่ - Pleural effusion หนา< 10 mm หลังติดตามมีความหนาเพิ'มขึ3น หรือ มีภาวะsepsis การส่งตรวจแนะนําให้ใช้ ultrasound guide aspiration นําpleural fluid ที'ได้ส่ง Gram stain, Culture, WBC, LDH, Protein, pH, Glucose ทุกราย ส่วน Cytology และ AFB จะพิจารณาส่งในกรณีที'สงสัย โดย Pleural fluid profile สามารถแยกระยะของ pleural infection ได้ดังแสดงในตารางที' 2 ตารางที'2 : ลักษณะของระยะของ Pleural infection Profile Simple exudate Empyema Organising stage Characteristic Free-flowing eXudate Fibrinopurulent Fibroblast proliferation,pleural peel organism $ No Present Present WBC Low High with PMN High with PMN predominant* predominant* LDH Less than half of serum >1000 IU/L pH** >7.2 <7.2 Glucose >2.2 mmol/L (>40 mg/L) <2.2 mmol/L (<40 mg/L) Treatment Antibiotic alone Chest tube drainage Surgery $ pleural infection พบเชื3อจากการ culture plural fluid ร้อยละ 54 และhemocultrure positive ร้อยละ 12 *ถ้าพบ WBC with lymphocyte predominant อาจจะเกิดจาก malignancy หรือ tuberculosis infection **การตรวจ pH ใส่ heparinized blood gas syringe ส่งตรวจจากเครื'อง blood gas ไมควรส่ ่งตรวจหาก pleural fluid มีลักษณะเป็น pus เพราะจะทําให้เครื'องตรวจเสียได้ ระวังไมให้ปนเปื่ 3 อนกบยาชาั เพราะจะทําให้ คา่ pH ลดลงได้ 9 Treatment เริ'มมีการกล่าวถึงการรักษาในศตวรรษที' 19 ด้วยการเปิดช่องอก แตพบว่ ามีอัตราการตายสูงถึงร้อยละ่ 70 ตอมาพัฒนาการรักษาด้วยการใส่ ่สายระบาย ร่วมกบการให้ยาปฎิชีวนะั กระทั3งปัจจุบันมีการใส่ยาเข้าไปใน ช่องหุ้มปอดและการผาตัดแบบส่ ่องกล้องทําให้อัตราตายลดลงเหลือร้อยละ4.3 (17–20) Richard W. Light นําเสนอแนวทางการรักษา Pleural infection ตามลักษณะของ Pleural fluid ในปี 1995 ดังตารางที' 3(21) ตารางที' 3 :แนวทางการรักษา pleural infection โดยแบงตามลักษณะ่ Pleural fluid 10 Antibiotics ผู้ป่วยทุกคนควรได้รับ Antibiotics โดยช่วงแรกให้ทางหลอดเลือดดํา เมื'ออาการดีขึ3นให้เปลี'ยนเป็นยา กินระยะเวลาอยางน้อย่ 3 สัปดาห์และมีข้อมูลบงชี่ 3ถึงประโยชน์ในการให้ยาเข้าไปใน Pleural space โดยให้ยาฆา่ เชื3อตามการตอบสนองตอยาของเชื่ 3อที'ตรวจพบและให้ครอบคุมเชื3อanaerobeหากเป็นpneumococcal infection โดยยาที'ผานเข้า่ Pleural space ได้ดี เช่น B-lactamase inhibitors, metronidazole, cephalosporins หรือหากตรวจ ไมพบเชื่ 3อ แนะนําให้ตามเชื3อก่อโรคจาก Community acquired และ anaerobe organisms แตหากเป็นการติดเชื่ 3อ ในโรงพยาบาล ควรให้ยาฆาเชื่ 3อที'ครอบคุมเชื3อ MRSA และ Anaerobe ไมแนะนําให้ยาฆ่ าเชื่ 3อกลุ่ม Macrolide ถ้าไมได้สงสัย่ atypical infection Chest tube drainage ข้อบงชี่ 3ในการใส่สายระบาย(22) 1. Frank pus or turbid/cloudy pleural effusion 2. Non purulent pleural fluid with Gram stain or culture found organisms แต่อาจยกเว้นในกรณีที'เชื3อเป็น S. pneumonia 3. Suspected pleural infection with pleural fluid pH<7.2 4. After Treat with antibiotic alone but clinical not improved or worst 5. Loculated pleural effusion 6. Large non purulent pleural effusion ไมมีความแตกต่ างของ่ outcome ในเรื'องขนาดของ chest tube drainage ใส่ขนาด>28 Fr แตถ้าขนาด10-่ 14 Fr สายมีขนาดเล็กควรflush สายเพื'อป้องกนอุดตันโดยflushั NSS 20-30 mL q 6 hrทาง three-way และ suction -20 cmH 2o(23)และพิจารณานําสายออกเมื'ออาการของผู้ป่วยดีขึ3น ปริมาณ pleural effusion < 100 mL/day Intrapleural fibrinolysis Intrapleural fibrinolysis มีประโยชน์ในการทําลาย loculationและช่วยลดความหนืดของ pleural effusionในช่วง empyema phase โดยใช้ร่วมกบั chest tube drainageหรือใช้ตามหลัง fail chest tube drainage เนื'องจากมี loculationปัจจุบันมีหลายการศึกษาทั3งที'เป็นRandomised trials และ Meta-analysis โดยใช้ Streptokinase(STK) 11 และ Urokinase (UK) ซึ'งปริมาณยา และวิธีแตกตางก่ นั เช่น
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