312.4 📋 章末速記 Summary

312.4.1 🔑 一句話總結

Pleural disease 三大族群：(1) pleural effusion — Light’s criteria 區分 transudate (HF, cirrhosis, nephrotic) 與 exudate (parapneumonic, malignancy, PE, TB, autoimmune)；(2) pneumothorax — PSP (tall thin young men) vs SSP (underlying disease) vs traumatic vs iatrogenic vs tension (EMERGENCY needle decompression)；(3) pleural malignancy — mesothelioma (asbestos latency 20-40 yr, CheckMate 743 nivolumab + ipi for advanced)；parapneumonic effusion 分 simple vs complicated vs empyema；MIST-2 = intrapleural tPA + DNase for loculated empyema；chylothorax (TG > 110) vs pseudochylothorax (cholesterol > 200)；malignant pleural effusion management = thoracentesis → pleurodesis (talc, bleomycin) 或 TPC (PleurX) for outpatient drainage。

312.4.2 💊 治療精要

  • diagnostic thoracentesis：cell count + protein + LDH + glucose + pH + Gram + culture + cytology + ADA + TG (chylothorax) + amylase (pancreatitis)
  • complicated parapneumonic + empyema：chest tube + IV antibiotics + intrapleural tPA + DNase (MIST-2) for loculations
  • PSP：small (< 2-3 cm) → observation + supplemental O2；moderate-large → aspiration / chest tube；recurrent → VATS pleurodesis + bullectomy
  • SSP：chest tube usually + pleurodesis after stabilization
  • tension pneumothorax：immediate needle decompression (2nd ICS MCL or 4-5th ICS MAL) → chest tube
  • malignant effusion：therapeutic thoracentesis → pleurodesis (talc) or TPC (PleurX) for outpatient
  • mesothelioma：CheckMate 743 nivolumab + ipilimumab > cisplatin + pemetrexed (chemo)；surgery + radiation in select
  • hemothorax：large bore chest tube；surgery if > 1.5 L initial or > 200 mL/h × 3-4 hr

312.4.3 🎯 盧醫師的考前提醒

  1. Light’s criteria 必記憶：exudate = pleural/serum protein > 0.5 OR pleural/serum LDH > 0.6 OR pleural LDH > 2/3 upper limit serum；diuretic-treated HF 25% misclassified as exudate
  2. pleural fluid 鑑別 by chemistry：glucose < 60 (complicated parapneumonic, RA, malignancy, TB, lupus)；pH < 7.20 (same)；ADA > 40 (TB)；TG > 110 (chylothorax)；cholesterol > 200 (pseudochylothorax)；amylase 很高 (esophageal rupture, pancreatitis)
  3. parapneumonic 分類治療：simple (pH > 7.30, LDH < 1000, glucose > 60) → 只給 abx；complicated (pH < 7.30 OR LDH > 1000 OR glucose < 60) → chest tube + abx；empyema (frank pus) → chest tube + abx
  4. MIST-2 (2011)：loculated empyema 用 intrapleural tPA + DNase combination 改善 drainage + ↓ surgical referral；MIST-1 (streptokinase only) 是 negative
  5. PSP vs SSP：PSP 在 tall thin young men 15-35 yo (smoking + family hx)；SSP 在 underlying lung disease (COPD #1, CF, ILD, PCP, cancer)
  6. tension pneumothorax 緊急 needle decompression：2nd ICS midclavicular OR 4-5th ICS midaxillary line；不要等 CXR — 臨床診斷即治療
  7. VATS pleurodesis indications：first SSP recurrence、second PSP；prevents future episodes
  8. mesothelioma CheckMate 743 (2021)：nivolumab + ipilimumab first-line > chemo (median OS 18.1 vs 14.1 months)；especially non-epithelioid benefit；epithelioid 預後較好
  9. chylothorax vs pseudochylothorax 鑑別：TG > 110 = chyle；cholesterol > 200 (chronic effusion → cholesterol crystals) = pseudo；治療 chyle = low-fat MCT + octreotide → thoracic duct ligation
  10. catamenial pneumothorax：young women + recurrent during menstruation + thoracic endometriosis (often diaphragmatic) + right-sided；hormonal suppression + VATS