各位好！今天与大家分享一篇近期发表在ERJ上的一篇专家共识。研究旨在介绍成人良性胸腔积液的诊疗路径，对良性胸腔积液的临床问题、诊疗思路、循证证据及相关细节的科研方向进行了总结和前瞻。堪称是有依据有数据有思考的系统综述。胸腔积液是常见病，一起来看看不同的角度能有什么新的启示~！
ERS Statement on Benign Pleural Effusions in Adults
Anand Sundaralingam, Elzbieta M Grabczak, Patrizia Burra, M.Inês Costa, Vineeth George, Eli Harriss, Ewa Jankowska, Julius P Janssen, Georgia Karpathiou, Christian B Laursen, Kornelija Maceviciute, Nick Maskell, Federico Mei, Blin Nagavci, Vasiliki Panou, Valentina Pinelli, José M Porcel, Sara Ricciardi, Samira Shojaee, Hugh Welch, Alberto Zanetto, Udaya Prabhakar Udayaraj, Giuseppe Cardillo, Najib M Rahman
Eur Respir J 2024; in press
The incidence of non-malignant pleural effusions (NMPE) far outweighs that of malignant pleural effusions (MPE) and is estimated to be at least 3-fold higher. These so called “benign” effusions do not follow a “benign course” in many cases, with mortality rates matching and sometimes exceeding that of MPEs. In addition to the impact on patients, healthcare systems are significantly affected, with recent US epidemiological data demonstrating that 75% of resource allocation for pleural effusion management is spent on NMPEs (excluding empyema). Despite this significant burden of disease, and by existing at the junction of multiple medical specialties, reflecting a heterogenous constellation of medical conditions, NMPEs are rarely the focus of research or the subject of management guidelines. With this ERS Taskforce, we assembled a multi-specialty collaborative across eleven countries and three continents to provide a Statement based on systematic searches of the medical literature to highlight evidence in the management of the following clinical areas: a diagnostic approach to transudative effusions, heart failure, hepatic hydrothorax, end stage renal failure, benign asbestos related pleural effusion, post-surgical effusion and non-specific pleuritis.
非恶性胸腔积液（NMBE）的发生率远远超过恶性胸腔积液（MBE），估计至少高出3倍。在许多情况下，这些所谓的“良性”渗出物并不遵循“良性病程”，死亡率与MBE相当，有时甚至超过。除了对患者的影响外，医疗保健系统也受到了显著地影响，最近的美国流行病学数据表明，胸腔积液管理的资源分配的75%用于NMBE（不包括脓胸）。尽管有如此沉重的疾病负担，并且由于存在于多个医学专业的结合处，反映了医疗诊治的不均质性，但NMBE很少成为研究的焦点或诊疗指南的主题。通过这个ERS工作组，我们在十一个国家和三大洲组建了一个多专业合作机构，根据医学文献的系统性搜索提供一份声明，以强调以下临床领域管理的证据：渗出液、心力衰竭、肝性胸水、终末期肾衰竭、良性石棉相关胸腔积液、手术后积液和非特异性胸膜炎的诊断方法。
1.背景上该共识并未纳入胸膜感染、慢性淋巴源性胸腔积液、结缔组织病相关胸腔积液、乳糜胸等。可能这些方向后续ERS也想以本篇的形式进行后续总结。
2.上细节（先英后中）：
首先本文是深深的打上了循证医学的烙印，可以算是在教科书的基础上，增加了决策的循证证据。PICO贯穿在全文，推荐有兴趣的小伙伴好好把附件的内容也读一下。
其次，主要介绍了临床诊疗思路、心衰-胸水、肝衰-胸水、肾衰-胸水、石棉相关的胸水、手术后胸水、非特异性胸膜炎相关胸水等7大方面。文章的结构组织框架清新脱俗，为什么这么说，因为讲到了理论背后的循证基础、科研前瞻。
第三，多看看同类指南与专家共识将有助于深入理解。
10.1016/j.arbres.2022.09.017
3.十大经典的该领域临床问题，有兴趣的小伙伴可以深入攻坚。
#JAMA 2019; 322 (8): 792
目录
1. INTRODUCTION
2. METHODS
3. Results
3.1 An overall diagnostic approach:
3.1.1 What tests are used to categorise a pleural effusion as a transudate?
Summary
3.1.2 Why distinguish transudates from exudates? (Table 1)
3.1.3 Pleural fluid tests for differentiating transudates from exudates (table 2)(Figure 1)
3.1.4 What are the scoring systems for categorizing a pleural effusion as a transudate?
Summary (Table 3)
3.1.5 Transudate-exudate differentiation: scoring systems and imaging studies (Table 3)(Figure 2)
3.2 Heart failure
3.2.1 What are the management options for refractory heart failure related effusions?
Summary
Review of the evidence (see table A)
3.2.2 What investigations are used for a unilateral effusion in a patient with known cardiac failure?
Summary (Figure 3 & Table 4)
Review of the evidence (Figure 3)
Imaging (Table 4)(Figure 2)
3.3 Hepatic Hydrothorax
3.3.1 What are the therapeutic options in patients with symptomatic refractory hepatic hydrothorax (HH)?
Summary
Pleural Effusions in end-stage renal failure (table D)(Table 5)
Diagnostic implications for pleural effusions in ESRF (Figure 5)
Management strategies for end-stage renal failure patients who present with effusions (table E)
3.4.2 What is the usual investigation and management of a PD associated pleuro-peritoneal leak (PPL)
3.5.1 In patients with suspected BAPE/DPT, what are the clinical features that can identify risk factors, diagnose the condition, and identify prognostic features?
Summary
Risk Factors
Clinical Features
Diagnostic Investigations
Radiology (Figure 7)
Laboratory Investigations
Clinical Course and Prognosis
Development of MPM
Lung function
3.5.2 In patients with established BAPE/DPT, what are the options for follow up?
Summary
Biopsy and re-biopsy
CT follow-up
3.6 Post-surgical pleural effusions
3.6.1 Usual treatment of post-surgical pleural effusions: thoracentesis/chest drain vs. conservative treatment.
3.7.1 What are the options for investigating a patient with an initial NSP finding on histology?
Summary
Definition and incidence of NSP
Histopathological features of NSP (Figure 9)
Factors associated with a false-negative finding of non-specific pleuritis on biopsy: Clinical features
Imaging features:
CT
Thoracic ultrasound
MRI
Biomarkers
Biopsy technique:
Image guided pleural biopsies
Rigid and semi-rigid thoracoscopic biopsies
Number of biopsies
Depth of biopsies
Size of biopsy specimens and type of scope (Table G)
Video-assisted thoracoscopic surgical biopsies (VATS) (Figure 8)
Summary
Follow up duration of patients with an NSP diagnosis, evidence in the literature. (Table I)
PET-CT scan as part of interval imaging
4. Conclusion
— 图表汇总—
3.1 An overall diagnostic approach:
3.1.1 What tests are used to categorise a pleural effusion as a transudate?
Summary
3.1.2 Why distinguish transudates from exudates?
Table 1. Causes for pleural effusions according to laterality (unilateral vs bilateral) and incidence.
3.1.3 Pleural fluid tests for differentiating transudates from exudates
Table 2 Light’s criteria to classify a pleural effusion as an exudate [35]
3.1.4 What are the scoring systems for categorizing a pleural effusion as a transudate?
Summary
Table 3 Scoring system for diagnosing pleural effusions secondary to cardiac failure in exudates (from Porcel et al [36])
3.1.5 Transudate-exudate differentiation: scoring systems and imaging studies
3.2 Heart failure
3.2.1 What are the management options for refractory heart failure related effusions?
3.2.2 What investigations are used for a unilateral effusion in a patient with known cardiac failure?
3.3 Hepatic Hydrothorax
3.3.1 What are the therapeutic options in patients with symptomatic refractory hepatic hydrothorax (HH)?
Summary
Pleural Effusions in end-stage renal failure
Diagnostic implications for pleural effusions in ESRF
Management strategies for end-stage renal failure patients who present with effusions
3.4.2 What is the usual investigation and management of a PD associated pleuro-peritoneal leak (PPL)
3.5.1 In patients with suspected BAPE/DPT, what are the clinical features that can identify risk factors, diagnose the condition, and identify prognostic features?
Summary
Risk Factors
Clinical Features
Diagnostic Investigations
Radiology
Laboratory Investigations
Clinical Course and Prognosis
Development of MPM
Lung function
3.5.2 In patients with established BAPE/DPT, what are the options for follow up?
Summary
Biopsy and re-biopsy
CT follow-up
3.6 Post-surgical pleural effusions
3.6.1 Usual treatment of post-surgical pleural effusions: thoracentesis/chest drain vs. conservative treatment.
3.7.1 What are the options for investigating a patient with an initial NSP finding on histology?
Summary
Definition and incidence of NSP
Histopathological features of NSP
Factors associated with a false-negative finding of non-specific pleuritis on biopsy: Clinical features
Imaging features:
CT
Thoracic ultrasound
MRI
Biomarkers
Biopsy technique:
Image guided pleural biopsies
Rigid and semi-rigid thoracoscopic biopsies
Number of biopsies
Depth of biopsies
Size of biopsy specimens and type of scope
Video-assisted thoracoscopic surgical biopsies (VATS)
Summary
Follow up duration of patients with an NSP diagnosis, evidence in the literature.
PET-CT scan as part of interval imaging
