Pleural effusion

PLEURAL EFFUSION

Hamad Emad H. Dhuhayr

CONTENTS

• SOEPEL

• PLUERAL EFFUSION

• PNEUMOTHORAX

• REFFERENCES

SOEPEL

• S- Khaled 85 year old Saudi male . he complained of dyspnea for one weak and coughing with sputum. He has DM from 30 years, HTN, stroke for 7 month and Parkinson disease.

• O- taking history and physical examination

• E- pleural effusion or pneumothorax or inspiration pneumonia.

• P- CXR, cbc, echo

• E- thoracentesis, tube thoracotomy and

• L- pleural effusion

CLINICAL APPROACH TO

PLEURAL EFFUSIONS

PLEURAL SPACE

The pleura consists of 2 layers1 – parietal pleura2 – visceral pleura

The space between the 2 layers is called the pleural space

Normally the pleural space contains:

• 3.5 to 7.0 ml of clear liquid• low protein content• small number of

mononuclear cells

• Definition.

Defined as an excess quantity of fluid in the pleural space caused either by ↑ pleural fluid formation or ↓ removal by the lymphatic system. The fluid may be transudative or exudative.

ETIOLOGY1. Transudative effusion: ↑ production of pleural fluid due to ↑ hydrostatic or ↓

oncotic pressures. Found in CHF, pulmonary embolism, cirrhosis, and nephrotic syndrome.

2. Exudative effusion: ↑ production due to abnormal capillary permeability or ↓ lymphatic clearance of fluid. Found in malignancy, pneumonia, TB, pulmonary embolism, pancreatitis, esophageal rupture, collagen vascular disease, and chylothorax.

3. In healthy patients, the pleural cavity contains a small volume of lubricating serous fluid, formed primarily by transudation from the parietal pleura and absorbed primarily by the capillaries and lymphatics. The balance between formation and removal of this fluid may be compromised by any disorder that increases the pulmonary or systemic venous pressure, lowers the plasma oncotic pressure, increases capillary permeability, or obstructs the lymphatic circulation.

SYMPTOMS/EXAM

• patients may experience dyspnea with large effusions. They may also complain Of pleuritic pain and have symptoms of pneumonia such as productive Cough, fever, and signs of consolidation.

• on exam, dullness to percussion, decreased fremitus, and ↓ breath sounds May be found on the affected side. Patients may show symptoms of their Underlying disease process (cancer, pneumonia, CHF, cirrhosis).

DIAGNOSIS• CXR: on upright PA and lateral films, blunting of costophrenic angles may be

present with effusions > 250 ml. Decubitus films can differentiate Pleural fluid from pleural scarring and can help determine if the fluid is Loculated .

• obtain fluid via thoracentesis and send for protein, glucose, LDH, cell Count, gram stain, and culture. Also obtain PH, fungal and mycobacterial Cultures, and cytology. In appropriate settings, look for pleural fluid Amylase, triglycerides, cholesterol, and hematocrit. Grossly purulent fluid Represents empyema.

• hemothorax: a pleural hematocrit-to-peripheral hematocrit ratio > 0.5.

• pancreatitis, pancreatic pseudocyst, adenocarcinoma of lung, or esophageal Rupture: ↑ pleural fluid amylase.

• malignancy: cytology is only 50%–60% sensitive for detection.

• pleural biopsy can help diagnose TB or cancer.

TREATMENT

• Transudative effusion: treat the underlying cause, and consider therapeutic Thoracentesis if symptomatic. No further workup is required.

• exudative effusion:

• parapneumonic: give appropriate antibiotics for infections; insert a Chest tube for drainage if complicated (eg, if ph < 7.2 or glucose < 60

• Mg/dl) or if empyema is present.

• malignant: treat the underlying malignancy; repeat thoracentesis or Chest tube insertion for symptom relief. Pleurodesis can ↓ reaccumulation Of fluid.

• hemothorax: rapid drainage via a large-bore chest tube to prevent fibrothorax.

• tuberculous: usually resolves with treatment of TB.

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Color of Fluid Suggested Diagnosis

Pale yellow (straw) Transudate, some exudates

Red (bloody) Malignancy or embolism or TB

Turbid Infected effusion

Pus Empyema

White (milky) Chylothorax or cholesterol effusion

Color of Fluid

PNEUMOTHORAX

pneumothoraxPeneumothorax is the accumulation of air in the pleural space. It may occur spontaneously or following trauma

Disorder CauseCollection

Haemothorax

Hydrothorax

Chylothorax

Pneumothorax

Blood

Proteinaceous Fluid

Lymph

Air

Chest trauma; rupture of aortic aneurysm

Congestive cardiac failure

Neoplastic infiltration; trauma

Spontaneous; traumatic

SPONTANEOUS

Results from rupture of a pleural bleb

Pleural bleb being a congenital defect of the alveolar wall connective tissue.

Patients are typically tall, thin, young males.

M:f ratio 6:1.

Usually apical affecting both lungs with equal frequency.

SPONTANEOUS

Secondary causes occur in patients with underlying disease :

COPD, TB, pneumonia, bronchial carcinoma, sarcoidosis and cystic fibrosis.

SPONTANEOUS

Patients present with sudden onset of unilateral pleuritic pain and increasing breathlessness.

The main aim of treatment is to get the patient back to active life as soon as possible.

INVESTIGATIONS Chest radiography may show an area devoid of lung markings.

May be more clearly seen on the expiratory film

MANAGEMENT

Small pneumothorax: no treatment, but review in 7-10 days.

Moderate pneumothorax: admit for simple aspiration.

REFFRENCES

• KUMAR

• WEBSITE

• CECIL