5 diseases of pleura
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
2,855
On Slideshare
2,855
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
165
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Diseases of Pleura Dr Yog Raj Khinchi
  • 2. Pleural Effusion
  • 3. Pleural effusion: Introduction• Collection of excess quantity of fluid in pleural space• Inflammatory or non inflammatory causes
  • 4. Pleural effusion: Classification• Transudates: due to diseases that affect the filtration of pleural fluid- CHF & hypoproteinemia• Exudates: inflammation or injury increases pleural membrane permeability to proteins and various types of cells
  • 5. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lympho Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 6. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 7. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy <1000 >1000 >5000 PMN Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 8. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 9. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 10. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 11. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 12. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 13. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 14. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 15. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 16. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho /M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 17. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  • 18. Pleural effusion: Causes• Bacterial pneumonias - Most common• TB, CCF, Hypoproteinemia• Obstruction to lymphatic drainage• Collagen vascular disease• Malignancies, Rheumatoid arthritis• Aspiration pneumonia, traumatic• Pulmonary embolism, chylothorax
  • 19. Pleural effusion: 3 Types1. Dry or plastic pleurisy2. Serofibrinous or serosanguineous pleurisy3. Purulent pleurisy or empyema
  • 20. 1. Dry pleurisy or plastic pleurisy Associated with• Acute bacterial infections• Tuberculosis• Connective tissue disorders- rheumatic fever
  • 21. Dry pleurisy: Pathology• Involvement of visceral pleura with small amount of yellow serous fluid• Adhesion between pleural surfaces• Pleural thickening• Fibrothorax due to fibrin deposition and severe adhesions
  • 22. Dry pleurisy: Clinical manifestations• Signs & symptoms of primary disease• Dull pleural pain, exaggerated by deep inspiration,cough, straining, referred to shoulder and back• Increased dullness on percussion and decreased breath sounds• Leathery, rough inspiratory and expiratory friction rub early in the disease• X-ray- haziness at the pleural surface or a dense, sharply demarcated shadow
  • 23. Dry pleurisy: Treatment• Treat underlying condition• If pneumonia is not present- strapping of chest to restrict expansion and analgesics• Strapping and cough suppressants not given if pneumonia is present
  • 24. 2. Serofibrinous pleurisy• Infections of lungs• Inflammatory conditions of mediastinum• Less commonly with- SLE, RF, neoplasms
  • 25. Serofibrinous pleurisy: Clinical features• Initially signs and symptoms of dry pleurisy• Asymptomatic if effusion is small• Large effusion: cough, dyspnoea, retractions, orthopnoea, cyanosis• Shift of mediastinum away from affected side, fullness of intercostal space, diminished tactile vocal fremitus• Dullness to flatness on percussion• Decreased or absent breath sounds
  • 26. Serofibrinous pleurisy: Clinical features...• In infants- bronchial breath sounds instead of absent breath sounds• Friction rub in the early stages• X-ray: homogenous opacity obliterating the normal pulmonary marking, obliteration of costophrenic angles and widening of interlobar fissure
  • 27. X-ray chest: Pleural Effusion
  • 28. Serofibrinous pleurisy: Treatment• Treat underlying cause• Thoracocentesis, up to 1 Liter of fluid• Tube thoracostomy in older child with parapneumonic effusion if pleural fluid pH<7.2 or glucose <50mg/dl
  • 29. 3. Purulent pleurisy / Empyema• Pus or microorganism in pleural fluid• Microorganism- by smear or culture In the absence of these:• pH of pleural fluid < 7.2• Lactic dehydrogenase (LDH) >1000IU/L• Glucose <than 40mg/dl• Lactate > 45mg/ml
  • 30. Empyema: Predisposing factors• Pneumonia in ½ of cases• Preceding H/O of pustules• Blunt trauma to chest/surgery/thoracocentesis• Viral infections (chickenpox, measles)• Severe malnutrition• Neglected foreign body• Extension from subphrenic, amoebic liver abscess• CHD• Peridontal disease, steroid, immunodeficiency
  • 31. Empyema: Etiology• Staphylococcus aureus, epidermidis• Streptococcus pneumoniae, viridans• H influenzae• Pseudomonas aeroginosa• E coli• Klebsiella aerogenes• Mycobacterium tuberculosis• Fungal/ EH (rare)
  • 32. Stages of Empyema• Exudative (1 to 3 days): parapneumonic effusion• Fibrino purulent (4 to 14 days): polymorpho nuclear & fibrin accumulation• Organizing stage (after 14 days): fibroblasts grow and producing an inelastic membrane
  • 33. Empyema: Exudative stage• Fluid is thin• Cellular content is low• Lungs are expandable• Pleural fluid- pH >7.3, glucose >60mg/dl, pleural fluid /serum glucose ratio >0.5, LDH < 1000 IU/L, Gram stain and culture negative
  • 34. Empyema: Fibrino purulent stage• pH and glucose level fall, LDH rises• Purulent and vicious, accumulation of neutrophils and fibrin• Tendency for loculations and limiting membranes• purulent fluid, PH <7.10, glucose <40mg/dl LDH >1000IU/L, Gram stain & culture +ve
  • 35. Empyema: Organizing stage• Thick pleura prevent entry of anti microbial drugs in the pleural space- drug resistance• Restrict lung movement
  • 36. Empyema: Clinical features• Common in poor socioeconomic group• Peak incidence 0-3 years• Chills, fever, dyspnoea, chest pain, referred pain, night sweat, malaise, cough, ↑sputum production• Pain abdomen & ileus• Tachypnoeic, anxious, pleural rub (disappear after fluid accumulates)
  • 37. Empyema: Clinical features...• Large fluid- fullness of intercostal spaces, diminished chest excursions• Shift of mediastinum• Dullness to percussion, decreased air entry, decreased tactile & vocal fremitus
  • 38. Empyema: Investigation & Diagnosis• History and examination findings• Confirm the presence of empyema, etiological agent & complications• Polymorph predominance, rarely leukopenia• X-ray chest- blunting of costophrenic angle, opacification of hemithorax with mediastinal shift to opposite side , lateral decubitus for small volume
  • 39. Empyema: Investigation...• USG- confirms, for thoracocentesis, pleural catheter placement, transudates anechoic, exudates echoic or anechoic, limiting membrane suggest loculation• CT scan- confirm fluid, loculation, pleural thickening• Pleurocentesis / thoracocentesis
  • 40. Empyema: Aspirate Investigation• Aspirate- Cell count and differential, Grams stain, culture, pH, protein, glucose, LDH, AFB stain & culture• Uncomplicated parapneumonic effusion:- pH>7.3, glucose> 60mg/dl, LDH,1000IU/L,• Complicated parapneumonic effusion:- pH<7.1, glucose<60mg, LDH>1000IU/L, microbes on Grams stain• Tuberculous empyema:- AFB <25% cases, Pleural biopsy & culture >90%, adenosine de aminase (ADA) >70U/L, PCR
  • 41. Empyema: Treatment Aims• Control infection• Drainage of pus• Expansion of lungs
  • 42. Empyema drainage• Inter costal drainage (ICD), under water seal, large catheter inserted in the site of pus accumulation• Loculated fluid/pus- drainage continued for 1 week• Chest tube kept till drainage is nil or < 30 ml/day
  • 43. Empyema: Inter Costal Drainage (ICD)
  • 44. Empyema: X-Ray chestBefore & After Inter costal drainage (ICD)
  • 45. Empyema: Antimicrobial therapyOrganism Drugs Alternate Duration Staph Clox + Amino 3rd gen Cephlo 1-4wk + CloxPneumo PenicillinG Ceftriaxone 1-2wk H influ Cefurox/ceftrioxone Chlorompenic 1-2wk /CefotaxPseudom Ceftazidine Impenum Cefoperazone Cilastatin, Aztreonam
  • 46. Empyema: Treatment...• Based on culture and sensitivity• Monotherapy not recommended• In anerobic infection- Clindamycin: 6-12wk• MRSA- Vancomycin• Antibiotics till afebrile, WBC normal, thoracostomy yield <50ml/day, X-ray clearing• H influenzae & S pneumoniae: 7-14 days• S aureus: 3-4 wk, anerobic: (variable) 6-12wk
  • 47. Empyema: Thrombolytic therapy• Multiloculated empyema by thoracostomy tube• Streptokinase 2,50,000 unit or urokinase 1,00.000 unit in 100ml normal saline instilled through tube & clamped for 3 hrs
  • 48. Empyema: Surgical therapy• Remains febrile and dyspnoeic after IV antibiotics and thorcostomy drain• Pleural thickening- decortication• Non expansion of lung• Bronchopleural fistula• Video assisted thoracoscopic surgery in multi loculated effusion• Thorocoscopic debridement and irrigation in multiloculated effusion
  • 49. Empyema: Complications• Bronchopleural fistula• Cutaneous fistula• Pyopneumothorax• Purulent pericarditis• Pulmonary abscess• Peritonitis secondary to rupture through diaphragm• Septic complications - meningitis, arthritis, osteomyelitis
  • 50. Empyema: Prognosis• In adequately treated cases prognosis is excellent• Follow up pulmonary functions suggest that residual disease is uncommon
  • 51. Pyopneumothorax
  • 52. Pneumothorax• Presence of gas in the Pleural space
  • 53. Pneumothorax: Classification• Spontaneous pneumothorax Primary , Secondary• Traumatic pneumothorax• Iatrogenic pneumothorax• Tension Pneumothorax
  • 54. Traumatic PneumothoraxClosed Open
  • 55. Pneumothorax: Causes• Rupture of pleural blebs • Transthoracic aspiration• Penetrating or non needle penetrating injuries • Thoracentesis• Pneumonia • Central intravenous• Asthma catheters• Cystic fibrosis • Mechanical Ventilation• COPD/ Bronchitis • Resuscitative efforts• Inhalation of some toxic substances, most notably crack cocaine
  • 56. Clinical Signs & Symptoms• Severity depends on the extent of the lung collapse.• Simple pneumothorax - asymptomatic or chest pain, dyspnea.• Extensive pneumothorax often produces pleuritic chest pain, dyspnea, tachypnea, cyanosis, Hyperresonance to percussion on the affected side.• Decreased breath sounds on the involved side.• If pneumothorax due to trauma - look for contusions or abrasions on the chest wall or a small puncture wound that does not allow free movement of air between the outside and the pleural cavity.
  • 57. Tension Pneumothorax: Signs/Symptoms• Clinical Presentation - Chest pain (90%), Dyspnea (80%), Anxiety, Fatigue• Physical examination - Respiratory distress and/or arrest, Cyanosis, Tracheal deviation, Pulsus paradoxus, Tachypnea, Tachycardia, Hypotension, Jugular venous distension• Hyperresonance of the chest wall on percussion• Unilaterally decreased or absent lung sounds• Increasing resistance to providing adequate ventilation assistance• Mental status changes, including decreased alertness and/or consciousness• Abdominal distension
  • 58. Tension Pneumothorax Lung parenchymal or bronchial injury one-way valve air trapping mediastinal structures - pushed to the contralateral side.mediastinum impinges on and compresses the contralateral lung
  • 59. Pneumothorax: Differential Diagnosis• Bronchogenic Cyst• Congenital Lung Malformations• Cystic Adenomatoid Malformation• Pleural Effusion, Pyo pneumothorax
  • 60. Investigations• Chest X-ray• Pulse oxymetry : SpO2• Arterial blood gas: arterial pO2
  • 61. Pneumothorax: Treatment Without continued air leak, asymptomatic and mildly symptomatic small pneumothorax• 100% oxygen• Sedation
  • 62. Tension Pneumothorax: Treatment• Severe respiratory and circulatory embarrassment• Emergency Needle aspiration• Either immediately or after needle aspiration a chest tube (ICD) should be inserted and attached to underwater seal drainage
  • 63. Decompression by Needle / ICD• 2nd intercostal space on the mid clavicular line• Upper border of the lower rib• Needle / ICD have to be connected to the underwater sealed drainage
  • 64. Indications for ICD1. Pneumothorax2. Hemothorax3. Hemopneumothorax4. Tension pneumothorax5. Empyema6. Chylothorax
  • 65. X-ray Pneumothorax: Before Treatment
  • 66. X-ray Pneumothorax: After Treatment