internal medicine

1. Respiratory DiseasesRespiratory Diseases
（呼吸系统疾病）（呼吸系统疾病）
JI WanshengJI Wansheng
Dept. of Internal medicineDept. of Internal medicine
Tel: 2602375, mobile: 13153609805Tel: 2602375, mobile: 13153609805

2. Pleural diseasesPleural diseases
1.1. Pleural effusionPleural effusion
2.2. PneumothoraxPneumothorax

3. Pleural effusionPleural effusion
 Pleural space lies between the lung andPleural space lies between the lung and
chest wall, which formed by the folding ofchest wall, which formed by the folding of
visceral and parietal pleura and normally,visceral and parietal pleura and normally,
a thin layer of fluida thin layer of fluid
 A pleural effusionA pleural effusion is an excessiveis an excessive
quantity of fluid in the pleural spacequantity of fluid in the pleural space

4. Etiology & pathogenesisEtiology & pathogenesis
Pleural fluid circulationPleural fluid circulation
1.1. Exudation orExudation or
transudation of Systemictransudation of Systemic
vessels (red)vessels (red)
2.2. Reabsorption viaReabsorption via
lymphatic vessels (white)lymphatic vessels (white)
3.3. Formation of pleuralFormation of pleural
effusion by circulatoryeffusion by circulatory
imbalanceimbalance

5. 1.1. Static hydrate pressure increasedStatic hydrate pressure increased
2.2. Increased permeability of pleuralIncreased permeability of pleural
capillarycapillary
3.3. Colloid pressure reduced in pleuralColloid pressure reduced in pleural
capillarycapillary
4.4. Drainage obstructed via lymphaticDrainage obstructed via lymphatic
vessels in parietal pleuravessels in parietal pleura
5.5. Pleural injuriesPleural injuries
6.6. FormationFormation>drainage>drainage →effusion→effusion

6. Symptoms and signsSymptoms and signs
 Dyspnea—most commonDyspnea—most common
 Chest pain and coughChest pain and cough
 History of heart failure, hepatitis, liver cirrhosis,History of heart failure, hepatitis, liver cirrhosis,
etcetc
 Signs –related to the quantity of pleural fluidSigns –related to the quantity of pleural fluid

7. Laboratory testingLaboratory testing

8. ColorColor DensityDensity ProteinProtein RivaltaRivalta CellsCells
TT Light yellowLight yellow
or clearor clear
<1.018<1.018 1010 ~30~30 ---- <300/uL, Lym<300/uL, Lym
ExEx Light yellowLight yellow
or whiteor white
1.0271.027 ~ 1.045~ 1.045 4141 ~85~85 ++ RBC and WBCRBC and WBC
EE Foggy,Foggy,
purulentpurulent
1.0211.021 ~1.033~1.033 3030 ~55~55 ---- N, toxicN, toxic
granules ingranules in
cellscells
HH RedRed 1.0301.030 ~1.045~1.045 ---- Like peripheralLike peripheral
bloodblood
CC Chylous orChylous or
fattyfatty
---- Plentiful L, fewPlentiful L, few
RBCRBC
T: transudation, Ex: exudation, E: empyema,
H: haemothorax, C: chylous pleural effusion

9. 1. Transudation: cell counting<100-300/ul, L
2. Exudation: WBC> 500/ul,
3. Empyema: WBC > 10,000/ul
4. Haemothorax: 5,000/ul, caused by TB,
pulmonary infarction & malignancy.
5. Chylous pleural effusion
6.6. ExaminationExamination forfor malignant cells &malignant cells & pathogens

10.  ProteinsProteins
1.1. E: >30g/L, PF/serum >0.5; Rivalta (+)E: >30g/L, PF/serum >0.5; Rivalta (+)
2.2. T: <30g/L, albumin, Rivalta testing (-)T: <30g/L, albumin, Rivalta testing (-)
 Lipids: chylous effusion, not precipitatedLipids: chylous effusion, not precipitated
after centrifuge, Sudan III staining: red,after centrifuge, Sudan III staining: red,
triglyceride >1.24mmol/L, normaltriglyceride >1.24mmol/L, normal
cholesterol. caused by injury of thoraciccholesterol. caused by injury of thoracic
ductduct
 Glucose: similar as serumGlucose: similar as serum
 LDH: ELDH: E >>200U/L, PF/serum >0.6 ,200U/L, PF/serum >0.6 ,
LDH>500U/LLDH>500U/L →malignancy or→malignancy or
accompanied with infectionaccompanied with infection
 Tumor markers: CEATumor markers: CEA

11. X-rayX-ray
1.1. Slight free effusionSlight free effusion →blunted→blunted
costodiaphragmatic anglecostodiaphragmatic angle
2.2. Large quantity of effusionLarge quantity of effusion →arc effusion→arc effusion
shadow pointed upward and outwardshadow pointed upward and outward
3.3. Gas-liquid thorax: gas-liquid planeGas-liquid thorax: gas-liquid plane
4.4. Wrapped effusionWrapped effusion →not changed with→not changed with
positionspositions

13. Normal orthodox film

14. Ultrasound & other examinationsUltrasound & other examinations
1.1. Ultrasound--Ultrasound-- guide thoracentesis for smallguide thoracentesis for small
amount or enveloped (wrapped) effusionamount or enveloped (wrapped) effusion
2.2. Pleural biopsy:Pleural biopsy: gained by thoracentesisgained by thoracentesis
or open surgery for tumor, TB or other pleuralor open surgery for tumor, TB or other pleural
DD
3.3. BronchoscopyBronchoscopy

15. DiagnosisDiagnosis
1.1. Effusion or not ?Effusion or not ?
2.2. Transudate or exudate ?Transudate or exudate ? Any ofAny of
following met?following met? PF/serum protein >0.5,PF/serum protein >0.5,
PF/serum LDH >0.6, PF LDH >2/3 upperPF/serum LDH >0.6, PF LDH >2/3 upper
serum limitserum limit
3.3. Etiology?Etiology?

16.  EtiologyEtiology
 Transudate:Transudate: common in congestive heartcommon in congestive heart
failure, liver cirrhosis, nephrotic syndrome,failure, liver cirrhosis, nephrotic syndrome,
hypoalbuminemia, etchypoalbuminemia, etc
 Exudate:Exudate: most common in TB pleurisy, other:most common in TB pleurisy, other:
pneumonia, lung abscess, bronchiectasis, etcpneumonia, lung abscess, bronchiectasis, etc
 Malignant effusion:Malignant effusion: by malignancy fromby malignancy from
neighboring organs (LC, breast cancer) , orneighboring organs (LC, breast cancer) , or
distal organs (GI or urinoprogenitive system)distal organs (GI or urinoprogenitive system)

17. Essentials of DiagnosisEssentials of Diagnosis
 Asymptomatic; pleuritic chest pain; dyspnea ifAsymptomatic; pleuritic chest pain; dyspnea if
effusion is largeeffusion is large
 ↓↓vocal fremitus, dullness, distant breath sounds;vocal fremitus, dullness, distant breath sounds;
bronchophony if effusion is largebronchophony if effusion is large
 Laboratory testingLaboratory testing
 Radiographic evidence of pleural effusionRadiographic evidence of pleural effusion
 Findings depend onFindings depend on thoracocentesis, pleuralthoracocentesis, pleural
biopsy, or thoracoscopebiopsy, or thoracoscope

18. Approach to diagnosisApproach to diagnosis
Pleural
effusion
Thoracentesis,
measure PF protein
and LDH
Any of following met?
PF/serum protein >0.5
PF/serum LDH >0.6
PF LDH >2/3 upper serum
limit
Exudate
s
Transudate
Yes No
Continued

19. Exudates
Measure G, amylase, cytology, differential cell count,
Culture, stain, tumor or TB markers
Amylase ↑:
Esophageal rupture
Pancreatic D
malignancy
G<60mg/dl:
Malignancy
Bacterial infection
Rheumatoid pleuritis
No diagnosis
Consider pulmonary embolus
Continued

20. No
Consider pulmonary embolus
Helical CT or lung scan
PF marker for TB
Symptoms improving
observeConsider thoracoscopy or open pleural biopsy
Treat for PE
Yes
Yes
Treat for TB
YesNo

21.  Effusion secondary toEffusion secondary to
1.1. Heart failureHeart failure
2.2. Liver cirrhosisLiver cirrhosis
3.3. Bacterial pneumoniaBacterial pneumonia
4.4. Malignancy: metastatic tumor orMalignancy: metastatic tumor or
mesotheliomamesothelioma
5.5. Pulmonary embolizationPulmonary embolization
6.6. Viral infectionViral infection
7.7. AIDSAIDS

22.  Tuberculous pleuritisTuberculous pleuritis
 Chylothorax: rupture of thoracic ductChylothorax: rupture of thoracic duct
 Hemothorax: hematocritHemothorax: hematocrit>50 that of the>50 that of the
peripheral blood: caused by trauma,peripheral blood: caused by trauma,
rupture of a blood vessel or tumorrupture of a blood vessel or tumor

23. TreatmentTreatment
 On etiologyOn etiology
1.1. Tuberculous pleuritis: anti-TBTuberculous pleuritis: anti-TB
chemotherapychemotherapy
2.2. Parapneumonic effusion: antibioticsParapneumonic effusion: antibiotics
3.3. CHF, liver cirrhosis, nephroticCHF, liver cirrhosis, nephrotic
syndrome: improving systemic functionssyndrome: improving systemic functions
4.4. Malignant effusion: metheliomaMalignant effusion: methelioma
5.5. Pulmonary embolizationPulmonary embolization
6.6. etcetc

24.  Treatment on large quantity ofTreatment on large quantity of
effusioneffusion
1.1. Reduce effusion quantity by aspiration. NotReduce effusion quantity by aspiration. Not
over 700ml 1over 700ml 1stst
time, not over 1000ml everytime, not over 1000ml every
time,time, because rapid & excessive reductionbecause rapid & excessive reduction →abrupt→abrupt 
of thoracic pressure →of thoracic pressure → pulmonary edema or acuteedema or acute
heart failureheart failure ----pleural reactionpleural reaction
2.2. PresentationsPresentations:: dizziness, sweating, and throbdizziness, sweating, and throb
3.3. Stop aspiration at once, in prostrate position,Stop aspiration at once, in prostrate position,
0.1% epinephrine 0.5ml subcutaneously0.1% epinephrine 0.5ml subcutaneously

25. PneumothoraxPneumothorax
 DefinitionDefinition
1.1. In normal status, no gas in pleuralIn normal status, no gas in pleural
cavitycavity
2.2. Gas accumulation in pleural cavityGas accumulation in pleural cavity
3.3. Common emergency of internalCommon emergency of internal
medicinemedicine

26. ClassificationClassification
1.1. Spontaneous: primary orSpontaneous: primary or
secondarysecondary
2.2. Traumatic: direct or indirectTraumatic: direct or indirect
trauma of chest walltrauma of chest wall
3.3. Nosocomial: caused by diagnosticNosocomial: caused by diagnostic
or therapeutic operationsor therapeutic operations

27. Etiology & pathogenesisEtiology & pathogenesis
1.1. Rupture of peripheral alveoli,Rupture of peripheral alveoli,
esp. bullaesp. bulla
2.2. Injury of chest wallInjury of chest wall
3.3. Aerogenous bacterial inAerogenous bacterial in
pleural cavity –pleural cavity –rare etiologyrare etiology
Main reasons

28. 1.1. Large quantity of gas accumulationLarge quantity of gas accumulation →→
disappearance of pleural negativedisappearance of pleural negative
pressure →increased pressure on heartpressure →increased pressure on heart
& large blood vessels →reduce cardiac& large blood vessels →reduce cardiac
output, rapid arrhythmia, hypotension,output, rapid arrhythmia, hypotension,
even shockeven shock
2.2. Tension pneumothorax → shift ofTension pneumothorax → shift of
mediastinum →circulatory disorders,mediastinum →circulatory disorders,
even death of suffocationeven death of suffocation

29.  Primary pneumothoraxPrimary pneumothorax
1.1. Thin, tall, male youth and adultsThin, tall, male youth and adults
2.2. X-ray: bulla neighboring pleura, more commonX-ray: bulla neighboring pleura, more common
on apexon apex
3.3. Formation of bulla is unclear, may related toFormation of bulla is unclear, may related to
smoking, height or bronchiolitissmoking, height or bronchiolitis
 Secondary pneumothorax:Secondary pneumothorax: To otherTo other
pulmonary D, which cause the incompletepulmonary D, which cause the incomplete
obstruction of bronchioles, then bulla formedobstruction of bronchioles, then bulla formed

30.  Menstrual pneumothorax:Menstrual pneumothorax: occurredoccurred
24~72 Hrs before menstruation, which may24~72 Hrs before menstruation, which may
caused by rupture of ectopic endometriumcaused by rupture of ectopic endometrium
 Pregnancy pneumothoraxPregnancy pneumothorax occurred withoccurred with
pregnancy (may be related to hormone andpregnancy (may be related to hormone and
thoracic compliance)thoracic compliance)

31.  Clinical classification ofClinical classification of
spontaneous pneumothoraxspontaneous pneumothorax
1.1. Closed: smaller orifice, closed with retractionClosed: smaller orifice, closed with retraction
of the lung, inner pressure of pleural cavity (+)of the lung, inner pressure of pleural cavity (+)
or (-)or (-)
2.2. Open: or communicated. Bigger orifice orOpen: or communicated. Bigger orifice or
caused by adhesion between 2 layer of pleura.caused by adhesion between 2 layer of pleura.
Inner pressure of pleural cavity waved aroundInner pressure of pleural cavity waved around
zero cmH2Ozero cmH2O
3.3. TensionTension

32.  Tension or pressure pneumoniaTension or pressure pneumonia
1.1. Valve opened to single directionValve opened to single direction
2.2. In inspiratory phase, gas enter into pleuralIn inspiratory phase, gas enter into pleural
cavity with thoracic expansion, but not expelledcavity with thoracic expansion, but not expelled
with thoracic retraction in expiratory phasewith thoracic retraction in expiratory phase
3.3. So gas accumulatedSo gas accumulated →→lung pressed, andlung pressed, and
mediastinum shifted to opposite sidemediastinum shifted to opposite side
4.4. Shift of mediastinum influence on blood reflux,Shift of mediastinum influence on blood reflux,
which , in turn influence cardiopulmonarywhich , in turn influence cardiopulmonary
functionsfunctions
5.5. A common emergencyA common emergency

33. Clinical manifestationClinical manifestation
 SymptomsSymptoms
1.1. History of exertional activities: taking sth heavy,History of exertional activities: taking sth heavy,
breath holding, etc.breath holding, etc.
2.2. Abrupt onset, characterized as a sudden lateralAbrupt onset, characterized as a sudden lateral
cutting or probing chest pain, followed by chestcutting or probing chest pain, followed by chest
oppression and dyspnea, or stimulant coughoppression and dyspnea, or stimulant cough
3.3. For tension pneumothorax, severeFor tension pneumothorax, severe
cardiopulmonary dysfunction may appear,cardiopulmonary dysfunction may appear,
characterized by fidgety, dysphoria, cyanosis,characterized by fidgety, dysphoria, cyanosis,
cold sweat, rapid pulse, arrhythmia, even comacold sweat, rapid pulse, arrhythmia, even coma

34.  SignsSigns
 None if less quantityNone if less quantity
 Typical signs when large quantityTypical signs when large quantity
1.1. Trachea shifted to opposite side, bulging halfTrachea shifted to opposite side, bulging half
thorax (affected side)thorax (affected side)
2.2. Respiratory movement & fremitus reducedRespiratory movement & fremitus reduced
3.3. Hyperresonance, disappearance of cardiac orHyperresonance, disappearance of cardiac or
hepatic dullnesshepatic dullness
4.4. Breath sound may disappear or reduceBreath sound may disappear or reduce

35. Sinus phrenicostalis

36. Normal lateral film

37. X-rayX-ray
 Typical charactersTypical characters
 Arc linear shadow (oppressed margin)Arc linear shadow (oppressed margin)
 Evaluation of accumulated gasEvaluation of accumulated gas
1.1. Distance between lateral chest wall and lungDistance between lateral chest wall and lung
margin: large amount ifmargin: large amount if ≥≥2cm, small amount if2cm, small amount if
<2cm<2cm
2.2. Distance between apex and top of thoracic top:Distance between apex and top of thoracic top:
large amount iflarge amount if ≥≥3cm, small amount if <3cm3cm, small amount if <3cm

39. pneumothorax

40. DiagnosisDiagnosis
 Large amount of gas accumulationLarge amount of gas accumulation
could be determined by typicalcould be determined by typical
symptoms, signs and X-raysymptoms, signs and X-ray
presentationspresentations
 Small amount of gas accumulationSmall amount of gas accumulation
lack symptom or signs, whichlack symptom or signs, which
should be alertshould be alert

41. Differential diagnosisDifferential diagnosis
1.1. AsthmaAsthma
2.2. Obstructive emphysemaObstructive emphysema
3.3. Acute myocardial infarctionAcute myocardial infarction
4.4. Pulmonary thromboembolismPulmonary thromboembolism
5.5. Pulmonary bullaPulmonary bulla
6.6. OthersOthers

42. TreatmentTreatment
 Aim: help to restore lungAim: help to restore lung
expansion, eradicate etiology,expansion, eradicate etiology,
reduce collapsereduce collapse
1.1. Conservative therapyConservative therapy
2.2. Closed thoracic drainageClosed thoracic drainage
3.3. Sclerification with chemical hardening agentSclerification with chemical hardening agent
4.4. SurgerySurgery
5.5. Treatment on complicationsTreatment on complications

43.  MethodMethod:: Gas ejection by thoracentesisGas ejection by thoracentesis
 IndicationIndication: small amount of gas, slight: small amount of gas, slight
dyspnea, good cardiopulmonary function, anddyspnea, good cardiopulmonary function, and
closed pneumothoraxclosed pneumothorax
 Amount for every ejectionAmount for every ejection << 1000ml, qd or qod1000ml, qd or qod
1. Conservative therapy1. Conservative therapy

44.  For tension pneumothoraxFor tension pneumothorax
 Resolve thoracic positive pressure inResolve thoracic positive pressure in
emergency, or else, severe complications mayemergency, or else, severe complications may
occuroccur
 Thoracentesis at once, emergent gas ejectionThoracentesis at once, emergent gas ejection
should be performed, in order to reduce thoracicshould be performed, in order to reduce thoracic
pressurepressure

45.  IndicationsIndications
1.1. Unstable pneumothoraxUnstable pneumothorax
2.2. Significant dyspneaSignificant dyspnea
3.3. Severe lung collapseSevere lung collapse
4.4. Communicated or tension pneumothoraxCommunicated or tension pneumothorax
5.5. Recurrent frequentlyRecurrent frequently
6.6. Any one of the above met, whatever theAny one of the above met, whatever the
amount of gas accumulationamount of gas accumulation
2. Closed thoracic drainage2. Closed thoracic drainage

46.  In order to avoid recurrence, chemicalIn order to avoid recurrence, chemical
hardening agent was injected to pleural cavityhardening agent was injected to pleural cavity
 The production of aseptic inflammation causedThe production of aseptic inflammation caused
the adhesion of visceral and parietal pleura tothe adhesion of visceral and parietal pleura to
close the cavityclose the cavity
3. Chemical pleural sclerification3. Chemical pleural sclerification

47.  Indications for Closed thoracicIndications for Closed thoracic
drainagedrainage
1.1. Persistent or recurrentPersistent or recurrent
2.2. Bilateral pneumothoraxBilateral pneumothorax
3.3. Accompanied with bullaAccompanied with bulla
4.4. Pulmonary dysfunction, not endure thePulmonary dysfunction, not endure the
surgerysurgery
 Common hardening agents:Common hardening agents: 多西环素、多西环素、
talc powder (talc powder ( 滑石粉滑石粉 ), etc; diluted by), etc; diluted by
normal saline 60~100ml, then injectednormal saline 60~100ml, then injected
by drainage duct, occluded for 1~2by drainage duct, occluded for 1~2
Hrs; sprinkle hardening agent underHrs; sprinkle hardening agent under
thoracoscopethoracoscope
Refuse surgery

48. 4. Surgery4. Surgery
 IndicationsIndications
1.1. Ineffective by medical methodsIneffective by medical methods
2.2. Persistent, bilateral, recurrentPersistent, bilateral, recurrent
pneumothoraxpneumothorax
3.3. Tension pneumothorax, failed inTension pneumothorax, failed in
drainagedrainage
4.4. Thickened pleuraThickened pleura →→atelectasisatelectasis
5.5. Or multiple bullaOr multiple bulla
 More success, low recurrenceMore success, low recurrence
 Methods: via thoracoscope or openMethods: via thoracoscope or open
surgerysurgery

49. 5. Treatment on complications5. Treatment on complications