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Pleural effusion

Pleural effusion

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Pleural effusion

  1. 1. PLEURAL EFFUSION Rana Shankor Roy
  2. 2. INTRODUCTION  The accumulation of serous fluid within the pleural space is termed pleural effusion.  This fluid may be------ Water(Hydrothorax) Blood(Hemothorax) Chyle(Chylothorax) Pus(Pyothorax or Empyema)
  3. 3. PLEURAL FLUID  Normal fluid in pleural space: 5-15ml.  At least 500ml fluid need to detect clinically.  At least 300ml fluid need to detect radiologically in PA view.  At least 100ml fluid need to detect radiologically in Lateral decubitus position.  Less than 100ml or small fluid can be detected by USG.
  4. 4. PLEURAL EFFUSION
  5. 5. WHAT ARE THE CAUSES?  Common causes are— Pneumonia TB Pulmonary Infarction Malignant disease Cardiac failure  Uncommon causes are--- Hypoproteinaemia(NS, Liver failure) CT disease(SLE, RA) Acute Rheumatic fever Meig’s syndrome(With ovarian tumor & Ascites)
  6. 6. CAUSES ACCORDING TO AGE  Young: Pulmonary TB, Para-pneumonic  Middle aged or elderly: Pulmonary TB, Para-pneumonic Bronchial carcinoma
  7. 7. CAUSES ACCORDING TO SIDE PREDOMINANT  Right: Liver abscess Meig's syndrome Dengue hemorrhagic fever  Left: Acute pancreatitis RA
  8. 8. TYPE  Transudative (Protein<3gm/dl), due to decreased oncotic pressure or elevated hydrostatic pressure ------ CCF NS Cirrhosis of liver Hypoproteinaemia Meig’s syndrome  Exudative (Protein>3gm/dl), due to increased capillary leak and diminished fluid resorption -------- Pulmonary TB Para-pneumonic effusion Bronchial carcinoma SLE, RA Acute pancreatitis
  9. 9. LIGHT’S CRITERIA: TRANSUDATE VS. EXUDATE Exudate is likely if one or more of the following criteria are met: • Pleural fluid protein : serum protein ratio > 0.5 • Pleural fluid LDH : serum LDH ratio > 0.6 • Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH
  10. 10. CASE PRESENTATION  Asymptomatic until it is large enough to cause respiratory compromise.  Breathlessness, particularly on exertion.  Chest pain(Due to pleurisy) on inspiration and coughing.  According to cause( Cough, Fever, Sputum, Weight loss, Hemoptysis)
  11. 11. WHAT YOU EXPECT IN PHYSICAL EXAMINATION?  Inspection: Restriction of movement in affected side.  Palpation: Incase of massive pleural effusion trachea & apex beat shifted the opposite side. Vocal fremitus reduced or absent in affected side. Total chest expansibility reduced.  Percussion: Percussion note is stony dull in affected side.  Auscultation: Breath sound diminished or absent in affected side. Vocal resonance is also diminished or absent in affected side.
  12. 12. DEFINITIVE SIGNS  Reduced or absent breath sound  Stony dull percussion note.
  13. 13. INVESTIGATIONS  Imaging: i) Erect chest X-ray P/A view: The classical appearance of pleural fluid on the erect PA chest film is of a curved shadow at the lung base, blunting the costophrenic angle and ascending towards the axilla. ii) USG of chest iii) CT scan of chest
  14. 14. INVESTIGATIONS  Pleural aspiration and biopsy: i) The presence of blood is consistent with pulmonary infarction or malignancy, but may result from a traumatic tap. ii) Biochemical analysis allows classification into transudate and exudates iii) Gram stain may suggest parapneumonic effusion. iv) A low pH suggests infection but may also be seen in rheumatoid arthritis, ruptured oesophagus or advanced malignancy.
  15. 15. BED SIDE CONFIRMATION  By needle aspiration
  16. 16. HOW TO ESTABLISH AETIOLOGY OF EFFUSION
  17. 17. PLEURAL EFFUSION
  18. 18. D/D  Thickened pleura.(No medistinal shifting, dullness impaired)  Mass lesion.
  19. 19. MANAGEMENT  Therapeutic aspiration: required to palliate breathlessness but removing more than 1.5 L at a time is associated with a small risk of re-expansion pulmonary oedema.  Treatment of the underlying cause.
  20. 20. IF CLINICALLY PLEURAL EFFUSION BUT NO FLUID ON ASPIRATION. CAUSES ARE-----  Fluid may be thick(Empyema).  Thickened pleura.  Mass lesion

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