pleura,lung,thorax.

1. Pleural effusion
Dr.Sivaraj Karri
Senior resident
Pulmonary medicine.

2. Pleura anatomy

3. definition
• Fluid in the pleural spaces
• It can be
• Blood : haemothorax
• Pus : empyema
• Chyle : chylothorax
• Effusions (divided by protein concentration)
• Transudates
• Exudates

4. causes
• Transudates
• Increase venous pressure
• Cardiac failure
• Constrictive pericarditis
• Fluid overload
• Hypoproteinaemia
• Liver cirrhosis
• Nephrotic syndrome
• Hypothyroidism
• Meig's syndrome (right pleural effusion and ovarian fibroma)
• Exudates
• Increase leakiness secondary to
• Infection : pneumonia,TB
• Inflammation : pulmonary infarction,RA,SLE,
• Malignancy : bronchogenic ca,metastases,lymphoma,mesothelioma,lymphangitis
carcinomatosis

5. symptoms
• Dyspnea
• Pleuritic chest pain
• Dry cough
• fever

6. signs
• Inspection
• Aspiration marks
• Palpation
• Tracheal deviation
• Decrease chest expansion
• Tactile vocal fremitus reduced
• Percussion
• Stony dullness
• Auscultation
• Diminished breath sounds on affected side
• Vocal resonance reduced
• Bronchial breathing (above the effusion

7. Look for signs of associated disease
• Malignancy : cachexia,clubbing,lymphadenopathy,radiation marks,
mastectomy scars
• Chronic liver disease
• Cardiac failure
• Hypothyroidism
• RA
• SLE

8. Tests
• CXR
• Small effusions blunt the costophrenic angles
• Large effusions seen as water dense shadows with concave upper borders
(meniscus sign)
• Completely horizontal upper border implies pneumothorax

10. Meniscus sign

14. tests
• Ultrasound
• Identifying the presence of pleural fluid
• Guiding diagnostic or therapeutic aspiration

15. Ultrasonography

16. CT Thorax

17. Tests
• Pleural biopsy
• If pleural analysis is inconclusive
• By using Abram's needle

18. tests
• Diagnostic aspiration
1.Percuss the upper border of the pleural effusion
2.Choose 1 or 2 intercostals below (don't go too low,beware of abdomen)
3.Infiltrate down to the pleura with 5-10mL of 1% lidocaine
4.Attach a 21G needle to a syringe,and insert it just above the upper border of
the rib (avoid neurovascular bundle)
5.Draw off 10-30mL of pleural fluid and send it to the lab
• Clinical chemistry : protein,glucose,pH,lDH,amylase
• Bacteriology : microscopy and culture,auramine stain,TB culture
• Immunology : rheumatoid factor,ANA,complement

21. Management

22. SUPPORTIVE TREATMENT
• Oxygen is necessary if SpO2 < 90%
• Fluid therapy if dehydrated or
unable/unwilling in drinking water
• Initiate IV antibiotics
• Analgesics and antipyretics
• Chest radiography & U/S
• Chest physiotherapy
• Respirometer exercise

23. • Treat the cause
 Pneumonia- initiate antibiotic treatment
A) Following community acquired pneumonia
• Cefuroxime
• Amoxicillin-clavulanic acid
• Penicillin & flucloxacillin
• Amoxicillin & flucloxaxillin
• Clindamycin
B) Hospital acquired pneumonia
Broader spectrum antibiotics that cover aerobic gram negative
rods

24.  2HRZE+4HRE
 Prednisolone 1-2mg/kg orally 4-6weeks promotes rapid
absorption of the pleural fluid and prevents fibrosis.
• Congestive cardiac failure- treat with
diuretics and
other anti-failure medications.

25. Tube Thoracostomy –
 Pneumothorax
 Pleural fluid loculated
 Recurrent Pleural effusion – eg: malignancy
 Effusion filling more than half the hemithorax
 Air fluid level – Hydro/Pyopneumothorax
 Pus in the pleural space - Empyema
 Hemothorax/Chylothorax
 Para pneumonic effusion

26.  VATS –
Failure to drain with a single small-bore tube
should also lead to thoracic surgery
consultation to avoid delays in case video
assisted thoracoscopy (VATS) becomes
necessary.

27. Physiotherapy management
 Incentive spirometry
-Improves lung function
-Minimise fluid build-up in the
lungs
-Improve air flow
 Chest physiotherapy
 percussion
 vibration
 segmental deep breathing exercise
 forced expiratory exercise
 coughing techniques

28. PHYSIOTHERAPY INTERVENTION
 It helps drain the excess fluid in the
pleuralspace
 Improves the lung function
 Alleviate the breathlessness
 Patient is ambulant with improve
cardiopulmonary endurance and reduce
fatigability

29. THANK YOU