The document discusses pleural effusion, which is an excess collection of fluid in the pleural space. It classifies pleural effusions as transudates or exudates and describes differences in their physical appearance, microscopy, and biochemical characteristics. It also discusses different types of pleural effusions including dry/plastic pleurisy, serofibrinous pleurisy, and purulent pleurisy/empyema. For each type, it describes their causes, clinical features, pathology, treatment and stages in the case of empyema.

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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho/M Lympho Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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
yellow
Microscopy <1000 >1000 >5000 PMN
Lympho/M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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
yellow
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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
yellow
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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
yellow
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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
yellow
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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
yellow
Microscopy No Cells Predominantly Pus cells
Lymphocytes
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.2 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho/M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho/M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho/M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho /M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 /
Turbid
Microscopy <1000 >1000 >5000 PMNs
Lympho/M Lymphocytes Pus cells
Pleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dl
Pleural fluid Protein / <0.5 >0.5 >0.5
Serum protein
Pleural fluid LDH / <0.6 >0.6 >0.6
Serum LDH
Pleural fluid pH >7.3 <7.3 <7.2
Pleural 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 Types
1. Dry or plastic pleurisy
2. Serofibrinous or serosanguineous pleurisy
3. 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 chest
Before & After Inter costal drainage (ICD)

45. Empyema: Antimicrobial therapy
Organism Drugs Alternate Duration
Staph Clox + Amino 3rd gen Cephlo 1-4wk
+ Clox
Pneumo PenicillinG Ceftriaxone 1-2wk
H influ Cefurox/ceftrioxone Chlorompenic 1-2wk
/Cefotax
Pseudom 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 Pneumothorax
Closed 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 ICD
1. Pneumothorax
2. Hemothorax
3. Hemopneumothorax
4. Tension pneumothorax
5. Empyema
6. Chylothorax

65. X-ray Pneumothorax: Before Treatment

66. X-ray Pneumothorax: After Treatment