Apparently a lengthy presentation actually very good for junior physicians as it covers all aspects of assessment, diagnosis and treatment of pleural effusion
Apparently a lengthy presentation actually very good for junior physicians as it covers all aspects of assessment, diagnosis and treatment of pleural effusion
Pleural effusion may be defined figuratively as the juice, oozing from the leaky lingerie of the lung. However the text book definition is the abnormal accumulation of fluid in the pleural space due to disturbances in the forces that keep the pleural fluid economy in equilibrium...
This presentation discusses steps in diagnosis of pleural effusion using a simulated patient scenario. Besides talking about different findings we can possibly see in a pt with pleural effusion on examination, CXR, USG, CT and labs, It also briefly discuss the proper steps in performing thoracocentesis.
I have prepared this mainly for residents doing post graduation in respiratory medicine and medicine. Special thanks to Dr. Avinash Babu for the help on malignant pleural effusion. My references are mainly Lights' pleural diseases and BTS guidelines.
Abnormal fluid accumulation in potential space in between parietal and visceral pleurae – there is imbalance between formation and absorption in response to injury, inflammation or both locally and systematically
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
3. The Right Lung
-Three lobes-the superior, middle and inferior, which are
separated by the horizontal fissure and the oblique
fissure.
-10 bronchopulmonary segments
The Left Lung
-Two lobes which are separated by the oblique fissure.
-10 bronchopulmonary segments
ANATOMY IN A HEALTHY LUNG
5. The main anatomy affected by pleural effusions are the layers in the
Lung
There are two layers-the parietal pleura and the visceral pleura.
• At the Hilum, the parietal pleura folds back on itself to become the visceral
pleura.
The pleural fluid contains –
-contains about 5-15ml of fluid at one time
-about 100-200ml of fluid circulates though the pleural space within a 24-hour
period
-has an alkaline pH of about 7.60 - 7.64
Protein content less than 2% (1-2 g/dL)
Glucose content similar to that of plasma
Mesothelial cells
Macrophages
Lymphocytes (few)
Sodium, potassium and calcium concentrations similar to that of interstitial fluid.
Lactate Dehydrogenase concentration of less than 50% of that of plasma
6. ANATOMY
OF A
HEALTHY
LUNG
A pleural effusion is an accumulation of fluid
between the parietal pleura and the visceral pleura.
Chest X-ray frontal view: 100-200ml pleural fluid
ANATOMY OF A
LUNG WITH A
PLEURAL
EFFUSION
8. ANATOMY & PHYSIOLOGY OF A LUNG WITH A
PLEURAL EFFUSION
• The fluid accumulates due to the over production of pleural fluid by the
mesothelial cells and separates the visceral and parietal pleura.
• This fluid can not be drained by the lymphatic system, and so therefore continues
to accumulate, resulting in a pleural effusion.
• The accumulation of fluid may also be due to changes in hydrostatic pressure or
oncotic pressure.
The lung has the natural tendency to collapse towards the hilum and this is
opposed by forces of similar magnitude in the chest wall tending to expand
outward. Thus the parietal and visceral pleura are kept in close apposition. If
increase fluid or air collect in the pleural space ,the effect of outward forces on the
underlying lung is diminished, and the lung tend to retract toward its hilum.
10. There are 4 different fluids which can accumulate in the pleural space.
• Blood HAEMOTHORAX
• Pus EMPYEMA
• Chyle CHYLOTHORAX
• Serous fluid HYDROTHORAX
• They can further be classified into TRANSUDATES and EXUDATES
depending on
– Chemical composition
– Mechanism of fluid formation
Light’s criteria: Transudate vs. Exudate
•
Pleural fluid protein / serum protein > 0.5
Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 ULN serum LDH
12. Mechanisms for pleural fluid accumulation:
• Increased hydrostatic pressure (Eg. CCF)
• Reduced plasma oncotic pressure (Eg. Hypoproteinaemia)
• Increased capillary permeability (Eg.TB, Tumour )
• Reduced lymphatic drainage from pleural space
(Obstrustioin by tumour, TB, radiation)
• Transdiaphragmatic passage of fluid (Eg. Liver disease,
Acute pancreatitis) .
13. Transudates
• Clear, pale yellow, watery substance
• Increase hydrostatic pressure,
• Decrease oncotic pressure
• Common causes:
Congestive heart failure
Cirrhosis of the Liver
Nephrotic syndrome
Hypoproteinaemia
Hypothyroidism
Acute rheumatic fever
14. Exudates
• Pale yellow and cloudy substance, has a low pH
• Influenced by local factors where fluid absorption is
altered (inflammation, infection, cancer)
• Rich in white blood cells.
• Common causes:
Pulmonary TB
Pneumonia
Bronchial carcinoma
Pulmonary infarction
Collagen disease (SLE, RA)
Lymphoma
Meig’s syndrome (Right pleural effusion, Ascites, Ovarian fibroma)
15. Blood stained fluid
Tends to loculate early
CT scan shows higher density measurement
Common causes:
-Chest injury
-Bronchial carcinoma
-Pulmonary infarction
-Lymphoma
Haemothorax
16. Chylothorax
• Milky fluid due to lymph and fats
• Chyle leaks from the thoracic duct due to
-damage to the lymphatic vessels.
-lymphatic obstruction (tumor) or trauma
• High triglyceride levels found in fluid analysis
• Common causes:
• Traumatic (thoracic surgery), trauma to thoracic duct
• Neoplastic ( Bronchial carcinoma, metastasis)
• Infective (TB)
• Lymphoma (involving thoracic duct)
17. Empyema
• Pus in pleural space
• Yellow, cloudy, and foul odor
• Has a pH > 7.2
• Common causes:
Pneumonia
Rupture of lung abscess,
Rupture of sub-phrenic abscess
Tuberculosis
Infected chest wounds
Secondary infection during aspiration of pleural fluid
18. Diagnosis of Pleural Effusions
• Medical history
• Physical examination
• Plain film chest x-ray – first line imaging
• CT
• Ultrasound imaging
Diagnosing Pleural Effusions
through Imaging
19. Characteristics on a supine
chest radiograph
• Fluid accumulates posteriorly
• Affected hemi-thorax appears whiter or
paler grey
• Apparent thickening of the pleura
• Approx 200 mls of fluid present before
abnormal pale grey appearance is
produced
20. First line imaging – Chest x-ray
Clear right side
hemi-diaphragm
and sharp
costophrenic
angle
Area of
homogenous
Whiteness, with
loss of hemi-
diaphragm
Meniscus shaped
upper border
Features on a PA or AP erect radiograph
21. A large right side pleural effusion
The heart
has been
pushed towards
the left side by the
fluid
Entire white-out
of right
hemi-thorax
22. Lateral decubitus chest radiograph
Free layering pleural effusion
At least 100ml
pleural fluid is
necessary
34. 4 signs
1.Displaced crus sign:
Pleural fluid may collect posterior to the diaphragmatic crux and therefore
displace the crus anteriorly, whereas ascites collects anterior to the crus and
may cause posterior displacement.
2.Diaphragm sign:
As an extension of the displaced crus sign,
Any fluid that is on the exterior of the dome of the diaphragms in the pleura,
whereas any that is within the dome is ascites
3.Interface sign:
The interface between the liver or spleen & pleural fluid is said to be less sharp
than that between the liver or spleen and ascites
4.Bare area sign:
The peritoneal coronary ligament prevents ascitic fluid from extending over the
entire posterior surface of the liver, whereas in a free pleural space, pleural
fluid may extend or over the entire posterior costophrenic recess behind the
liver
35. Ultrasound
• No radiation,
• Small effusions missed on CXR
• Even 20-25 ml of fluid can be detected
• Transudate-Anechoic, Exudative- Reflectative +/-
• Identify pleural thickening and masses
• Used to guide thoracocentisis
37. MRI
• Not used to image pleural effusion
• Incidental finding
38. Treatment
• Needed if patient becomes breathless
• Small effusions are left and ‘observed’
• Usually directed at underlying cause
(antibiotics for pneumonia)
• Underlying cause treated effusion will go
away for good
• If not it will return within few weeks
40. Pleurodesis
• Chemical inserted into pleural space
• Parietal and visceral layers become irritated
• Closes space
• Painful
Pleuroperitoneal Shunt
• Internal shunt
• Fluid drains from chest into abdominal cavity
Pleurectomy
• Operation to remove the pleura
• Most severe cases
Firstly I am going to review the anatomy and physiology of a healthy lung, and then we will consider the anatomy of a lung with a pleural effusion. The right lung accountable for 56% of the total lung volume, and is divided up into 3 lobes-the superior, middle and inferior lobe. This diagram nicely demonstrates these lobes, and the fissures which separate them. (point on the oblique and horizontal fissure)The left lung is slightly smaller as it makes up 44% of the total lung volume, due to the asymmetrical position of the heart. The left lung only has two lobes which are separated by an oblique fissure.
The lungs have two membranes-the parietal pleura and the visceral pleura. The parietal pleura is the outside membrane which lines the thoracic cavity and the visceral pleura is the inside membrane which lines the lungs. The parietal pleura receives its blood supply from the systematic circulation and contains sensory nerve endings. The visceral pleura receives its blood supply from the low pressure pulmonary circulation and has no sensory nerve endings.The parietal pleura folds back on itself at the hilum to become the visceral pleura, making it a continuous membrane.The mesothelium plays a huge part in pleural effusions. It is a membrane that forms the lining of the pleura, and includes the pleura, the pericardium (the lining around the heart) and the peritoneum (the lining around the abdominal cavity). The main function of the mesothelium is to a produce serous fluid which acts a lubricate that is secreted between the parietal pleura and the visceral pleura to reduce the friction and provide a non-adhesive, protective surface to help facilitate movement.The volume of this pleural fluid in health is around 10ml and has a pH of 7.60- 7.64. there is an oncotoic pressure of 25cm H2O.The contents and characteristics of pleural fluid can alter when a pleural effusion occurs, but typically when the lung is healthy the pleural fluid contains glucose content similar to that of plasma, mesothelial cells, macrophages and lymphocytes. It also contains sodium, potassium and calcium concentrations similar to that of interstitial fluid, and Lactate Dehydrogenase which lizzie will explore later.
This diagram nicely demonstrates the difference in appearance between the anatomy of a healthy lung and that of a lung with a pleural effusion. As you can see there is an accumulation of fluid between the parietal pleura and the visceral pleura.
Now we will look at how this anatomy alters when a pleural effusion occurs.The fluid which accumulates tends to be pleural fluid, although it can also be blood or chyle, which is a milky fluid consisting of lymph and fat.The pleural fluid accumulates due to the over production of pleural fluid by the mesothelial cells, and as it can not be drained by the lymphatic system, it continues to collect between the parietal pleura and the visceral pleura resulting in a pleural effusion.Changes in hydrostatic pressure or oncotic pressure may also be responsible for a pleural effusion.Other changes to the anatomy may include pleural thickening and mediastinal pleural thickening, which can be spotted easily using CT, which sadie will cover later in the presentation. Another typical change to anatomy is the appearance of pleural nodules which can range from 2mm to 4cm. These appear as small, round shadows which can appear anywhere in the lung field. I have found this x-ray which nicely demonstrates them.The accumulation of fluid may also cause an increase in pressure, which results in a typical symptom of a pleural effusion of chest pain, although this tends to only occur once there is 500ml of accumulated fluid.
Filling both CP angle and parallelly extending up the lateral chest wall Sign of increased left arterial pressure or lymphatic spread
Contour of diaphragm is altered & apex being more lateral than usual Left- increased distance between the gastric bubble and lung baseMove with change of postureDD- Retrocardiac mass, Subphrenic abscess/collection, Phrenic nr palsy, Basal pneumonitis
Requires less fluid to cause blunting of Posterior CP angle than Lateral CP angleDisplaces highest point of affected hemi diaphragm laterally
Often associated with free other pleural fluid and may extend into the fissure (fig)…. Rt Para tracheal shadow increased due to enlarged LNComparatively little depth but considerable width, rather like a convex lensExtrapleural opacities tend to have much sharper outlineDiff between pleural mass, thickening or loculated fluid is difficult in CXR ,,, need USG or CT Pseudo or Vanishing tumour
Occurs secondary to pleural disease or adhesionsNo change In position with change in posture
CT scan of the chest which demonstrates loculated pleural effusion in the left major fissure (arrow) in a patient after coronary bypass. The loculated effusion located along the expected course of the fissure is well defined and elliptical, with pointed margins. The Effusion is similar to water in its attenuation therefore its appearance is that of fluid.
Axial CT image of the lower chest in patient with acute lymphoblastic leukemia. A small dependent, crescent-shaped area with attenuation similar to that of water in the right hemithorax is consistent with a tiny right pleural effusion (arrow).
CT scan of the chest demonstrates a mass in the right upper lobe eating into the pleura (*). Irregular soft-tissue thickening of the pleural surface (arrow) and pleural effusion (E) are present. These findings are most consistent with primary lung neoplasm with pleural metastasis and malignant pleural effusion (adenocarcinoma).
CT image at the level of the lower chest in a patient with both ascites and right-sided effusion. The ascites is on the right side by the blue color on the image. The effusion is yellow, and a small portion of the right lung is marked pink. The diaphragm is indicated by a red arrow. The interface between the effusion and the liver (yellow arrows) is less defined than the interface between the liver and ascites (blue arrows). The effusion, unlike ascites, extends posterior to the area of the liver.