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Pleural effusion dr.anush
- 1. Pleural Effusion Prepared by :Dr.Anush Resident of Thoracic Surgery
- 2. Overview – Introduction – Classification –Pathogenesis – Etiology – Clinical features – Investigation – Management
- 3. Introduction – Pleural effusionis defined as abnormal of fluid in the pleural space . – The pleural space contains normally 0.3ml/kg/h body weight of pleural fluid . (Partial Capillaries) – Lymphatic's have the capacity to absorb 20 time more then what is produced. – Fluid accumulates in the pleural cavity due to either changing in hydrostatic and oncotic pressure or changed permeability of the pleura.
- 4. Con… – The pleuralspace normally contains only about 10-20 ml of serous. – Pleural fluid normally seeps(drip) continually into the pleural space from the capillaries lining the parietal pleural and is reabsorbed by the visceral pleural capillaries and lymphatic system. – Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.
- 5. Composition of pleuralfluid – Volume 0.3ml/kg/h – Cells /mm3 1000-5000 Mesothelium cells 60% Monocyte 30% Lymphocytes 5% PMINs 5% – Protein <50% plasma level (105-333iu/l) – Glucose =plasma level (90-120) – PH > plasma level (7.6-7.64)
- 6. Classification – Can beunilateral or bilateral and classified – A) based on sit : Apical Inter lobar Sub – pulmonic Mediastinal - B)based on mechanism and type of pleural fluid 1. Transudative ( alteration in hydrostatic and oncotic pressure ) 2. Exudative (alteration in pleural permeability)
- 7. Cont. C(based on mechanismand type of pleural fluid formed : Pyogenic Chylous Heamothorax Pseudochylous Hydrothorax
- 8. Pathophysiology – Trsnsudative Pleuraleffusion – Hydrostatic pressure oncotic pressure – Unable to remain the fluid with in a intravascular space – Fluid shift interstitial space – EFFUSION
- 9. Cont. .. – ExudativeEffusion – Invasion of microbes – Initiaon of inflammatory reaction – Vasodilation (increase capillary permeability – Leak of plasma protein decrease oncotic pressure – Fluid shift into interstitial space
- 10. Etiology – EXUDATIVE – Infection: Pneumonia ,Bronchiectasis ,Pancreatitis ,TB,Lung Abscess – Collagen vascular disease : SLE,RA,Polyarthritis – Neoplastic:Leukemias and lymphomas – Drug :Bromocriptin,Amiodarone,Nitrofuantoin,dentrolene,INH – Post radiation – Traumatic
- 11. Con… – TRANSUDATIVE: – Renalcause : Nephritic Syndrome – Cardiac Case : Hepatic failure – Nutritional : PEM – Hypothyroidism
- 12. Cont.… – Pyogenic : –Lung Abscess – Septicemia – Chest wall injuries – Rupture of esophagus – Rupture of sub phrenic abscess – Rupture of liver abscess Chylous Trauma to thoracic duct Tumor (mediastina lymphoma) Tuberculosis Lymphatic obstruction Heamothorax Chest wall injuries Bleeding disorders Neoplasms Drugs-anticoagulants Pulmonary infarction
- 13. Cont. .. – Psudochyloushydrothorax – Rheumatoid pleuritits CHF – Tuberculosis Hepatic and renal failure
- 14. Clinical features – Manypatients have no symptoms due to the effusion when effusion is small. – Pleuritic chest pain : pleural inflammation – Dry- Non productive cough : irritation of pleural surface – Dyspnea : large effusion--lung compression
- 15. Physical examination – Inspection: –Absent or diminished movements of affected side – Fullness of chest with bulging intercostal spaces – Palpation: – Diminished breath sounds over – Percussion: – Stony dullness to percussion – Auscultation: – Absence of breath sounds over the effusion
- 16. Investigations – Total anddifferential leucocyte counts CBC – •CRP, ESR, – Radiological examination: – • X-ray chest PA view done in erect position-a total of 300mL of fluid is needed to diagnose pleural effusion clinically and radio logically – • Even 50mL of fluid can be demonstrated radio logically in lateral decubitus
- 17. Findings – • Obliterationof cardio phrenic and cost phrenic angles – • Loculated effusions – • Lateral decubitus on side of effusion will show a shift in the fluid level • Tracheal and mediastinal shifts are seen in massive effusion
- 19. Con… – Ultrasonogram – Usefulin differentiating between loculated pleural effusion and tumor – CT Scan :Helpful if the effusion is minimal or loculated – Pleural fluid aspiration (Thoracocentesis) – Diagnostic: – Helps to differentiate between exudates and transudates – Therapeutic: Massive collection or rapid collection of pleural fluid Severe respiratory distress Suspected empyema Massive mediastinal shift
- 20. Gross appearance – Straw-coloured –• Blood stained – • Purulent – • Chylous
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- 22. lIGHT’S CRITERIA: – •At least one of the following criteria should be satisfied to identify exudates: – Pleural fluid to serum total protein ratio- more than 0.5 – Pleural fluid to serum LDH ratio- more than 0.6 – None of these criteria should be satisfied in a transudate effusion
- 23. Roth’s criteria – •If serum-pleural fluid albumin gradient is more than 1.2 it is transudate, else exudate.
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- 25. Management of P.E –Treatment of underlying case . – Therapeutic aspiration/ Thoracentesis is necessary in order to relieve dyspnea. – Precautions : – Removing more than 1L-1.5l in one episode in inadvisable – Can result in re-expansion pulmonary edema – Should never be aspirated to dryness before the exact etiology is determined
- 26. Complications –Large effusion couldlead to respiratory failure
- 27. Complication of thoracentesis –Iatrogenic pneumonia – Infection – Dry tap or bloody tap – Re-expansion pulmonary edema – Pain and respiratory distress
- 29.