The document covers various types and causes of pleural effusions and pneumothorax, outlining features such as signs, symptoms, diagnostic methods, and treatments. It discusses differentiating between transudative and exudative effusions, the importance of diagnostic imaging, and the role of pleural fluid analysis. Management options include aspiration, drainage, and addressing underlying conditions, with specific surgical interventions for complications.

3.  Pleuritis – Dry pleurisy
 Pleural effusion – Hydrothorax
 Hemothorax
 Pyothorax – empyema
 Chylothorax
 Pneumothorax
 Hydro-pneumothorax
 Pyo-pneumothorax
 Fibrothorax – Pleural thickening

4. Exudative effusion
 Tuberculosis
 Bacterial – Synpneumonic
Post pneumonic
 Malignant
 Connective tissue disorders
 Pulmonary thromboembolism
Transudative: CHF, constrictive pericarditis, Nephrotic syndrome,
hypoproteinemia, cirrhosis

5.  Chest pain or heaviness
 Breathlessness and cough
 General – weakness, fatigue, night-sweats, fever
Signs:
 Tracheal and mediastinal shift
 Bulging of hemithorax
 Movements – diminished
 P. note – impaired / dull/ stony dull
 Br. Sounds – Decreased / absent
Pl. rub, Egophony, etc.
Symptoms & signs of underlying disease

6. i. Physical examination
ii. Chest radiology
CXR: Opacity, rising level, or massive
CT chest to see the underlying lungs,
mediastinal LN etc.
iii. Sputum, if available
iv. Tuberculin skin test
v. Pleural fluid aspiration (Pleurocentesis)
vi. pleural biopsy / thoracoscopy

12. 1. Pleural fluid chemistry: pH, Fluid LDH level
Fluid total protein and corresponding serum protein
Fluid glucose and corresponding serum glucose
2. Special chemistry: Fluid Amylase, Triglycerides, Cholesterol
3. Total and differential cell count
4. Cytological examination: Special stains for malignancy, fungal infections
5. Immunological studies: Fluid ANA, Rheumatoid factor, Adenosine deaminae
6. Special immuno-Cytology
Flow Cytometry for diagnosis of lymphoma
Tumor markers for diagnosis of malignant pl effusion

13.  Pleural biopsy
▪ Closed bx with Abram’s needle
▪ Thoracoscopic
(Biopsy exam. May reveal granulomas or other histopath.
Depending upon the cause)
 Thoracoscopy – “Gold standard procedure” – examination and
biopsy

14. Appearance Underlying Disease
Pale yellow Most transudates
Turbid Inflammatory exudates
Pus Empyema
Hemothorax Trauma, malignancy, Pulmonary embolism,Thoracic
endometriosis
Milky fluid Chylothorax
Brown Amebic liver abscess
Black Fungal infection (aspergillus niger)
Yellow to green Rheumatoid pleurisy

16. Common causes of Transudative Pleural Effusion
 Heart failure (left and bi-ventricular failure)
 Cirrhosis of liver, Nephrotic syndrome
 Hypoalbuminemia, Constrictive pericarditis
 Peritoneal dialysis Subclavian vein thrombosis
Common causes of Exudative Pleural Effusion
 Tuberculosis
 Non-tubercular infections (Bacterial, Fungal)
 Malignancies (Lung, pleura, metastases)
 Connective tissue diseases (RA, SLE)
 Pulmonary thromboembolism

17.  Atlectasis
 Benign asbestos pleural effusion
 Hypoalbuminemia
 Nephrotic syndrome
 Peritoneal dialysis
 Rheumatoid effusion
 Trapped lung
 Urinothorax
 Yellow Nail syndrome

18. PancreaticType Amylase SalivaryType Amylase
Acute pancreatitis Adenocarcinoma of lung
Squamous cell lung cancer
Chronic pancreatitis Undifferentiated lung cancer
Ovarian Cancer
Pancreatic pleural fistula Multiple myeloma
Lymphoma
Lymphatic leukemia
Pneumonia
Tuberculosis

19. Traumatic Non-traumatic
Mediastinal, lung and cardiac surgery Benign
Lyphangioieiomyomatosis
Neck surgery especially on left side Tuberous sclerosis
Central line placement aspecially on left side Filariasis
Amylodosis
Benign mediastinal tumors
Endoscopic sclerotherapy Malignant
Penetrating surgery to neck and thorax Lymphoma
Mediastinal metastasis
Post delivery Primary lung cancer
Kaposi’s Sarcoma

20.  Fluid aspiration – therapeutic
 Chest-tube drainage (empyema, pneumothorax, hemothorax)
 Treatment of underlying disease:
- Tuberculosis
- Bacterial/ fungal infections
- Malignancy etc.
(Tmt of transudative effusion mostly consists of tmt of the cause of
effusion)

21.  Depend upon the underlying etiology
 Increase in fluid causes breathlessness and respiratory distress
 Broncho-pleural fistula formation
 Hydropneumothorax may occur
 Empyema and pyo-pneumothorax
 Pleural fibrosis, thickening, chest deformity
 Chest movement restriction – long term
 May lead to chronic cor pulmonale

22.  Pus in the pleural cavity
 Commonly occurs as a complication of pneumonia
Sometimes, iatrogenic following aspiration, trauma
Symptoms & Signs: Fever, rigors, sweating, malaise
Tender hemithorax, Signs of bulging (Acute) or retraction (chronic
empyema)
Diagnosis: History, Chest X Ray, CT Chest, TLC, DLC, CRP, ESR etc
Pl fluid/ pus examination – Gram’s stain, culture

23.  Staphylococcus aureus, MRSA, S. epidermidis
 Streptococcus intermedius, St pneumoniae, St pyogenes, Streptococcus milleria
 Anaerobes: Fusobacterium, Bacteriods Peptosteptococcus, Prevotella spp.,
Clostridium spp.
 Klebsiella pneumoniae
 Pseudomonas aeruginosa
 Escherichia coli
 Enterobacter supp.
 Mycobacterium tuberculosis
 Actinomyces spp.

24.  Drainage – ICTD
 Antibiotics – change according to causative organism and
sensitivity reports
 Surgical intervention: Adhesiolysis
Decortication
Lung resection

25.  Therapeutic closure of pleural cavity through adhesion of pleural
membranes
 Done in case of recurrent effusion
 Total drainage of fluid with ICTD following by administration of
pleurodesic agent such as:
- Tetracycline, doxycyclkine, mepacrine
- Talc powder or slurry
- Betadine
- Cytotoxic agents: Bleomycin

26. Pneumothorax
spontaneous
primary
secondary
traumatic
iatrogenic
non-iatrogenic

27. Primary: Cause unidentified
Secondary: Identifiable cause
 Obstructive airway disease/ Bullous emphysema, Asthma
 Infections: Tuberculosis
 Pneumonias – Staphylococcal
 Fungal infections
 Lung cancer
 Connective tissue diseases
 Interstitial lung disease
 Miscellaneous: Lymphangioleimyomatosis
Histiocytosis, Morfan’s Syndrome

28.  Acute: Sudden onset chest pain, breathlessness
 Chronic/ Loculated: Heaviness, pain, breathlessness
 Symptoms of underlying illness
Signs:
- Bulge of hemithorax
- Shift of mediastinum to opposite side
- Movements diminished
- Percussion note – hyper-resonant
- Breath sounds – diminished
- Bronchial breathing/ egophony

29. Clinical features also depend upon the type of pneumothorax
 Communicating (Open): Pt may be comfortable at rest,
breathless on exertion. Sign of BP Fistula may be present
 Non-communicating (Closed): Subacute or chronic. May be
loculated.
Tension pneumothorax (Expanding): Acute with respiratoy
distress.

30.  History & physical examination
 Chest X-Ray, CT scanning
 Investigations for cause of pneumothorax
 Thoracoscopic examination

31. A B

32. Pleural line

35.  Tension pneumothorax
 Respiratory distress, shock
 Leakage of air to mediastinum and pericardial cavity
(pneumomediastinum), subcutaneous tissues (subcutaneous
emphysema), peritoneal cavity (pneumoperitoneum) etc.
 Cardiac compression – cardiac temponade
 Infection in the pleural cavity, hydro and pyo-pneumothorax,
fistula etc.

36. 1. Drainage with a pig-tail catheter/ chest-tube under water-seal
Acute and tension pneumothorax:
Immediate drainage is required.
2. Supportive tmt: Oxygenation
Treatment of underlying etiology
3. Surgery depending upon the cause
(Bullectomy, lobar or lung resection etc)
4. Recurrent pneumothorax: Pleurodesis

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