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Pleural effusion

pulmonary disease

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PLEURAL EFFUSION
Hamad Emad H. Dhuhayr
CONTENTS
• SOEPEL
• PLUERAL EFFUSION
• PNEUMOTHORAX
• REFFERENCES
SOEPEL
• S- Khaled 85 year old Saudi male . he complained of dyspnea for
one weak and coughing with sputum. He has DM from 30 years,
HTN, stroke for 7 month and Parkinson disease.
• O- taking history and physical examination
• E- pleural effusion or pneumothorax or inspiration pneumonia.
• P- CXR, cbc, echo
• E- thoracentesis, tube thoracotomy and
• L- pleural effusion
CLINICAL APPROACH TO
PLEURAL EFFUSIONS
PLEURAL SPACE
The pleura consists of 2 layers
1 – parietal pleura
2 – visceral pleura
The space between the 2 layers is called the pleural
space
Normally the pleural space contains:
• 3.5 to 7.0 ml of clear liquid
• low protein content
• small number of mononuclear cells
• Definition.
Defined as an excess quantity of fluid in the pleural space caused either by ↑
pleural fluid formation or ↓ removal by the lymphatic system. The fluid may be
transudative or exudative.

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Pleural effusion

  • 2. CONTENTS • SOEPEL • PLUERAL EFFUSION • PNEUMOTHORAX • REFFERENCES
  • 3. SOEPEL • S- Khaled 85 year old Saudi male . he complained of dyspnea for one weak and coughing with sputum. He has DM from 30 years, HTN, stroke for 7 month and Parkinson disease. • O- taking history and physical examination • E- pleural effusion or pneumothorax or inspiration pneumonia. • P- CXR, cbc, echo • E- thoracentesis, tube thoracotomy and • L- pleural effusion
  • 5. PLEURAL SPACE The pleura consists of 2 layers 1 – parietal pleura 2 – visceral pleura The space between the 2 layers is called the pleural space Normally the pleural space contains: • 3.5 to 7.0 ml of clear liquid • low protein content • small number of mononuclear cells
  • 6. • Definition. Defined as an excess quantity of fluid in the pleural space caused either by ↑ pleural fluid formation or ↓ removal by the lymphatic system. The fluid may be transudative or exudative.
  • 7. ETIOLOGY 1. Transudative effusion: ↑ production of pleural fluid due to ↑ hydrostatic or ↓ oncotic pressures. Found in CHF, pulmonary embolism, cirrhosis, and nephrotic syndrome. 2. Exudative effusion: ↑ production due to abnormal capillary permeability or ↓ lymphatic clearance of fluid. Found in malignancy, pneumonia, TB, pulmonary embolism, pancreatitis, esophageal rupture, collagen vascular disease, and chylothorax. 3. In healthy patients, the pleural cavity contains a small volume of lubricating serous fluid, formed primarily by transudation from the parietal pleura and absorbed primarily by the capillaries and lymphatics. The balance between formation and removal of this fluid may be compromised by any disorder that increases the pulmonary or systemic venous pressure, lowers the plasma oncotic pressure, increases capillary permeability, or obstructs the lymphatic
  • 8. SYMPTOMS/EXAM • patients may experience dyspnea with large effusions. They may also complain Of pleuritic pain and have symptoms of pneumonia such as productive Cough, fever, and signs of consolidation. • on exam, dullness to percussion, decreased fremitus, and ↓ breath sounds May be found on the affected side. Patients may show symptoms of their Underlying disease process (cancer, pneumonia, CHF, cirrhosis).
  • 9. DIAGNOSIS • CXR: on upright PA and lateral films, blunting of costophrenic angles may be present with effusions > 250 ml. Decubitus films can differentiate Pleural fluid from pleural scarring and can help determine if the fluid is Loculated . • obtain fluid via thoracentesis and send for protein, glucose, LDH, cell Count, gram stain, and culture. Also obtain PH, fungal and mycobacterial Cultures, and cytology. In appropriate settings, look for pleural fluid Amylase, triglycerides, cholesterol, and hematocrit. Grossly purulent fluid Represents empyema. • hemothorax: a pleural hematocrit-to-peripheral hematocrit ratio > 0.5. • pancreatitis, pancreatic pseudocyst, adenocarcinoma of lung, or esophageal Rupture: ↑ pleural fluid amylase. • malignancy: cytology is only 50%–60% sensitive for detection. • pleural biopsy can help diagnose TB or cancer.
  • 11. TREATMENT • Transudative effusion: treat the underlying cause, and consider therapeutic Thoracentesis if symptomatic. No further workup is required. • exudative effusion: • parapneumonic: give appropriate antibiotics for infections; insert a Chest tube for drainage if complicated (eg, if ph < 7.2 or glucose < 60 • Mg/dl) or if empyema is present. • malignant: treat the underlying malignancy; repeat thoracentesis or Chest tube insertion for symptom relief. Pleurodesis can ↓ reaccumulation Of fluid. • hemothorax: rapid drainage via a large-bore chest tube to prevent fibrothorax. • tuberculous: usually resolves with treatment of TB.
  • 13. 13 Color of Fluid Suggested Diagnosis Pale yellow (straw) Transudate, some exudates Red (bloody) Malignancy or embolism or TB Turbid Infected effusion Pus Empyema White (milky) Chylothorax or cholesterol effusion Color of Fluid
  • 15. Peneumothorax is the accumulation of air in the pleural space. It may occur spontaneously or following trauma Disorder CauseCollection Haemothorax Hydrothorax Chylothorax Pneumothorax Blood Proteinaceous Fluid Lymph Air Chest trauma; rupture of aortic aneurysm Congestive cardiac failure Neoplastic infiltration; trauma Spontaneous; traumatic
  • 16.  Results from rupture of a pleural bleb  Pleural bleb being a congenital defect of the alveolar wall connective tissue.  Patients are typically tall, thin, young males.  M:f ratio 6:1.  Usually apical affecting both lungs with equal frequency.
  • 17.  Secondary causes occur in patients with underlying disease : COPD, TB, pneumonia, bronchial carcinoma, sarcoidosis and cystic fibrosis.
  • 18. Patients present with sudden onset of unilateral pleuritic pain and increasing breathlessness. The main aim of treatment is to get the patient back to active life as soon as possible.
  • 19.  Chest radiography may show an area devoid of lung markings. May be more clearly seen on the expiratory film
  • 20.  Small pneumothorax: no treatment, but review in 7-10 days.  Moderate pneumothorax: admit for simple aspiration.