Pleural diseases

PLEURAL DISEASES : 

PLEURAL DISEASES TDMC Alappuzha

Pleural fluid Normal : 

Pleural fluid Normal Amount -0.15 ml / kg. Ultra filtrate of plasma. Cells < 1000 wbc/cumm. Sugar, Na+, K+, Ca2+ = that of serum. pH 7.6 Protein < 2 g% LDH< .5 times of serum.

Pleural effusion : 

Pleural effusion Collection of fluid in Pleural space. Production and absorption. Transudative- Systemic Cause. Exudative- Local Cause. Why Differentiate? Cause of Local Disease. Modified Lights criteria.

Slide 4: 

115-221U/L SPAG

EFFUSION DUE TO HEART FAILURE : 

EFFUSION DUE TO HEART FAILURE Isolated right sided pleural effusions are more common. Thoracentesis if the effusions are not bilateral and comparable in size, if thepatient is febrile, or if the patient has pleuritic chest pain, Rx with diuretics NT-proBNP >1500 pg/mL is virtually diagnostic

HEPATIC HYDROTHORAX : 

HEPATIC HYDROTHORAX In ~5% of patients with cirrhosis and ascites. Direct movement of peritoneal fluid through small openings in the diaphragm. Usually right-sided. Large enough to produce severe dyspnea.

PARAPNEUMONIC EFFUSION : 

PARAPNEUMONIC EFFUSION A/w bacterial pneumonia, lung abscess, or bronchiectasis Empyema refers to a grossly purulent effusion. Aerobic bacterial pneumonia and pleural effusion present with an acute febrile illness with chest pain, sputum production, and leukocytosis. Anaerobic -present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration.

Parapneumonic effusion : 

Parapneumonic effusion Lateral decubitus radiograph, computed tomography (CT) of the chest, or ultrasound. If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed.

Complicated effusion : 

Complicated effusion Loculated pleural fluid. Pleural fluid pH < 7.20. Pleural fluid glucose < 3.3 mmol/L (<60 mg/dl) Positive gram stain or culture of the pleural fluid. The presence of gross pus in the pleural space.

Complicated.. : 

Complicated.. If fluid recurs /complicating characteristics- a repeat thoracentesis should be performed. If fluid cannot be completely removed with thoracentesis, -a chest tube and fibrinolytic. or performing thoracoscopy with the breakdown of adhesions. Decortication should be considered when the above are ineffective.

MALIGNANCY : 

MALIGNANCY Second most common type of exudative pleural effusion. Lung carcinoma, breast carcinoma, and lymphoma. Dyspnea, out of proportion to the size of the effusion. Exudate,+/-low glucose level.

Diagnosis : 

Diagnosis

Treatment : 

Treatment Symptomatic only symptom attributed to effusion itself is dyspnea. if the dyspnea is relieved with a therapeutic thoracentesis: small indwelling catheter. tube thoracostomy +sclerosing agent.

MESOTHELIOMA : 

MESOTHELIOMA Primary tumors that arise from the mesothelial cells lining the pleural cavities Most are related to asbestos exposure. Present with chest pain and shortness of breath. CXR- pleural effusion, generalized pleural thickening, and a shrunken hemithorax. Thoracoscopy or open pleural biopsy is usually necessary to establish the diagnosis.

PULMONARY EMBOLIZATION : 

PULMONARY EMBOLIZATION Commonly overlooked. Dyspnea is the most common symptom. Exudate Diagnosis spiral CT scan or pulmonary arteriography. Rx same as other patients with pulm embolism

TB Pleuritis : 

TB Pleuritis Common. Associated with primary TB Primarily d/t hypersensitivity. Present with fever, weight loss, dyspnea, and/or pleuritic chest pain. Exudate with predominantly small lymphocytes.

Diagnosis : 

Diagnosis Rx Same as for pulmonary TB

Effusions D/t Viral Infections : 

Effusions D/t Viral Infections Large portion of Undiagnosed Effusions. Resolve spontaneously with no residua. If patient with undiagnosed effusion improves symptomatically, ITS WISER NOT TO BE TOO AGGRESSIVE!!!

HIV : 

HIV MCC- KSV. 2nd parapneumonic. Cryptococcosis, TB, Primary effusion lymphoma. PCP very uncommon cause of PLEURAL EFFUSION.

CHYLOTHORAX : 

CHYLOTHORAX Damage to thoracic duct. Trauma, tumours in mediastinum. Milky, TGC>110. Pseudochylous. Rx Chest tube+ Octreotide. Pleuroperitoneal shunt. Prolonged tube thoracostomy avoided.

HEMOTHORAX : 

HEMOTHORAX Hematocrit >half of blood, Most are the result of trauma. Other causes- rupture of a blood vessel or tumor. Tube thoracostomy for drainage and continuous quantification of bleeding. hemorrhage >200 mL/h =>thoracoscopy or thoracotomy.

MISCELLANEOUS CAUSES : 

MISCELLANEOUS CAUSES amylase- Esophageal/ Pancreatic d/s. Febrile with PMN in exudate but parenchyma normal- Abdominal abscess. Ovary-Fibroma, Hyperstimulation. Drugs can cause pleural effusion-the associated fluid is usually eosinophilic. Post CABG. abdominal surgery,radiation therapy, liver, lung, or heart transplantation; Intravascular insertion of central lines

Transudative Pleural Effusions : 

Transudative Pleural Effusions Congestive heart failure Cirrhosis Pulmonary embolization Nephrotic syndrome Peritoneal dialysis Superior vena cava obstruction Myxedema Urinothorax

EXUDATIVE : 

EXUDATIVE 1. Neoplastic diseases a. Metastatic disease b. Mesothelioma 2. Infectious diseases a. Bacterial infections b. Tuberculosis c. Fungal infections d. Viral infections e. Parasitic infections 3. Pulmonary embolization 4. Gastrointestinal disease a. Esophageal perforation b. Pancreatic disease c. Intraabdominal abscesses d. Diaphragmatic hernia e. After abdominal surgery f. Endoscopic variceal sclerotherapy g. After liver transplant 5. Collagen-vascular diseases a. Rheumatoid pleuritis b. Systemic lupus erythematosus c. Drug-induced lupus d. Immunoblastic lymphadenopathy e. Sjögren's syndrome

EXUDATIVE : 

EXUDATIVE 6. Post-coronary artery bypass surgery 7. Asbestos exposure 8. Sarcoidosis 9. Uremia 10. Meigs' syndrome 11. Yellow nail syndrome 12. Drug-induced pleural disease a. Nitrofurantoin b. Dantrolene c. Methysergide d. Bromocriptine e. Procarbazine f. Amiodarone 13. Trapped lung 14. Radiation therapy 15. Post-cardiac injury syndrome 16. Hemothorax 17. Iatrogenic injury 18. Ovarian hyperstimulation syndrome 19. Pericardial disease 20. Chylothorax

PNEUMOTHORAX : 

PNEUMOTHORAX

Pneumothorax : 

Pneumothorax Pneumothorax is the presence of gas in the pleural space. Spontaneous pneumothorax -occurs without antecedent trauma to the thorax. Primary spontaneous pneumothorax occurs in the absence of underlying lung disease.

Slide 30: 

Traumatic pneumothorax results from penetrating or nonpenetrating chest injuries. A tension pneumothorax is a pneumothorax in which the pressure in the pleural space is positive throughout the respiratory cycle.

PRIMARY SPONTANEOUS PNEUMOTHORAX : 

PRIMARY SPONTANEOUS PNEUMOTHORAX Smokers Apical Subpleural blebs. Recurrence 50%. Aspiration with needle. If no re-expansion thoracoscopy with stapling of blebs and pleural abrasion. Almost 100% successful.

Secondary Spontaneous Pneumothorax : 

Secondary Spontaneous Pneumothorax Etiology COPD Cystic fibrosis Interstitial lung disease such as sarcoidosis or eosinophilic granuloma Pneumocystis Recurrence rates higher than for primary spontaneous pneumothorax

Treatment of Secondary Pneumothorax : 

Treatment of Secondary Pneumothorax Chest tube Pleurodesis with first event with or without thoracoscopy

TENSION PNEUMOTHORAX : 

TENSION PNEUMOTHORAX Medical emergency During mechanical ventilation or resuscitative efforts. The positive pleural pressure is life-threatening Compromises ventilation as well as venous return Difficulty in ventilation during resuscitation or high peak inspiratory pressures during mechanical ventilation . A large-bore needle ,second anterior intercostal space. Gas escape -diagnosis is confirmed. The needle should be left in place until a thoracostomy tube can be inserted.

Mesotheolioma : 

Mesotheolioma Associated with asbestos exposure (even very modest exposures) Latency of 35-40 years No association with smoking. Difficult diagnosis by cytology. Therefore, usually a biopsy is recommended. Three histological subtypes Epithelial Sarcomatous Mixed

Treatment of Mesothelioma : 

Treatment of Mesothelioma Extrapleural pneumonectomy 5% surgical mortality Median survival of 21 months (best with epithelial histology) 5 year survival 22% There may be a role for multimodality therapy using chemotherapy and radiation therapy

THANKYOU : 

THANKYOU