Pleural Effusion and Pneumothorax

Pleural effusion and Pneumothorax:

Pleural effusion and Pneumothorax

Normal pleura:

Normal pleura Two layers: Visceral Parietal - accounts for most secretion and absorption of pleural fluid. Normal pleural fluid volume: 7-10ml

Pleural effusion:

Pleural effusion

Pathogenesis of pleural effusion:

Pathogenesis of pleural effusion TRANSUDATE Elevated capillary hydrostatic pressure - cardiac failure. Reduced capillary oncotic pressure - hypoalbuminemia. EXUDATE Enhanced capillary permeability - inflammation. Obstructed lymphatics - tumor. Movement of fluid from extrathoracic site - pancreatitis.

Pleural effusion Left side:

Pleural effusion Left side

Pleural effusion Right side:

Pleural effusion Right side

Pleural effusion Right side:

Pleural effusion Right side

Interlobar Effusion:

Interlobar Effusion

Hydropneumothorax:

Hydropneumothorax

Sub pulmonic effusion:

Sub pulmonic effusion Blunting of costophrenic angle Medial displacement of costophrenic angle "Elevated diaphragm" The peak of the dome of diaphragm more medial

Clinical manifestations:

Clinical manifestations Symptoms: dyspnea pain- "pleuritic" or "dull ache“ Cough asymptomatic Physical examination: enlarged hemithorax reduced vocal fremitus dullness to percussion decreased breath sounds, friction-rub

Approach to a pleural effusion:

Approach to a pleural effusion Plain chest X-ray - Distribution is determined by gravity. Obliteration of lateral costophrenic angle Fluid higher laterally (PA film) and semicircular meniscus on lateral films. Detects > 175ml of fluid May be subpulmonic, loculated or "pseudotumor

Clinical approach- cont:

Clinical approach- cont Decubitus x-rays/PA x-ray Ultrasound Computerised tomography, MRI Pleural tap!! Closed pleural biopsy Thoracoscopy Open pleural biopsy

Criteria of Light:

Criteria of Light Pleural fluid protein/serum protein ratio greater than 0.5 Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6 Pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH (a cut-off value of 200 IU/L was used previously) Pleural fluid is classified as an exudate if it meets any one of the aforementioned criteria if all three characteristics are not met, then the fluid is classified as a transudate

Differential diagnosis- transudate:

Differential diagnosis- transudate Congestive cardiac failure Hepatic cirrhosis Nephrotic syndrome Peritoneal dialysis Glomerulonephritis Urinothorax Myxedema Pulmonary embolism Sarcoidosis.

Differential diagnosis- exudate:

Differential diagnosis- exudate Parapneumonic effusion Malignancy - lung, breast, lymphoma, mesothelioma Tuberculosis Pulmonary emboli Abdominal disease Esophageal perforation Collagen vascular disease

Differential diagnosis- exudate:

Differential diagnosis- exudate Drugs- nitrofurantoin, bromocryptine,amiodarone, methtrexate. Asbestos Dressler's syndrome Meig's syndrome, Yellow-nail syndrome, Sarcoidosis, Uremia, Myxedema

Chylothorax and Empyema:

Chylothorax and Empyema Chylothorax: TG > 110mg/ dl or chylomicrons in fluid Tumor (lymphoma), trauma, lymhangiomyomatosis. Pseudochylothorax Empyema - "pus" in the pleural space "Complicated pleural effusion": Thick pus pH < 7.00 or glucose < 60mg/ dl Positive gram stain or culture pH <7.2 and LDH >1000U

Pleural fluid Adenosine Deaminase:

Pleural fluid Adenosine Deaminase ADA levels tend to be higher in tuberculous pleural effusions than in other exudates. A level above 70 U/L is highly suggestive of tuberculous pleuritis, whereas a level below 40 U/L virtually rules out this diagnosis. Other pleural diseases where high ADA levels may be seen are rheumatoid pleuritis and empyema

Pleural fluid amylase:

Pleural fluid amylase Amylase Elevated pleural fluid amylase is seen with pancreatitis and esophageal rupture, and in approximately 10% of malignant effusions.

Pleural Biopsy:

Pleural Biopsy Pleural Biopsy The use of Abrams' needle to obtain specimens from the parietal pleura has become less frequent with the increasing availability of improved serum markers and thoracoscopy. At present, a needle biopsy of the pleura is used mainly to diagnose tuberculous pleuritis when other markers (eg, ADA) are negative .

Treatment of pleural effusion:

Treatment of pleural effusion Treat underlying cause Thoracocentesis Chemical pleurodesis - talc or other Pleuro-abdominal shunt Streptokinase Surgery

Pneumothorax:

Pneumothorax

Pneumothorax:

Pneumothorax Air in the pleural space Open

Pneumothorax-Left side:

Pneumothorax-Left side

Hydropneumothorax-Right side:

Hydropneumothorax-Right side

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PNEUMOMEDIASTINUM

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PNEUMOMEDIASTINUM

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PNEUMOMEDIASTINUM

Classification of Pneumothorax:

Classification of Pneumothorax Spontaneous pneumothorax Primary - no identifiable pathology Secondary - underlying pulmonary disorder Catamenial Traumatic ,Blunt or penetrating thoracic trauma Iatrogenic ,Postoperative ,Mechanical ventilation Thoracocentesis ,Central venous cannulation

Pathophysiology of an Open Pneumothorax:

Pathophysiology of an Open Pneumothorax Air enters the pleural space from the outside Pressure outside the chest and inside the chest equalize Air enters the chest and collapses the lung If the defect is greater than 2/3 the diameter of the trachea air enters with each breath

Pathophysiology of Closed Pneumothorax:

Pathophysiology of Closed Pneumothorax A defect in the visceral pleural allows air to enter the pleural space Intrapleural pressure rises Lung tissue is compressed

Spontaneous Pneumothorax:

Spontaneous Pneumothorax A pneumothorax that occurs unexpectedly in healthy people (men) Cause Ruptured bleb Occurs without a known event Treatment sclerosing therapy surgery

Primary spontaneous pneumothorax:

Primary spontaneous pneumothorax Usually occurs in young healthy adult men 85% patients are less than 40 years old Male : female ratio is 6:1 Bilateral in 10% of cases Occurs as result of rupture of an acquired subpleural bleb Blebs have no epithelial lining and arise from rupture of the alveolar wall Frequency of spontaneous pneumothorax increases after each episode Most recurrences occur within 2 years of the initial episode

Secondary spontaneous pneumothorax:

Secondary spontaneous pneumothorax Accounts for 10-20% of spontaneous pneumothoraces can be due to: Chronic obstructive pulmonary disease with bulla formation Interstitial lung disease Primary and metastatic neoplasms Ehlers-Danlos syndrome Marfan's syndrome

Tension Pneumothorax:

Tension Pneumothorax Air enters the pleural space either from the lung or the outside Air is unable to escape Air collapses the lung Increased pressure displaces the lung and trachea to the opposite side Compression of the opposite lung Decreased venous return

Tension Pneumothorax:

Tension Pneumothorax Clinical Manifestations Deviation of the trachea toward the affected side Diminished or absent breath sounds on the affected side Cardiac output significantly decreases

Symptoms of pneumothorax:

Symptoms of pneumothorax Sudden shortness of breath Painful breathing Sharp chest pain, often on one side Chest tightness Dry, hacking cough Bluish color skin (because of a lack of oxygen) Engorgement of the neck veins (in tension pneumothorax) Low blood pressure or shock (in tension pneumothorax) Rapid heartbeat

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Management of Pneumothorax

Management of Spontaneous pneumothorax:

Management of Spontaneous pneumothorax Depends symptoms and the radiological size of the pneumothorax Small asymptomatic pneumothoraces (<20%) may simply be followed with serial chest x-rays If drainage required a chest drain should be inserted Through the 5th intercostal space Just above the upper border of the rib Blunt insertion (rather than using the trocar) should be used Position should be checked with a chest x-ray Should be connected to an underwater seal placed below the level of the patient

Management of Tension pneumothorax:

Management of Tension pneumothorax Prophylactic chest drains should be inserted in patients with rib fractures prior to ventilation Tension pneumothorax requires immediate needle aspiration Inserted anteriorly through the 2nd intercostal space Chest drain can then be inserted

Surgery and chemical pleurodesis :

Surgery and chemical pleurodesis Surgery is required for Air leak persisting for more than 10 days Failure of lung re-expansion Recurrent spontaneous pneumothorax Surgical options include Partial pleurectomy Operative abrasion of pleural lining Resection of pulmonary bullae Poor-risk patients may benefit from chemical pleurodesis with tetracycline