Clinical Approach to

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Clinical Approach to PLEURAL EFFUSIONS
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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 Normal width of the pleural
space is 10-20 mm
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Pleura
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Pleura
Visceral pleura envelope all surfaces of the
lungs, including the interlobar fissures.
Parietal pleura cover the inner surface of the
thoracic cavity, including the diaphragm, and
ribs.
At the Hilum where pulmonary vessels, bronchi,
and nerves enter the lung tissue, the parietal
pleura is continuous with the visceral pleura.
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• PLEURAL EFFUSION
• Normally the pleural space contains
• 3.5 to 7.0 ml of clear liquid
• low protein content
• small number of mononuclear cells
• Pleural effusion presence of large amount of
  fluid in the pleural space irrespective of the
  underlying causes

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PLEURAL FLUID FORMATION AND ABSORTION
PLEURAL SPACE
INTERCOSTAL MICROVESSELS
BRONCHIAL MICROVESSELS
VEIN
VEIN
ARTERY
ARTERY
?
LYMPHATICS TO MEDIASTINAL NODES
PLEURAL FLUID
STOMA
PLEURAL SPACE
VISCERAL PLEURAL
PARIETAL PLEURAL
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MOVEMENTS OF FLUID IS BASED ON STARLINGS LOW
STARLINGS LOW L . A (PCAP PPl)
(?CAP ?Pl)
L Filtration coefficient A Surface area Cap
Capillary Pl Pleural
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PLEURAL FLUID FORMATION AND ABSORTION

• The rate of fluid formation is 0.02 ml/kg/hour.
• The rate of fluid clearance is 0.2 ml/kg/hour.

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PLEURAL FLUID FORMATION AND ABSORTION
PLEURAL SPACE
INTERCOSTAL MICROVESSELS
BRONCHIAL MICROVESSELS
VEIN
VEIN
ARTERY
ARTERY
?
LYMPHATICS TO MEDIASTINAL NODES
PLEURAL FLUID
STOMA
PLEURAL SPACE
VISCERAL PLEURAL
PARIETAL PLEURAL
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Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia) plasma
oncotic pressure (hypoalbuminemia) pleural
membrane permeability (malignancy) lymphatic
obstruction (malignancy) diaphragmatic defect
(hepatic hydrothorax) thoracic duct rupture
(chylothorax)
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Symptoms

• key symptom -------gt shortness of breath
• Fluid filling the pleural space makes it hard for
  the lungs to fully expand, causing the patient to
  take many breaths so as to get enough oxygen.
• If parietal pleura is irritated -------gt mild
  pain or a sharp stabbing
• 
  pleuritic type of pain.
• Some patients will have a dry cough.

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Symptoms
Occasionally ------gt no symptoms at all. This
is more likely when the effusion results from
recent abdominal surgery, cancer, or
tuberculosis. Tapping on the chest will show
stony dullness, and decrease breath sound
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Diagosisn of pleural effustion

• x ray
• The fluid itself can be seen at the bottom of the
  lung or lungs, hiding the normal lung structure.
• If heart failure is present,
• the x-ray shadow of the heart will be enlarged.
• Ultrasound may disclose a small effusion that
  caused no abnormal findings during chest
  examination.
• C.T. scan is very helpful if the lungs
  themselves are diseased.

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• Management of Pleural effusion

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PLEURAL EFFUSION
Indication for Pleural Fluid Analysis

• Diagnostic ( detect underlying diagnosis)
• Therapeutic (relief shortness of breath)

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PLEURAL EFFUSION
DIAGNOSTIC THORACENTESIS

• CONTRAINDICATIONS
• Bleeding tendency
• Thrombocytopenia (decrease platelets less 25000
  u3/dl )
• Prolonged PT or PTT greater than twice normal,
• A very small volume of pleural fluid

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Color of Fluid
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
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Transudates vs Exudates
LIGHTS CRITERIA
1. Pleural Protein divided by serum protein
gt0.5 2. Pleural fluid LDH divided by Serum LDH
gt0.6 3. Pleural fluid LDH gt 2/3 the upper limit
of normal for the serum LDH.
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Causes of Transudates and Exudates
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PLEURAL EFFUSION

• CELL COUNT
• Transudate lt 1000 but 20 gt 1000 and rarely gt
  10,000/mm3
• Exudate gt 1000/mm3
• Limited value (unless gt 50,000/mm3 ? emphyema)

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PLEURAL EFFUSION
PF LYMPHOCYTE-PREDOMINANT EXUDATES (gt80)
Causes TB Lymphoma Chronic lymphocytic
leukaemia
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PLEURAL EFFUSION
BIOCHEMISTY Glucose lt 3.3 mmol/L or 1/2 serum
glucose (simultaneous) - Rheumatoid pleurisy
(85) - Empyema (80) - Malignancy (40)
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PLEURAL EFFUSION
The mechanism responsible for pleural fluid low
glucose include

• Decreased transport of glucose from blood to
  pleural fluid
• Increased utilization of glucose by constituents
  of pleural fluid, such as neutrophils, bacteria
  (empyema), and malignant cells

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PLEURAL EFFUSION

• BIOCHEMISTY
• Pleural fluid pH
• - Normal pleural fluid pH is gt 7.6
• - Transudates pH 7.40-7.55
• - Exudates pH is 7.30-7.45
• Should always be measured in a blood gas machine
• Parapneumonic - pH lt 7.0 predicts complicated
  effusion that is unlikely to resolve without
  chest tube drainage.
• Malignant effusion with a pH lt 7.3 is associated
  with poor survival.
• If pH lt 6.0 think of ruptured esophagus

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PLEURAL EFFUSION
The mechanism responsible for pleural fluid
acidosis (pH lt7.30) include

• Increased acid production by pleural fluid cells
  and bacteria
• Decreased hydrogen ion efflux from the pleural
  space, due to pleuritis, tumor, or pleural
  fibrosis.

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PLEURAL EFFUSION
DIAGNOSES ASSOCIATED WITH PLEURAL FLUID ACIDOSIS
(pH lt7.30) AND LOW GLUCOSE CONCENTRATION
(PF/SERUM lt0.5)
Diagnosis Usual pH (Incidence) Usual
Glucose Concentration
(mg/dL) Empyema 5.50-7.29 (-100) lt40 Malignancy
6.95-7.29 (33) 30-59 Tuberculous
pleurisy 7.00-7.29 (20) 30-59
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PLEURAL EFFUSION

• CYTOLOGY
• positive in about 60 of patients with malignant
  effusion

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PLEURAL EFFUSION

Patients with Abnormal Chest Radiograph
Suspect pleural disease
Blunting of costophrenic angle?
YES
Lateral decubitus chest radiographs
Yes
No
Diagnostic thoracentesis
Fluid thickness gt 10mm
Observe
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PLEURAL EFFUSION
SUMMARY
Diagnostic thoracentesis
Any of the following met? PF/serum protein
gt0.5 PF/serum LDH gt0.6 PF LDH gt2/3 upper normal
Serum limit
Yes
No
Exudate
Transudate
Appearance of plueral fluid, pH glucose,
cytology and differential cell count of pleural
fluid
Treat CHF, cirrhosis, or nephrosis
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Treatment
direct treatment at what is causing it, rather
than treating the effusion itself
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pneumothorax

• Peneumothorax is the accumulation of air in the
  pleural space. It may occur spontaneously or
  following trauma

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Spontaneous

• 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.
• MF ratio 61.
• Usually apical affecting both lungs with equal
  frequency.

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Spontaneous

• Secondary causes occur in patients with
  underlying disease
• COPD, TB, pneumonia, bronchial carcinoma,
  sarcoidosis and cystic fibrosis.

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Spontaneous

• 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.

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Investigations

• Chest radiography may show an area devoid of
  lung markings.
• May be more clearly seen on the expiratory film

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Management

• Small pneumothorax no treatment, but review in
  7-10 days.
• Moderate pneumothorax admit for simple
  aspiration.

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The End