Pleural Effusions

PLEURAL EFFUSIONS

Pleural effusion  Pleural

effusion is the presence of fluid within the pleural space, the pleural can be the site of both benign and malignant diseases that may represent primary pleural processes, localized extrapleural diseases, or systemic illnesses. Pain and dyspnea are the most common symptoms of pleural disease.

Anatomy of pleural membrane and pleural space 1234 Pleural membrane consists of parietal pleura and visceral pleura  A space situated between parietal and visceral pleura is called pleural space  It is normally filled with 5 - 10 milliliter of serous fluid 

Anatomy of pleural membrane and pleural space 1234 Parietal pleura Receiving its blood supply from the systemic circulation and containing sensory nerve ending

Anatomy of pleural membrane and pleural space 1234 Visceral pleura Receiving its blood supply from the low pressure pulmonary circulation and containing no sensory nerve fibers So the pleural pain is mediated through somatic intercostal nerves of the chest wall and through the phrenic nerve, causing chest wall or back pain and pain referred to the shoulder, respectively.

Mechanism of formation-resorption of pleural fluid Parietal pleura

Visceral pleura

Hydrostatic pressure(30)

Pressure of pleural space (5)

11

Permeability of systemic circulation(34)

Permeability of pleural fluid (8)

34

5+8+30-34=9

34-(5+8+11)=10

The mechanisms that lead to accumulation of pleural fluid l. Increased hydrostatic pressure in microvascular circulation (congestive heart failure) 2. Decreased colloidal osmotic pressure in microvascular circulation (severe hypoalbuminemia ) 3. Increased permeability of the microvascular circulation (pneumonia) 4. Decrease in the intrapleural pressure 5. Impaired lymphatic drainage from the pleural space (malignant effusion) 6. Movement of fluid from peritoneal space ( ascites ) 7.Rupture of a vascular or lymphatic structure (trauma, cancer)

Transudates and exudates  Pleural

effusions, being a common medical problem, have been classically divided into transudates and exudates. Differentiation is of particular importance because in the case of a transudate, aetiology and therapy are directed to the underlying congestive heart failure, cirrhosis, or nephrosis; Alternatively, if the effusion proves to be an exudate, malignancy is suspected and a more extensive diagnostic procedure is needed.

Two kinds of pleural effusions Transudates and exudates Transudate           

Cause Apperance Specific gravity Coagulability Rivalta test Protein content ΘP. To serum Pre LDH Θ P. To s Cell count Differential cell

non-inflammatory light yellow <1.018 unable negative <30g/L < 0.5 < 200 I U/ L < 0.6 < 100×10 6/ L Lymphocyte

Exudate flammatory,tumor yellow, purulent >1.018 able positive >30g/L > 0.5 > 200 I U / L > 0.6 > 500×10 6 / L Different

Common causes of pleural effusions Transudates 1. Generalized salt and water retention, e.g., congestive heart failure, nephrotic syndrome, hypoalbuminemia 2. Ascites, e.g., cirrhosis, meigs' syndrome, peritoneal dialysis 3. Vascular obstruction, e.g., superior vena cava obstruction 4. Tumor

Exudates l. Infectious diseases, e.g., TB, bacterial pneumonias, and other infectious diseases.

2. Tumor 3. Pulmonary infarction 4. Rheumatic diseases

Clinical manifestations  Symptoms:

asymptomatic pain- "pleuritic" or "dull ache“ cough Dyspnea  Physical examination: enlarged hemithorax reduced vocal fremitus dullness to percussion decreased breath sounds, friction-rub

Approach to a pleural effusion  Plain

chest X-ray Distribution is determined by gravity.. Obliteration off lateral costophrenic angle Fluid higher laterally (PA film) and semicircular meniscus on lateral films..

Clinical approach- cont.  x-rays  Ultrasound  Computerized

tomography

 MRI  Closed

pleural biopsy  Thoracoscopy  Open pleural biopsy

Empyema  Empyema

l. 2. 3. 4.

- "pus" in the pleural space

TB Pulmonary infection Trauma Esophageal rupture

Empyema  "Complicated  Thick

pleural effusion":

pus  pH < 7.00 or glucose < 60mg/ dl  Positive gram stain or culture  pH <7.2 and LDH >1000U

Hemothorax  Defined

as pleural fluid hematocrit of 50% of blood hematocrit  Will coagulate & may lead to loculation with complications of fibrothorax & possible empyema  If small,, may defibrinate & remain free flowing

Hemothorax l. 2. 3. 4. 5.

Trauma Tumor Pulmonary infarction TB Spontaneous pneumothorax

Chylous effusion 1. 2. 3. 4.

Trauma Tumor TB Thrombosis of the left subclavian vein

Bilateral effusion 1. Generalized salt and water retention e.g., congestive heart failure nephrotic syndrome 2. Ascites 3. Pulmonary infarction 4. Tumor 5. TB

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T B ( Tuberculosis ) is the most common cause of pleural effusion , especially in young people Malignant pleural effusion is frequently met in aged people today Pleural transudation is most commonly caused by congestive heart failure

Diagnostic procedures

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History(primary diseases) clinical signs physical examinations 

clinical signs pleural pain, ♦ dyspnea, ♦ tachypnea, ♦ mild outward bulging of the intercostal spaces, ♦ decreased tactile fremitus, ♦ dullness or flatness, ♦ decreased transmission of breath and vocal sounds in the area of the effusion, ♦ and occasionally pleural friction sound in its early stage (dry pleurisy) ♦

Diagnostic procedures

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Chest X-ray examination Blunting of the normally sharp costophyrenic angle, a concave shadow with its highest margin along the pleural surface, shift of the mediastinum and the trachus toward the normal side

Pleural effusion

Diagnostic procedures

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Ultrasonic examination To localize a small pleural effusion and determine the correct site for performance of a thoracentesis

Diagnostic procedures

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Thoracentesis To aspirate the effusion for laboratory examination: Appearance, Specific gravity, Protein content, Cell counts, Glucose, LDH lipid content, Rheumatoid factor (RF), Gram stain and culture, Cytologic examination, etc.

Diagnostic procedures

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Pleural biopsy To obtain a specimen for histologic examination and culture

Diagnostic procedure is there pleural effusion or not ? Thoracentesis transudates? exsudates? what is the etiology? Treatment based on the etiology

Treatment Treatment for pleural effusions, whether transudates or exudates is primarily for the underlying pulmonary or systemic disease: ♦ aspiration of fluid is usually indicated to establish the diagnosis It is also therapeutically used to relieve dyspnea from a large effusion

Tuberculous pleural effusion  TB

remains the most common cause of pleural effusion in young people  Etiology: tubercle bacillus  Pathogenesis: host hypersensitivity to tubercular protein in pleural tubercles  Delayed hypersensitivity

Clinical Manifestations  Generalized

symptoms of toxicity of TB:

Fever, high sweat, fatigue and weight loss, etc.  Those

of pleural effusion:

Pleuritic pain, short breath and dyspnea, etc.  Pleural fluid is exudative and usually reveals lymphocytosis  Rarely pleural fluid is blood stained  The PPD or OT test usually positive

Diagnosis  Based

on mentioned findings and some examinations of pleural fluids, and culture of material obtained at biopsy of the pleura and pleural fluids.  except for pleural effusions caused by other causes.

Treatment (1) Standard antituberculous regimens ( usually short course of antituberculous chemotherapy is used )

(2) Administration of corticosteroid during the first several weeks of treatment (3) Thoracentesis

Empyema  Thick

purulent fluid with more than 100,000 cells per cubic millimeter or fluid with PH values less than or equal to 7. 20 should be treated as a presumptive empyema  The general objectives of therapy of empyema are the elimination of both the systemic and local infection.

Treatment of acute empyema (1)

Control of infection systemic and local (2) Repeated thoracentesis or drainage of the empyema, removal of the purulent material, with obliteration and sterilization of the pleural space

(3) elimination of the underlying disease process (4) Chronic empyema is primarily treated operatively , Operative therapy is also indicated in the empyema with associated bronchopleural fistula or with the ipsilateral ruined lung.

Treatment of malignant pleural effusion  Use

systemic anti-tumor medicines  Local treatments