PLEURAL EFFUSION-EMPYEMA-PNEUMOTHORAX Dr Alpana K Somale Lecturer Department of Pediatrics , B.Y.L.Nair Hospital Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer History Dyspnea (most common) Mild, non-productive cough Severe cough with sputum or blood Pneumonia vs. bronchial lesion Constant chest well pain Cancerous invasion of chest wall Pleuritic chest pain PE vs. inflammatory pleural effusion Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Physical Exam Decreased breath sounds Dullness to percussion Decreased tactile fremitus Pleural friction rub Mediastinal shift away from the effusion Egophany (E to A) Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Causes CHF Malignancy Infection PE Others include hepatic cirrhosis, hypoalbuminemia, collagen vascular dz, TB, trauma, chylothorax, radiation, or pancreatitis Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Pathophysiology ↑ Hydrostatic Pressure (e.g. CHF) ↑ Vascular Permeability (e.g. Pneumonia) ↓ Oncotic Pressure (e.g. Nephrotic syndrome ↑ Intrapleural Negative Pressure (e.g. atelectasis) ↓ Lymphatic drainage (e.g. mediastinal carcinomatosis) Cotran, Ramzi, Vinay Kumar, Tucker Collins. Robins Pathologic Basis of Disease. Philadelphia: Elsevier, 1999. Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Workup CXR/CT Thoracentesis Lab studies on fluids include protein, LDH, cytology, cell count, specific gravity, pH, amylase, glucose, Gram’s stain, bacterial/fungal cultures Plasma LDH and protein AFB stain and Cx if TB suspected If CV dz suspected, send for RF & ANA Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Treatment Treat underlying dz (such as CHF,nephrotic syndrome) if transudative fluid Exudative fluids - Drain and pleurodese for palliative treatment vs chemo if caused by malignancy Drain if empyema or causing severe respiratory symptoms Surgery Decortication for thick areas restricting breathing Drainage of loculated areas Pleuroperitoneal shunts for recurrent effusions Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Pneumothorax Defined Definition – “What?” “Pneumo”- gas “Thorax” – chest cavity Analagous to Pleural Effusion Pathophysiology – “How? Pleural space Baseline (-) pressure space Parietal Pleura Visceral Pleura Normal inspiration Diaphragm Transmit (-) Pressure Pathologic inspiration XS gas disrupts transmission of (-) pressure Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Types of Pneumothorax Spontaneous Pneumothorax Primary - rupture of subpleural bleb “Jimmy is a tall, wiry, 21-year old male, who plays trombone in the marching band….” Secondary - underlying lung/pleural disease #1 – emphysema Chronic bronchitis, asthma, TB, … Traumatic Pneumothorax Open Chest wall is penetrated : outside air enters pleural space Closed Chest wall is intact Ex. Fractured rib Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Types of Pneumothorax 2 Tension Pneumothorax “Ball-valve mechanism” Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration One of our own patients Variations Hemo-thorax Chylo-thorax Injury to thoracic duct Empyema Parapneumonic effusions in community-acquired pneumonia Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Symptoms Dyspnea Pleuritic chest pain Nerve endings at pleural capsule Sense of impending doom Sudden onset Tension pneumothorax Spontaneous pneumothorax Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Physical Exam - Signs Unstable patients vs. Stable patients Vital Signs Asymmetric chest expansion Deviated trachea Diminished breath sounds unilaterally Hyper-resonance unilaterally Decreased tactile fremitus Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Diagnosis Stable patient CXR Monitor size by measuring distance from lateral lung margin to chest wall Be sure that pneumothorax is not expanding Unstable patient Thoracentesis Rapid release of air Vital signs stabilize rapidly Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Imaging Plain Radiographs Upright PA on inspiration Detect other pathologies: pneumonia, cardiac, etc. Partially collapsed lung Tension Pneumothorax Trachea and mediastinum deviate contralaterally Ipsilateral depressed hemi-diaphragm Chest CT Not routine Only to assess the need for surgery (thoracotomy) Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Treatment Small pneumothorax Resolve over days to weeks Supplemental oxygen and observation Tension pneumothorax Immediate decompression via chest tube or needle thoracostomy Spontaneous pneumothorax Asymptomatic – outpatient, f/u with serial CXR Symptomatic – inpatient, chest tube Recurrent pneumothorax – CT to evaluate need for thoracotomy Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer Tube Thoracostomy a.k.a. Chest tube Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer
Dr Alpana K Somale, lecturer