1. PLEURAL EFFUSION-EMPYEMA-PNEUMOTHORAX
Dr Alpana K Somale
Lecturer
Department of Pediatrics , B.Y.L.Nair Hospital
Dr Alpana K Somale, lecturer

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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

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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

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Causes
CHF
Malignancy
Infection PE
Others include hepatic cirrhosis, hypoalbuminemia, collagen vascular dz, TB, trauma, chylothorax, radiation, or pancreatitis
Dr Alpana K Somale, lecturer

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
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Tube Thoracostomy
a.k.a. Chest tube
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