1. Pleural effusion, Pyothorax & pneumothorax
Dr Sarika Gupta, Asst. Professor

2. DEFINITION
Pleural effusion: inflammation of the pleura, accompanied by collection of fluid in the pleural space.
Normal Pleural fluid: 0.3 ml/kg BW
Protein: 1.5 g/dL
pH: alkaline (7.60)
Cells: 1700 cells/ml (75% macrophages, 23% lymphocytes & 2% mesothelial cells)

3. Pleural space should be virtually fluid free
Pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura as a continuous process
Pleural space should be virtually fluid free

4. Intrapulmonary pressure
-the pressure within the alveoli as the chest expands on inspiration the intrapulmonary pressure becomes more negative, which causes air to be sucked into the lungs.
Intrapleural pressure
-Negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration negative pressure may be lost if fluid collects in the pleural space, making the lung unable to expand fully.

5. Fluid accumulates in the pleural space by three mechanisms:
increased drainage of fluid into the space
increased production of fluid by cells in the space
decreased drainage of fluid from the space

6. Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)

7. CAUSES TRANSUDATIVE (usually bilateral ) Congestive heart failure
Cirrhosis
Nephrotic syndrome
Constrictive pericarditis
Peritoneal dialysis
EXUDATIVE (usually unilateral)
Parapneumonic effusion
Tuberculosis
Connective tissue disorders
Malignancy
Pancreatitis
Subphrenic abscess
Severe dengue
Radiation pleuritis
CHYLOUS
Congenital chylothorax
Post-traumatic
HEMOTHORAX
Blunt trauma
Malignancy

8. CLINICAL FEATURES History: Small pleural effusion: asymptomatic
Large pleural effusion: pleuritic chest pain, abdominal pain, pain during inspiration or coughing
The child may prefer to lie on the affected side (to decrease respiratory excursions)
Cough
Fever
Respiratory distress, dyspnea, orthopnea, or cyanosis

9. CLINICAL FEATURES Examination: Tracheal deviation to the opposite side
Bulging chest wall on the affected side with reduced movement
Decreased vocal fremitus
Dullness to percussion
Decreased or absent breath sounds
Diminished whispering pectoriloquy & decreased vocal resonance
Egophony-audible at the upper level of pleural effusion due to prtially collapsed underlying lung

10. CLINICAL FEATURES Examination: Pleural friction rub:
Inflamed parietal & visceral pleurae rub against each other
leathery, rough in character
Heared in both inspiration and expiration
Disappears rapidly as the size of effusion increases
If a child remains pyrexial or unwell 48 hours after admission for pneumonia, parapneumonic effusion/empyema must be excluded. 

11. DIAGNOSIS Chest radiograph (x-ray)
-able to distinguish >200ml of fluid (blunted costophrenic angles)
-Chest radiographs acquired in the lateral decubitus position are more sensitive and can pick up as little as 50 ml of fluid.
Pleural fluid analysis
Chest ultrasound
-locates small amounts or isolated loculated pockets of fluid
-able to give precise position of accumulation
Computed Tomography (CT) scan
-Differentiates between fluid collection, lung abscess, or tumor

12. PLEUAL EFFUSION
Created by an abnormal collection of fluid in the pleural space
Seen in chest X-ray with presence of about 200ml pleural fluid
Fluid in X-ray seen as a dense, white shadow with a concave upper edge (fluid level)

14. CT scan of chest showing loculated pleural effusion in left side
CT scan of chest showing loculated pleural effusion in left side. Some thickening of pleura is also noted.

15. Pleural fluid analysis
Routine tests
Gross examination
Pleural fluid/serum protein ratio
Pleural fluid/serum LDH ratio
Cytology and culture

16. Pleural fluid analysis
Tests in selected cases
Pleural fluid cholesterol
Pleural fluid/serum cholesterol ratio
Lactate
Enzymes
Interferon ᵞ
CRP
Tumor markers

17. Gross examination
Transudates: typically clear, pale yellow to straw-colored, odorless & do not clot.
Exudates: show variable degrees of cloudiness or turbidity & they often clot if not heparinized
A feculent odor may be detected in anaerobic infections

18. Gross examination
A bloody pleural effusion (hematocrit >1%) suggests trauma, malignancy, or pulmonary infarction.
A pleural fluid hematocrit greater than 50% of the blood hematocrit is good evidence for a hemothorax
Turbid, milky, and/or bloody specimens should be centrifuged and the supernatant examined. If the supernatant is clear, the turbidity is most likely due to cellular elements or debris. If the turbidity persists after centrifugation, a chylous effusion is likely

19. Differential Leukocyte Count and Cytology
Cytological analysis will establish the diagnosis of metastatic carcinoma in 70% or more of cases

20. Chemical analysis
Light’s Criteria (Sensitivity 99%, Specificity 98%) )
Criteria
Transudate
Exudate
Pleural fluid protein:serum protein ratio
≤0.5
> 0.5
Pleural fluid LDH:serum LDH
≤0.6
> 0.6
Pleural fluid LDH
≤200
>200

21. Microbiological examination:
The sensitivity of the Gram stain is approximately 50%
For patients with suspected M. tuberculosis, direct staining of tuberculous effusions for acid-fast bacteria has a sensitivity of 20%–30% and positive cultures are found in 50%–70% of cases

22. Chemical analysis Glucose:
The glucose level of normal pleural fluid, transudates, and most exudates is similar to serum levels
Decreased pleural fluid glucose, accepted as a level below 60 mg/dL (3.33 mmol/L) or a pleural fluid/serum glucose ratio less than 0.5, is most consistent and dramatic in rheumatoid pleuritis and grossly purulent parapneumonic exudates

23. Lactate:
Pleural fluid lactate levels: useful adjunct in the rapid diagnosis of infectious pleuritis
Levels are significantly higher in bacterial and tuberculous pleural infections than in other pleural effusions
Values greater than 90 mg/dL (10 mmol/L) have a positive predictive value for infectious pleuritis of 94% and a negative predictive value of 100%

24. Amylase:
Elevations above the serum level (usually 1.5–2.0 or more times greater) indicate the presence of pancreatitis, esophageal rupture, or malignant effusion
Elevated amylase derived from esophageal rupture or malignancy is the salivary isoform, which differentiates it from pancreatic amylase

25. Lactate dehydrogenase:
Pleural fluid LD levels rise in proportion to the degree of inflammation
In addition to their use in separating exudates from transudates, declining LD levels during the course of an effusion indicate that the inflammatory process is resolving
Conversely, increasing levels indicate a worsening condition requiring aggressive workup or treatment

26. Adenosine deminase:
>40 unit/l
Tuberculosis
Interferon-γ:
Pleural fluid interferon (IFN)-γ levels are significantly increased in the pleural fluid of patients with tuberculous pleuritis
The sensitivity of levels of 3.7 IU/L or greater is 99%, and the specificity is 98%
Consider when ADA is unavailable or nondiagnostic

27. pH:
Pleural fluid pH measurement has the highest diagnostic accuracy in assessing the prognosis of parapneumonic (pneumonia-related) effusions
A parapneumonic exudate with a pH greater than generally resolves with medical therapy alone
A pH less than 7.20 indicates a complicated parapneumonic effusion (loculated or associated with empyema), requiring surgical drainage.
A pH below 6.0 is characteristic of esophageal rupture, although the pH in severe empyema may be 6.0 or less

28. Lipids:
Helpful in identifying chylous effusions
Pleural fluid triglyceride levels > 110 mg/dL indicate a chylous effusion
values from 60–110 mg/dL require lipoprotein electrophoresis to confirm a chylothorax
Nonchylous effusions : triglyceride levels <50 mg/dL & no chylomicrons on electrophoresis

29. Cholesterol:
Cholesterol measurements may be useful in separating transudates from exudates, especially when there is a question regarding Light’s criteria
A total cholesterol value of 54 mg/dL or more and a pleural fluid/serum cholesterol ratio of 0.32 or higher have sensitivity and specificity values similar to Light’s criteria

30. Immunologic studies:
Approximately 5% of patients with RA and 50% with SLE develop pleural effusions
RF is commonly present in pleural effusions associated with seropositive RA
ANA titers may be useful in the diagnosis of effusion due to lupus pleuritis

31. TREATMENT Therapy should be aimed at the underlying disease
Transudative effusion by fluid overload as in cardiac or renal failure: diuretics & fluid management
Nephrotic syndrome and cirrhosis of liver: Albumin infusion
Tubercular pleural effusion: Anti-tubercular drugs

32. TREATMENT Chylous pleural effusion:
Thoracocentesis or placement of ICD tube followed by feeding with MCT
Continuous development: discontinuation of oral feeds and TPN
Somatostatin & Octreotide
Traumatic hemothorax: drainage of blood with proper replacement
Recurrent pleural effusion due to malignancies: prolonged placement of catheter or pleurodesis

33. TREATMENT Parapneumonic effusion Analgesia Supplemental oxygen
Systemic antibiotics
based on the in vitro sensitivities of the responsible organism (Staphylococcus, S. pneumoniae, and H. influenzae)
Duration: 2 wk. With staphylococcal infections: systemic antibiotic therapy for 3-4 wk; anaerobic empyema weeks
Instillation of antibiotics into the pleural cavity does not improve results

34. TREATMENT Parapneumonic effusion
Tube thoracostomy is considered necessary if the pleural fluid pH is <7.20 or the pleural fluid glucose level is <50 mg/dL
If the fluid is clearly purulent, tube drainage with thrombolytic therapy or video-assisted thoracoscopic surgery (VATS) or open decortication

35. TREATMENT Thoracentesis Diagnostic thoracentesis
A needle is inserted into
the chest wall to remove the
collection of fluid
50-100ml of fluid is sent
for analysis; Determines the type of fluid (transudate or exudate)
temporarily relieve symptoms
Potential complications: bleeding, infection & pneumothorax

36. TREATMENT
BUT if sufficient fluid reaccumulates to cause respiratory embarrassment, chest tube drainage should be performed
Rapid removal of ≥1 L of pleural fluid may be associated with the development of reexpansion pulmonary edema
Chest tube drainage

37. Chest tube drainage

38. TREATMENT Thrombolytic therapy
Promote drainage, decrease fever, lessen need for surgical intervention & shorten hospitalization
Streptokinase 15,000 U/kg in 50 mL of 0.9% saline daily for 3-5 days and urokinase 40,000 U in 40 mL saline every 12 hr for 6 doses
Anaphylaxis with streptokinase & both drugs can be associated with hemorrhage

39. TREATMENT
Video-assisted thoracoscopic surgery (VATS) or Open decortication
The child who remains febrile & dyspneic >72 hr after initiation of therapy with intravenous antibiotics and thoracostomy tube drainage, surgical decortication via VATS or, less often, open thoracotomy may speed recovery
If pleural fluid septa are detected on ultrasound, immediate VATS can be associated with a shortened hospital course

40. EMPYEMA

41. DEFINITION
Empyema or Purulent Pleurisy: Empyema is an accumulation of pus in the pleural space
Most often associated with pneumonia due to Staphylococcus aureus & Streptococcus pneumoniaea
The relative incidence of Haemophilus influenzae empyema has decreased (Hib vaccination)
Also produced by rupture of a lung abscess into the pleural space, by contamination introduced from trauma or thoracic surgery or by mediastinitis or the extension of intra- abdominal abscesses

42. EPIDEMIOLOGY
Most frequently encountered in infants & preschool children
Predisposing factors: preceding history of pustules, blunt trauma to the chest, viral infection, severe malnutrition, contiguous extension

43. PATHOLOGY
Empyema has 3 stages: exudative, fibrinopurulent, and organizational
Exudative stage: 1-3 days
Fibrinopurulent stage: 4-14 days
Organizational stage: After 14 days

44. PATHOLOGY
Exudative stage: fibrinous exudate forms on the pleural surfaces
Fibrinopurulent stage: fibrinous septa form, causing loculation of the fluid & thickening of the parietal pleura
If the pus is not drained, it may dissect through the pleura into lung parenchyma, producing bronchopleural fistulas and pyopneumothorax, or into the abdominal cavity or through the chest wall (empyema necessitatis)
Organizational stage: fibroblast proliferation; pockets of loculated pus develop into thick-walled abscess cavities or the lung may collapse & become surrounded by a thick, inelastic envelope (peel)

45. CLINICAL MANIFESTATIONS
The initial signs & symptoms are primarily those of bacterial pneumonia
Children treated with antibiotic agents may have an interval of a few days between the clinical pneumonia phase & the evidence of empyema
Most patients are febrile (fever may be absent in immunocompromised patients), develop increased work of breathing or respiratory distress & often appear more ill
Physical findings are identical to those for uncomplicated parapneumonic effusion & the 2 conditions are differentiated only by thoracentesis

46. DIAGNOSIS
The effusion is empyema if bacteria are present on Gram staining, the pH is <7.20, glucose<40 mg/dl and LDH>1000 IU/L and there are >100,000 neutrophils/µL
Cultures of the fluid must always be performed
Blood cultures also have a high yield

47. DIAGNOSIS
Tuberculous empyema can be confirmed by stains for AFB in fewer than 25% of cases but pleural biopsy and culture can dignose more than 90% cases, ADA (>70 U/L)

48. COMPLICATIONS Bronchopleural fistulas
Usually respond to adequate drainage, nutritional support & sealing of the open communication over the lung surface
Prolonged bronchopleural fistulas (>2-3 weeks) requires decortication, lobectomy or thoracoplasty

49. COMPLICATIONS Pyopneumothorax
Purulent pericarditis & pulmonary abscesses
Peritonitis from extension through the diaphragm & osteomyelitis of the ribs
Septic complications: meningitis, arthritis
Septicemia is often encountered in H. influenzae and pneumococcal infections
Peel: may restrict lung expansion and may be associated with persistent fever and temporary scoliosis
Empyema necessitans
Gastropleural fistula

50. COMPLICATIONS
Diaphragmatic palsy
Horner’s syndrome

51. TREATMENT Systemic antibiotics
Staphylococcus aureus: cloxacillin & aminoglycoside or 3 gen cephlosporin & aminoglycoside
Gram-ve organism: cefotaxim & aminoglycoside
Gram stain inconclusive: cefotaxim & cloxacillin
Resistant Staphylococcus: vancomycin, teicoplanin & linezolid
Thoracentesis

52. TREATMENT Chest tube drainage with or without a fibrinolytic agent
Indications for surgical treatment:
Pleural thickening
Loculated empyema
Non-expansion of lungs with intercostal drainage
Bronchopeural fistula
Video-assisted thorascopic surgery: effective in lysis of adhesions in multiloculted effusions & removal of fibrinous material from pleural cavity
Open decortication: significant pleural thickening

53. TREATMENT
The long-term clinical prognosis for adequately treated empyema is excellent & follow-up pulmonary function studies suggest that residual restrictive disease is uncommon, with or without surgical intervention

54. PNEUMOTHORAX
PNEUMOTHORAX

55. DEFINITION
Accumulation of extra pulmonary air within the chest, most commonly from leakage of air from within the lung
PNEUMOTHORAX
CLOSED-air entry into the pleural space by disruption of pulmonary parenchyma
OPEN-due to disruption in the integrity of chest wall & parietal pleura

56. ETIOLOGY Closed pneumothorax Open pneumothorax -Pulmonary disease
Foreign body
RDS
Respiratory infections
Bronchial asthma
Cystic fibrosis
Chemical pneumonitis
Diffuse lung disease
Tumors
-Iatrogenic
Mechanical ventilation
Central venous catheterization
Open pneumothorax
Invasive pleural & pulmonary procedures
Chest trauma
Spontaneous pneumothorax
Idiopathic (ruptured subpleural blebs)
Familial

57. PATHOGENESIS
The tendency of the lung to collapse is balanced in the normal resting state by the inherent tendency of the chest wall to expand outward, creating negative pressure in the intrapleural space
When air enters the pleural space, the lung collapses
In simple pneumothorax, intrapleural pressure is atmospheric, and the lung collapses up to 30%.
In complicated, or tension pneumothorax, continuing leak causes increasing positive pressure in the pleural space, with further compression of the lung, contralateral shift of mediastinal structures & decreases in venous return and cardiac output

58. CLINICAL MANIFESTATIONS
Sudden onset
Dyspnea, pain, & cyanosis
Trachea & heart may be shifted toward the unaffected side
Hyperinflation & reduced movements on affected side
Respiratory distress with retractions
Decreased vocal fremitus & vocal resonance
Markedly decreased breath sounds and a tympanitic percussion note over the involved hemithorax
When fluid is present, there is usually a sharply limited area of tympany above a level of flatness to percussion

59. CLINICAL MANIFESTATIONS
Succussion splash: to rule out hydropneumothorax
Coin test
Friction test

60. Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax, hyperresonant percussion notes are produced over the affected area.

61. Breath sounds diminish as gas accumulates in the intrapleural space.

62. As gas accumulates in the intrapleural space, the chest diameter increases on the affected side in a tension pneumothorax.

63. Alveolar Hyperventilation Acute Ventilatory Failure
Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
Acute Ventilatory Failure
100
Point at which disease becomes severe and patient begins to become fatigued 90
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70
PaCO2
Pa02 or PaC02 60 50 40 30
PaO2 20 10
PaO2 and PaCO2 trends during acute ventilatory failure (Large pneumothorax)

64. DIAGNOSIS By radiographic examination
When the possibility of diaphragmatic hernia is being considered, a small amount of barium may be necessary to demonstrate that it is not free air but is a portion of the gastrointestinal tract that is in the thoracic cavity
Ultrasound can also be used to establish the diagnosis

65. TREATMENT
Extent of the collapse & nature and severity of the underlying disease
A small (<5%) or even moderate-sized pneumothorax in an otherwise normal child may resolve without specific treatment, usually within about 1 wk
Needle aspiration: tension pneumothorax & primary spontaneous pneumothorax
If the pneumothorax is recurrent, secondary or under tension or there is >5% collapse: chest tube drainage
Pneumothorax complicating malignancy: chemical pleurodesis or surgical thoracotomy

67. TREATMENT
Closed thoracotomy: adequate to reexpand the lung in most patients
Chemical pleurodesis: recurrent pneumothoraces; introduction of talc, doxycycline, or iodopovidone into the pleural space
Open thoracotomy: plication of blebs, closure of fistula, stripping of the pleura and basilar pleural abrasion; Stripping and abrading the pleura leaves raw, inflamed surfaces that heal with sealing adhesions
VATS: preferred therapy for blebectomy, pleural stripping, pleural brushing and instillation of sclerosing agents; less morbidity than with open thoracotomy