1. Pleural Effusion, Pneumothorax and Atelectasis1

2. The Pleural Space Overview and definitions
Visceral pleura cover each lung, while the parietal pleura covers the outer structures that bound the lungs.
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3. The Pleural Space (cont.)
Pleural fluid about 10 to 20 mm thick separates the visceral from parietal pleura.
There is ~8 ml of fluid per hemithorax.
Pleural fluid is very similar to interstitial fluid.
This fluid minimizes the friction caused by the lungs to expanding in the thorax during inspiration.
Pleural pressure is typically negative due to outward thoracic recoil and inward recoil of lung. 3

4. Pleural Effusion

5. Pleural Effusions Transudative (excessive fluid pressure)
Any abnormal accumulation of fluid in the pleura is considered a pleural effusion.
Fluid enters the pleural space in face of increased pressure.
Either increased fluid production or blockage of drainage can result in pleural effusions.
Two Types:
Transudative (excessive fluid pressure)
Exudative (infectious process) 5

6. Pleural Effusions
Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by increased pressure in the blood vessels or a low blood protein count.
Congestive heart failure is the most common cause.
Exudative effusions are caused by blocked blood vessels or lymph vessels, inflammation, lung injury, and tumors. 6

7. Pleural Effusions
The most common causes of transudative (watery fluid) pleural effusions include:
Heart failure
Pulmonary embolism
Cirrhosis
Post open heart surgery
Exudative (protein-rich fluid) pleural effusions are most commonly caused by:
Pneumonia
Cancer
Kidney disease
Inflammatory disease 7

8. CHF ( with pulmonary edema)
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10. Diagnostic Tests for Pleural Effusions
Chest radiography
Most common method of detecting effusions
Upright PA and lateral decubitus are useful.
1-cm meniscus lung to rib allows for thoracentesis
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11. Diagnostic Tests for Pleural Effusions (cont.)
Ultrasonography and computed tomography
Ultrasound is very sensitive to pleural effusions.
May use to localize and direct for thoracentesis
Contrast-enhanced CT is most sensitive study for effusions.
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13. Treatment Thoracentesis
Percutaneous needle aspiration of effusion sample
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14. Diagnostic Tests for Pleural Effusions (cont.)
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15. Management for Pleural Effusions
Chest thoracotomy tubes
Designed for tight fit in tissues to avoid leaks and allow drainage of effusion and subsequent lung reexpansion
Tube is attached to chest drainage unit.
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16. Management for Pleural Effusions (cont.)
Pleurodesis
Process fusing parietal and visceral pleurae, which prevents further formation of effusions
Can be performed by surgical abrasion or introduction of chemical irritant, most commonly talc
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17. Management for Pleural Effusions (cont.)
Pleuroperitoneal shunt and Pleurex catheter
For effusions refractory to all other treatment options
Small pump moves fluid from pleura to peritoneal cavity.
Pleurex catheter connects to suction at home to drain persistent effusions.
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18. Types: Spontaneous Tension Open Closed pneumothorax
Air in the pleural space
Types:
Spontaneous
Tension
Open
Closed

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20. Pneumothorax Traumatic pneumothorax Penetrating chest trauma
Common secondary to bullet or knife penetration
Chest tube is usually adequate to treat.
May require surgery if bleeding is severe
Blunt trauma
Broken ribs puncture lung with air escape into pleura.
Chest tube is all that is generally required. 20

21. Pneumothorax (cont.) Iatrogenic
Most common cause of traumatic pneumothorax
Common iatrogenic causes are
Needle aspiration lung biopsy
Thoracentesis
Central venous catheter placement 21

22. Pneumothorax (cont.) Spontaneous Pneumothorax with no obvious cause
Primary spontaneous pneumothorax
Occurs with no underlying lung disease
Most (80%) have small subpleural blebs
Typically happens in tall, thin, young adults
>90% have had short-term smoking history
Smoking cessation recommended
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23. Pneumothorax (cont.) Therapy Chest tubes buy time
Resolution is mostly determined by lung healing
Small bore: placed via small incision in second intercostal space (ICS), midclavicular line or laterally, fifth–seventh ICS
Connected to underwater seal or Heimlich valve
Large bore: placed via blunt dissection, usually connected to “three-bottle” chest drainage system
Chest tubes are sutured in place
Pleurodesis: consider with recurrent pneumothoraces
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24. Pneumothorax (cont.) Complications Tension pneumothorax
Pleural air pressure exceeds atmospheric pressure
Radiographic appearance
Mediastinal shift, diaphragmatic depression, flattened ribs
Clinical presentation
Venous return and cardiac output decrease with hypotension and tachycardia
Hypoxemia due to alveolar collapse
Treatment: emergency needle decompression
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25. Pneumothorax (cont.) Therapy 100% Oxygen
Should be administered to all patients
Supplemental O2 speeds absorption of air from pleural space
Observation of stable patients
Primary: observe 4 hours, if no enlargement: home
Secondary and iatrogenic: hospitalize and observe carefully,
If there is any deterioration (SpO2, RR, etc) - drain
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27. Pneumothorax (cont.) Diagnosis Chest radiography
Requires good quality film
In ICU, 30% of pneumothoraces are missed due to:
Low-quality film
Supine position of patient on AP film
Air hidden behind thoracic or mediastinal structures
CT may be used to confirm size and presence of pneumothorax.
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28. atelectasis a- without tel/o: complete
-ectasis: stretching, dilation, expansion
Without complete expansion of a lung
collapsed lung

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30. hemothorax hem/o blood -thorax: chest, pleural cavity
Blood in the pleural cavity

31. pyothorax
py/o
-thorax
Pus in the chest
empyema of the chest