PLEURAL EFFUSION

Pulmonology & Respiratory Medicine Departement

Brawijaya University/Saiful Anwar Hospital
Malang

DEFINITION
Pleural

effusions, the result of the

accumulation of fluid in the pleural space

Normally, pleural fluid in pleural cavity amount 1-20 ml.

Pleural fluid in pleural cavity is constant. There is
equlibrium between production and absorsption by
pleural viceralis.

CAUSES OF A PLEURAL EFFUSION

Pleural Effusion can be caused by several

mechanisms:
increased permeability of the pleural membrane
increased pulmonary capillarpressure
decreased negative intrapleural pressure
decreased oncotic pressure
Obstructed lymphatic flow

Pleural effusion indicate the presence of disease which may be

Pulmonary, pleural or extrapulmonary
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CLASSIFIED OF PLEURAL EFFUSION

Transudative

Exudative

Most accurate way of

differentiating

Lights criteria

Lights criteria criteria a

The pleural fluid is an exudate if one or more of
the following criteria are met:
Pleural fluid protein divided by serum protein >0.5
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid LDH more than two-thirds the upper limits

of normal serum LDH

CAUSES OF TRANSUDATIVE PL.EFFUSION

Very common causes
Left ventricular failure
Liver cirrhosis
Hypoalbuminaemia
Peritoneal dialysis

Less common causes

Hypothyroidism
Nephrotic syndrome
Mitral stenosis
Pulmonary embolism

Rare causes
Constrictive pericarditis
Urinothorax
Superior vena cava obstruction
Ovarian hyperstimulation
Meigs syndrome

CAUSES OF EXUDATIVE PL.EFFUSION

Common causes

Malignancy
Parapneumonic effusions
Less common causes
Pulmonary infarction
Rheumatoid arthritis
Autoimmune diseases
Benign asbestos effusion
Pancreatitis
Post-myocardial infarction syndrome
Rare causes
Yellow nail syndrome
Drugs
Fungal infections
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DIAGNOSTIC (1)
History taking and physical examination
Fluid < 300 cc, The symptom is disappear
The fluid >300 cc, The symptom are decreasing movement
of hemithoraks, stem fremitus and breath sound decrease,
or disappear.
Pleural fluid > 1000 cc can cause the chest more convex
than contralateral, auscultation egophoni
The fluid >2000 cc push the mediastinum to the normal
site

DIAGNOSTIC (2)
Plain radiography
PA and lateral chest radiographs should be performed

Ultrasound findings
Ultrasound guided pleural aspiration should be used as

a safe and accurate method of obtaining fluid if

the effusion is small or loculated.
Fibrinous septations are better visualised on
ultrasound

CT Scan
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DIAGNOSTIC (2)
A diagnostic pleural fluid sample should be gathered

with a fine bore (21G) needle and a 50 ml syringe. The

sample should be placed in both sterile vials and
blood cultur bottles and analysed for protein,
lactatdehydrogenase (LDH, to clarify borderline,
protein values), pH, Gram stain, AFB stain, cytology,
and microbiological culture.

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DIFFERENTIAL DIAGNOSIS
Lung Tumor
Swarte/Tickening of pleura
Atelectasis inferior lobe
High level potition of diaphragma

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COMPLICATION
Complication of pleural effusion depend on

underlying desease :
Empiema
Swarte
Respiratory failure

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Management
The management of pleural effusion depend on
management of underlying desease and

thoracocentesis.
Thoracocentesis indication:
Release of Shortnes of breath that caused by fluid

accumulation
Diagnosis with examine the pleural fluid

Thoracocentesis pleural fluid in the first

time not more than 1000 cc, can result
lung edema with symptom cough and
dyspnea.
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continued..
Lack of thoracocentesis:
Thorakosentesis can cause lost of protein
Infection (empyema)
Pneumothoraks

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EMPYEMA (1)
Definition:
Presence of pus in the pleural space
Causes:
Direct extension of a pulmonary parenchymal infection
into pleural space
Post surgical infection
Trauma
From abdominal infection (ex: subdiaphragmatic
abscess)
Complication of thoracosinthesis or pleural biopsy
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 About half of the empyema isolates

consist of only anaerobic bacteria and

the other half of mixed anaerobic and
aerobic organism.

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EMPYEMA (2)
Symtoms
Usually non specific
80% : dyspnea and fever
70% : cough and chest pain
Constitusional complaint : weight loss, fatigue, malaise

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THERAPY
Appropriate antibiotic therapy
Initial choice of antibiotic depends on clinical setting
and should be guideed by the result of the gram stain of
pleural fluid and sputum
Adequate pleural drainage
Chest tube placement (WSD)
Thoracosintesis

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HEMOTHORAX
Definition:
Presence of significant amount of blood in the pleural
space
Causes:
Most comman: trauma (penetrating or penetrating)
Occasionally iatrogenic prosedure
Uncomman: malignancy, during unticoagulant therapy

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CHYLOTHORAX
True chylous effusions result from disruption of the

thoracic duct or its tributaries. This leads to the

presence of chyle in the pleural space
Chylothorax

must
be
distinguished
from
pseudochylothorax or cholesterol pleurisy which
results from the accumulation of cholesterol crystals in
a long standing pleural effusion

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CAUSES OF CHYLOTHORAX AND

PSEUDOCHYLOTHORAX
Chylothorax

Pseudochylothorax

Neoplasm: lymphoma,
metastatic carcinoma
Trauma: operative,
penetrating injuries
Miscellaneous: tuberculosis,
sarcoidosis,
lymphangioleiomyomatosis,
cirrhosis, obstruction of
central veins, amyloidosis

Tuberculosis
Rheumatoid arthritis
Poorly treated empyema

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MALIGNANT PLEURAL EFFUSION

Malignant pleural effusion is a condition in which

cancer causes an abnormal amount of fluid to collect

between the thin layers of tissue (pleura) lining the
outside of the lung and the wall of the chest cavity. Lung
cancer and breast cancer account for about 50-65% of
malignant pleural effusions[1]. Other common causes
include mesothelioma and lymphoma.

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Pulmonology & Respiratory Medicine Departement

Brawijaya University/Saiful Anwar Hospital
Malang

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PNEUMOTHORAX
Pneumothorax is defined as air in the pleural
space.
Classification:
Based on occurrence:

Arrtificial
Traumatic
Spontaneous

Based on kind of fistel:

Open pneumothorax
Close pneumothorax
Ventile pneumothorax
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SPONTANEOUS PNEUMOTHORAX
Primary pneumothorax
arise in otherwise healthy people without any lung
disease.
subpleural blebs and bullae are likely to play a role in the
pathogenesis since they are found in up to 90% of cases
of primary pneumothorax at thoracoscopy or
thoracotomy and in up to 80% of cases on CT scanning
Secondary pneumothotax
pneumothoraces arise in subjects with underlying lung
disease
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SECONDARY PNEUMOTHORAX
More serious than spontaneous primary pneumothorax,

because it further decrease the pulmonaryfunction of a

patient whose reserve is already diminished
The preseent of the underlying disease makes the
management pneumothorax more dificcult.
Causes:
COPD >>

Lung tumor
Tuberculosis
Other pulmonary infection
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DIAGNOSTIC TUMOR

COLLAPS TREATMENT IN
LUNG TUBERCULOSIS

Adakalanya disertai denga

-Pneumoperitoneum
-phrenikus tripsi
( n phrenikus dilumpuhkan
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OPEN PNEUMOTHORAX
Is pneumothorax that there is connection between pleural

cavity and bronchus

Expiration

+2
Inspiration -2

NORMAL:
Expiration -4
Inspiration -8

30 minutes

+2
-2

-9 cm H2O
-12 cm H2O
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CLOSED PNEUMOTHORAX
pneumothorax that there is no connection between

pleural cavity and bronchus

Expiration

-4
Inspiration -12

30 minutes

-4
-12

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VENTIL PNEUMOTHORAX
Tension pneumothorax occurs because the opening that

allows air to enter the pleural space functions like a valve,

and with every breath more air enters and cannot escape.
Severe hypoxia follows, with a resultant drop in blood
pressure and level of consciousness
Expiration

+2
Inspiration -12

30 min

-4
-12

30 min +10
+6

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DIAGNOSIS VENTIL PNEUMOTHORAX (1)

Symptoms and signs of tension pneumothorax may

include the following:

Chest pain (90%)
Dyspnea (80%)

Anxiety
Acute epigastric pain (a rare finding)
Fatigue

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DIAGNOSIS VENTIL PNEUMOTHORAX (2)

Physical
Respiratory distress or respiratory arrest unilaterally
Tachycardia
Hypotension
Pulsus paradoxus
Increasing of JVP
Trachea, cardiac deviation
Cardiac arrest associated with asystole or pulseless
electrical activity

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DIAGNOSIS VENTIL PNEUMOTHORAX (3)

Physical
Pneumothorax ventil Dextra

Inspection Static
Widening ICS
Dinamic
Palpation Stem fremitus

Percution

HS
HS
HS

N
N
N

D>S, deviation of trachea,

D<S
N
N
N
Auscultation

V V
V V
V V

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DIAGNOSIS VENTIL PNEUMOTHORAX (4)

Work up

Lab: BGA
Chest radiography
USG
CT Scan
Proef puncture

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DIFFERENTIAL DIAGNOSIS
PNEUMOTHORAX

Emphysematous lung

Asthma bronchiale
Giant bullae
Acute Myocard Infarction

Hernia diaphragmatica

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COMPLICATION OF
PNEUMOTHORAX
Pleural effusion
Emphysema subcutis
Syock cardiogenic
Respiratory distress

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INSPIRA
EKSPIRASI
SI
PNEUMOTHORAX SPONTANEA
VENTIL
SAAT EKSPIRASI TEKANAN SEMAKIN MENINGKAT
MATI OLEH KARENA:
MEDIASTINUM TERDORONG KE SISI YANG SEHAT
GAGAL KARDIOVASKULER DAN GAGAL NAPAS
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1. pneumothorax traumatica
2. pneumothorax spontanea

1
1

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PNEUMOTHORAX
PENDORONGAN MEDIASTINUM
HEMITHORAX CEMBUNG & GERAK RESPIRASI TERTINGGAL
PARU KOLAPS & MEDIASTINUM TERDESAK UDARA KEARAH SISI YANG SEHAT
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PNEUMOTHORAX VENTIL
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CHEST X-RAY PNEUMOTHORAX

Picture 2. Right-sided pneumothorax due to stab wound

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CHEST X-RAY PNEUMOTHORAX (LANJUTAN)

Picture 3. A true pneumothorax line.Note that the visceral pleural line is observed
clearly, with the absence of vascular marking beyond the pleural line.

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Estimate lung collaps

Light Index
lung
PNX% = 100

1hemithorax

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TREATMENT OF PNEUMOTHORAX
Primary spontaneous pneumothorax
Observation

Recommanded that only asymtomatic patient with

pneumothorax less than 15 %

Oxigen suplementation
Gas absorbtion will exceed
Simple aspiration
Tube thoracostomy

Thoracoscopy VATS
Pleurodesis

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TREATMENT OF PNEUMOTHORAX (2)

Secondary spontaneous pneumothorax
Oxigen suplementation
The initial treatment for nearly every that patient should
be tube thoracostomy
Simple aspiration should not be performed because it
frequently is ineffective and does not decrease the
likehood of a reccurence
Tube thoracostomy
Thoracoscopy VATS
Pleurodesis
Treatment the underlying diseses
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a - semprit 5ml / 10ml dengan

jarum infus yang besar
b - kondom / sarung tangan karet
yang lama, ujungnya dipotong
serong

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ALAT KONTRA
VENTIL
WSD

WSD

( Water Sealed Drainage )

udara

UDARA DALAM
CAVUM PLEURAE
KELUAR

TIP :

+10 cmH2O
+20 cmH2O

UDARA LUAR TIDAK

DAPAT MASUK
KEDALAM CAVUM
PLEURAE

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INSERTED THORAX CATHETER

Indication:
Pneumothorax > 20% of lung volume/ventil.
Malignant Pleural effusion
Empyema
Hematothorax > 300cc
Chilothorax
Post operatif thoracotomy
The patient use ventilator/respirator

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 Lokasi:
ICS
IC

ICS

VII/VIII
II/III
IV/V

P.A.L
M.C.L: Cara Monaldi
M.A.L: Cara Buelau

Persiapan Alat:
Klem desinf, duk
Kasa, duk berlubang
Madrin, kanul
Gunting, pinset
Jarum jahit, benang
Spuit, anestesi
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REPLACEMENT THORAX CATHETER

Indication:
THE LUNG has inflated. The. Catheter has diklem 24
hour.
Empyema: pus (-) fluid <100cc/day.
Hemato thorax <100cc/day.
Patient does not need respirator again/ Weaning=
disapih.

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PLEURODESIS
Pleurodesis is a medical procedure in which the

pleural space is artificially obliterated. It involves the

adhesion of the two pleura
Chemical
Surgical

Indication:
recurrent pneumothorax
recurrent pleural effusion/ Malignant pleural effusion

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CHEMICAL PLEURODESIS
Chemicals such as:
bleomycin
tetracycline
povidon iodine
Slurry of talc

Introduce into the pleural space through a chest drain.

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