PLEURAL EFFUSION

Dr. Ririek Parwitasari, SpP

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 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.

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 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

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 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

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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

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 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)
Histery 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

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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 bplaced in both sterile vials and blood
culturbottles and analysed for protein,
lactatdehydrogenase (LDH, to clarify borderline,
protein values), pH, Gram stain, AAFB 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, Tuberculosis

metastatic carcinoma Rheumatoid arthritis
Trauma: operative, Poorly treated empyema
penetrating injuries
Miscellaneous: tuberculosis,
sarcoidosis,
lymphangioleiomyomatosis,
cirrhosis, obstruction of
central veins, amyloidosis

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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 30 minutes +2
Inspiration -2 -2

NORMAL:
Expiration -4 -9 cm H2O
Inspiration -8 -12 cm H2O

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 CLOSED PNEUMOTHORAX
pneumothorax that there is no connection between
pleural cavity and bronchus

Expiration -4 30 minutes -4
Inspiration -12 -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 30 min -4 30 min +10

Inspiration -12 -12 +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 D>S, deviation of trachea,
Widening ICS
Dinamic D<S
Palpation Stem fremitus N
N
N
Percution HS N Auscultation V V
HS N V V
HS N 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

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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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djois
PNEUMOTHORAX VENTIL

djois

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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

3
lung
PNX% = 100 1-
3
hemithorax

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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
WSD VENTIL
WSD
udara ( Water Sealed Drainage )

UDARA DALAM
CAVUM PLEURAE
KELUAR

UDARA LUAR TIDAK

+10 cmH2O DAPAT MASUK
TIP : KEDALAM CAVUM
+20 cmH2O PLEURAE

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djois
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 VII/VIII P.A.L
IC II/III M.C.L: Cara Monaldi
ICS IV/V 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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 Atelectasis is defined as diminished
volume affecting all or part of a lung

Atelectasis is divided
physiologically into obstructive and
nonobstructive causes.

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 TYPE OF ATELECTASIS
1. Obstructive atelectasis
most common type and results from reabsorption of
gas from the alveoli when communication between
the alveoli and the trachea is obstructed.
Causes of obstructive atelectasis include foreign
body, tumor, and mucous plugging.
2. Nonobstructive atelectasis
caused by loss of contact between the parietal and
visceral pleurae, compression, loss of surfactant, and
replacement of parenchymal tissue by scarring or
infiltrative disease.

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 PHYSICAL
The physical examination findings show dullness to
percussion over the involved area and diminished or
absent breath sounds. Chest excursion in the area is
reduced or absent. The trachea and the heart are
deviated toward the affected side.

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Workup
Laboratory Studies
BGA: hypoxemia, PaCO2 level is usually normal or low as a
result of the increased ventilation.

Imaging Studies
Chest radiographs and CT scans show direct and indirect
signs of lobar collapse.5 Direct signs include displacement
of fissures and opacification of the collapsed lobe.

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Complete right lung atelectasis.

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Right upper lobe collapse and consolidation.

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Complications

Complications may include the following:

Acute pneumonia
Bronchiectasis
Hypoxemia and respiratory failure
Sepsis
Pleural effusion and empyema

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TREATMENT
The treatment of atelectasis depends on the
underlying etiology.

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Alat de Graaf

mengisi udara
Pneumothorax artificialis

djois
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