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PLEURAL SPACE

The pleura consists of 2 layers


1 – parietal pleura
2 – visceral pleura

The space between the 2 layers is called


the pleural space

Normal width of the pleural space is


10-20 mm

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Parietal pleura Visceral pleura
cover the inner surface envelope all surfaces
of the thoracic cavity,
of the lungs, including
including the
diaphragm, and ribs. the interlobar fissures.

At the Hilum
where pulmonary vessels, bronchi, and nerves
enter the lung tissue, the parietal pleura is
continuous with the visceral pleura.
PLEURAL EFFUSION

Normally the pleural space contains:

• 3.5 to 7.0 ml of clear liquid


• low protein content
• small number of mononuclear cells

Pleural effusion: presence of large amount of fluid


in the pleural space irrespective of the underlying
causes
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PLEURAL FLUID FORMATION AND ABSORTION

PLEURAL SPACE
INTERCOSTAL BRONCHIAL
MICROVESSELS MICROVESSELS

VEIN VEIN
ARTERY ARTERY

?
LYMPHATICS TO
MEDIASTINAL
NODES

PLEURAL FLUID

STOMA

PLEURAL SPACE

PARIETAL PLEURAL VISCERAL PLEURAL 6


MOVEMENTS OF FLUID IS BASED ON STARLING’S LOW

STARLING’S LOW :

L . A [ (PCAP – PPl) – (CAP – Pl) ]

L: Filtration coefficient
A: Surface area
Cap: Capillary
Pl: Pleural

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PLEURAL FLUID FORMATION AND ABSORTION

• The rate of fluid formation is 0.02 ml/kg/hour.

• The rate of fluid clearance is 0.2 ml/kg/hour.

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PLEURAL FLUID FORMATION AND ABSORTION

PLEURAL SPACE
INTERCOSTAL BRONCHIAL
MICROVESSELS MICROVESSELS

VEIN VEIN
ARTERY ARTERY

?
LYMPHATICS TO
MEDIASTINAL
NODES

PLEURAL FLUID

STOMA

PLEURAL SPACE

PARIETAL PLEURAL VISCERAL PLEURAL 9


Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)

lymphatic obstruction (malignancy)


diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)
* key symptom -------> shortness of breath
Fluid filling the pleural space makes it hard for the lungs to fully
expand, causing the patient to take many breaths so as to get enough
oxygen.
* If parietal pleura is irritated -------> mild pain or a sharp stabbing
pleuritic type of pain.
** Some patients will have a dry cough.
Occasionally ------> no symptoms at all.
* This is more likely when the effusion results from:
recent abdominal surgery, cancer, or tuberculosis.
* Tapping on the chest will show stony dullness, and decrease breath
sound
Diagosisn of pleural effustion
x ray
The fluid itself can be seen at the bottom of the lung or lungs,
hiding the normal lung structure.
If heart failure is present,
the x-ray shadow of the heart will be enlarged.

Ultrasound may disclose a small effusion that caused no


abnormal findings during chest examination.
C.T. scan is very helpful if the lungs themselves are diseased.
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Management of Pleural effusion

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PLEURAL EFFUSION

Indication for Pleural Fluid Analysis

• Diagnostic ( detect underlying diagnosis)

• Therapeutic (relief shortness of breath)

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PLEURAL EFFUSION

DIAGNOSTIC THORACENTESIS

CONTRAINDICATIONS

• Bleeding tendency
• Thrombocytopenia (decrease platelets less
25000 u3/dl )
• Prolonged PT or PTT greater than twice
normal,

• A very small volume of pleural fluid

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Color of Fluid
Color of Fluid Suggested Diagnosis
Pale yellow (straw) Transudate, some exudates
Red (bloody) Malignancy or embolism or TB
Turbid Infected effusion
Pus Empyema
White (milky) Chylothorax or cholesterol
effusion

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Transudates vs Exudates
LIGHT’S CRITERIA*

1. Pleural Protein divided by serum protein >0.5


2. Pleural fluid LDH divided by Serum LDH >0.6
3. Pleural fluid LDH > 2/3 the upper limit of normal for
the serum LDH.

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Causes of Transudates and Exudates

Tronsudote Exudate

Left Heart Failure Bacterial Pneumonia


Hypoproteinaemia Carcinoma Bronchus
Constrictive Pericarditis Pulmonary Infarction
Hypothyroidism Tuberculosis
Cirrhosis Connective-tissue Disease
PLEURAL EFFUSION
CELL COUNT

• Transudate < 1000 but 20% > 1000 and rarely >
10,000/mm3
• Exudate > 1000/mm3
• Limited value (unless > 50,000/mm3 
emphyema)

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PLEURAL EFFUSION
PF LYMPHOCYTE-PREDOMINANT EXUDATES (>80%)

Causes
TB
Lymphoma
`Chronic lymphocytic leukaemia

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PLEURAL EFFUSION
BIOCHEMISTY

Glucose < 3.3 mmol/L or 1/2 serum glucose


(simultaneous)
- Rheumatoid pleurisy (85%)
- Empyema (80%)
- Malignancy (40%)

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PLEURAL EFFUSION
The mechanism responsible for pleural fluid low
glucose include;

• Decreased transport of glucose from blood to


pleural fluid

• Increased utilization of glucose by constituents


of pleural fluid, such as neutrophils, bacteria
(empyema), and malignant cells

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PLEURAL EFFUSION
BIOCHEMISTY

Pleural fluid pH:


- Normal pleural fluid pH is > 7.6
- Transudates – pH 7.40-7.55
- Exudates – pH is 7.30-7.45
• Should always be measured in a blood gas machine
• Parapneumonic - pH < 7.0 predicts “complicated effusion” that is
unlikely to resolve without chest tube drainage.
• Malignant effusion with a pH < 7.3 is associated with poor survival.
• If pH < 6.0 think of ruptured esophagus

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PLEURAL EFFUSION
The mechanism responsible for pleural fluid acidosis
(pH <7.30) include;

• Increased acid production by pleural fluid cells


and bacteria

• Decreased hydrogen ion efflux from the pleural


space, due to pleuritis, tumor, or pleural
fibrosis.

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PLEURAL EFFUSION
DIAGNOSES ASSOCIATED WITH PLEURAL FLUID
ACIDOSIS (pH <7.30) AND LOW GLUCOSE
CONCENTRATION (PF/SERUM <0.5)

Diagnosis Usual pH (Incidence) Usual Glucose


Concentration
(mg/dL)
Empyema 5.50-7.29 (-100%) <40
Malignancy 6.95-7.29 (33%) 30-59
Tuberculous pleurisy 7.00-7.29 (20%) 30-59

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PLEURAL EFFUSION

CYTOLOGY

 positive in about 60% of patients


with malignant effusion

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PLEURAL EFFUSION

Patients with Abnormal Chest Radiograph

Suspect pleural disease

Blunting of costophrenic angle?


YES

Lateral decubitus chest


radiographs

Yes No
Diagnostic Fluid thickness > Observe
thoracentesis 10mm

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PLEURAL EFFUSION
SUMMARY
Diagnostic
thoracentesis

Any of the following met?


Yes PF/serum protein >0.5 No
PF/serum LDH >0.6
PF LDH >2/3 upper normal Serum limit

Exudate Transudate

Appearance of plueral fluid, pH & Treat CHF,


glucose, cytology and differential cell cirrhosis, or
count of pleural fluid nephrosis
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direct treatment at what is causing it,
rather than treating the effusion itself
Peneumothorax is the accumulation of air in the pleural space. It may occur
spontaneously or following trauma

Disorder Collection Cause

Chest trauma; rupture of aortic


Haemothorax Blood
aneurysm
Hydrothorax Proteinaceous Fluid Congestive cardiac failure
Chylothorax Lymph Neoplastic infiltration; trauma
Pneumothorax Air Spontaneous; traumatic
 Results from rupture of a pleural bleb
 Pleural bleb being a congenital defect of the alveolar wall
connective tissue.
 Patients are typically tall, thin, young males.
 M:F ratio 6:1.
 Usually apical affecting both lungs with equal frequency.
 Secondary causes occur in patients with underlying
disease :

 COPD, TB, pneumonia, bronchial carcinoma,


sarcoidosis and cystic fibrosis.
Patients present with sudden onset of unilateral pleuritic pain
and increasing breathlessness.
The main aim of treatment is to get the patient back to active
life as soon as possible.
 Chest radiography may show an area devoid of
lung markings.

 May be more clearly seen on the expiratory film


 Small pneumothorax: no treatment, but
review in 7-10 days.
 Moderate pneumothorax: admit for simple
aspiration.
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