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PLEURAL EFFUSION
ANDPNEUMOTHORAX
By:
WIDIRAHARDJO
Pulmonary Department, Faculty of Medicine,
Sumatera Utara University/ Adam Malik Hospital
Medan
2011
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ANATOMY OF THE PLEURAI. Pleura is the serous membrane:
1. Visceral pleura: covers the lung parenchyma, untilinterlobar fissures
2. Parietal pleura: covers the mediastinum,
diaphragm and the rib cage.The space between the two layers of pleura call as
pleural space.
II. Pleural space contain a film of fluid: pleural fluid, aslubricant and allows the sliding between the two pleuras
during respiratory movements. No air in the pleural
space and no communication between right and left
pleural space.
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ANATOMY OF THE PLEURA
(contd)
III. Histology: covered by a single layer ofmesothelial cells. Within the pleura are bloodvessels, mainly capillaries, lymphatic lacunas
(only in the parietal pleura), and connectivetissue.
Two important function of the connectivetissue in the visceral pleura:
- contributes to the elastic recoil of the lung
- restricts the volume to which the lung can
be inflated
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ANATOMY OF THE PLEURA
(contd)
Elastic and collagen fibers areinterdependent elements.
The mesothelial cells are active cells,sensitive and responsive to various stimuliand very fragile. They may betransformed into macrophage.
Scanning electron microscopy: microvilliare present diffusely over the pleuralsurface:
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ANATOMY OF THE PLEURA
(contd)
IV. Pleural fluid: the important in the understanding
are volume, thickness, cellular components, and
physicochemical factors.Normally a small amount of pleural fluid present,
behaves as a continuous system.
The total white cell count of 1,500/mm3,with 70% monocytes (mononuclear cell). The
protein, ionic concentrations are differ significantly
from serum.
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ANATOMY OF THE PLEURA
(contd)
V. Blood supply: from the systemic capillaries
VI. Lymphatics: the lymphatic vessels in the parietalpleura are in communication with the pleural
space by stomas.
VII.Innervation: sensory nerve endings are presentin the costal and diaphragmatic parietal pleura.
The visceral pleura contains no pain fibers.
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PHYSIOLOGY OF THE PLEURAL SPACE
I. The pleural space is important in thecardiopulmonary physiology, as a buffer zone for overloading of fluid in the circulatory system of the lung.
The gradient of pressure depend on the threecomponents:
- cardiac rhythm
- respiratory rhythm- elastic recoil of the lung
PLEURODYNAMIC: the capacity of thepleural space to change in the pleural pressurevariability.
The normal pleural pressure ranged from - 8,1 to-11,2 cmH2O (the negative or sub atmospheric
pressure).
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Intrapleural pressure
- 8,1 Cm H2O 0 Cm H2O
inspiration expiration
Negative / sub atmospheric pressure
-11,2 Cm H2O
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PHYSIOLOGY OF THE PLEURAL SPACE
(contd)
The pleural pressure changes associated with manypleural diseases. Commonly by the increasing ofpleural pressure.
Pleural fluid formation from:
- pleural capillaries
- interstitial spaces of the lung- intrathoracic lymphatic
- intrathoracic blood vessels
- peritoneal cavity
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PHYSIOLOGY OF THE PLEURAL SPACE
(contd)
Pleural fluid absorption:
- Lymphatic clearance: fluid clearance through
the pleural lymphatics is though to explain thelack of fluid accumulation normally.
Stomas in the parietal pleura, as an initial
drainage. There are no stomas in the visceralpleura.
- Capillaries clearance: few for small molecules and
water across both pleural surfaces.
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CLINICAL MANIFESTATIONS
I. Symptoms: mainly dictated by underlying process,
may have no symptom to severe illness.- pleuritic chest pain
- dullness
- non productive cough
- dyspnea
II. Physical examination:
- inspection: sizes of the hemithoraces and the
intercostal space- palpation
- percussion
- auscultation: decreased or absent breath sounds,
pleural rubs
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LABORATORY APPROACH
Separation of exudates from transudates
Appearance of pleural fluid
BronchoscopyThoracoscopy
Needle biopsy of the pleura
Open pleural biopsy
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PLEURAL DISEASES
Pleural effusion
Pneumothorax
Empyema
Hydropneumothorax Pyopneumothorax
Hemothorax
Chylothorax Mesothelioma
Etc
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PLEURAL EFFUSION
Definition: an accumulation of pleural fluid
in the pleural space.
Pathogenesis:
= Increased pleural fluid formation
= Decreased pleural fluid absorption
= Both increased formation and decreasedabsorption
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PLEURAL EFFUSION (contd)
Increased pleural fluid formation:
- increased interstitial fluid in the lung
- increased intravascular pressure in pleura
- increased permeability of the capillaries inthe pleura
- decreased pleural pressure
- increased fluid in the peritoneal cavity
- disruption of the thoracic duct
- disruption of the blood vessel in the thorax
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PLEURAL EFFUSION (contd)
Decreased pleural fluid absorption:
- obstruction of the lymphatics draining
- elevation of systemic vascular pressure
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Clinical manifestations:
= Symptoms: mainly dictated by the underlyingprocess; may be no symptom, pleuritic chest
pain, referred pain, dullness, dry/ non
productive cough, and dyspnea.= Physical examination: change in sizes of
hemithoraces and intercostal spaces. Tactile
fremitus is absent or attenuated, dull inpercussion, decreased or absent breath sounds,
pleural rub during the latter of inspiration and
early expiration (to and fro pattern)
PLEURAL EFFUSION (contd)
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PLEURAL EFFUSION (contd)
Separation of transudative or exudative effusion:Light`s criteria for exudative pleural effusion, if
we found one or more of:
= pleural fluid protein divided by serum proteingreater than 0,5
= pleural fluid LDH divided by serum LDH
greater than 0,6= pleural fluid LDH greater than two thirds of
the upper limit
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exudative transudative
Tuberculosis
Tumor
PneumoniaTrauma
Collagen disease
Asbestosis
UremiaRadiation
Sarcoidosis
Emboli
Congestive heart
Nephrotic syndrome
Cirrhosis hepatisMeigs syndrome
Hydronephrosis
Peritoneal dialysis
PLEURAL EFFUSION (contd)
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TRANSUDATIVE PLEURAL EFFUSION
Occurs when the systemic factors influencing theformation and absorption of pleural fluids are
altered.
The most common cause: congestive heart
failure (CHF);
Pathogenesis: pressure in the pulmonary capillary
elevated fluid enter the interstitial spaces of
the lung across the visceral pleura into the
pleural space.
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TRANSUDATIVE PLEURAL EFFUSION
(contd)
Clinical manifestation: associated withCHF:
- dyspnea on excertion
- peripheral edema- orthopnea or paroxysmal nocturnal
dyspnea
- distended neck vein- rales
- gallop
- signs of the pleural effusion
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TRANSUDATIVE PLEURAL EFFUSION
(contd)
Treatment:
- digitalis
- diuretics- afterload reduction
- thoracocentesis
- pleuroperitoneal shunt
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TUBERCULOUS PLEURAL EFFUSION
Pathogenesis:
- sequel to a primary tuberculous infection
(post primary infection)- reactivation
- result from rupture of subpleural caseous
focus in the lung- delayed hypersensitivity
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TUBERCULOUS PLEURAL EFFUSION
(contd)
Clinical manifestation:- most common as an acute illness: < 1
week
- cough, usually nonproductive
- chest pain, ussually pleuritic
- fever
- younger than patients with parenchymal
tb
- usually unilateral and can be of any size
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TUBERCULOUS PLEURAL EFFUSION
(contd)
Diagnosis:- acid fast bacilli of: sputum, pleural fluid
pleural biopsy specimen
- granulomas in the pleura (on
thoracoscopy)
- elevated of ADA (adenosine deaminase)
- 20% with parenchymal infiltrate
- 39% with hilar adenopathy
- tuberculin skin test
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TUBERCULOUS PLEURAL EFFUSION
(contd)
Treatment:
- Chemotherapy
- Corticosteroid- Thoracocentesis
- WSD (water sealed drainage)
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PNEUMOTHORAX
DEFINITION: air in the pleural space.CLASIFICATION:
1. Spontaneous pneumothoraxoccur without antecedent trauma or other obvious cause,
devided into:
Primary spontaneous pneumothorax (PSP): occur in
healthy individuals
Secondary spontaneous Pneumothorax (SSP):occur as a
complication of underlying lung disease, most commonly
COPD (chronic obstructive pulmonary disease).
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PNEUMOTHORAX
2. Traumatic pneumothorax:
occur as a result of direct or indirect trauma to
the chest:3. Iatrogenic pneumothorax: occur as a an
intended or inadvertent consequence of a
diagnostic or therapeutic maneuver.
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INCIDENCE
Males: 7,4/100.000 per year
Females: 1,2/100.000 per year
Relative risk in smoker 7-102 times higher
Usually taller and thinner, associate with genetical
predisposed to bleb formation Peak age of the occurrence is in the early 20s
Rare after age 40
PRIMARY SPONTANEOUS PNEUMOTHORAX
(PSP)
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PRIMARY SPONTANEOUS PNEUMOTHORAX
PATHOPHYSIOLOGY The negative/ sub atmospheric
pressure of the pleural space and
The positive pressure of the alveolarpressure always positive
Develop of communication between
alveolus and pleural space Air flow from alveolus into pleural
space
PRIMARY SPONTANEOUS PNEUMOTHORAX
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CLINICAL MANIFESTATION
The main symptom: chest pain and dyspnea
Usually develop at rest
PD: moderate tachycardia. If HR > 140 or if
hypotension, cyanosis is present, a tension
pneumothorax should be suspected
Larger of the chest, move less, absent of
fremitus tactile, hyper resonant in percussion
note and reduced or absent the breath soundon the affected side.
The trachea may be sifted toward the contra
lateral side
PRIMARY SPONTANEOUS PNEUMOTHORAX
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PRIMARY SPONTANEOUS PNEUMOTHORA
DIAGNOSIS:= Clinical history
= Physical diagnostic
= Chest x-ray: is a definitive diagnostic,
showed the visceral pleural line. Expiratory
films are more sensitive than are inspiratory
films.
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QUANTITATION:
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PRIMARY SPONTANEOUS PNEUMOTHORAX
RECURENCE RATE:
= Without thoracotomy: 52%, 62% and 83% in
patient had first, second and third
pneumothoraces respectively
= Chest CT may predict the recurrence, where
the individual with numerous and the largest
bullae would be most likely had recurrence
TREATMENT
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TREATMENT
A. Observation
= Resorbed of the air in the pleural space about
1,25% per day, if the communication between
the alveoli and pleural space is eliminate
= Bed rest
B. Supplemental Oxygen
= Supplemental oxygen: increased the rate of air
absorption until 6 time
= As a routine treatment for all type of
pneumothorax
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TREATMENTC. Aspiration
= As a initial treatment for psp > 15%
= By G-16 needle with internal
polyethylene catheter, inserted into
anterior 2ndICS at mid clavicle line after
local anesthesia, a three way stopcock
and 60ml syringe
= 64% successful
= Tube thoracostomy for unexpanded lung
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TREATMENT
D. Tube thoracostomy= Permits the air to be evacuated effectively
and rapidly
= Connected to underwater seal (WSD), low
pressure continuous suction (up to
100cmH2O), or to a Heimlich valve.
E. Pleurodesis= Instilation of any sclerosing agent to the pleural
space or by abrasion of the pleuras to create
obliteration of the pleural space.
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TREATMENT
F. Thoracoscopy= Direct view to the entire thoracic cavity
= To treat the bullous disease responsible
for the pneumothorax= To create a pleurodesis
G. Thoracotomy
= For patient who fail to previous
treatment
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SECONDARY SPONTANEOUS
PNEUMOTHORAX (SSP) SSP are more serious than PSP, because
decreased the lung function of patient withalready compromised lung function.
INCIDENS: 6,3/100.000/year (US) ETIOLOGIC FACTORS:
= COPD
= TB= Asthma
= Pneumonia
= Lung cancer
S C S T S
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SECONDARY SPONTANEOUS
PNEUMOTHORAX CLINICAL MANIFESTATIONS:
= More severe than PSP
= Mostly: dyspnea, chest pain, cyanosis,
and hypotension
= Mortality: 16%, is associated with
respiratory failure
= Recurrent rate: 44%
= PD: similar to PSP, but less helpful,
especially for patient with COPD
SECONDARY SPONTANEOUS
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SECONDARY SPONTANEOUS
PNEUMOTHORAX
DIAGNOSIS: established by chest x-ray, show of a
visceral pleural line. Must differentiation from
large bulla, if any doubt, CT thorax may be done.
TREATMENT:
The goals are to rid the pleural space of air
and to decreased a recurrence; treatment are
the same as PSP, except the aspiration is a limited
role in SSP.
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MADE IN ENGLAND
PUMP
CC
WSC
PCC
SAFETY TUBE
25
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PUMP
CC
WSC
PCC
25
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MADE IN INDONESIA
PUMP
CC
WSC
PCC
25
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PUMP
CC
WSC
PCC
25
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MADE IN INDONESIA
PUMP
CC
WSC
SAFETY TUBE
50
PCC
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