Pleural Effusion

Pleurisy acute pleural inflammation caused by irritation of parietal

pleura
Secondary to viral respiratory tract infections and pneumonia

Clinical features Pain which is localized ,sharp and fleeting .

It is made worse by coughing ,sneezing, deep breathing and movement
and may radiate to the shoulder.
On auscultation there is scratchy sound at the affected area called
pleural rub .
Treatment analgesics and anti inflammatory medications
( indomethacin ,codeine )
Pleural effusion
Abnormal accumulation of fluid in the pleural cavity is called pleural
effusion

Movement of fluid from parietal pleura capillaries into the pleural space
at the rate of .01ml/kg body wt /hr and absorption of fluid occurs by the
parietal lymphatics .the resultant homeostasis maintains 5-15mls of
fluid in the pleural cavity .
 pathophysiology

Increase in the hydrostatic pressure

Decrease in the oncotic pressure
Abnormal capillary permeability
Reduced lymphatic clearance
Infection in the pleural space (empyema and para pneumonic effusion)
Bleeding into the pleural space (hemothorax)
classification on the basis of lab chemistry
Exudative
Ratio of pleural fluid protein to serum protein is >.5
Ratio of pleural fluid LDH to serum LDH is >.6
Pleural fluid LDH is > 2/3of upper limit of nprmal serum LDH

Transudative
Ratio of pleural fluid protein to serum protein is <.5
Ratio of pleural fluid LDH to serum LDH is <.6
Pleural fluid LDH is < 2/3of upper limit of nprmal serum LDH
 Causes
Exudative Transudative
Pneumonia Heart failure 90%
Cancer liver cirrhosis e ascites
Bacterial infections Nephrotic syndrome
Viral infections SVC obstruction
Fungal infections Pulmonary embolism
Tuberculosis Atelectasis
Uremia
Connective tissue diseases
Clinical features
Symptoms dry cough ,pleuritic chest pain , dyspnea
Signs
Inspection reduced chest movements ,bulging on the affected side
Palpation reduced chest expansion ,tracheal displacement to opposite
side and reduced vocal fremitus
Percussion stony dull
Auscultation reduced or absent breath sounds ,reduced vocal
resonance
Bronchial breath sounds due to compression of adjusant lung tissue
Investigations
X Ray Chest PA view (175-200ml) Obliteration of costophrenic angle
Uniform dense opacity e curved upper level
Concavity facing axilla
X Ray Chest lateral view(100 mls)
CT Scan chest
Ultrasound chest
Pleural fluid analysis for cell count ,glucose ,protein,cytology,culture
sensitivity
Additional tests PH,LDH,ADA,amylase ,complement levels ,triglyceride
level .
Pleural biopsy for culture and detection of TB granulomas
Uncomplicated Para pneumonic
Clear to turbid
WBC 5000-25000 M
RBCS <5000
Glucose equal to serum levels
Resolves e treatment of pneumonia
Empyema
Turbid to purulent
WBC 25000 to 100,000 P
RBCS <5000
Glucose less than serum levels
PH <7.2
Drainage is required
Tuberculosis
Serous to serosanguinous
WBCS 5000 to 10000 M
RBCS <10000
Glucose equal to serum levels
Protein>4 g/dl
LDH High
Malignancy
Turbid to bloody
WBCS 1000-100000 M
RBCS 100to several thousand
Glucose equal to serum
Cytology positive for malignant cells
Treatment
Treat the underlying cause
Therapeutic aspiration (750ml -1000 ml)
Tuberculosis Anti Tuberculosis treatment
Para Pneumonic Effusion Antibiotics
Chest intubation for frank pus,pleural glucose <40mg/dl
fluid Ph. <7.2 ,LDH>1000
Pleurodesis is done for recurrent effusion like malignant
Obliteration of pleural space by the instillation of Talc ,saline or
streptomycin
Thankyou