PLEURAL EFFUSION

Pulmonology & Respiratory Medicine Departement

Brawijaya University/Saiful Anwar Hospital
Malang

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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

Light’s criteria

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 Light’s 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)
 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

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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 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, • 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

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

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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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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