of 50/50
PLEURAL DISEASE PLEURAL DISEASE

PLEURAL DISEASE. Pleural Diseases Pleural effusions Pleural malignancy Hemothorax Pneumothorax

  • View
    275

  • Download
    12

Embed Size (px)

Text of PLEURAL DISEASE. Pleural Diseases Pleural effusions Pleural malignancy Hemothorax Pneumothorax

  • Slide 1

PLEURAL DISEASE Slide 2 Pleural Diseases Pleural effusions Pleural malignancy Hemothorax Pneumothorax Slide 3 The Mechanisms of Pleural Effusion Increased hydrostatic pressure (Cardiac failure) Decreased oncotic pressure (Protein deficiency) Decreased pleural cavity negative pressure (Atelectasis) Increased permeability in microvascular circulation (nfections, inflammation) Impaired lymphatic drainage of pleural space (Tumor, fibrosis) Transperitoneal route (Congenital defects, ascite) Slide 4 Symptoms Chest pain (inspiratory) Decreases when the fluid increases Decreases when the fluid increases Dyspnea Cough Symptoms of the underlying disease Fever Fever Hemoptysis Hemoptysis Weight loss Weight loss...... Physical signs No physical signs can be detected when the fluid is less than 300 ml ncreased size of the affected hemithorax psilateral restriction of chest wall motion VT absent Dullness (>300-400 ml) Diminished breath sounds or inaudible Pleural friction rub Slide 5 Radiology The fluid initially accumulates in the more dependent recesses of the thoracic cavity forming a Damoiseau Line 200-300 ml of pleural effusion can be detected on standard chest radiograph as blunting of the costophrenic angle Slide 6 Slide 7 Massive pleural fluid often shifts the mediastinum to the opposite side Slide 8 Accumulation of the fluid between the diaphragm and the interior surface of the lung (Subpulmonic fluid): The hemidiaphragm appears to be elevated (Widening the distance between the top of the gastric bubble and the top of the left hemidiaphragm (>2 cm) and flatened Blunting of the posterior costophrenic angle on the lateral chest radiograph Slide 9 Smaller amounts of pleural fluid can be detected on lateral decubitus radiography as the free intrapleural fluid moves from top of the diaphragm to the dependent chest wall Pleural effusion in a lateral decubitus radiograph Slide 10 Unusual localized pleural effusions can be seen due to the localized obliteration of the pleural space often by inflammatory conditions Slide 11 Ultrasound is able to demonstrate smaller amounts of fluid as 100 ml CT has similar sensitivity to ultrasound, not routine but can be performed to evaluate concomitant paranchymal lesions CT is sensitive in identifying pleural thickening and calcification Slide 12 Slide 13 Thoracentesis Thoracentesis is indicated in all cases of pleural efusion of unknown origin The site should be selected according to clinical examination If the effusion is small thoracentesis can be performed under ultrasound guidance Slide 14 Thoracentesis is usually performed for diagnosis Apperiance of the fluid (Serous, bloody, purulent) Apperiance of the fluid (Serous, bloody, purulent) Biochemical, microbiological, cytological examination of the fluid Biochemical, microbiological, cytological examination of the fluid It can also be performed for the drainage of excess fluid (Therapotic) to relieve dyspnea The amount of fluid should not exceed 1000-1500 cc at a time to avoid hemodynamic complications and reexpansion pulmonary edema The amount of fluid should not exceed 1000-1500 cc at a time to avoid hemodynamic complications and reexpansion pulmonary edema Slide 15 Pleural Fluid analysis Appereance Serous (light to dark, clear) Serous (light to dark, clear) Serosangineous (Blood tinged can be due to thoracentesis itself) Serosangineous (Blood tinged can be due to thoracentesis itself) Hemorrhagic (hemothorax if hct>50% of blood hct) Hemorrhagic (hemothorax if hct>50% of blood hct) Purulent (fetid odor in aerobic infections) Purulent (fetid odor in aerobic infections) Chylous (milky) Chylous (milky) Slide 16 Biochemical evaluation Exudative Exudative Transudative Transudative Some special hints Some special hints Microbiological evaluation Cellular structure Cellular structure Special stains and culture Special stains and culture Cytologic evaluation Slide 17 Biochemical Evaluation Exudate Dark yellow color Dark yellow color Total protein >3 gr/dl Total protein >3 gr/dl Density >1016 Density >1016 Light Criteria: Light Criteria: Protein pl/s>0.5Protein pl/s>0.5 LDH pl/s>0.6LDH pl/s>0.6 LDH >200 or >2/3 of normal upper value of serumLDH >200 or >2/3 of normal upper value of serum Transudate Light yellow color Total proteinSlide 18 Albumine Gradient: Serum albumine- Pleural fluid albumine Serum albumine- Pleural fluid albumine 1.2 gr/dlTransudate Pleural Cholesterol >60 mg/dl: Eksudate Pl/S bilirubine >0.6:Exudate Slide 19 Microbiologic evaluation RBC >100 000/mm 3 Trauma, Trauma, Pulmonary infarction Pulmonary infarction malignancy malignancy WBC > 1000/mm 3 : exudate > 10 000/mm 3 : emphyema, parapnomonic effusion (PNL predominates) > 10 000/mm 3 : emphyema, parapnomonic effusion (PNL predominates) Lymphocytes >50% : tuberculosis, malignancy, lymphoma, fungus, myxedema Slide 20 Gram staining Ziehl-Neelsen staining Cultures for specific and nonspecific infections PCR Slide 21 Transudative Pl. Eff. Increased hydrostatic pressure Increased hydrostatic pressure Congestive heart failureCongestive heart failure Constrictive pericarditisConstrictive pericarditis Pericardial effusionPericardial effusion Pulmonary thromboemboliPulmonary thromboemboli Decreased oncotic pressure Decreased oncotic pressure CirrhosisCirrhosis Nephyrotic syndromeNephyrotic syndrome MalnutritionMalnutrition Increased capillary permeability Increased capillary permeability MyxedemaMyxedema Pulmonary thromboemboliPulmonary thromboemboli Transperitoneal transport Transperitoneal transport Peritoneal dialysisPeritoneal dialysis AscitesAscites Exudative Pl. Eff. Infectious diseases Pnomonia, lung abscess Tuberculosis Fungal infections Subphrenic abscess Neoplastic diseases Metastatic Mesothelioma Lymphoma Immunologic reactions Dressler syndrome Sistemic Lupus Er. Rheumatoid artritis Churg strauss syndrome Wegener granulomatosis Slide 22 Exudative Pl Eff Gastrointestinal disease Pancreatitis Causes of peritoneal exuda Drug induced Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbasine Amiodorone Postsurgical Pulmonary thromboembolism Slide 23 Exudative Pl Eff Sarcoidosis Uremic pleuritis Asbestos exposure Chylothorax Hemothorax Yellow nail syndrome Slide 24 Special characteristics: Milky appearance Chylothorax Triglyceride >110 mg/dl Triglyceride >110 mg/dl Pl TG/sTG>1 Pl TG/sTG>1 Cholesterol crystal (-) Cholesterol crystal (-) Chylomicrons (+) Chylomicrons (+) Sterile (bacteriostatic) Sterile (bacteriostatic) Noniritative (do not cause pleural thickening) Noniritative (do not cause pleural thickening) Ety: Trauma, surgery, lymphoma Ety: Trauma, surgery, lymphoma Pseudochylothorax Triglyseride 250 mg/dl Pl Ch/s Ch>1 Ety: RA, Tbc Emphyema PH Eosinophilia >10 % of the total cells Air or blood in the pleural space Air or blood in the pleural space Recurrent punctionsRecurrent punctions Pulmonary embolismPulmonary embolism Benign asbestos effusions Benign asbestos effusions Resolving pleural infections Resolving pleural infections Echinococus infection Echinococus infection Loeffler syndrome Loeffler syndrome Hodgkins lymphoma Hodgkins lymphoma Drug induced pleural eff. Drug induced pleural eff. Slide 28 If the effusion is transudative the main cause should be treated If the effusion is exudative and not emphyema further diagnostic procedures should be considered Cytologic examination Cytologic examination Closed pleural needle biopsy Closed pleural needle biopsy Thoracoscopy (VATS) Thoracoscopy (VATS) Thoracotomy Thoracotomy Slide 29 Treatment Treatment of the specific cause Drainage of the excess fluid Pleurodesis (Performed to achieve fusion between visceral and parietal pleural layers. Main indications are malignant effusions, rarely recurrent benign effusions when other treatments have failed. After the removal of pleural fluid completely by thoracal tube, special sclerosing agents (tetracycline, doxycycline, bleomycine, talc etc) are injected to the pleural cavity) Surgical pleurectomy Pleuroperitoneal shunt Slide 30 Cardiac effusions Predominantly caused by left ventricular failure, elevated pulmonary capillary pressure >50% are bilateral effusions or 27% right sided only. Usually the heart is enlarged on chest x ray, phantom tumor (pseudotumor) can be present on the right side Resolves with diuretics and treatment for left ventricular failure Slide 31 Slide 32 Infectious pleuresy, emphyema Bacterial pneumonia is associated with an effusion in 40% of cases The effusion may be parapneumonic without infection (uncomplicated) or culture positive (complicated, emphyema) Parapneumonic effusions are treated with appropiate antibiotics Antibiotic treatment + Tube drainage is indicated if emphyema occurs Slide 33 Tube drainage indications in complicated parapneumonic effusion Purulent appearance Gram staining (+) for bacteria Plevral fluid glucose1000 IU/L Slide 34 Tuberculosis pleurisy Usually occurs soon after the primary infection and mainly affects children or teenager group Pathogenetic mechanisms include direct invasion of AFB to pleura or delayed type hypersensitivity reaction The onset of symptoms may be acute or subacute Typical symptoms of pleural effusion and general symptoms of tb may be present Slide 35 Exudative effusion, lymphocyte predominance, low glucose, low mesothelial cells ( Other Pleural Diseases Hemothorax Plevral fluid htc>50% of serum Plevral fluid htc>50% of serum Can be traumatic or nontraumatic: Can be traumatic or nontraumatic: atrogenicatrogenic Pulmonary infarctionPulmonary infarction TumorsTumors Rupture of aneurismRupture of aneurism Anticoagulan treatmentAnticoagulan treatment Thoracic endometriosisThoracic endometriosis Treatment: Treatment: intrapleural drainageintrapleural drainage thoracotomy thoracotomy Slide 37 Chylothorax Direct passage of chyle from the thoracic duct into the pleural cavity Direct passage of chyle from the thoracic duct into the pleural cavity TG>110 mg/dl TG>110 mg/dl Cause: Cause: Tumors (Lymphoma)Tumors (Lymphoma) Trauma (surgery)Trauma (surgery) Congenital defectsCongenital defects LymhangioleiomyomatosisLymhangioleiomyomatosis TuberosclerosisTuberosclerosis Treatment. Pleural drainage Parenteral nutrition Bed rest (to decrease lymphatic drainage) Surgical ligation of thoracic duct Chemotherapy or RT Slide 38 Fibrothorax A thick fibrous tissue formed on visceral pleura A thick fibrous tissue formed on visceral pleura Cause: Cause: EmpyemaEmpyema TuberculosisTuberculosis HemothoraxHemothorax Treatment: Decortication Treatment: Decortication Slide 39 Slide 40 Slide 41 Pneumothorax (Px) Presence of free air between the visceral and parietal pleura Presence of free air between the visceral and parietal pleura Divided into 3 Divided into 3 Open Px ( Penetrating trauma)Open Px ( Penetrating trauma) Closed PxClosed Px Spontaneous (Primary, Secondary) Spontaneous (Primary, Secondary) Closed trauma Closed trauma iatrogenic iatrogenic Tension Px (Penetrating trauma)Tension Px (Penetrating trauma) Slide 42 Physical examination: Hypersonority on percusion Hypersonority on percusion Reduced breath sounds Reduced breath sounds Hypotension and cardiac tamponade may occur depending on the size of the pneumothorax Hypotension and cardiac tamponade may occur depending on the size of the pneumothorax Radiology: Pleural line Pleural line Hyperlucency at the periphery Hyperlucency at the periphery Mediastinal shift Mediastinal shift Expiration film, lateral decubitus film can be used when the lesion is not apparent Expiration film, lateral decubitus film can be used when the lesion is not apparent Slide 43 Slide 44 Slide 45 Slide 46 Slide 47 Measurement of the average diameters of the collapsed lung and the affected hemithorax can be used 100-(8 3 /11 3 )100=% 62 >2 cm pleural line from thoracic line in hiler region is large px Simple observation with rest and supplemental oxygen can be used for asymptomatic patients with a small (