Pleural Effusion Farm

8/9/2019 Pleural Effusion Farm

1/40

Pleural effusion


2/40

Pleura

Mesothelial lining of

each hemithorax Derived from

embryonic coelomic

lining

Visceral pleura: lung

Parietal pleura: wall-Costal

-Diaphragmatic

-Mediastinal

-Cervical

Pleural Cavity

Potential space between visceral & parietal pleura

Capillary layer of serous fluid produced by mesothelium

Reduces friction Surface tension provides cohesion between lung and thoracic wall


3/40

Pleural space

A relative vacuum in the space keeps the visceraland parietal pleurae in close proximity.

The small volume of pleural fluid, which has been

calculated at 0.1-0.2 ml/kg/day, serves as alubricant to facilitate movement of the pleuralsurfaces against each other in the course ofrespirations.

This small volume of fluid is maintained throughthe balance of hydrostatic and oncotic pressureand lymphatic drainage, a disturbance of whichmay lead to pathology.


4/40

Physiology of the Pleural Space

Pleural fluid production : Starling force

Hydrostatic pressure : intracapillary pressure

supply parietal and visceral pleura

Oncotic pressure : related with serum protein and

pleural fluid protein

Blood supply

Parietal pleura : intercostal artery

Visceral pleura : bronchial artery


5/40


Venous drainage

Parietal pleura : intercostal vein

Visceral pleura : pulmonary vein

intercostal vein P. > pulmonary vein P.

Parietal pleura P. > Visceral pleura P.

fluid from capillary at parietal pleura mesothelial cell

pleural space absorb to visceral pleura


6/40


In human

P. in pleural space < P. in parietal and visceral pleura

Pleural fluid from both parietal and visceral pleura

Pleural space

Lymphatic opening at parietal pleura


7/40


From: Cretien, J, Bignon, J., Hirsch, A, eds: The Pleura in Health and Disease.

New York: Marcel Dekker, 1985, p182.


8/40

Pleural effusion

A pleural effusion is an abnormal collection of fluid inthe pleural space.

resulting from excess fluid production or decreased

absorption.

most common manifestation of pleural diseasePleural effusion is an indicator of an underlying disease

process that may be pulmonary or nonpulmonary in

origin, acute or chronic.


9/40

Pathophysiology

Normal pleural fluid has the followingcharacteristics: Clear ultrafiltrate of plasma that originates from the

parietal pleura

pH 7.60-7.64

Protein content less than 2% (1-2 g/dL)

Fewer than 1000 WBCs per cubic millimeter

Glucose content similar to that of plasma

Lactate dehydrogenase (LDH) less than 50% of plasma Sodium, potassium, and calcium concentration similar

to that of the interstitial fluid


10/40

Pathophysiology

1. increase fluid production1.1Starling force pulmonary capillary pressure (CHF)

plasma oncotic pressure

(hypoalbuminemia,cirrhosis) transudate intrapleural pressure (atelectasis)

1.2 capillary permeability

capillary permeability (Pneumonia,PE) exudate

1.3 fluid leakage from

Ascites Mediastinum (rupture esophagus or thoracic duct)

Retroperitoneum ( pancreatic pseudocyst)


11/40

Pathophysiology

2. decreased absorption

Decreased lymphatic drainage or Lymphaticobstruction (malignancy) exudate


12/40

Differentiation of transudates and exudates

Transudates

< 0.5

< 0.6

< 2/3 the upper

limit for serum

Exudates

> 0.5

> 0.6

>2/3 the upper

limit for serum

Pleural Fluid

Pleural/serumProtein

Pleural/serum

LDH

Pleural

LDH

Lights criteria


13/40

Transudative Pleural effusions

Congestive heart failure

Cirrhosis

Nephrotic syndrome

Peritoneal dialysis

Superior vena cava obstruction

Myxedema Urinothorax


14/40

Exudative Pleural Effusions

Neoplastic diseases

Metastatic disease

Mesothelioma

Infectious diseases

Bacterial infections

Tuberculosis

Fungal infections

Viral infections

Parasitic infections


15/40


Pulmonary embolization

Gastrointestinal disease

Esophageal perforation

Pancreatic disease

Intraabdominal abscesses

Diaphragmatic hernia

After abdominal surgery

Endoscopic variceal sclerotherapy

After liver transplant


16/40


Collagen-vascular diseases

Rheumatoid pleuritis

Systemic lupus erythematosus

Drug-induced lupus

Immunoblastic lymphadenopathy

Sjgren's syndrome

Wegener's granulomatosis Churg-Strauss syndrome


17/40


Post-coronary artery bypass surgery

Asbestos exposure

Sarcoidosis Uremia

Meigs' syndrome

Yellow nail syndrome


18/40


Trapped lung

Radiation therapy

Post-cardiac injury syndrome

Hemothorax

Iatrogenic injury

Ovarian hyperstimulation syndrome

Pericardial disease

Chylothorax


19/40


Drug-induced pleural disease

Nitrofurantoin

Dantrolene

Methysergide

Bromocriptine

Procarbazine

Amiodarone


20/40

HistoryHistory

abdominal surgery alcoholism, pancreatitis

asbestos exposure

CA

cardiac surgery : CABG uremia

cirrhosis

trauma

post EGD drug

SLE

RA


21/40

Sign & symptom

dyspnea

pleuritic chest pain

cough

fever hemoptysis

weight loss


22/40


23/40

DIAGNOSIS

CXR

U/S

CT scan

Thoracentesis Pleural biopsy


24/40

CXR

primary diagnostic tool because of its availability,accuracy, and low cost

Pleural fluid typically collects in the pleural space on an

upright chest radiograph, primarily the posteriorcostophrenic recess, followed by the lateral recess.

200 mL are required to cause blunting of the lateralrecess on a posteroanterior (PA) film.

As little as 50 mL of fluid will cause blunting of theposterior costophrenic recess on a lateral upright film.

A lateral decubitus chest radiograph may detect aslittle as 5 mL of fluid.


25/40

CXR

Small effusion : blunting of CP angle

Moderate effusion : meniscus sign

Massive effusion : trachea & mediastinal shiftto the contralateral side


26/40

Massive pleural effusion

often attributable to an underlying malignancy

Other conditions that must be considered include congestive

heart failure, tuberculosis (TB)

usually have an accompanying mediastinal shift to the

contralateral side differential diagnosis in the absence of mediastinal shift :

carcinoma of the ipsilateral mainstem bronchus with or

without ipsilateral lung atelectasis

fixed mediastinum caused by fibrosis or tumor infiltration ofmediastinal LN

tumor infiltration of the ipsilateral lung

malignant mesothelioma

complete atelectasis of the ipsilateral lung


27/40

Bilateral pleural effusion

Systemic process

DDx

CHF Cirrhosis

nephrotic syndrome

hypoalbuminemia


28/40

Unilateral pleural effusion

Local inflammation

DDx

Parapneumonic effusion

Empyema

TB

Parasitic infection

Tumor Trauma

Lymphatic obstruction


29/40

CXR PA upright : 200 ml


30/40

CXR lateral : 50 ml


31/40

CXR lateral decubitus : 5 ml


32/40


33/40

empyema


34/40

Lung abscess


35/40

U/S

detect as little as 5-50 mL of pleural fluid

identify loculated fluid collections

guide needle insertion for thoracentesis orchest tube placement


36/40


37/40

CT Scanning permits imaging of the entire pleural space,

pulmonary parenchyma and vasculature, mediastinum,and pericardium.

Distinguishing benign from malignant pleuralinvolvement

One or more of the following suggests malignancy:

circumferential pleural thickening

nodular pleural thickening

parietal pleural thickening (>1 cm) mediastinal pleural involvement

Distinguishing pleural disease (empyema) &pulmonary disease (lung abscess)


38/40

Pleural effusion


39/40


40/40

Documents

Pleural Effusion Farm