PLEURAL EFFUSION,

PYOTHORAX &
PNEUMOTHORAX

Dr Sarika Gupta, Asst. Professor

DEFINITION

Pleural effusion: inflammation of the pleura, accompanied by

collection of fluid in the pleural space.
Normal Pleural fluid: 0.3
ml/kg BW
Protein: 1.5 g/dL
pH: alkaline (7.60)
Cells: 1700 cells/ml (75%
macrophages, 23%
lymphocytes & 2%
mesothelial cells)

Pleural fluid is produced by the parietal

pleura and absorbed by the visceral pleura as
a continuous process

Pleural space should be virtually fluid free

Fluid accumulates in the pleural space by three

mechanisms:
increased drainage of fluid into the space
increased production of fluid by cells in the space
decreased drainage of fluid from the space

Development of Pleural Effusion

pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)

CAUSES
TRANSUDATIVE
(usually bilateral )
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Constrictive pericarditis
Peritoneal dialysis
CHYLOUS
Congenital chylothorax
Post-traumatic

EXUDATIVE (usually unilateral)

Parapneumonic effusion
Tuberculosis
Connective tissue disorders
Malignancy
Pancreatitis
Subphrenic abscess
Severe dengue
Radiation pleuritis

HEMOTHORAX
Blunt trauma
Malignancy

CLINICAL FEATURES
History:
Small pleural effusion: asymptomatic
Large pleural effusion: pleuritic chest pain, abdominal pain,
pain during inspiration or coughing
The child may prefer to lie on the affected side (to decrease
respiratory excursions)
Cough
Fever
Respiratory distress, dyspnea, orthopnea, or cyanosis

CLINICAL FEATURES
Examination:
Tracheal deviation to the opposite side
Bulging chest wall on the affected side with reduced movement
Decreased vocal fremitus
Dullness to percussion
Decreased or absent breath sounds
Diminished whispering pectoriloquy & decreased vocal
resonance
Egophony-audible at the upper level of pleural effusion due to
prtially collapsed underlying lung

CLINICAL FEATURES
Examination:
Pleural friction rub:
Inflamed parietal & visceral pleurae rub against each other
leathery, rough in character
Heared in both inspiration and expiration
Disappears rapidly as the size of effusion increases
If a child remains pyrexial or unwell 48 hours after admission
for pneumonia, parapneumonic effusion/empyema must be
excluded.

DIAGNOSIS

Chest radiograph (x-ray)

-able to distinguish >200ml of fluid (blunted costophrenic
angles)
-Chest radiographs acquired in the lateral decubitus position
are more sensitive and can pick up as little as 50 ml of fluid.
Pleural fluid analysis
Chest ultrasound
-locates small amounts or isolated loculated pockets of fluid
-able to give precise position of accumulation
Computed Tomography (CT) scan
-Differentiates between fluid collection, lung abscess, or tumor

PLEUAL EFFUSION

Created by an abnormal
collection of fluid in the
pleural space
Seen in chest X-ray with
presence of about 200ml
pleural fluid
Fluid in X-ray seen as a
dense, white shadow with a
concave upper edge (fluid
level)

CT scan of chest showing loculated pleural effusion in left side. Some

thickening of pleura is also noted.

Pleural fluid analysis

1.

Routine tests
Gross examination
Pleural fluid/serum protein ratio
Pleural fluid/serum LDH ratio
Cytology and culture

Pleural fluid analysis

2.

Tests in selected cases

Pleural fluid cholesterol
Pleural fluid/serum cholesterol ratio
Lactate
Enzymes
Interferon
CRP
Tumor markers

Gross examination

Transudates: typically clear, pale yellow to straw-colored,

odorless & do not clot.
Exudates: show variable degrees of cloudiness or turbidity
& they often clot if not heparinized
A feculent odor may be detected in anaerobic infections

Gross examination

A bloody pleural effusion (hematocrit >1%) suggests trauma,

malignancy, or pulmonary infarction.
A pleural fluid hematocrit greater than 50% of the blood
hematocrit is good evidence for a hemothorax
Turbid, milky, and/or bloody specimens should be
centrifuged and the supernatant examined. If the supernatant
is clear, the turbidity is most likely due to cellular elements
or debris. If the turbidity persists after centrifugation, a
chylous effusion is likely

Chemical analysis
Lights Criteria (Sensitivity 99%, Specificity 98%)
)
Criteria
Transudate
Exudate
Pleural fluid
protein:serum
protein ratio

0.5

> 0.5

Pleural fluid
LDH:serum LDH

0.6

> 0.6

Pleural fluid LDH

200

>200

Microbiological examination:
The sensitivity of the Gram stain is approximately 50%
For patients with suspected M. tuberculosis, direct staining of
tuberculous effusions for acid-fast bacteria has a sensitivity of
20%30% and positive cultures are found in 50%70% of
cases

Chemical analysis
Glucose:

The glucose level of normal pleural fluid, transudates, and

most exudates is similar to serum levels

Decreased pleural fluid glucose, accepted as a level below 60

mg/dL (3.33 mmol/L) or a pleural fluid/serum glucose ratio
less than 0.5, is most consistent and dramatic in rheumatoid
pleuritis and grossly purulent parapneumonic exudates

Lactate:
Pleural fluid lactate levels: useful adjunct in the rapid
diagnosis of infectious pleuritis
Levels are significantly higher in bacterial and tuberculous
pleural infections than in other pleural effusions
Values greater than 90 mg/dL (10 mmol/L) have a positive
predictive value for infectious pleuritis of 94% and a negative
predictive value of 100%

Amylase:
Elevations above the serum level (usually 1.52.0 or more
times greater) indicate the presence of pancreatitis,
esophageal rupture, or malignant effusion
Elevated amylase derived from esophageal rupture or
malignancy is the salivary isoform, which differentiates it
from pancreatic amylase

Lactate dehydrogenase:
Pleural fluid LD levels rise in proportion to the degree of
inflammation
In addition to their use in separating exudates from
transudates, declining LD levels during the course of an
effusion indicate that the inflammatory process is resolving
Conversely, increasing levels indicate a worsening condition
requiring aggressive workup or treatment

Adenosine deminase:
>40 unit/l
Tuberculosis
Interferon-:
Pleural fluid interferon (IFN)- levels are significantly
increased in the pleural fluid of patients with tuberculous
pleuritis
The sensitivity of levels of 3.7 IU/L or greater is 99%, and the
specificity is 98%
Consider when ADA is unavailable or nondiagnostic

pH:
Pleural fluid pH measurement has the highest diagnostic
accuracy in assessing the prognosis of parapneumonic
(pneumonia-related) effusions
A parapneumonic exudate with a pH greater than 7.30
generally resolves with medical therapy alone
A pH less than 7.20 indicates a complicated parapneumonic
effusion (loculated or associated with empyema), requiring
surgical drainage.
A pH below 6.0 is characteristic of esophageal rupture,
although the pH in severe empyema may be 6.0 or less

Lipids:
Helpful in identifying chylous effusions
Pleural fluid triglyceride levels > 110 mg/dL indicate a
chylous effusion
values from 60110 mg/dL require lipoprotein
electrophoresis to confirm a chylothorax
Nonchylous effusions : triglyceride levels <50 mg/dL & no
chylomicrons on electrophoresis

Immunologic studies:
Approximately 5% of patients with RA and 50% with SLE
develop pleural effusions
RF is commonly present in pleural effusions associated with
seropositive RA
ANA titers may be useful in the diagnosis of effusion due to
lupus pleuritis

TREATMENT
1.

Therapy should be aimed at the underlying disease

Transudative effusion by fluid overload as in cardiac or

renal failure: diuretics & fluid management

Nephrotic syndrome and cirrhosis of liver: Albumin

infusion

Tubercular pleural effusion: Anti-tubercular drugs

TREATMENT

Chylous pleural effusion:

Thoracocentesis or placement of ICD tube followed by
feeding with MCT
Continuous development: discontinuation of oral feeds and
TPN
Somatostatin & Octreotide
Traumatic hemothorax: drainage of blood with proper
replacement
Recurrent pleural effusion due to malignancies: prolonged
placement of catheter or pleurodesis

TREATMENT
Parapneumonic effusion

Analgesia

Supplemental oxygen

Systemic antibiotics

based on the in vitro sensitivities of the responsible organism

(Staphylococcus, S. pneumoniae, and H. influenzae)

Duration: 2 wk. With staphylococcal infections: systemic

antibiotic therapy for 3-4 wk; anaerobic empyema-6-12
weeks

Instillation of antibiotics into the pleural cavity does not

improve results

TREATMENT
Thoracentesis
Diagnostic thoracentesis

A needle is inserted into

the chest wall to remove the
collection of fluid
50-100ml of fluid is sent
for analysis; Determines the type of fluid (transudate or
exudate)
temporarily relieve symptoms
Potential complications: bleeding, infection & pneumothorax

TREATMENT

BUT if sufficient fluid reaccumulates to cause respiratory

embarrassment, chest tube drainage should be performed
Rapid removal of 1 L of pleural fluid may be associated
with the development of reexpansion pulmonary edema

Chest tube drainage

TREATMENT

Thrombolytic therapy
Promote drainage, decrease fever, lessen need for surgical
intervention & shorten hospitalization
Streptokinase 15,000 U/kg in 50 mL of 0.9% saline daily for
3-5 days and urokinase 40,000 U in 40 mL saline every 12 hr
for 6 doses
Anaphylaxis with streptokinase & both drugs can be
associated with hemorrhage

TREATMENT

Video-assisted thoracoscopic surgery (VATS) or Open

decortication
The child who remains febrile & dyspneic >72 hr after
initiation of therapy with intravenous antibiotics and
thoracostomy tube drainage, surgical decortication via VATS
or, less often, open thoracotomy may speed recovery
If pleural fluid septa are detected on ultrasound, immediate
VATS can be associated with a shortened hospital course

EMPYEMA

DEFINITION

Empyema or Purulent Pleurisy: Empyema is an

accumulation of pus in the pleural space
Most often associated with pneumonia due to Staphylococcus
aureus & Streptococcus pneumoniaea
The relative incidence of Haemophilus influenzae empyema
has decreased (Hib vaccination)
Also produced by rupture of a lung abscess into the pleural
space, by contamination introduced from trauma or thoracic
surgery or by mediastinitis or the extension of intraabdominal abscesses

EPIDEMIOLOGY

Most frequently encountered in infants & preschool children

Predisposing factors: preceding history of pustules, blunt
trauma to the chest, viral infection, severe malnutrition,
contiguous extension

PATHOLOGY

Empyema has 3 stages: exudative, fibrinopurulent, and

organizational
Exudative stage: 1-3 days
Fibrinopurulent stage: 4-14 days
Organizational stage: After 14 days

PATHOLOGY

Exudative stage: fibrinous exudate forms on the pleural

surfaces
Fibrinopurulent stage: fibrinous septa form, causing
loculation of the fluid & thickening of the parietal pleura
If the pus is not drained, it may dissect through the pleura into
lung parenchyma, producing bronchopleural fistulas and
pyopneumothorax, or into the abdominal cavity or through the
chest wall (empyema necessitatis)
Organizational stage: fibroblast proliferation; pockets of
loculated pus develop into thick-walled abscess cavities or the
lung may collapse & become surrounded by a thick, inelastic
envelope (peel)

CLINICAL MANIFESTATIONS

The initial signs & symptoms are primarily those of bacterial

pneumonia
Children treated with antibiotic agents may have an interval of
a few days between the clinical pneumonia phase & the
evidence of empyema
Most patients are febrile (fever may be absent in
immunocompromised patients), develop increased work of
breathing or respiratory distress & often appear more ill
Physical findings are identical to those for uncomplicated
parapneumonic effusion & the 2 conditions are differentiated
only by thoracentesis

DIAGNOSIS

The effusion is empyema if bacteria are present on Gram

staining, the pH is <7.20, glucose<40 mg/dl and LDH>1000
IU/L and there are >100,000 neutrophils/L
Cultures of the fluid must always be performed
Blood cultures also have a high yield

COMPLICATIONS

1.

Bronchopleural fistulas
Usually respond to adequate drainage, nutritional support &
sealing of the open communication over the lung surface
Prolonged bronchopleural fistulas (>2-3 weeks) requires
decortication, lobectomy or thoracoplasty

COMPLICATIONS
2.
3.
4.

5.
6.

7.

8.
9.

Pyopneumothorax
Purulent pericarditis & pulmonary abscesses
Peritonitis from extension through the diaphragm &
osteomyelitis of the ribs
Septic complications: meningitis, arthritis
Septicemia is often encountered in H. influenzae and
pneumococcal infections
Peel: may restrict lung expansion and may be associated with
persistent fever and temporary scoliosis
Empyema necessitans
Gastropleural fistula

TREATMENT

Systemic antibiotics
Staphylococcus aureus: cloxacillin & aminoglycoside or 3 gen
cephlosporin & aminoglycoside
Gram-ve organism: cefotaxim & aminoglycoside
Gram stain inconclusive: cefotaxim & cloxacillin
Resistant Staphylococcus: vancomycin, teicoplanin & linezolid
Thoracentesis

TREATMENT
Chest tube drainage with or without a fibrinolytic agent
Indications for surgical treatment:
a) Pleural thickening
b) Loculated empyema
c) Non-expansion of lungs with intercostal drainage
d) Bronchopeural fistula
1. Video-assisted thorascopic surgery: effective in lysis of
adhesions in multiloculted effusions & removal of fibrinous
material from pleural cavity
2. Open decortication: significant pleural thickening

TREATMENT

The long-term clinical prognosis for adequately treated

empyema is excellent & follow-up pulmonary function studies
suggest that residual restrictive disease is uncommon, with or
without surgical intervention

PNEUMOTHORAX

PNEUMOTHORAX

DEFINITION

Accumulation of extra pulmonary air within the chest, most

commonly from leakage of air from within the lung

ETIOLOGY
Closed pneumothorax
-Pulmonary disease
Foreign body
RDS
Respiratory infections
Bronchial asthma
Cystic fibrosis
Chemical pneumonitis
Diffuse lung disease
Tumors
-Iatrogenic
Mechanical ventilation
Central venous catheterization

Open pneumothorax
Invasive pleural &
pulmonary procedures
Chest trauma
Spontaneous pneumothorax
Idiopathic (ruptured
subpleural blebs)
Familial

PATHOGENESIS

The tendency of the lung to collapse is balanced in the normal

resting state by the inherent tendency of the chest wall to
expand outward, creating negative pressure in the intrapleural
space
When air enters the pleural space, the lung collapses
In simple pneumothorax, intrapleural pressure is atmospheric,
and the lung collapses up to 30%.
In complicated, or tension pneumothorax, continuing leak
causes increasing positive pressure in the pleural space, with
further compression of the lung, contralateral shift of
mediastinal structures & decreases in venous return and cardiac
output

CLINICAL MANIFESTATIONS

Sudden onset
Dyspnea, pain, & cyanosis
Trachea & heart may be shifted toward the unaffected side
Hyperinflation & reduced movements on affected side
Respiratory distress with retractions
Decreased vocal fremitus & vocal resonance
Markedly decreased breath sounds and a tympanitic
percussion note over the involved hemithorax
When fluid is present, there is usually a sharply limited area
of tympany above a level of flatness to percussion

CLINICAL MANIFESTATIONS

Succussion splash: to rule out hydropneumothorax

Coin test
Friction test

DIAGNOSIS

By radiographic examination
When the possibility of diaphragmatic hernia is being
considered, a small amount of barium may be necessary to
demonstrate that it is not free air but is a portion of the
gastrointestinal tract that is in the thoracic cavity
Ultrasound can also be used to establish the diagnosis

TREATMENT

Extent of the collapse & nature and severity of the

underlying disease
A small (<5%) or even moderate-sized pneumothorax in an
otherwise normal child may resolve without specific treatment,
usually within about 1 wk
Needle aspiration: tension pneumothorax & primary
spontaneous pneumothorax
If the pneumothorax is recurrent, secondary or under tension or
there is >5% collapse: chest tube drainage
Pneumothorax complicating malignancy: chemical pleurodesis
or surgical thoracotomy

TREATMENT

Closed thoracotomy: adequate to reexpand the lung in most

patients
Chemical pleurodesis: recurrent pneumothoraces; introduction
of talc, doxycycline, or iodopovidone into the pleural space
Open thoracotomy: plication of blebs, closure of fistula,
stripping of the pleura and basilar pleural abrasion; Stripping
and abrading the pleura leaves raw, inflamed surfaces that heal
with sealing adhesions
VATS: preferred therapy for blebectomy, pleural stripping,
pleural brushing and instillation of sclerosing agents; less
morbidity than with open thoracotomy