Professional Documents
Culture Documents
Melvin A. Pasay, MD, FPCP, FPCCP
Section of Pulmonary Medicine
De La Salle University Medical Center
DEFINITION
PREVALENCE
• Estimates of the incidence of pleural effusions vary
• Transudative effusions
– congestive heart failure
• Exudative effusions
– malignancy
– pulmonary embolism
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
SIGNS AND SYMPTOMS
• Many patients are asymptomatic
DIAGNOSIS
Chest Radiography
DIAGNOSIS
Ultrasound
DIAGNOSIS
Computed Tomography
DIAGNOSIS
• Criteria of Light
Additional Markers
• Cholesterol
– higher in exudates than transudates
Additional Markers
• Serum-pleural Fluid Albumin Gradient
– with a cut-off of 12 g/L (exudates if below that level,
transudates if above)
– specificity of 100%
Additional Markers
• Glucose
– Very low glucose levels (less than 25 mg/100 mL) are seen in a
few diseases. Rheumatoid arthritis, tuberculosis, empyema, and
tumors/malignancy with extensive involvement of the pleura
Additional Markers
• Amylase
– Elevated pleural fluid amylase is seen with pancreatitis and
esophageal rupture
Additional Markers
• pH
– Normal pleural fluid pH estimated to be around 7.64
Additional Markers
• Adenosine Deaminase
– higher in tuberculous pleural effusions than in other exudates
Other Diagnostic
Modalities
• Pleural Biopsy
– less frequent with the increasing availability of improved
serum markers and thoracoscopy
Other Diagnostic
Modalities
• Thoracoscopy
– more popularity with the advent of video-assisted
technology
(eg, thoracentesis)
THERAPY AND
OUTCOMES
Therapeutic Thoracentesis:
THERAPY AND
OUTCOMES
Pleural Sclerosis and Fibrinolytics
THERAPY AND
OUTCOMES
Surgical Therapy
Pleural Effusions in
Specific Diseases
• Collagen-vascular Diseases
– pleura is involved in a majority of patients with systemic lupus
erythematosus (SLE)
– pleural effusions are small and bilateral
– most common symptom is chest pain
– finding of LE cells and high antinuclear antibody titers in pleural
fluid
– SLE effusions are usually responsive to corticosteroids
– Pleural effusions occur less commonly in patients with rheumatoid
arthritis
– occur more commonly in men
– low glucose level (less than 25 mg/dL)
– little evidence that corticosteroids are beneficial in treating
rheumatoid pleurisy
Pleural Effusions in
Specific Diseases
• Malignancy
– more commonly involved through metastasis
– Lung and breast cancer are the leading causes of
metastatic disease to the pleura
– less common causes are hematologic (eg, lymphoma and
leukemia), ovarian, and gastrointestinal tumors
– Cytologic examination of the pleural fluid is positive in
more than 50% of cases with pleural involvement
– Immunocytometry has been used to establish the
diagnosis
Pleural Effusions in
Specific Diseases
• Chylothorax
– Leakage of chyle from a disruption of the thoracic duct
Pleural Effusions in
Specific Diseases
• Hemothorax
– gross appearance of pleural fluid is bloody
Pleural Effusions in
Specific Diseases
• Post-coronary Artery Bypass Graft
– Approximately one-half of patients who undergo coronary artery
bypass grafting develop pleural effusions
– related to pleural trauma during surgery or bleeding into the
pleural space
– Within 30 days of surgery, the fluid is bloody, eosinophilic, and
easily resolvable with drainage (thoracentesis)
– After 30 days, the fluid is clear-yellow and predominantly
lymphocytic, but these effusions are difficult to manage because
they frequently recur
– usually exudative.
Other Pleural Diseases
Asbestos-related Pleural Disease
Pneumothorax
• air leaks into the area between the lungs and
chest wall (pleural space)
• A lung collapses in proportion to the amount of
air that leaks into your chest cavity
• partial collapse is much more common
• tension pneumothorax, a life-threatening
condition, requires immediate medical care
Symptoms
• may have few signs or symptoms
• Sudden, sharp chest pain on the same side as the affected lung
• Shortness of breath, which may be more or less severe,
depending on how much of the lung is collapsed
• A feeling of tightness in your chest
• A rapid heart rate
• heart function may be impaired
Types
Primary spontaneous pneumothorax
• usually occurs in otherwise healthy people
• most common in tall, thin men — many of them
smokers — between 20 and 40 years of age
• develop when a small air blister (bleb) on the lung
ruptures
• genetic factors also may play a role
• usually mild because pressure from the collapsed
portion of the lung in turn collapses the bleb.
Types
Secondary spontaneous pneumothorax
Types
Traumatic pneumothorax
• Any blunt or penetrating injury to the chest can cause
lung collapse
• Knife and gunshot wounds, a blow to the chest, even a
deployed air bag can cause a pneumothorax
• certain medical procedures such as the insertion of
chest tubes, cardiopulmonary resuscitation (CPR) and
lung or liver biopsies
• Pneumothorax is especially common in people whose
breathing is aided by a mechanical ventilator.
Types
Tension pneumothorax
• The most serious type of pneumothorax
• pressure in the pleural space is greater than
the atmospheric pressure
• can cause the affected lung to collapse
completely.
• can also push the heart toward the
uncollapsed lung
• comes on suddenly, progresses rapidly and is
fatal if not treated quickly.
Treatment
• The goal in treating a pneumothorax is to relieve the
pressure on the lung
• The best method for achieving this depends on the
severity of the lung collapse and sometimes on your
overall health:
• Observation
Other Pleural Diseases
Pneumothorax
Air between the lung and chest wall (in the pleural space) is termed a
"pneumothorax".Table 5 lists the classification of pneumothoraces. Common
causes of pneumothoraces include trauma, iatrogenic factors (eg, thoracentesis,
mechanical ventilation), chronic obstructive pulmonary disease, infection, and
malignancy.
The incidence of primary spontaneous pneumothorax is higher in men less than
40 years old, and the relative risk rises with heavier smoking. Secondary
spontaneous pneumothorax is a more serious condition, since it further
compromises an already abnormal lung function. Most secondary spontaneous
pneumothoraces are related to chronic obstructive pulmonary disease or
infection (eg, Pneumocystis carinii). Trauma-related pneumothorax can result
either in an open (to the atmosphere) pneumothorax or a closed (tension)
pneumothorax, in which intrapleural pressures frequently exceed atmospheric
pressures. Table 6 summarizes the currently adopted guidelines by the ACCP
for the treatment of spontaneous pneumothorax. Traumatic pneumothorax
usually requires the placement of a tube thoracostomy until the air leak
resolves. The ACCP consensus statement also recommends surgical intervention
(thoracoscopy with bullectomy and a procedure to produce pleural symphysis)
in preventing the recurrence of secondary pneumothoraces.