PLEURAL EFFUSIONS

Professor Dr. Sameena Akram

PLEURAL EFFUSIONS

ANATOMY OF A HEALTHY LUNG

ANATOMY OF A LUNG WITH A PLEURAL EFFUSION

http://www.themesotheliomalibrary.com/pleural-effusions3.gif

A pleural effusion is an accumulation of fluid between the parietal pleura and the visceral pleura.

O PATHOPHYSIOLOGY OF PLEURAL EFFUSION

Capillary Pressure Or Plasma Proteins

Capillary Permeability= Exudate

Formation Of Excess Fluid= Transudate

Accumulation Of Pus In The Pleural Space=empyema

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Oncotic pressure

Hydrostatic Pressure

Increased peritoneal fluid

TRANSUDATE VS. EXUDATE

O Non-inflammatory
O Inflammatory in nature O Exudate means there is a O Trans means movement of

fluid due to changes in pressure gradients O due to imbalance of hydrostatic or oncotic pressure

release of fluid. O Exudative pleural effusion are due to changes in capillary permeability. O The capillaries are inflamed and are not as selective and allow fluid to leak into the pleural space.
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TRANSUDATES
Result from an imbalance of hydrostatic or oncotic pressures inflammation is absent

CAUSES: Congestive Heart Failure Cirrhosis Nephrotic Syndrome Peritoneal Dialysis Urinary Obstruction

Pulmonary Emboly
Constructive Pericarditis Atelectasis

Meigs Syndrome
Hypothyroidism

EXUDATES
Result from inflammation of the pleura or obstruction of lymphatic flow
CAUSES: Parapneumonic effusion Connective tissue disease Tbc Malignancy Trauma Drugs Pancreatit GIS disease Chylothorax

CLINICAL SYMPTOMS AND SIGNS

O

O O O

Symptoms Dyspnea is the most common symptoms at presentation and usually indicates large (>500 mL) effusion Pleuritic Chest pain Cough,usually non productive Other symptoms occurring with pleural effusions are associated more closely with the underlying disease process.

O O O O O

O
O

Signs Dullness or decreased resonance to percussion Diminished or inaudible breath sounds Decreased tactile fremitus Pleural friction rub Asymmetric expansion of thoracic cage Mediastinal shift Other findings that provide clues to the cause of pleural effusion

INVESTIGATIONS
O Chest radiograph (x-ray)

-able to distinguish >200ml of fluid

O Chest ultrasound

-locates small amounts or isolated loculated

pockets of fluid -able to give precise position of accumulation
O Computed Tomography (CT) scan

-Differentiates between fluid collection, lung

abcess, or tumor

FIRST LINE IMAGING CHEST X-RAY

Features on a PA or AP erect radiograph

Clear right side hemi-diaphragm and sharp costophrenic angle

Meniscus shaped upper border

Area of homogenous Whiteness, with loss of hemidiaphragm silhouette

A LARGE RIGHT SIDE PLEURAL EFFUSION

Entire white-out of right hemi-thorax

The heart has been pushed towards the left side by the fluid

ULTRASOUND
O Second point of imaging O No radiation O Small effusions missed on CXR O Used to guide thoracocentisis O Dark space on image

http://www.cardiovascularultrasound.com/content/figures/1476-7120-6-16-7-l.jpg

Heart Right Lung

Left Lung

Crescentshaped pleural effusion

Ribs

Aorta
http://emedicine.medscape.com/article/media

Irregular soft-tissue thickening

Mass, right upper lobe

Pleural effusion

Aorta
http://emedicine.medscape.com/article/media

THERAPEUTIC INTERVENTIONS
O Thoracentesis-needle aspiration of fluid in pleural
O O

space. Usually 1200-1500ml /time. Antibiotics if due to infectious process. Chest tube to drain fluid/air. Pleurodesis-instillation of chemical agent (doxycycline) into pleural space to create inflammatory response (scar tissue) to adhese the visceral and parietal pleura. Treat underlying condition that is causing the effusion.
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Algorithm for the Evaluation of Patients with Pleural Effusion

Light R. N Engl J Med 2002;346:1971-1977

TREATMENT
O Needed if patient becomes breathless

O Small effusions are left and observed

O Usually directed at underlying cause (antibiotics for

pneumonia) O Underlying cause treated effusion will go away for good O If not it will return within few weeks

THANKYOU