Eff Pleura & Pneu Kuliah Kbk Sm V

8/10/2019 Eff Pleura & Pneu Kuliah Kbk Sm V

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Pulmonology & Respiratory Medicine DepartementBrawijaya University/Saiful Anwar Hospital

Malang

PLEURAL EFFUSION

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DEFINITION

Pleural effusions, the result of the

accumulation of fluid in the pleural space

Normally, pleural fluid in pleural cavity amount 1-20 ml.

Pleural fluid in pleural cavity is constant. There is

equlibrium between production and absorsption bypleural viceralis.

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CAUSES OF A PLEURAL EFFUSION

Pleural Effusion can be caused by severalmechanisms: increased permeability of the pleural membrane

increased pulmonary capillarpressure

decreased negative intrapleural pressure decreased oncotic pressure

Obstructed lymphatic flow

Pleural effusion indicate the presence of disease which may be

Pulmonary, pleural or extrapulmonary 3


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CLASSIFIED OF PLEURAL EFFUSION

Transudative Exudative

Lights criteria

Most accurate way of

differentiating

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Lights criteria criteria a

The pleural fluid is an exudate if one or more of

the following criteria are met:

Pleural fluid protein divided by serum protein >0.5

Pleural fluid LDH divided by serum LDH >0.6

Pleural fluid LDH more than two-thirds the upper limits

of normal serum LDH

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CAUSES OF TRANSUDATIVE PL.EFFUSION

Very common causes Left ventricular failure

Liver cirrhosis

Hypoalbuminaemia

Peritoneal dialysis

Less common causes Hypothyroidism Nephrotic syndrome

Mitral stenosis

Pulmonary embolism

Rare causes

Constrictive pericarditis Urinothorax

Superior vena cava obstruction

Ovarian hyperstimulation Meigs syndrome

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CAUSES OF EXUDATIVE PL.EFFUSION

Common causes

Malignancy

Parapneumonic effusions

Less common causes

Pulmonary infarction Rheumatoid arthritis

Autoimmune diseases

Benign asbestos effusion

Pancreatitis

Post-myocardial infarction syndrome Rare causes

Yellow nail syndrome

Drugs

Fungal infections

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DIAGNOSTIC (1) History taking and physical examination

Fluid < 300 cc, The symptom is disappear

The fluid >300 cc, The symptom are decreasing movement

of hemithoraks, stem fremitus and breath sound decrease,or disappear.

Pleural fluid > 1000 cc can cause the chest more convexthan contralateral, auscultation egophoni

The fluid >2000 cc push the mediastinum to the normalsite

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DIAGNOSTIC (2) Plain radiography

PA and lateral chest radiographs should be performed

Ultrasound findings Ultrasound guided pleural aspiration should be used as

a safe and accurate method of obtaining fluid if

the effusion is small or loculated.

Fibrinous septations are better visualised onultrasound

CT Scan

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DIAGNOSTIC (2) A diagnostic pleural fluid sample should be gathered

with a fine bore (21G) needle and a 50 ml syringe. The

sample should be placed in both sterile vials and

blood cultur bottles and analysed for protein,

lactatdehydrogenase (LDH, to clarify borderline,

protein values), pH, Gram stain, AFB stain, cytology,

and microbiological culture.

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DIFFERENTIAL DIAGNOSIS Lung Tumor

Swarte/Tickening of pleuraAtelectasis inferior lobe

High level potition of diaphragma

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COMPLICATION Complication of pleural effusion depend on

underlying desease :

Empiema

Swarte

Respiratory failure

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Management

The management of pleural effusion depend onmanagement of underlying desease andthoracocentesis.

Thoracocentesis indication:

Release of Shortnes of breath that caused by fluidaccumulation

Diagnosis with examine the pleural fluid

Thoracocentesis pleural fluid in the firsttime not more than 1000 cc, can resultlung edema with symptom cough anddyspnea.

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continued..

Lack of thoracocentesis:

Thorakosentesis can cause lost of protein

Infection (empyema)

Pneumothoraks

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EMPYEMA (1)

Definition: Presence of pus in the pleural space

Causes: Direct extension of a pulmonary parenchymal infection

into pleural space

Post surgical infection

Trauma From abdominal infection (ex: subdiaphragmatic

abscess)

Complication of thoracosinthesis or pleural biopsy

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About half of the empyema isolatesconsist of only anaerobic bacteria and

the other half of mixed anaerobic andaerobic organism.

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EMPYEMA (2) Symtoms

Usually non specific 80% : dyspnea and fever

70% : cough and chest pain

Constitusional complaint : weight loss, fatigue, malaise

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THERAPY

Appropriate antibiotic therapy

Initial choice of antibiotic depends on clinical settingand should be guideed by the result of the gram stain ofpleural fluid and sputum

Adequate pleural drainage

Chest tube placement (WSD) Thoracosintesis

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HEMOTHORAX Definition:

Presence of significant amount of blood in the pleuralspace

Causes:

Most comman: trauma (penetrating or penetrating)

Occasionally iatrogenic prosedure Uncomman: malignancy, during unticoagulant therapy

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CHYLOTHORAX True chylous effusions result from disruption of the

thoracic duct or its tributaries. This leads to thepresence of chyle in the pleural space

Chylothorax must be distinguished frompseudochylothorax or cholesterol pleurisy which

results from the accumulation of cholesterol crystals ina long standing pleural effusion

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CAUSES OF CHYLOTHORAX AND

PSEUDOCHYLOTHORAX

Chylothorax Pseudochylothorax

Neoplasm: lymphoma,metastatic carcinoma

Trauma: operative,penetrating injuries

Miscellaneous: tuberculosis,sarcoidosis,

lymphangioleiomyomatosis,cirrhosis, obstruction ofcentral veins, amyloidosis

Tuberculosis

Rheumatoid arthritis

Poorly treated empyema

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MALIGNANT PLEURAL EFFUSION Malignant pleural effusion is a condition in which

cancer causes an abnormal amount of fluid to collect

between the thin layers of tissue (pleura) lining theoutside of the lung and the wall of the chest cavity. Lungcancer and breast cancer account for about 50-65% ofmalignant pleural effusions[1]. Other common causes

include mesotheliomaand lymphoma.

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http://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Pleurahttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Mesotheliomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Lymphomahttp://en.wikipedia.org/wiki/Mesotheliomahttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Malignant_pleural_effusionhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Breast_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Lung_cancerhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Chest_cavityhttp://en.wikipedia.org/wiki/Pleurahttp://en.wikipedia.org/wiki/Cancer


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Pulmonology & Respiratory Medicine Departement

Brawijaya University/Saiful Anwar Hospital

Malang

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PNEUMOTHORAX

Pneumothorax is defined as air in the pleuralspace.

Classification: Based on occurrence:

Arrtificial

Traumatic

Spontaneous

Based on kind of fistel: Open pneumothorax

Close pneumothorax

Ventile pneumothorax

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SPONTANEOUS PNEUMOTHORAX

Primary pneumothorax

arise in otherwise healthy people without any lungdisease.

subpleural blebs and bullae are likely to play a role in thepathogenesis since they are found in up to 90% of casesof primary pneumothorax at thoracoscopy orthoracotomy and in up to 80% of cases on CT scanning

Secondary pneumothotax

pneumothoraces arise in subjects with underlying lungdisease

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SECONDARY PNEUMOTHORAX

More serious than spontaneous primary pneumothorax,because it further decrease the pulmonaryfunction of apatient whose reserve is already diminished

The preseent of the underlying disease makes themanagement pneumothorax more dificcult.

Causes:

COPD >> Lung tumor

Tuberculosis

Other pulmonary infection

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DIAGNOSTIC TUMOR

COLLAPS TREATMENT IN

LUNG TUBERCULOSIS

Adakalanyadisertai deng

-Pneumoperitoneum

-phrenikus tripsi

( n phrenikus dilumpuhka

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OPEN PNEUMOTHORAX

Is pneumothorax that there is connection between pleuralcavity and bronchus

Expiration +2 30 minutes +2Inspiration -2 -2

NORMAL:Expiration -4 -9 cm H2O

Inspiration -8 -12 cm H2O

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CLOSED PNEUMOTHORAX pneumothorax that there is no connection between

pleural cavity and bronchus

Expiration -4 30 minutes -4

Inspiration -12 -12

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VENTIL PNEUMOTHORAX

Tension pneumothorax occurs because the opening thatallows air to enter the pleural space functions like a valve,and with every breath more air enters and cannot escape.

Severe hypoxia follows, with a resultant drop in bloodpressure and level of consciousness

Expiration +2 30 min -4 30 min +10

Inspiration -12 -12 +6

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DIAGNOSIS VENTIL PNEUMOTHORAX (1)

Symptoms and signs of tension pneumothorax mayinclude the following:

Chest pain (90%)

Dyspnea (80%)

Anxiety

Acute epigastric pain (a rare finding)

Fatigue

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Physical

Respiratory distress or respiratory arrest unilaterally

Tachycardia

Hypotension

Pulsus paradoxus

Increasing of JVP

Trachea, cardiac deviation

Cardiac arrest associated with asystole or pulselesselectrical activity

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Physical Pneumothorax ventil Dextra

Inspection Static D>S, deviation of trachea,

Widening ICSDinamic D


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Work up

Lab: BGA

Chest radiography

USG

CT Scan

Proef puncture

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DIFFERENTIAL DIAGNOSIS

PNEUMOTHORAX

Emphysematous lungAsthma bronchiale

Giant bullae

Acute Myocard Infarction

Hernia diaphragmatica

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COMPLICATION OF

PNEUMOTHORAX

Pleural effusion

Emphysema subcutis

Syock cardiogenic

Respiratory distress

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PNEUMOTHORAX SPONTANEA

VENTIL

SAAT EKSPIRASI TEKANAN SEMAKIN MENINGKAT

MATI OLEH KARENA:

MEDIASTINUM TERDORONG KE SISI YANG SEHAT

GAGAL KARDIOVASKULER DAN GAGAL NAPAS

INSPIRA

SI

EKSPIRASI

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1. pneumothorax traumatica

2 th t


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PNEUMOTHORAX

PENDORONGAN MEDIASTINUM

HEMITHORAX CEMBUNG & GERAK RESPIRASI TERTINGGAL

PARU KOLAPS & MEDIASTINUM TERDESAK UDARA KEARAH SISI YANG SEHATdjois

1

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2. pneumothorax spontanea

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PNEUMOTHORAX VENTIL

djois

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CHEST X-RAY PNEUMOTHORAX

Picture 2. Right-sided pneumothorax due to stab wound

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CHEST X-RAY PNEUMOTHORAX (LANJUTAN)

Picture 3. A true pneumothorax line.Note that the visceral pleural line is observedclearly, with the absence of vascular marking beyond the pleural line.

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Estimate lung collaps

Light Index

PNX% = 100 1 -

lung 3

hemithorax3

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TREATMENT OF PNEUMOTHORAX

Primary spontaneous pneumothorax Observation

Recommanded that only asymtomatic patient with

pneumothorax less than 15 % Oxigen suplementation

Gas absorbtion will exceed

Simple aspiration

Tube thoracostomy Thoracoscopy VATS

Pleurodesis

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TREATMENT OF PNEUMOTHORAX (2)

Secondary spontaneous pneumothorax Oxigen suplementation

The initial treatment for nearly every that patient shouldbe tube thoracostomy

Simple aspiration should not be performed because itfrequently is ineffective and does not decrease thelikehood of a reccurence

Tube thoracostomy

Thoracoscopy VATS Pleurodesis

Treatment the underlying diseses

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a- semprit 5ml / 10ml dengan

jarum infus yang besar

b- kondom / sarung tangan karet

yang lama, ujungnya dipotong

serong

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ALAT KONTRA

VENTIL

WSD

W

ater

S

ealed

D

rainage )

UDARA DALAM

CAVUM PLEURAE

KELUAR

UDARA LUAR TIDAK

DAPAT MASUK

KEDALAM CAVUM

PLEURAE

WSD

+10cmH2OTIP :

+20 cmH2O

djois

udara

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INSERTED THORAX CATHETER Indication:

Pneumothorax > 20% of lung volume/ventil.

Malignant Pleural effusion Empyema

Hematothorax > 300cc

Chilothorax

Post operatif thoracotomy The patient use ventilator/respirator

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Lokasi:

ICS VII/VIII P.A.L

IC II/III M.C.L: Cara Monaldi

ICS IV/V M.A.L: Cara Buelau

Persiapan Alat: Klem desinf, duk

Kasa, duk berlubang

Madrin, kanul

Gunting, pinset

Jarum jahit, benang

Spuit, anestesi

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REPLACEMENT THORAX CATHETER Indication:

THE LUNG has inflated. The. Catheter has diklem 24

hour.

Empyema: pus (-) fluid


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PLEURODESIS Pleurodesis is a medical procedure in which the

pleural space is artificially obliterated.It involves theadhesion of the two pleura

Chemical Surgical

Indication:

recurrent pneumothorax recurrent pleural effusion/ Malignant pleural effusion

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http://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Pleural_cavity


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CHEMICAL PLEURODESIS

Chemicals such as:

bleomycin

tetracycline

povidon iodine

Slurry of talc

Introduce into the pleural space through a chest drain.

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Eff Pleura & Pneu Kuliah Kbk Sm V

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