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![Pleural Effusions introduction The movement of fluid across the pleural](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-1.jpg)
Pleural Effusions introduction
The movement of fluid across the pleural membranes is
complicated but in general is governed by Starling's law of capillary exchange
5 to 10 L of fluid transgress the pleural space over a 24-hour period
Under physiologic conditions, most pleural fluid reabsorption is through lymphatics of the parietal pleura
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![Pleural Effusions introduction imbalance of accumulation and absorption of pleural](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-2.jpg)
Pleural Effusions introduction
imbalance of accumulation and absorption of pleural fluid will
lead to the development of a pleural effusion:
1. Increased hydrostatic pressure
2. Increased negative intrapleural pressure
3. Increased capillary permeability
4. Decreased plasma oncotic pressure
5. Decreased or interrupted lymphatic drainage
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![Pleural Effusions introduction About 300 mL of fluid is required](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-3.jpg)
Pleural Effusions introduction
About 300 mL of fluid is required for the
development of costophrenic angle blunting seen on an upright chest radiograph.
At least 500 mL of effusion is necessary for detection on clinical examination.
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![Transudative Vs. Exudative Effusions Criteria: 1. Pleural fluid protein/serum protein](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-4.jpg)
Transudative Vs. Exudative Effusions
Criteria:
1. Pleural fluid protein/serum protein greater
than 0.5
2. Pleural fluid LDH/serum LDH greater than 0.6
3. Pleural fluid LDH 1.67 times normal serum
These criteria misidentify ~25% of transudates as exudates
A transudative pleural effusion occurs when systemic factors that influence the formation and absorption of pleural fluid are altered.
An exudative pleural effusion occurs when local factors that influence the formation and absorption of pleural fluid are altered
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![Diagnostic Approach The leading causes of transudative pleural effusions in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-5.jpg)
Diagnostic Approach
The leading causes of transudative pleural effusions in the United
States are left-ventricular failure and cirrhosis
The leading causes of exudative pleural effusions are bacterial pneumonia, malignancy, viral infection, and pulmonary embolism.
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![Pleural fluid analysis Gross appearance (pus- Empyema, black- Aspergillus, green-](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-6.jpg)
Pleural fluid analysis
Gross appearance (pus- Empyema, black- Aspergillus, green- Biliothorax, white- Chylothorax)
Very
high LDH- empyema, rheumatoid pleurisy, malignancy
High triglyceride- Chylothorax
Low glucose- Rheumatoid pleurisy, parapneumonic effusion or empyema, Malignant effusion, Tuberculous pleurisy, Lupus pleuritis, Esophageal rupture
Low pH- parapneumonic effusion or empyema, Malignant effusion
High amylase- Acute pancreatitis, Chronic pancreatic pleural effusion, Esophageal rupture, Malignancy
adenosine deaminase (ADA), interferon gamma - Tuberculous pleurisy
Lymphocytosis- tuberculous pleurisy, lymphoma, sarcoidosis, chronic rheumatoid pleurisy
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-7.jpg)
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![Effusion Due to Heart Failure A diagnostic thoracentesis should be](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-8.jpg)
Effusion Due to Heart Failure
A diagnostic thoracentesis should be performed
if the effusions are not bilateral and comparable in size, if the patient is febrile, if the patient has pleuritic chest pain or if the effusion persists despite therapy
A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic of an effusion secondary to congestive heart failure
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![Hepatic Hydrothorax Pleural effusions occur in ~5% of patients with](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-9.jpg)
Hepatic Hydrothorax
Pleural effusions occur in ~5% of patients with cirrhosis and
ascites
effusion is usually right-sided
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![Parapneumonic Effusion Parapneumonic effusions are associated with bacterial pneumonia, lung](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-10.jpg)
Parapneumonic Effusion
Parapneumonic effusions are associated with bacterial pneumonia, lung abscess, or
bronchiectasis and are probably the most common cause of exudative pleural effusion
Empyema refers to a grossly purulent effusion
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![Parapneumonic Effusion Patients with aerobic bacterial pneumonia and pleural effusion](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-11.jpg)
Parapneumonic Effusion
Patients with aerobic bacterial pneumonia and pleural effusion present with
an acute febrile illness consisting of chest pain, sputum production, and leukocytosis
Patients with anaerobic infections present with a subacute illness
If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed
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![Uncomplicated Vs. Complicated parapneumonic effusion An uncomplicated parapneumonic effusion has](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-12.jpg)
Uncomplicated Vs. Complicated parapneumonic effusion
An uncomplicated parapneumonic effusion has "exudative"
chemistries, normal pH and glucose, and negative cultures
A complicated parapneumonic effusion typically has "exudative" chemistries, a low pleural pH (pH <7.20), a low glucose, and is often loculated
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![Indication for pleural drainage Loculated pleural fluid Pleural fluid pH](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-13.jpg)
Indication for pleural drainage
Loculated pleural fluid
Pleural fluid pH <7.20
Pleural fluid glucose <3.3
mmol/L (<60 mg/dL)
Positive Gram stain or culture of the pleural fluid
Presence of gross pus in the pleural space
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![Before and after driange](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-14.jpg)
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![Treatment of parapneumonic effusion An empiric, broad spectrum antibiotic that](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-15.jpg)
Treatment of parapneumonic effusion
An empiric, broad spectrum antibiotic that includes
coverage for anaerobic organisms
In patients with an uncomplicated parapneumonic effusion that is small to moderate in size, free flowing, and has a pH of 7.20 or greater there is no indication for drainage
In patients with a large, loculated, or complicated parapneumonic effusion there is indication for prompt drainage of any remaining pleural fluid by chest tube.
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![Effusion Secondary to Malignancy Malignant pleural effusions secondary to metastatic](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-16.jpg)
Effusion Secondary to Malignancy
Malignant pleural effusions secondary to metastatic disease are
the second most common type of exudative pleural effusion
The three tumors that cause ~75% of all malignant pleural effusions are lung carcinoma, breast carcinoma, and lymphoma
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![Effusion Secondary to Malignancy The diagnosis usually is made via](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-17.jpg)
Effusion Secondary to Malignancy
The diagnosis usually is made via cytology of
the pleural fluid
If the initial cytologic examination is negative, thoracoscopy is the best next procedure if malignancy is strongly suspected
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![Treatment of Malignant pleural effusion If the patient's lifestyle is](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-18.jpg)
Treatment of Malignant pleural effusion
If the patient's lifestyle is compromised
by dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, one of the following procedures should be considered:
therapeutic thoracentesis
insertion of a small indwelling catheter
pleurodesis
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![Pneumothorax introduction Pneumothorax is the accumulation of air within the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-19.jpg)
Pneumothorax introduction
Pneumothorax is the accumulation of air within the pleural space
Pneumothorax
can be spontaneous or occur secondary to a traumatic, surgical, therapeutic, or disease-related event
pneumothorax compresses lung tissue and reduces pulmonary compliance, ventilatory volumes, and diffusing capacity
If air enters the pleural space repeatedly and is unable to escape, positive pressure will develop in the pleural space. This situation is called a tension pneumothorax
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![Pneumothorax introduction Patients with pneumothorax most commonly present with chest](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-20.jpg)
Pneumothorax introduction
Patients with pneumothorax most commonly present with chest pain (sharp
and pleuritic) and dyspnea
Characteristic physical findings include:
Hyperresonance on percussion
Breath sounds are diminished to absent.
Subcutaneous emphysema may be palpated
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![diagnosis A pneumothorax usually is seen on the standard posteroanterior chest radiograph](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-21.jpg)
diagnosis
A pneumothorax usually is seen on the standard posteroanterior chest radiograph
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![Hydropneumothorax](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-22.jpg)
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![Classifications of Pneumothorax Spontaneous Primary Secondary Traumatic Iatrogenic Esophageal perforation](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-23.jpg)
Classifications of Pneumothorax
Spontaneous
Primary
Secondary
Traumatic
Iatrogenic
Esophageal perforation
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![primary spontaneous pneumothorax A primary spontaneous pneumothorax occurs in the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-24.jpg)
primary spontaneous pneumothorax
A primary spontaneous pneumothorax occurs in the absence
of underlying lung disease
Patients are often tall, thin and smoker men from 25 to 40 years of age (rare after age 40)
Risk factor include: smoking, family history, Marfan syndrome, homocystinuria, and thoracic endometriosis
Primary spontaneous pneumothoraxes are usually due to rupture of apical pleural blebs (>85%)
25-50% of patients with a first time spontaneous pneumothorax will have a recurrence (most recurrences occurring within the first year )
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![Treatment of primary spontaneous pneumothorax Small pneumothoraces ( Indications for](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-25.jpg)
Treatment of primary spontaneous pneumothorax
Small pneumothoraces (<20%, ≤2 to 3
cm between the lung and chest wall on a chest radiograph) that are stable may be monitored if the patient has few symptoms. An uncomplicated pneumothorax reabsorbs at a rate of about 1% per day.
Indications for intervention include progressive pneumothorax, delayed pulmonary expansion, or development of symptoms.
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![Treatment of primary spontaneous pneumothorax Moderate (20%-40%) and large (>40%)](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-26.jpg)
Treatment of primary spontaneous pneumothorax
Moderate (20%-40%) and large (>40%) pneumothoraces
nearly always are associated with persistent symptoms that cause physical limitations and require intervention
Simple needle aspiration of a pneumothorax may relieve symptoms and can promote quicker lung re-expansion
Tube thoracostomy (chest tube insertion) and underwater seal drainage are the mainstays of treatment for spontaneous pneumothorax.
The classic location for chest tube insertion is through the fourth, fifth, or sixth intercostal space in the mid to anterior axillary line.
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![Treatment of primary spontaneous pneumothorax Complications of chest tube insertion](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-27.jpg)
Treatment of primary spontaneous pneumothorax
Complications of chest tube insertion for
pneumothorax are infrequent but include laceration of an intercostal vessel, laceration of the lung, intrapulmonary or extrathoracic placement of the chest tube, and infection.
When an air leak persist for more than 72 hours or the lung not completely re-expand, surgical intervention is warranted
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![Indication for Surgical intervention in spontaneous pneumothorax Air leak that](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-28.jpg)
Indication for Surgical intervention in spontaneous pneumothorax
Air leak that persist
for more than 72 hours or when the lung not completely re-expand
Bilateral simultaneous pneumothoraces
Complete (100%) pneumothorax
Pneumothorax associated with tension or borderline cardiopulmonary reserve
Pneumothorax in patients in high-risk professions or activities
A recurrence pneumothorax
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![Surgical intervention for spontaneous pneumothorax Apical blebs are resected. The](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-29.jpg)
Surgical intervention for spontaneous pneumothorax
Apical blebs are resected. The parietal
pleura over the apex of the hemithorax can be removed (pleurectomy), abraded (mechanical pleurodesis), or treated with talc or tetracycline-like agents (chemical pleurodesis or poudrage).
The recurrence rate of these procedures, performed open or closed, is less than 5%
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![Secondary spontaneous pneumothorax Most secondary pneumothoraxes are due to chronic](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-30.jpg)
Secondary spontaneous pneumothorax
Most secondary pneumothoraxes are due to chronic obstructive
pulmonary disease
Pneumothorax in patients with lung disease is more life-threatening than it is in normal individuals because of the lack of pulmonary reserve in these patients.
Treatment of secondary pneumothorax is very similar to PSP but most of the patients with secondary pneumothorax should be treated with tube thoracostomy.
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![Preventing recurrence smoking cessation VATS pleurodesis- The rate of recurrent](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-31.jpg)
Preventing recurrence
smoking cessation
VATS pleurodesis- The rate of recurrent pneumothorax is less
than 5 percent after VATS with bleb/bullae resection and pleurodesis
Chemical pleurodesis- decreases the recurrence rate for pneumothorax to 15-25%
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![Traumatic pneumothoraxes Traumatic pneumothoraxes can result from both penetrating and](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-32.jpg)
Traumatic pneumothoraxes
Traumatic pneumothoraxes can result from both penetrating and blunt
chest trauma
Some times when a hemopneumothorax is present, one chest tube should be placed in the superior part of the hemithorax to evacuate the air and another should be placed in the inferior part of the hemithorax to remove the blood.
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![Traumatic pneumothoraxes](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-33.jpg)
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![Iatrogenic pneumothorax Iatrogenic pneumothorax is a type of traumatic pneumothorax](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-34.jpg)
Iatrogenic pneumothorax
Iatrogenic pneumothorax is a type of traumatic pneumothorax that is
becoming more common. The leading causes are transthoracic needle aspiration, thoracentesis, and the insertion of central intravenous catheters.
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![tension pneumothorax hemodynamic collapse (decreased venous return to the heart](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-35.jpg)
tension pneumothorax
hemodynamic collapse (decreased venous return to the heart and reduced
cardiac output)
severe respiratory compromise
compression or collapse of the entire lung
shifting of the mediastinum and heart away from the pneumothorax
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![Diagnosis of tension pneumothorax The diagnosis is made by physical](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/134715/slide-36.jpg)
Diagnosis of tension pneumothorax
The diagnosis is made by physical examination:
An enlarged
hemithorax with no breath sounds.
Hyperresonance to percussion
Shift of the mediastinum to the contralateral side
Low blood pressure