week 1 pleuraldisease - 30 oktober 2012.pptx

7/26/2019 Week 1 PleuralDisease - 30 Oktober 2012.pptx

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PLEURAL DISEASE

Yani Purnamasari NP Sp.P


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Defnisi

The pleural cavity contains a relatively smallamount of uid, approximately 10 mL on eachside.

Pleural uid volume is maintained y aalance et!een uid production and removal

Li"ht and collea"ues in 1#$% & ##' of pleurale(usions ) transudative or exudative.


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Pleura and Pleural Cavity

Pleural *avity+ Potential space et!een

visceral parietal

pleura

+ *apillary layer of serousuid produced ymesothelium

+ -educes friction

+ Surface tension providescohesion et!een lun" andthoracic !all


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Pleural sac andrecesses


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Pleural diseases include:

Pneumothorax Pleural e(usion)

Transudatesexudates, hematothorax,

cylothorax pseudocylothorax,empyema, pleural e(usion in spesi/cdiseases SL, e.t.c 2

Pleural tumors Pleurisy pleural inammation2


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Pleurisy pleural inammation2

Pleurisy is an inammation of the pleura, thelinin" of the lun"s & pain.

3nammation )4 infection

4 dama"in" a"ent irritates the pleural

surface.

Pleurisy cases ) pleural e(usion or as ein"5dry.6


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Pleural tumors) anormal "ro!ths on thepleurae.

4 eni"n i.e. pleural pla7ues2

4 mali"nant

8esothelioma is a type of mali"nant cancer

associated !ith asestos exposure.


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Pleural e(usion) a uid accumulation !ithin thepleural space.

9normal collections of pleural uid )

4 excessive uid volume i.e. excess intravenous uids,renal failure2,

4 decreased uid protein e.". cirrhosis, proteinuria2,

heart failure,

4 leedin" hemothorax2,

4 infections parapneumonic e(usions, pleuralempyema2,

4 inammation4 mali"nancies

4 perforation of thoracic or"ans i.e. chylothorax,esopha"eal rupture2.


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mpyema

mpyema is pus in the pleural cavity: it

consists of polymorphonuclear leu;ocytesand /rin.

caused & an infection

-is; factors include )

acterial pneumonia, lun" ascess,thoracic sur"ery, trauma or in


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Prevalence

incidence of pleural e(usions vary & up

to 1 million in the =nited States. The more common causes of )

4 transudative e(usions reect a

systemic perturation 2are con"estiveheart failure hypoaluminemic statese."., cirrhosis2

4 exudative e(usions si"nify underlyin"

local pleuropulmonary disease2 aremali"nancy, infection e.".,pneumonia2, and pulmonary emolism.


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Pathophysiology

The accumulation of pleural uid can usually eexplained y >formation or ? asorption, or oth.

3ncreased pleural uid )

4 elevation of hydrostatic pressure e."., con"estiveheart failure2,

4 decreased colloid osmotic pressure e."., cirrhosis,nephrotic syndrome2,

4 increased capillary permeaility e."., infection,neoplasm2,

4 passa"e of uid throu"h openin"s in thediaphra"m e."., cirrhosis !ith ascites2,

4 reduction of pleural space pressures e.".,atelectasis2.


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@ecreased pleural uid asorption )

4 lymphatic ostruction

4 elevation of systemic venous

pressures resultin" in impairedlymphatic draina"e e."., superiorvena cava ASB*C syndrome2.


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Physiology o the Pleural Space

Drom) *retien, E, Fi"non, E., Girsch, 9, eds) The Pleura in Gealth and @isease.

Ne! Yor;) 8arcel @e;;er, 1#HI, p1H%.


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-espiratory physiolo"y pleural e(usionsproduce )

4 restrictive ventilatory defect

4 decrease the total lun" capacity4 func4tional residual capacity

4 forced vital capacity

They can cause ventilation4perfusionmismatches and, !hen lar"e enou"h,compromise cardiac outpu


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he di!erential diagnosis opleural e!usions is

Select Causes o ransudates 9telectasis early2 *irrhosis *on"estive heart failure Gypoaluminemia Nephrotic syndrome

Peritoneal dialysis =rinothorax


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Select Causes o E"udates 9sestos exposure 9telectasis chronic2*hylothorax *onnective tissue disease @ru"s e."., amiodarone2 sopha"eal rupture Gemothorax 3nfection acteria, viruses, fun"i, tuerculosis, or

parasites2 8ali"nancy Pancreatitis

Postcardiotomy syndrome Pulmonary emolism Sudiaphra"matic ascess =remia


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Signs and sy#pto#s

8any patients & asymptomaticpleural e(usion2. Symptoms are usually due to the underlyin"

disease process)

4 pleuritic chest pain indicates inammation ofthe parietal pleura ecause the visceral pleurais not innervated and thus not sensitive to pain2.

4 dry, nonproductive cou"h and dyspnea.

4 physical examination e(usion2) reduced tactilefremitus, dull or at note on percussion, anddiminished or asent reath sounds onauscultation.


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Diagnosis

The posteroanterior and lateral chestradio"raphs & dia"nosin" a pleural e(usion &most uid collects around the inferior surface ofthe lun"

I0 mL of uid &on lateral radio"raph2 as ameniscus posteriorly,

J I00 mL is present, the meniscus usuallyoscures the entire hemidiaphra"m.

The lateral decuitus /lms help in di(erentiatin"free uid from loculated uid that !hich iscon/ned y /rous pleural adhesions2.


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eura seases gns : eura


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eura seases gns : euraE!usion

+9ccumulation of uid in the pleural space+ Transudative vs. exudative e(usion

+ mpyema as potential se7uelae to exudativee(usion


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Ultrasound

=ltrasound &a dia"nostic tool and as anaid in performin" thoracentesis & todi(erentiate et!een solid and li7uid

components identifyin" pleural uidloculations2.


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SerumPleural Fluid Albumin Gradient

misidentify some transudates as exudativee(usions e."., in patients !ith heart failure!ho under"o diuretic treatment2 & -othand collea"ues used the serum4e(usionalumin "radientserum aluminconcentration minus e(usion aluminconcentration2 !ith a cuto( of 1% "Lexudates if elo! that level, transudates ifaove2, and otained a speci/city of 100'as compared !ith $%' !ith Li"htKs criteria.


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Diagnostic test: Light&s criteria

or an e"udate: any o:

protein e(usion) protein serum ratio 0.I

L@G M0$ 3=ml L@G e(usion) L@G serum ratio 0.


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Glucose

Bery lo! "lucose levels O %I m"100mL2, althou"h not patho"nomonic, are

seen in a fe! diseases.-heumatoid arthritis, tuerculosis,empyema, and tumors or mali"nancy &very lo! "lucose levels.


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Amylase

levated pleural uid amylase is seen!ith pancreatitisand esopha"eal rupture

and in approximately 10' of mali"nante(usions.


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pH

Normal pleural uid pG ) $.Q.

4 pG O $.M0 & inammatory or in/ltrative

process parapneumonic e(usions,empyema, mali"nancy, connective tissue

diseases, tuerculosis, and esopha"ealrupture.

4 =rinothorax is peculiar in that it is theonly cause of a lo! pG transudativee(usion.


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Management of Patients withParapneumonic Eusions

Pleural Anato#y Pleural 'luid(acteriology

Pleural'luidChe#istry

)eedorDrainage

8inimal e(usion R10 mm on

lateral decuitus vie!2: free4o!in"

*x and S

un;no!n

pG un;no!n No

Small to moderate e(usion 10mm to R one half of hemithoraxon lateral decuitus vie!2: free4o!in"

Ne"ative *xand S

pG $.%0 No

Lar"e e(usion one half ofhemithorax on lateral decuitusvie!2 or loculated uid orthic;ened pleura

Positive *x orS

pG R $.%0 Yes

9ny Pus pG R $.0 Yes

*x ) culture, S ) "ram stain


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Adenosine !eaminase

9denosine deaminase levels J $0 =L ishi"hly su""estive of tuerculous pleuritis,

!hereas a level less than Q0 =L virtuallyrules out this dia"nosis.

ther pleural diseases ) > adenosinedeaminase & rheumatoid pleuritis and

empyema


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"ther !iagnostic Modalities

Pleural #iopsy

The use of an 9rams needle to otainspecimens from the parietal pleura has

ecome less common !ith the increasin"availaility of improved serum mar;ersand thoracoscopy.

Needle iopsy of the pleura &to dia"nose

tuerculous pleuritis !hen other mar;erse."., adenosine deaminase2 arene"ative.


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$horacoscopy

3nvasive techni7ues &for the dia"nosis of pleural e(usions&video4assisted technolo"y B9TS2.

Thoracoscopy )

4 visual evaluation of the pleura,4 direct tissue samplin", and

4 therapeutic intervention e."., dissectin" loculations andpleurodesis2.

8edical thoracoscopy performed y pulmonolo"ists under

conscious sedation2 and video4assisted thoracoscopicsur"ery B9TS2, !hich is performed y sur"eons under"eneral anesthesia, are indicated for dia"nosin" pleurale(usions that have remained undia"nosed despiteprevious, less4invasive tests e."., thoracentesis2.


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Diagnosis o PleuralE!usion


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reat#ent and outco#es

$herapeutic $horacentesis

@raina"e of a pleural e(usion &indicated in complicatedparapneumonic e(usions or empyema&for symptomaticrelief of dyspnea, and to evaluate underlyin" lun"parenchyma pleural uid acteriolo"y culture and ramstain2, and pleural uid chemistry pG22.

Therapeutic thoracentesis &at any one time, no morethan 1 L to 1.I L of uid should e removed unlesspleural space pressure is monitored2 to avoid re4

expansion pulmonary edema and post4thoracentesisshoc;.

Supplemental oxy"en & ecause post4thoracentesisdecreases in arterial oxy"enation


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Pleural Sclerosis and Fibrinolytics

4 The use of a sclerosin" a"ent &to produce achemical serositis and suse7uent /rosis of

the pleura is indicated in recurrentsymptomatic mali"nant e(usions.

4 9"ents ) talc, doxycycline, leomycin, and7uinacrine .

4 9ll uid must e drained initially and thatfull expansion of the underlyin" lun" usuallyvia a tue thoracostomy2 is essential eforeproceedin" !ith sclerosis.


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Surgery

complicated pleural e(usions & parietalpleurectomy and decorticationof the

visceral pleura.the patientKs "eneral medical condition,expected lon"4term pro"nosis, andaseline lun" function should e

considered efore proceedin" !ithsur"ery2


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Pleural E!usions in SpecifcDiseases

%ollagen &ascular !iseases

The pleural e(usion in patients !ithsystemic lupus erythematosus SL2 &

small and ilateral, chest pain.lupus erythematosus cells and hi"hantinuclear antiody titers in pleural uidhave a hi"h speci/city ut are not

sensitive 2

?

responsive to corticosteroids.


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Pleural e(usions &rheumatoid arthritisand, SL e(usions & men.

4 rheumatoid e(usions is their lo!"lucose level R%I m"dL2.

4 rheumatoid factor in pleural uid &elevated in other inammatory states.

?

little evidence that corticosteroids areene/cial in treatin" rheumatoid pleurisy


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Malignancy

neoplastic disease & metastasis than throu"hprimary tumors.

4 Lun" and reast cancers & metastatic disease

to the pleura. ther less common causes arehematolo"ic e."., lymphoma, leu;emia2,ovarian, and "astrointestinal tumors.

4 *ytolo"ic of the pleural uid & positive J I0'

of cases 24 Tumor mar;ers e."., carcinoemryonic anti"enA*9C are not speci/c enou"h.

4 3mmunocytometry & the dia"nosis of lymphoma


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%hylothora'

Lea;a"e of chyle from a disruption of thethoracic duct leads to a chylothorax.

& mil;y uid &measurin" pleural uidtri"lyceride levels

4 9 tri"lyceride J 110 m"dL con/rms thedia"nosis, !hereas O Q0 m"dL excludes the

dia"nosis.4 chylomicronsin the e(usion usin"electrophoresis2 & estalishes the dia"nosis.


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Pleural Diseases $ Signs *: Chylothora"

+ Lea;a"e of lymph+ =sually a result of sur"ical trauma durin" mediast.proc.+ Traumatic vs nontraumatic+ Traumatic) %M, unilateral+ Nontraumatic) 1M, ilateral, assoc. !ith SB*thromosis


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Co##on Causes o Chylothora" Dilariasis 3diopathic 3ntestinal lymphan"iectasia

Lymphan"iomyomatosis Suclavian venous thromosis Trauma includin" sur"ery2

Tumors


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Treatment of a chylous e(usion &preventin"the complications of malnutrition due to the

continuous loss of protein, fat, andelectrolytes. *onservative measures includeshiftin" to a medium4chain tri"lyceride diet tominimiUe the accumulation of uid and total

parenteral nutrition. @e/nitive treatment modalities & thoracic duct

li"ation or pleuroperitoneal shunt implantation. Pleurodesis is not very e(ective due to the

anti4inammatory characteristics of chyle.


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Hemothora' pleural uid is loody& the pleural uid

hematocrit J I0' of the peripheral loodhematocrit.

Gemothorax most commonly results from chesttrauma.

Nontraumatic hemothorax & mali"nancy orpulmonary emolism.

?

re7uires immediate chest tue thoracostomy and,

if leedin" persists draina"e %00 mLhr2&thoracotomy.


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Pleural Diseases $ Signs +:,e#othora"

+ 3ntrathoracic leedin" e.".,trauma2

+ Numerous sources of

potential leeds

+ Lar"e hemothorax)hypovolemic shoc;,restricted ipsilateralventilation contralateralmediastinal shift

+ *lottin" may not e tooprolematic except forcatheters2


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%oronary Artery #ypass Graft one half of patients !ho under"o coronary artery ypass

"raftin"& develop pleural e(usions. The pathophysiolo"y & is unclear pleural trauma durin"

sur"ery or leedin" into the pleural space2. Li"ht and co!or;ers)divided these lar"e e(usions into t!o

cate"ories)

4 those that occur !ithin M0 days of sur"ery &the uid isloody, eosinophilic, and easily resolvale !ith draina"ethoracentesis2.

4 9fter M0 days & the uid is clear yello! and predominantlylymphocytic, ut these e(usions are diVcult to mana"e

ecause they often recur. 3n either case, it is easy todistin"uish these e(usions from those caused y con"estiveheart failure, ecause the former are usually exudative.


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"ther Pleural !iseases

Pneumothora' 9ir in the pleural space &pneumothorax. *auses ) trauma, iatro"enic factors e."., thoracentesis,

mechanical ventilation2, chronic ostructive pulmonarydisease, infection, and mali"nancy.

Primary spontaneous pneumothorax &> in men youn"er thanQ0 years, and the relative ris; rises !ith heavy smo;in".

8ost secondary spontaneous pneumothoraces & to chronicostructive pulmonary disease or infection e.".,Pneumocystis jiroveci2.

Trauma4related pneumothorax can result either in an open tothe atmosphere2 pneumothorax or a closed tension2pneumothorax, in !hich intrapleural pressures commonlyexceed atmospheric pressures.


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Pleural Diseases $ Signs-: Pneu#othora"

+ Presence of free air or "as in thepleural cavity

+ Types of pneumothorax

+ pen pneumothorax

+ Spontaneous pneumothorax

+ Tension pneumothorax

+ *ollapse of ipsilateral lun" due topressure chan"e disruption ofsurface tension

+ Potential for mediastinal shifts


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pneu#othora"


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Classifcation o Pneu#othora" Traumatic or iatro"enic Spontaneous !ithout antecedent cause2) Primary no underlyin" lun" patholo"y2 Secondary underlyin" lun" patholo"y2


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Traumatic pneumothorax usually re7uiresplacement of a thoracostomy tue untilthe air lea; resolves.

The 9**P consensus statement &sur"ical intervention thoracoscopy !ithullectomy and a procedure to producepleural symphysis2 in preventin" the

recurrence of secondarypneumothoraces.1

. S
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/pleural-disease/http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/pleural-disease/


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.anage#ent o SpontaneousPneu#othora"

Pri#ary Spontaneous Pneu#othora"

Stale Patients !ith Small Pneumothoracesservation in the emer"ency department for M to hours

@ischar"e home if a repeat chest radio"raph excludes pro"ression

Dollo! up 1%4QH hours !ith repeat chest radio"raph & resolution Stale Patients !ith Lar"e Pneumothoraces

GospitaliUation-e4expansion of lun" usin" a small4ore catheter or placin" a 14%% D chest tue

Suction if lun" fails to re4expand =nstale Patients !ith Lar"e Pneumothoraces

GospitaliUation*hest tue placement !ith 14%% D standard chest tue

=se %Q4%H D chest tue if the patient has a lar"e air lea; orre7uires positive4pressure ventilation


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Secondary Spontaneous Pneu#othora" GospitaliUation servation or treatment !ith a chest

tue, dependin" on the extent of thesymptoms and the course of thepneumothorax


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Asbestos()elated Pleural !isease asestos exposure J %0 years &the classic pleural

pla7ues to e(usions and mali"nancy &the pleuraluid &the presence of mesothelial cells !ithatypical features & mesothelioma.

mesothelioma and asestos &most patients are

middle4a"edand have history of asestos exposure. The dia"nosis & the history of cou"h and pleuritic

chest painas !ell as chest *T results and /ndin"sof elevated hyaluronic acid levels in pleural uid.

The dia"nosis & tissue iopsy thoracoscopy orthoracotomy2.

Pro"nosis & poor R1 year survival after dia"nosis2


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Pleural Diseases $ Signs /: .alignant.esothelio#a

+ Neoplasm of pleural serosa

+ Lin;ed to asestos exposure

+ *oalescence of pleural pla7ues

+ 8ay e restricted to parietalpleura ut can involvevisceral pleura

+ *an lead to contracture of allstructures in a(ected

hemithorax


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A*!S()elated Pleural !isease The immunolo"ic impairment in 93@S & infectious

complications acterial parapneumonic e(usionsand empyema2.

3n developin" countries)

tuerculous,Pneumocystis jiroveci in patients !ith93@S, & pleural e(usions.

P. jiroveci& pneumothorax

Pleural e(usions can also occur !ith WaposiKssarcoma and non4God";inKs lymphoma, andresponses to treatment these disease & poor.

S


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Su##ary

Pleural e(usion is usually the result of an imalance et!een uid

production and removal. Li"htKs criteria help di(erentiate transudative pleural e(usions, !hich

usually reect a systemic disease, from exudative e(usions, !hichusually si"nify underlyin" local pleuropulmonary2 disease.

The more common causes of transudative e(usions are con"estive heartfailure and hypoaluminemic states e."., cirrhosis2: common causes of

exudative e(usions are mali"nancy, infections e."., pneumonia2, andpulmonary emolism. 3deally, the !or;up of a ne! pleural e(usion e"ins !ith a dia"nostic

thoracentesis unless the amount of uid is too small. The mana"ement of pleural e(usions associated !ith pneumonia

parapneumonic e(usions2 is ased on the pleural space anatomy,

pleural uid acteriolo"y culture and ram stain2, and pleural uidchemistry pG2. 8edical or sur"ical thoracoscopy o(ers the advanta"es of visual

evaluation of the pleura and direct tissue samplin", and it can e helpfulfor the dia"nosis of un;no!n pleural e(usions and in the mana"ementof complicated e(usions.


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week 1 pleuraldisease - 30 oktober 2012.pptx

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