Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Pulmonary Medicine 2 Approach To Pleural Disease PPT-Powerpoint Presentations and lecture notes
APPROACH TO PLEURAL
DISEASES
PULMONARY MEDICINE
OBJECTIVES
? Know different pleural diseases
? Know their clinical features
? Identify pleural diseases on Chest xray
? Know the approach (diagnosis and management)
PLEURAL DISEASES
? PLEURAL EFFUSION
? PNEUMOTHORAX
? HEMOTHORAX
? PYOTHORAX
? CHYLOTHORAX
? PLEURAL MALIGNANCY (Primary and Secondary)
CASE 1
25 year old male presented in OPD with
Dry cough, Breathlessness, Chest pain on deep inspiration since 20 days
On Physical examination ?
Dull note on percussion over left infrascapular area
Breath sound intensity were decreased with decreased TVF and VR over same
area
CHEST XRAY
HOW TO APPROACH
? USG Chest
On ipsilateral decubitus
Chest xray
Light's Criteria
TRANSUDATIVE PLEURAL EFFUSION
EXUDATIVE PLEURAL
EFFUSION
5
>50%
Most patients with a reduced pleural fluid glucose level (<60 mg/dL) have one of
four conditions:
? Parapneumonic effusion,
? Malignant pleural effusion,
? Tuberculous pleuritis, or
? Rheumatoid pleural effusion
OPTIONS WHEN NO DIAGNOSIS IS OBTAINED AFTER INITIAL
THORACENTESIS
? Observation
? Bronchoscopy
? A pulmonary infiltrate is present on the chest radiograph or the chest CT scan
? Hemoptysis is present
? The pleural effusion is massive, that is, it occupies more than three fourths of the
hemithorax.
? The mediastinum is shifted toward the side of the effusion
? Thoracoscopy
? Needle Biopsy of the Pleura ? if thoracoscopy is not available
CASE 2
A 50 year old male, case of COPD, presented in OPD with
? Worsening breathlessness with right side chest pain since 1 day
? On Exmination
? Hyperresonant percussion note right side
? Decreased breath sound intensity right side with decrease TVF and VR
CHEST X-RAY
PNEUMOTHORAX
? SPONTANEOUS
? PRIMARY
? SECONDARY
? TRAUMATIC
? DIRECT/ INDIRECT TRAUMA
? IATROGENIC
QUANTITATION OF PNEUMOTHORAX
Collin's method
Light's Index
TREATMENT ? PRIMARY SPONTANEOUS
PNEUMOTHORAX
? Upto 15 % volume
? Observation with supplemental oxygen
? > 15 % volume
? Tube thoracostomy
TREATMENT ? SECONDARY SPONTANEOUS
PNEUMOTHORAX
? TUBE THORACOSTOMY WITH INSTILLATION OF A SCLEROSING AGENT
? MEDICAL THORACOSCOPY
? VIDEO-ASSISTED THORACOSCOPIC SURGERY
For Persistent air leak
TREATMENT ? IATROGENIC PNEUMOTHORAX
No/Mild symptoms,
< 40% of the hemithorax
Observation with supplemental
O2
More than mildly symptomatic,
ASPIRATION/TUBE
> 40% of the hemithorax
THORACOSTOMY
If the patient is on mechanical
ventilation
Tube thoracostomy
TREATMENT ? NON IATROGENIC TRAUMATIC
PNEUMOTHORAX
? TUBE THORACOSTOMY [May not be necessary for patients with
small pneumothoraces or those with occult pneumothoraces]
TENSION PNEUMOTHORAX
? Intrapleural pressure exceeds atmospheric pressure throughout
expiration and often during inspiration as wel
? Mostly, patients on Mechanical ventilation
? One way valve mechanism
CLINICAL FEATURES
? The patient appears distressed with rapid labored respirations,
cyanosis, and usually profuse diaphoresis, hypotension, and
marked tachycardia
? Contralateral mediastinal shift
TREATMENT
? TUBE THORACOSTOMY
HEMOTHORAX
? Penetrating or nonpenetrating chest trauma
? Occasionally, iatrogenic ? Placement of central venous catheters
percutaneously by the subclavian or internal jugular route
TREATMENT ? TRAUMATIC HEMOTHORAX
? TUBE THORACOSTOMY (LARGE BORE 2436 F)
Advantages
? It allows more complete evacuation of the blood from the pleural space;
? It stops the bleeding if the bleeding is from pleural lacerations;
? It allows one to quantitate easily the amount of continued bleeding;
? It may decrease the incidence of subsequent empyema because blood is a good culture
medium;
? The blood drained from the pleural space may be autotransfused; and
? The rapid evacuation of pleural blood decreases the incidence of subsequent
fibrothorax
? Videoassisted thoracic surgery (VATS)
NON TRAUMATIC HEMOTHORAX
? Metastatic malignant pleural disease [m/c]
? Complication of anticoagulant therapy
TREATMENT
? Tube thoracostomy
? VATS
PYOTHORAX
? Parapneumonic effusion Pleural effusion associated with bacterial pneumonia, lung
abscess, or bronchiectasis
? Empyema Pus in pleural space
Evolution of parapneumonic effusion :
1. Exudative stage
2. Fibro-purulent stage
3. Organization stage
Bacteriology:
Aerobic [Gm Positive > Gm Negative] > Mixed Aerobic & Anaerobic > Anaerobic
Str. Pneumonie,
E. Coli,
Bacteroids,
Staph aureus
Pseudomona
Peptostreptococcus
s, Klebsiella
Clinical manifestation :
? Acute fever,
? Chest pain,
? Leukocytosis
Diagnosis:
Chest xray
USG chest
Diagnostic thoracocentesis
CHEST XRAY
USG CHEST
CT CHEST
Bad prognostic factors:
? Pus present in pleural space
? Gram stain of pleural fluid positive
? Pleural fluid glucose below 40 mg/dl
? Pleural fluid culture positive
? Pleural fluid pH <7.0
? Pleural fluid LDH >3 x upper normal limit for serum
? Pleural fluid loculated
Treatment options
? Therapeutic thoracentesis
? Tube thoracostomy
? Tube thoracostomy with the intrapleural administration of fibrinolytics
? Thoracoscopy with the breakdown of adhesions
? Thoracotomy with decortication
PRIMARY PLEURAL MALIGNANCY
? Malignant Mesothelioma
? Solitary Fibrous Tumors of the Pleura
Malignant mesotheliomas :
? Multiple white or gray granules, nodules, or flakes on parietal pleura.
? Pleural surface becomes progressively thicker and nodular
? Tumor extends to form a continuous layer encasing the lung - contraction
of the involved hemithorax.
CHEST X-RAY
CHEST CT
SOLITARY FIBROUS TUMORS OF THE PLEURA
? Mostly benign
? 7 60 % malignant
? Grossly, appear as firm, encapsulated yellow tumors, which may
be vascular with prominent veins over their external surfaces
CHEST X-RAY
CHEST CT
METASTATIC PLEURAL MALIGNANCY
PLEURAL EFFUSIONS RELATED TO METASTATIC
MALIGNANCY
THANK YOU
This post was last modified on 08 April 2022