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