Download MBBS Pulmonary Medicine Presentations 2 Approach To Pleural Disease Lecture Notes

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