Copia - Copia - Pleural disorders

Gonzalez MD

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HY:Pleural disorders

Student´s resources

DeGowin’s Diagnostic Examination, 11e. Chapter 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems. https://bibliodig.uag.mx:2091/content.aspx?sectionid=247755673&bookid=2927#247756010 Robbins & Cotran Pathologic Basis of Disease. The Lung. Inflammatory Pleural Effusions. https://bibliodig.uag.mx:2113/#!/content/book/3-s2.0-B9780323531139000157?scrollTo=%23hl0003862 Robbins & Cotran Pathologic Basis of Disease. The Lung. Diseases of Vascular Origin. https://bibliodig.uag.mx:2113/#!/content/book/3-s2.0-B9780323531139000157?scrollTo=%23hl0002909

ÍNDICE

CONTENT

1. Pleural effusion, concept
2. Classification of pleural effusions
3. Signs and symptoms
4. Auscultation
5. Imaging

ÍNDICE

Gonzalez MD

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HY:Pleural effusions

Introduction

It s estimated that approximately 0.26 ml of fluid per kilogram of body weight is contained within each pleural cavity. This fluid is both produced and absorbed primarily on the parietal surface and is dependent on the balance of hydrostatic and oncotic pressure differences. Lymphatic vessels lying in the parietal pleura are responsible for pleural fluid resorption, and the flow rate of these vessels can increase by a factor of approximately 20 in response to increases in pleural liquid formation. A clinically significant effusion will be seen only when fluid production substantially overwhelms the ability of the lymphatic vessels to resorb fluid, because of high production, diminished resorption, or a combination of these two fact.

Advanced medical interventions in pleural disease. ERS 2021.

A pleural fluid protein level higher than 3 g per deciliter or a pleural fluid cholesterol level higher than 45 mg per deciliter has been shown to indicate the presence of an exudative effusion (in abscense of protein levels)

One of the first steps in the evaluation of the pleural fluid is to distinguish those who have inflammatory (exudative) effusions from those who have noninflammatory (transudative) effusions. The use of Light’s criteria for differentiating exudative from transudative effusion According to Light’s criteria, a patient is considered to have an exudative effusion when any one of the following findings is present:

1. A ratio of pleural fluid protein to serum protein higher than 0.5
2. A ratio of pleural fluid lactate dehydrogenase level to serum LDH level higher than 0.6
3. A pleural fluid LDH level higher than 200 IU per liter (or >67% of the upper limit of the normal range for serum LDH level).

Pleural effusions: Exudates vs Transudates

Advanced medical interventions in pleural disease. ERS 2021.

Formation of pleural effusion:

1. Altered permeability of the pleural membranes (eg, inflammation, malignancy, pulmonary embolism)
2. Reduction in intravascular oncotic pressure (eg, hypoalbuminemia due to nephrotic syndrome or cirrhosis)
3. Increased capillary permeability or vascular disruption (eg, trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uremia, pancreatitis)
4. Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation (eg, congestive heart failure, superior vena cava syndrome)
5. Decreased lymphatic drainage or complete lymphatic vessel blockage, including thoracic duct obstruction or rupture (eg, malignancy, trauma)
6. Increased peritoneal fluid with microperforated extravasation across the diaphragm via lymphatics or microstructural diaphragmatic defects (eg, hepatic hydrothorax, cirrhosis, peritoneal dialysis)
7. Movement of fluid from pulmonary edema across the visceral pleura

Causes of pleural effusions/Pathogenesis

Advanced medical interventions in pleural disease. ERS 2021.

Diaphragmatic injury ++++

• Congestive heart failure
• Pulmonary edema
• Diaphragmatic injuries
• Esophageal rupture and tears
• Hypothyroidism and myxedema coma
• Lung neoplasms
• Pancreatitis

Additional causes of pleural effusions

Advanced medical interventions in pleural disease. ERS 2021.

Symptoms: The most commonly associated symptoms are progressive dyspnea, cough, and pleuritic chest pain.

Typically, there are no clinical findings for effusions less than 300 mL. With effusions greater than 300 mL, chest wall/pulmonary findings may include the following:

1. Dullness to percussion
2. Decreased tactile fremitus
3. A symmetrical chest expansion, with diminished or delayed expansion on the side of the effusion
4. Mediastinal shift away from the effusion: This finding is observed with effusions greater than 1000 mL.
5. Diminished or inaudible breath sounds
6. Egophony (known as "E-to-A" changes) at the most superior aspect of the pleural effusion
7. Pleural friction rub

Physical examination

Advanced medical interventions in pleural disease. ERS 2021.

Thoracentesis should be performed for new and unexplained pleural effusions when sufficient fluid is present to allow a safe procedure. Laboratory testing helps to distinguish pleural fluid transudates from exudates. Certain types of exudative pleural effusions might be suspected simply by observing the gross characteristics of the fluid:

1. Frankly purulent fluid indicates an empyema
2. A putrid odor suggests an anaerobic empyema
3. A milky, opalescent fluid suggests a chylothorax, resulting most often from lymphatic obstruction by malignancy or thoracic duct injury by trauma or surgical procedure
4. Grossly bloody fluid may result from trauma, malignancy, postpericardiotomy syndrome, or asbestos-related effusion and indicates the need for a spun hematocrit test of the sample.

A pleural fluid hematocrit level of more than 50% of the peripheral hematocrit level defines a HEMOTHORAX, which often requires tube thoracostomy Black pleural fluid suggests infection with Aspergillus niger or Rizopus oryzae, malignant melanoma, non-small cell lung cancer or ruptured pancreatic pseudocyst, or charcoal-containing empyema

Approach considerations

Advanced medical interventions in pleural disease. ERS 2021.

Purulent fluid drainage from a patient with frank empyema (purulent fluid)

Advanced medical interventions in pleural disease. ERS 2021.

Black pleural fluid (pancreatic pseudocyst rupture)

Advanced medical interventions in pleural disease. ERS 2021.

Normal pleural fluid has the following characteristics: Clear ultrafiltrate of plasma that originates from the parietal pleura A pH of 7.60-7.64 Protein content of less than 2% (1-2 g/dL) Fewer than 1000 white blood cells per cubic millimeter Glucose content similar to that of plasma Lactate dehydrogenase (LDH) less than 50% of plasma

Normal pleural fluid

Advanced medical interventions in pleural disease. ERS 2021.

Effusions of more than 175 mL are usually apparent as blunting of the costophrenic angle on upright posteroanterior chest radiographs. Layering of an effusion on lateral decubitus films defines a freely flowing effusion and, if the layering fluid is 1 cm thick, indicates an effusion of greater than 200 mL that is amenable to thoracentesis. .

Chest Radiography

Advanced medical interventions in pleural disease. ERS 2021.

Pleural effusion: blunted costophrenic angle (right)

Advanced medical interventions in pleural disease. ERS 2021.

Pleural effusion: blunted costophrenic angle (left)

Advanced medical interventions in pleural disease. ERS 2021.

Pleural effusion

Advanced medical interventions in pleural disease. ERS 2021.

Approach

Treatment Approach

Advanced medical interventions in pleural disease. ERS 2021.

Gonzalez MD

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HY:Pneumothorax

Types of Pneumothorax:

• Spontaneous pneumothorax: Occurs without an obvious injury. Commonly affects tall, thin males aged 10-30.
• Secondary: Due to underlying lung disease (COPD, asthma, cystic fibrosis).
• Traumatic pneumothorax: Caused by chest injury. Blunt trauma (e.g., car accident, falls). Penetrating trauma (e.g., stab wound, gunshot wound).
• Iatrogenic (e.g., after lung biopsy, central line insertion).
• Tension pneumothorax: A life-threatening emergency. Air enters the pleural space but cannot escape, leading to increased pressure. Causes compression of the heart and great vessels.

Definition: Air leaks into the space between your lung and chest wall. Can be life-threatening and requires prompt diagnosis and treatment.

Pneumothorax

Etiology

Symptoms:

• Sudden chest pain, often sharp and stabbing.
• Shortness of breath (dyspnea).
• Rapid heart rate (tachycardia).
• Cough.

Diagnosis:

• Physical Examination: Decreased breath sounds on the affected side. Chest X-ray: Confirms the presence of air in the pleural space. Sensitivity >80%.
• CT Scan: More detailed imaging. Useful for detecting small pneumothoraces and underlying lung disease. Sensitivity >95%.

Pneumothorax

A pneumothorax is, when looked for, usually easily appreciated on erect chest radiographs. Typically they demonstrate:

1. Visible visceral pleural edge is seen as a very thin, sharp white line
2. No lung markings are seen peripheral to this line
3. Peripheral space is radiolucent compared to the adjacent lung
4. Lung may completely collapse mediastinum should not shift away from the pneumothorax unless a tension pneumothorax is present

Pneumothorax: Diagnosis

Pneumothorax: Diagnosis

1. Oxygen administration to promote air reabsorption.
2. Follow-up chest X-rays to monitor progress.
3. Needle aspiration: Insertion of a needle into the pleural space to remove air.
4. Chest tube Insertion (Thoracostomy): Insertion of a tube into the pleural space to continuously drain air and fluid. Connected to a drainage system with a one-way valve or suction.

Pneumothorax: Treatment

Gonzalez MD

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HY:Pleural disorders summary

Pneumothorax: Treatment

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