3. Pleural effusion: Introduction
• Collection of excess quantity of fluid in pleural space
• Inflammatory or non inflammatory causes
4. Pleural effusion: Classification
• Transudates: due to diseases that affect the
filtration of pleural fluid- CHF & hypoproteinemia
• Exudates: inflammation or injury increases pleural
membrane permeability to proteins and various
types of cells
21. Dry pleurisy: Pathology
• Involvement of visceral pleura with small amount of
yellow serous fluid
• Adhesion between pleural surfaces
• Pleural thickening
• Fibrothorax due to fibrin deposition and severe
adhesions
22. Dry pleurisy: Clinical manifestations
• Signs & symptoms of primary disease
• Dull pleural pain, exaggerated by deep
inspiration,cough, straining, referred to shoulder and
back
• Increased dullness on percussion and decreased breath
sounds
• Leathery, rough inspiratory and expiratory friction rub
early in the disease
• X-ray- haziness at the pleural surface or a dense, sharply
demarcated shadow
23. Dry pleurisy: Treatment
• Treat underlying condition
• If pneumonia is not present- strapping of chest to
restrict expansion and analgesics
• Strapping and cough suppressants not given if
pneumonia is present
24. 2. Serofibrinous pleurisy
• Infections of lungs
• Inflammatory conditions of mediastinum
• Less commonly with- SLE, RF, neoplasms
25. Serofibrinous pleurisy: Clinical features
• Initially signs and symptoms of dry pleurisy
• Asymptomatic if effusion is small
• Large effusion: cough, dyspnoea, retractions,
orthopnoea, cyanosis
• Shift of mediastinum away from affected side,
fullness of intercostal space, diminished tactile vocal
fremitus
• Dullness to flatness on percussion
• Decreased or absent breath sounds
26. Serofibrinous pleurisy: Clinical features...
• In infants- bronchial breath sounds instead of absent
breath sounds
• Friction rub in the early stages
• X-ray: homogenous opacity obliterating the normal
pulmonary marking, obliteration of costophrenic
angles and widening of interlobar fissure
28. Serofibrinous pleurisy: Treatment
• Treat underlying cause
• Thoracocentesis, up to 1 Liter of fluid
• Tube thoracostomy in older child with
parapneumonic effusion if pleural fluid pH<7.2 or
glucose <50mg/dl
29. 3. Purulent pleurisy / Empyema
• Pus or microorganism in pleural fluid
• Microorganism- by smear or culture
In the absence of these:
• pH of pleural fluid < 7.2
• Lactic dehydrogenase (LDH) >1000IU/L
• Glucose <than 40mg/dl
• Lactate > 45mg/ml
30. Empyema: Predisposing factors
• Pneumonia in ½ of cases
• Preceding H/O of pustules
• Blunt trauma to chest/surgery/thoracocentesis
• Viral infections (chickenpox, measles)
• Severe malnutrition
• Neglected foreign body
• Extension from subphrenic, amoebic liver abscess
• CHD
• Peridontal disease, steroid, immunodeficiency
32. Stages of Empyema
• Exudative (1 to 3 days):
parapneumonic effusion
• Fibrino purulent (4 to 14 days):
polymorpho nuclear & fibrin accumulation
• Organizing stage (after 14 days):
fibroblasts grow and producing an inelastic membrane
33. Empyema: Exudative stage
• Fluid is thin
• Cellular content is low
• Lungs are expandable
• Pleural fluid- pH >7.3, glucose >60mg/dl, pleural fluid
/serum glucose ratio >0.5, LDH < 1000 IU/L, Gram
stain and culture negative
34. Empyema: Fibrino purulent stage
• pH and glucose level fall, LDH rises
• Purulent and vicious, accumulation of neutrophils
and fibrin
• Tendency for loculations and limiting membranes
• purulent fluid, PH <7.10, glucose <40mg/dl LDH
>1000IU/L, Gram stain & culture +ve
35. Empyema: Organizing stage
• Thick pleura prevent entry of anti microbial drugs in
the pleural space- drug resistance
• Restrict lung movement
36. Empyema: Clinical features
• Common in poor socioeconomic group
• Peak incidence 0-3 years
• Chills, fever, dyspnoea, chest pain, referred pain,
night sweat, malaise, cough, ↑sputum production
• Pain abdomen & ileus
• Tachypnoeic, anxious, pleural rub (disappear after
fluid accumulates)
37. Empyema: Clinical features...
• Large fluid- fullness of intercostal spaces, diminished
chest excursions
• Shift of mediastinum
• Dullness to percussion, decreased air entry,
decreased tactile & vocal fremitus
38. Empyema: Investigation & Diagnosis
• History and examination findings
• Confirm the presence of empyema, etiological agent
& complications
• Polymorph predominance, rarely leukopenia
• X-ray chest- blunting of costophrenic angle,
opacification of hemithorax with mediastinal shift to
opposite side , lateral decubitus for small volume
41. Empyema: Treatment
Aims
• Control infection
• Drainage of pus
• Expansion of lungs
42. Empyema drainage
• Inter costal drainage (ICD), under water seal, large
catheter inserted in the site of pus accumulation
• Loculated fluid/pus- drainage continued for 1 week
• Chest tube kept till drainage is nil or < 30 ml/day
46. Empyema: Treatment...
• Based on culture and sensitivity
• Monotherapy not recommended
• In anerobic infection- Clindamycin: 6-12wk
• MRSA- Vancomycin
• Antibiotics till afebrile, WBC normal, thoracostomy
yield <50ml/day, X-ray clearing
• H influenzae & S pneumoniae: 7-14 days
• S aureus: 3-4 wk, anerobic: (variable) 6-12wk
47. Empyema: Thrombolytic therapy
• Multiloculated empyema by thoracostomy tube
• Streptokinase 2,50,000 unit or urokinase 1,00.000
unit in 100ml normal saline instilled through tube &
clamped for 3 hrs
48. Empyema: Surgical therapy
• Remains febrile and dyspnoeic after IV antibiotics
and thorcostomy drain
• Pleural thickening- decortication
• Non expansion of lung
• Bronchopleural fistula
• Video assisted thoracoscopic surgery in multi
loculated effusion
• Thorocoscopic debridement and irrigation in
multiloculated effusion
55. Pneumothorax: Causes
• Rupture of pleural blebs • Transthoracic aspiration
• Penetrating or non needle
penetrating injuries • Thoracentesis
• Pneumonia • Central intravenous
• Asthma catheters
• Cystic fibrosis • Mechanical Ventilation
• COPD/ Bronchitis
• Resuscitative efforts
• Inhalation of some toxic
substances, most
notably crack cocaine
56. Clinical Signs & Symptoms
• Severity depends on the extent of the lung collapse.
• Simple pneumothorax - asymptomatic or chest
pain, dyspnea.
• Extensive pneumothorax often produces pleuritic
chest pain, dyspnea, tachypnea, cyanosis,
Hyperresonance to percussion on the affected side.
• Decreased breath sounds on the involved side.
• If pneumothorax due to trauma - look for contusions
or abrasions on the chest wall or a small puncture
wound that does not allow free movement of air
between the outside and the pleural cavity.
57. Tension Pneumothorax: Signs/Symptoms
• Clinical Presentation - Chest pain (90%), Dyspnea
(80%), Anxiety, Fatigue
• Physical examination - Respiratory distress and/or
arrest, Cyanosis, Tracheal deviation, Pulsus paradoxus,
Tachypnea, Tachycardia, Hypotension, Jugular venous
distension
• Hyperresonance of the chest wall on percussion
• Unilaterally decreased or absent lung sounds
• Increasing resistance to providing adequate ventilation
assistance
• Mental status changes, including decreased alertness
and/or consciousness
• Abdominal distension
58. Tension Pneumothorax
Lung parenchymal or
bronchial injury
one-way valve
air trapping
mediastinal structures
- pushed to the
contralateral side.
mediastinum impinges on
and compresses the
contralateral lung
61. Pneumothorax: Treatment
Without continued air leak, asymptomatic and mildly
symptomatic small pneumothorax
• 100% oxygen
• Sedation
62. Tension Pneumothorax: Treatment
• Severe respiratory and circulatory embarrassment
• Emergency Needle aspiration
• Either immediately or after needle aspiration a chest
tube (ICD) should be inserted and attached to
underwater seal drainage
63. Decompression by Needle / ICD
• 2nd intercostal space on the mid clavicular line
• Upper border of the lower rib
• Needle / ICD have to be connected to the
underwater sealed drainage
