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PLEURAL SPACE

The pleura consists of 2 layers1 – parietal pleura2 – visceral pleura

The space between the 2 layers is called the pleural space

Normal width of the pleural space is 10-20 m

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Parietal pleura

cover the inner surface

of the thoracic cavity,

including the

diaphragm, and ribs.

Visceral pleura

envelope all surfaces

of the lungs, including

the interlobar fissures.

At the HilumAt the Hilum where pulmonary vessels, bronchi, and nerves

enter the lung tissue, the parietal pleura is

continuous with the visceral pleura.

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PLEURAL EFFUSION

Normally the pleural space contains:

• 3.5 to 7.0 ml of clear liquid• low protein content• small number of mononuclear cells

Pleural effusion: presence of large amount of fluid in the pleural space irrespective of the underlying causes

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PLEURAL SPACEINTERCOSTAL

MICROVESSELS

PLEURAL FLUIDPLEURAL FLUID

VEINVEIN

ARTERYARTERY

LYMPHATICS TO LYMPHATICS TO MEDIASTINAL MEDIASTINAL

NODESNODES

STOMASTOMA

??

BRONCHIAL MICROVESSELS

VEINVEIN

ARTERYARTERY

VISCERAL PLEURALPARIETAL PLEURAL

PLEURAL SPACE

PLEURAL FLUID FORMATION AND ABSORTION

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MOVEMENTS OF FLUID IS BASED ON STARLING’S LOW

STARLING’S LOW :

L . A [ (PCAP – PPl) – (CAP – Pl) ]

L: Filtration coefficient A: Surface areaCap: CapillaryPl: Pleural

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• The rate of fluid formation is 0.02 ml/kg/hour.

• The rate of fluid clearance is 0.2 ml/kg/hour.

PLEURAL FLUID FORMATION AND ABSORTION

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PLEURAL SPACEINTERCOSTAL

MICROVESSELS

PLEURAL FLUIDPLEURAL FLUID

VEINVEIN

ARTERYARTERY

LYMPHATICS TO LYMPHATICS TO MEDIASTINAL MEDIASTINAL

NODESNODES

STOMASTOMA

??

BRONCHIAL MICROVESSELS

VEINVEIN

ARTERYARTERY

VISCERAL PLEURALPARIETAL PLEURAL

PLEURAL SPACE

PLEURAL FLUID FORMATION AND ABSORTION

Development of Pleural Effusion

pulmonary capillary pressure (CHF)

capillary permeability (Pneumonia)

plasma oncotic pressure (hypoalbuminemia)

pleural membrane permeability (malignancy)

lymphatic obstruction (malignancy)

diaphragmatic defect (hepatic hydrothorax)

thoracic duct rupture (chylothorax)

* key symptom -------> shortness of breath

Fluid filling the pleural space makes it hard for the lungs to fully

expand, causing the patient to take many breaths so as to get

enough oxygen.

* If parietal pleura is irritated -------> mild pain or a sharp

stabbing

pleuritic type of pain.

** Some patients will have a dry cough.

Occasionally ------> no symptoms at all.

* This is more likely when the effusion results from:

recent abdominal surgery, cancer, or tuberculosis.

* Tapping on the chest will show stony dullness, and decrease breath

sound

x ray

The fluid itself can be seen at the bottom of the lung or lungs,

hiding the normal lung structure.

If heart failure is present,

the x-ray shadow of the heart will be enlarged.

Ultrasound may disclose a small effusion that caused no

abnormal findings during chest examination.

C.T. scan is very helpful if the lungs themselves are diseased.

Diagosisn of pleural effustion

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Management of Pleural effusion

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Indication for Pleural Fluid Analysis

• Diagnostic ( detect underlying diagnosis)

• Therapeutic (relief shortness of breath)

PLEURAL EFFUSION

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DIAGNOSTIC THORACENTESIS

CONTRAINDICATIONS

• Bleeding tendency • Thrombocytopenia (decrease platelets less

25000 u3/dl )• Prolonged PT or PTT greater than twice

normal,

• A very small volume of pleural fluid

PLEURAL EFFUSION

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Color of Fluid Suggested Diagnosis

Pale yellow (straw) Transudate, some exudates

Red (bloody) Malignancy or embolism or TB

Turbid Infected effusion

Pus Empyema

White (milky) Chylothorax or cholesterol effusion

Color of Fluid

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1. Pleural Protein divided by serum protein >0.5

2. Pleural fluid LDH divided by Serum LDH >0.6

3. Pleural fluid LDH > 2/3 the upper limit of normal for the serum LDH.

Transudates vs Exudates

LIGHT’S CRITERIA*

Tronsudote Exudate

Left Heart Failure Bacterial PneumoniaCarcinoma BronchusHypoproteinaemia

Constrictive Pericarditis Pulmonary InfarctionHypothyroidismCirrhosis Connective-tissue Disease

Tuberculosis

Causes of Transudates and Exudates

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CELL COUNT

• Transudate < 1000 but 20% > 1000 and rarely > 10,000/mm3

• Exudate > 1000/mm3

• Limited value (unless > 50,000/mm3 emphyema)

PLEURAL EFFUSION

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PF LYMPHOCYTE-PREDOMINANT EXUDATES (>80%)

PLEURAL EFFUSION

Causes

TB

Lymphoma

`Chronic lymphocytic leukaemia

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BIOCHEMISTY

Glucose < 3.3 mmol/L or 1/2 serum glucose (simultaneous)

- Rheumatoid pleurisy (85%)

- Empyema (80%)

- Malignancy (40%)

PLEURAL EFFUSION

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The mechanism responsible for pleural fluid low glucose include;

• Decreased transport of glucose from blood to pleural fluid

• Increased utilization of glucose by constituents of pleural fluid, such as neutrophils, bacteria (empyema), and malignant cells

PLEURAL EFFUSION

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BIOCHEMISTY

Pleural fluid pH:- Normal pleural fluid pH is > 7.6

- Transudates – pH 7.40-7.55

- Exudates – pH is 7.30-7.45

• Should always be measured in a blood gas machine

• Parapneumonic - pH < 7.0 predicts “complicated effusion” that is unlikely to resolve without chest tube drainage.

• Malignant effusion with a pH < 7.3 is associated with poor survival.

• If pH < 6.0 think of ruptured esophagus

PLEURAL EFFUSION

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The mechanism responsible for pleural fluid acidosis (pH <7.30) include;

• Increased acid production by pleural fluid cells and bacteria

• Decreased hydrogen ion efflux from the pleural space, due to pleuritis, tumor, or pleural fibrosis.

PLEURAL EFFUSION

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DIAGNOSES ASSOCIATED WITH PLEURAL FLUID ACIDOSIS (pH <7.30) AND LOW GLUCOSE

CONCENTRATION (PF/SERUM <0.5)

PLEURAL EFFUSION

Diagnosis Usual pH (Incidence) Usual GlucoseConcentration

(mg/dL)

Empyema 5.50-7.29 (-100%) <40

Malignancy 6.95-7.29 (33%) 30-59

Tuberculous pleurisy 7.00-7.29 (20%) 30-59

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CYTOLOGY

positive in about 60% of patients with malignant effusion

PLEURAL EFFUSION

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Patients with Abnormal Chest Radiograph

Suspect pleural disease

Lateral decubitus chest radiographs

YES

Blunting of costophrenic angle?

Fluid thickness > 10mm

Yes NoDiagnostic thoracentesis

Observe

PLEURAL EFFUSION

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Diagnostic thoracentesis

Any of the following met?PF/serum protein >0.5PF/serum LDH >0.6

PF LDH >2/3 upper normal Serum limit

Exudate Transudate

Appearance of plueral fluid, pH & glucose, cytology and differential cell

count of pleural fluid

SUMMARYPLEURAL EFFUSION

Yes No

Treat CHF, cirrhosis, or nephrosis

direct treatment at what is causing it, rather than treating the effusion itself

Peneumothorax is the accumulation of air in the pleural space. It may occur spontaneously or following trauma

Disorder CauseCollection

Haemothorax

Hydrothorax

Chylothorax

Pneumothorax

Blood

Proteinaceous Fluid

Lymph

Air

Chest trauma; rupture of aortic aneurysm

Congestive cardiac failure

Neoplastic infiltration; trauma

Spontaneous; traumatic

Results from rupture of a pleural bleb Pleural bleb being a congenital defect of the alveolar wall connective tissue. Patients are typically tall, thin, young males. M:F ratio 6:1. Usually apical affecting both lungs with equal frequency.

Secondary causes occur in patients with underlying disease :

COPD, TB, pneumonia, bronchial carcinoma, sarcoidosis and cystic fibrosis.

Patients present with sudden onset of unilateral pleuritic pain and increasing breathlessness. The main aim of treatment is to get the patient back to active life as soon as possible.

Chest radiography may show an area devoid of lung markings.

May be more clearly seen on the expiratory film

Small pneumothorax: no treatment, but review in 7-10 days. Moderate pneumothorax: admit for simple aspiration.

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