cr piopneumothoraks nicky fixd

7/22/2019 CR Piopneumothoraks Nicky FIXd

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Abdomen

Inspection : abdomen flat, no tension, no dilatedveins

Palpation : no percussion pain, no defense

muscular, no enlarged liver Percussion : timpanic, percussion pain (-), shifting

dullness (-)

Auscultation : bowel movement (+), normal

Extemity : warm , oedem regio dorsum pedis dextra etsinistra (+), oedem regio antebrachii dextra (+), cyanosis (-)


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Laboratory and Imaging(RSAM July 23rd 2013)

Hb 14.0 g/dl (N : 13,5-18 gr% )

ESR 40 mm/jam (N : 0-10 mm/jam)

Leucocyte 96.000/ml (N : 4500-10.700)

Diff count 0/0/0/60/34/6 (N : 0-1/ 1-3/2-6/50-70/20-40/2-8)

Trombocyte 460.000 /ul (N : 150.000-400.000/ul)

Chemical Blood

OT/PT 19/23 ul (N : 6-30/6-45 ul) Ureum 19 u/l (N : 10-40 u/l)

Creatinin 23 u/l (N : 0,7-1,3 u/l)

GDS 151 mg/dl (N : 70-200 mg/dl)


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Sensitivity Test:


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Postero-anterior chest Roentgen ( July 8th2013)

Conclusion : Hidropneumothoraks dextra withcolaps in right lung field

Interpretation :

Bones and joints (clavicula, scapula,

costae, vertebrae) are intact

Trachea deviasi (-)

Avascular and hyperluscent area in

left lung field

Blunting of right costophrenic angle

(air fluid level form)Invisible infiltrat in left lung field

Size of cor is normal


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RESUME

Os came with complaints of left chest pain through to the back and abdomen,

accompanied by shortness, and productive cough. Chest pain felt since 2 months

before entering the hospital but patients do not care and continued to work. Osfeel chest pain severe increasingly since 2 days. Os feel nauseous and he vomit

since 2 days before entering the hospital. Os complained of shortness. Tightness is

felt if he in activity. He can not work as usual. Tightness has been felt since 2 days

before entering the hospital. Tightness is reduced when at rest but he was still

difficult to breathe. Os also complained of productive cough, cough has been felt

since first week before entering the hospital. Cough is persistent with sputum and

the colour is yellowish, now he is not cough anymore. He did not notice any

wheezing or weird breath sounds. He also said that he never been sweaty night,

low appetite, and weight loss. Him weight is same with he has illness. Os came to

the clinic and recommended to get x-rays examination . X-rays examination results

illustrated there was fluid in the lungs. Os has a history of intermittent fever and

the fever still common when taking the stall medicine. Os did not has a long cough

history. Os did not has a history of ATD (Anti Tuberculosis Drug). Os did not has a

history of dibetes melitus. Os did not has a history of hypertension.


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Physical examination revealed the patient looks ill but notin acute distress, compos mentis, Pulse 74 bpm, regular,Temperature 38.70C, Respiration Rate 36 x/minute, BMI22,49 kg/m2, Ananemic conjunctiva +/+. Chest examinationrevealed WSD tube inserted into fifth intercostal space, left

axillary line. Decreased left side thoracic expansion andabsent breath sound on the left side. Laboratory findingsrevealed mild anemia (Hb 14 g/dl), total leucocyte count of26.000. The posteroanterior chest x ray revealed a leftpneumothorax with left lung infiltrat.

From WSD fluid we found secret like pus, and the result ofbactery culture found gram-negative rods bacteria(Alkaligenes Sp)


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Diagnosis

Piopneumothoraks

Treatment

O2 2 Litres/minute IVFD RL gtt X/minute

Ceftriaxone 1 g/ 12 hours (IV)

Metronidazol / 12 hours (IV)

Ambroxol sirup 3x1C Observe the development of WSD till the undulations and

Bubble negative

Chest X-Ray if the lug re-expands, then off WSD


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Prognosis

Quo ad vitam : dubia

Quo ad functionam : dubia

Quo ad sanationam : dubia ad bonam

Recommended Examination

Lipid profile, uric acid serum

ECG

Acid-resistant bacteria

Sitology bacteria


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SECTION 2nd

REFERENCE

A. PLEURAL EFFUSION

1.1 EtiologyAlthough the etiologic spectrum of pleural

effusion is extensive, most pleural effusions

are caused by congestive heart failure,

pneumonia, malignancy, or pulmonary

embolism.


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Pleural effusions are generally classified astransudates or exudates, based on themechanism of fluid formation and pleural fluidchemistry. Transudates result from an imbalance in oncotic and

hydrostatic pressures, whereas

exudates are the result of inflammation of the pleuraor decreased lymphatic drainage.

In some cases, the pleural fluid may have acombination of transudative and exudativecharacteristics.


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1.3 Clinical Manifestations

The clinical manifestations of pleural effusion

are variable and often are related to the

underlying disease process.

The most commonly associated symptoms are

progressive dyspnea,

cough, and

pleuritic chest pain.


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1.4 Physical Examinations

Physical findings in pleural effusion are variableand depend on the volume of the effusion.

Generally, there are no physical findings foreffusions smaller than 300 mL.

With effusions larger than 300 mL, findings mayinclude the following:

asymmetrical chest expansion, with diminished ordelayed expansion on the side of the effusion,

decreased tactile fremitus, and

Dullness to percussion,


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Mediastinal shift away from the effusion - This is

observed with effusions of greater than 1000 mL;

Displacement of the trachea and mediastinum towardthe side of the effusion is an important clue to

obstruction of a lobar bronchus by an endobronchial

lesion, which can be due to malignancy or, less

commonly, to a nonmalignant cause, such as a foreign

body.

Diminished or inaudible breath sounds

Egophony ("e" to "a" changes) at the most

superior aspect of the pleural effusion Pleural friction rub


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Other physical findings, as follows, may suggest

the underlying cause of the pleural effusion:

Peripheral edema, distended neck veins, and S3gallop

suggest congestive heart failure. Edema may also be amanifestation of nephrotic syndrome; pericardial

disease; or, combined with yellow nails, the yellow

nail syndrome.

Cutaneous changes with ascites suggest liver disease

Lymphadenopathy or a palpable mass suggests

malignancy.


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These criteria require simultaneousmeasurement of pleural fluid and serum proteinand LDH. However, a meta-analysis of 1448patients suggested that the following combined

pleural fluid measurements might have sensitivityand specificity comparable to the criteria fromLight et al for distinguishing transudates fromexudates:

Pleural fluid LDH value greater than 0.45 of the upperlimit of normal serum values

Pleural fluid cholesterol level greater than 45 mg/dL

Pleural fluid protein level greater than 2.9 g/dL


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The more common causes of exudates include thefollowing: Parapneumonic causes,

Malignancy (most commonly, lung or breast cancer,lymphoma, leukemia; less commonly, ovarian carcinoma,stomach cancer, sarcomas, melanoma)[9], Pulmonaryembolism, Collagen-vascular conditions (rheumatoidarthritis, systemic lupus erythematosus),

Tuberculosis (TB), Pancreatitis,

Trauma,

Postcardiac injury syndrome,

Esophageal perforation, Radiation pleuritis, Sarcoidosis, Fungal infection,

Pancreatic pseudocyst, Intra-abdominal abscess, Status-post coronary artery bypass graft surgery, Pericardialdisease, Meigs syndrome (benign pelvic neoplasm withassociated ascites and pleural effusion),


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Ovarian hyperstimulation syndrome,

Drug-induced pleural disease (see Pneumotox On

Linefor an extensive list of drugs that can cause

pleural effusion), Asbestos-related pleural disease, Yellow nail syndrome

(yellow nails, lymphedema, pleural effusions),

Uremia,

Trapped lung (localized pleural scarring with theformation of a fibrin peel prevents incomplete lung

expansion, at times leading to pleural effusion),
http://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=enhttp://www.pneumotox.com/indexf.php?fich=clin0&lg=en


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1.6 Radiography Effusions of more than 175 mL are usually apparent as

blunting of the costophrenic angle on uprightposteroanterior chest radiographs.

On supine chest radiographs, which are commonly used inthe intensive care setting, moderate to large pleuraleffusions may appear as a homogenous increase in densityspread over the lower lung fields.

Apparent elevation of the hemidiaphragm, lateraldisplacement of the dome of the diaphragm, or increaseddistance between the apparent left hemidiaphragm andthe gastric air bubble suggests subpulmonic effusions. (Seethe images below.)
http://refimgshow%289%29/


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http://refimgshow%289%29/http://refimgshow%289%29/


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1.9 Treatment and Management

Transudative effusions are usually managed by treating theunderlying medical disorder. However, whether transudates

or exudates, large, refractory pleural effusions causingsevere respiratory symptoms, even if the cause isunderstood and disease-specific treatment is available, canbe drained to provide relief.

The management of exudative effusions depends on theunderlying etiology of the effusion. Pneumonia, malignancy, or TB causes most diagnosed exudative

pleural effusions, with the remainder typically deemedidiopathic.

Complicated parapneumonic effusions and empyemas shouldbe drained to prevent development of fibrosingpleuritis.

Malignant effusions are usually drained to palliate symptomsand may require pleurodesis to prevent recurrence.


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Medications cause only a small proportion of all pleuraleffusions and are associated with exudative pleuraleffusions.

However, early recognition of these iatrogenic causes

of pleural effusion avoids unnecessary additionaldiagnostic procedures and leads to definitive therapy,which is discontinuation of the medication.

Implicated drugs include medications that cause drug-

induced lupus syndrome (eg, procainamide,hydralazine, quinidine), nitrofurantoin, dantrolene,methysergide, procarbazine, and methotrexate.


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B. PNEUMOTHORAX

2.1 Background

Pneumothorax is defined as the presence of air orgas in the pleural cavity (ie, the potential spacebetween the visceral and parietal pleura of thelung). The clinical results are dependent on the

degree of collapse of the lung on the affectedside. Pneumothorax can impair oxygenationand/or ventilation.


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Tension pneumothorax

A tension pneumothorax is a life-threatening

condition that develops when air is trapped in

the pleural cavity under positive pressure,

displacing mediastinal structures and

compromising cardiopulmonary function.


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2.4 Risk Faktor

A wide variety of disease states and circumstances mayresult in a pneumothorax.

Primary and secondary spontaneous pneumothorax

Risks factors for primary spontaneous pneumothorax (PSP)include the following:

Smoking

Tall, thin stature in a healthy person

Marfan syndrome

Pregnancy

Familial pneumothorax


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Diseases and conditions associated with secondaryspontaneous pneumothorax include the following:

Chronic obstructive lung disease (COPD) or emphysema:Increased pulmonary pressure due to coughing with abronchial plug of mucus or phlegm bronchial plug may playa role.

Asthma Human immunodeficiency virus/acquired

immunodeficiency syndrome (HIV/AIDS) with PCP infection

Necrotizing pneumonia

Tuberculosis

Sarcoidosis Cystic fibrosis

Bronchogenic carcinoma or metastatic malignancy
http://emedicine.medscape.com/article/296301-overviewhttp://emedicine.medscape.com/article/230802-overviewhttp://emedicine.medscape.com/article/1001602-overviewhttp://emedicine.medscape.com/article/1001602-overviewhttp://emedicine.medscape.com/article/230802-overviewhttp://emedicine.medscape.com/article/296301-overview


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Causes of traumatic pneumothorax include thefollowing: Trauma: Penetrating and nonpenetrating injury

Rib fracture

High-risk occupation (eg, diving, flying)

Traumatic pneumothoraces can result from bothpenetrating and nonpenetrating lung injuries.Complications include hemopneumothorax andbronchopleural fistula. Traumatic

pneumothoraces often can create a 1-way valvein the pleural space (only letting in air withoutescape) and can lead to a tension pneumothorax.


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2.5 Physical Examination The presentation of a patient with pneumothorax

may range from completely asymptomatic to life-threatening respiratory distress. Symptoms may include diaphoresis, splinting chest

wall to relieve pleuritic pain, and cyanosis (in the caseof tension pneumothorax).

Findings on lung auscultation also vary depending on

the extent of the pneumothorax. Affected patients may also reveal altered mental

status changes, including decreased alertness and/orconsciousness (a rare finding).


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2.6 Diagnostic Considerations

Spontaneous Pneumothorax

Because patients with primary spontaneous

pneumothorax (PSP) will have apical emphysematouspulmonary disease on computed tomography (CT)

scanning or thoracoscopy,


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2.7 Differential Diagnoses Acute Coronary Syndrome

Acute Respiratory Distress Syndrome

Aortic Dissection

Congestive Heart Failure and Pulmonary Edema

Esophageal Rupture and Tears

Myocardial Infarction

Pericarditis and Cardiac Tamponade

Pulmonary Embolism

Rib Fracture


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Figure 2.1 Radiograph of a patient with a small spontaneous primary pneumothorax

Figure 2.2 Close radiographic view of patient with a small spontaneous primary pneumothorax (same patient as from the previous image).
http://refimgshow%282%29/http://refimgshow%281%29/


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Figure 2.6 Radiograph of a patient with a large spontaneous tension pneumothorax.


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2.9 Treatment

Pharmacotherapy

Observation without oxygen

Supplemental oxygen

Simple aspiration

Chest tube placement

One-way valve insertion (portable system)

Thoracostomy with continuous wall suction

SECTION 3rd


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SECTION 3

DISCUSSION

How is the mechanism of piopneumothoraks in this patient?

Many mechanisms can result in abnormal amounts of pleural fluid, including:

Increased hydrostatic pressures in the microvascular circulation.

Decreased oncotic pressures in the microvascular circulation.

Decreased pleural space pressure (resulting from lung collapse).

Increased permeability of the microvascular circulation.

Obstruction of lymphatic drainage

Pleural effusion is a secondary disease being related to tuberculosis or other lung disease such as TB,pneumonia, trauma, etc., because there is irritation on the lining of pleural cavity, thus altering the

permeability of the membrane and decreasing the oncotic pressure needed to drain the excess fluid in the

pleural space. normally there is a small amount of pleural fluid in the pleural space that lubricates the

parietal and visceral pleura during expiring and inspiring.

If the primary lesion enlarges, pleural effusion is a distinguishing finding. This effusion develops because

the bacilli infiltrate the pleural space from an adjacent area. Dullness to percussion and a lack of breathsounds are physical findings indicative of a pleural effusion because excess fluid has entered the pleural

space.

Pio Pneumothorax is Pneumothorax with empiema in one field of lung, the common etiology of pio

pneumotorax is that from the lungs like pneumonia, lungs abces, fistula bronkopleural, tuberculosa, and

from extra pulmonal is thorax injury, thorax surgery, thorakocentecis in pleural effusion, etc.

What are the problems of the patient ?


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What are the problems of the patient ?

The problem of the patient that we found including :

Piopneumothorax

The patient was admitted to the hospital because complaints of left chest

pain through to the back and abdomen, accompanied by shortness, and

productive cough. Chest pain felt since 2 months before entering the

hospital but patients do not care and continued to work. Os feel chest

pain severe increasingly since 2 days. Os feel nauseous and he vomit since

2 days before entering the hospital. Os complained of shortness. Tightness

is felt if he in activity. He can not work as usual. Tightness has been feltsince 2 days before entering the hospital. Tightness is reduced when at

rest but he was still difficult to breathe. Os also complained of productive

cough, cough has been felt since first week before entering the hospital.

Cough is persistent with sputum and the colour is yellowish, now he is not

cough anymore. Besides, the absence of weird breath sounds (likewheezing) and no history of asthma attack make asthma is unlikely. The

absence of high fever makes pneumonia is unlikely too.


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Then, it could be confirmed by physical examination.

The absence of breath sound in one side of the

chest along with decreased expansion movement ,decreased vocal fremitus, and hypersonor percussion

could lead to the pneumothorax diagnosis.

Pneumothorax itself is one of the complication of

empiema.


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Is the management of the patient ?

O2 2 Litres/minute

IVFD RL gtt X/minute

Ceftriaxone 1 g/ 12 hours (IV) Metronidazol / 12 hours (IV)

Ambroxol sirup 3x1C

Observe the development of WSD till theundulations and Bubble negative

Chest X-Ray if the lug re-expands, then off WSD


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What is the complications that may in this

patient?

Complications of pleural effusions include collapse

of the lung; pneumothorax, or air in the chestcavity, which is a common side effect of the

thoracentesis procedure; and empyemas

(abscesses) caused by infection of the pleural

fluid, which require drainage of the fluid.


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A pleural effusion may cause or worsen a lung infection, such aspneumonia. The extra fluid may get infected and form a pocket ofpus, which is called empyema (em-peye-EE-ma). You may haveother problems, such as a collapsed lung. The problems you mayhave depend on what is causing your pleural effusion. Talk to yourcaregiver about any concerns you may have about your illness or

treatment.

Pio Pneumothorax is Pneumothorax with empiema in one field oflung, the common etiology of pio pneumotorax is that from thelungs like pneumonia, lungs abces, fistula bronkopleural,

tuberculosa, and from extra pulmonal is thorax injury, thoraxsurgery, thorakocentecis in pleural effusion, etc, the commoncomplication from piopneumothorax is syok septic and it will becaused of death for this patient.

cr piopneumothoraks nicky fixd

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