Pleural Effusion, Pneumothorax and Pleural Effusion, Pneumothorax and AtelectasisAtelectasis

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The Pleural SpaceThe Pleural SpaceOverview and definitionsOverview and definitions Visceral pleura cover each lung, while the Visceral pleura cover each lung, while the

parietal pleura covers the outer structures parietal pleura covers the outer structures that bound the lungs. that bound the lungs.

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The Pleural Space (cont.)The Pleural Space (cont.) Pleural fluid about 10 to 20 mm thick Pleural fluid about 10 to 20 mm thick

separates the visceral from parietal pleura.separates the visceral from parietal pleura. There is ~8 ml of fluid per hemithorax.There is ~8 ml of fluid per hemithorax. Pleural fluid is very similar to interstitial fluid.Pleural fluid is very similar to interstitial fluid. This fluid minimizes the friction caused by This fluid minimizes the friction caused by

the lungs to expanding in the thorax during the lungs to expanding in the thorax during inspiration.inspiration.

Pleural pressure is typically negative due to Pleural pressure is typically negative due to outward thoracic recoil and inward recoil of outward thoracic recoil and inward recoil of lung. lung.

Pleural EffusionPleural Effusion

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Pleural EffusionsPleural Effusions Any abnormal accumulation of fluid in the Any abnormal accumulation of fluid in the

pleura is considered a pleural effusion.pleura is considered a pleural effusion. Fluid enters the pleural space in face of Fluid enters the pleural space in face of

increased pressure.increased pressure. Either increased fluid production or blockage of Either increased fluid production or blockage of

drainage can result in pleural effusions.drainage can result in pleural effusions. Two Types:Two Types:

Transudative (excessive fluid pressure)Transudative (excessive fluid pressure)Exudative (infectious process)Exudative (infectious process)

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Pleural EffusionsPleural Effusions Transudative pleural effusions are Transudative pleural effusions are

caused by fluid leaking into the pleural caused by fluid leaking into the pleural space. This is caused by increased space. This is caused by increased pressure in the blood vessels or a low pressure in the blood vessels or a low blood protein count. blood protein count.

Congestive heart failure is the most is the most common cause.common cause.

Exudative effusions are caused by Exudative effusions are caused by blocked blood vessels or lymph vessels, blocked blood vessels or lymph vessels, inflammation, lung injury, and tumors. inflammation, lung injury, and tumors.

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Pleural EffusionsPleural EffusionsThe most common causes of transudative (watery fluid) pleural The most common causes of transudative (watery fluid) pleural effusions include:effusions include:Heart failure Heart failure Pulmonary embolism Pulmonary embolism Cirrhosis Cirrhosis Post open heart surgery Post open heart surgery

Exudative (protein-rich fluid) pleural effusions are most Exudative (protein-rich fluid) pleural effusions are most commonly caused by:commonly caused by:Pneumonia Pneumonia Cancer Cancer Pulmonary embolism Pulmonary embolism Kidney disease Kidney disease Inflammatory disease Inflammatory disease

CHF ( with pulmonary edema)CHF ( with pulmonary edema)

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Diagnostic Tests for Diagnostic Tests for Pleural EffusionsPleural Effusions

Chest radiographyChest radiography Most common method of detecting effusionsMost common method of detecting effusions

Upright PA and lateral decubitus are useful.Upright PA and lateral decubitus are useful. 1-cm meniscus lung to rib allows for thoracentesis1-cm meniscus lung to rib allows for thoracentesis

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Diagnostic Tests for Pleural Diagnostic Tests for Pleural Effusions (cont.)Effusions (cont.)

Ultrasonography and computed tomographyUltrasonography and computed tomography Ultrasound is very sensitive to pleural Ultrasound is very sensitive to pleural

effusions.effusions. May use to localize and direct for thoracentesisMay use to localize and direct for thoracentesis

Contrast-enhanced CT is most sensitive Contrast-enhanced CT is most sensitive study for effusions.study for effusions.

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TreatmentTreatmentThoracentesisThoracentesis Percutaneous needle aspiration of Percutaneous needle aspiration of

effusion sampleeffusion sample

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Diagnostic Tests for Pleural Diagnostic Tests for Pleural Effusions (cont.)Effusions (cont.)

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Management for Pleural Management for Pleural EffusionsEffusions

Chest thoracotomy tubesChest thoracotomy tubes Designed for tight fit in tissues to avoid leaks Designed for tight fit in tissues to avoid leaks

and allow drainage of effusion and subsequent and allow drainage of effusion and subsequent lung reexpansionlung reexpansion

Tube is attached to chest drainage unit.Tube is attached to chest drainage unit.

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Management for Pleural Management for Pleural Effusions (cont.) Effusions (cont.)

Pleurodesis Pleurodesis Process fusing parietal and visceral pleurae, Process fusing parietal and visceral pleurae,

which prevents further formation of effusionswhich prevents further formation of effusions

Can be performed by surgical abrasion or Can be performed by surgical abrasion or introduction of chemical irritant, most commonly introduction of chemical irritant, most commonly talctalc

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Management for Pleural Management for Pleural Effusions (cont.)Effusions (cont.)

Pleuroperitoneal shunt and Pleurex catheterPleuroperitoneal shunt and Pleurex catheter For effusions refractory to all other treatment For effusions refractory to all other treatment

optionsoptions

Small pump moves fluid from pleura to Small pump moves fluid from pleura to peritoneal cavity.peritoneal cavity.

Pleurex catheter connects to suction at home Pleurex catheter connects to suction at home to drain persistent effusions.to drain persistent effusions.

pneumothoraxpneumothorax

Air in the pleural spaceAir in the pleural space

Types:•Spontaneous•Tension•Open•Closed

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PneumothoraxPneumothorax

Traumatic pneumothoraxTraumatic pneumothoraxPenetrating chest traumaPenetrating chest trauma

Common secondary to bullet or knife Common secondary to bullet or knife penetrationpenetration

Chest tube is usually adequate to treat.Chest tube is usually adequate to treat. May require surgery if bleeding is severeMay require surgery if bleeding is severe

Blunt traumaBlunt trauma Broken ribs puncture lung with air escape Broken ribs puncture lung with air escape

into pleura.into pleura. Chest tube is all that is generally required. Chest tube is all that is generally required.

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Pneumothorax (cont.)Pneumothorax (cont.)

IatrogenicIatrogenic Most common cause of traumatic Most common cause of traumatic

pneumothoraxpneumothorax Common iatrogenic causes areCommon iatrogenic causes are

•Needle aspiration lung biopsyNeedle aspiration lung biopsy

•ThoracentesisThoracentesis

•Central venous catheter placementCentral venous catheter placement

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Pneumothorax (cont.)Pneumothorax (cont.)

SpontaneousSpontaneous Pneumothorax with no obvious causePneumothorax with no obvious cause

Primary spontaneous pneumothoraxPrimary spontaneous pneumothorax Occurs with no underlying lung diseaseOccurs with no underlying lung disease Most (80%) have small subpleural blebsMost (80%) have small subpleural blebs Typically happens in tall, thin, young adultsTypically happens in tall, thin, young adults >90% have had short-term smoking history>90% have had short-term smoking history

• Smoking cessation recommendedSmoking cessation recommended

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Pneumothorax (cont.)Pneumothorax (cont.)TherapyTherapy Chest tubes buy timeChest tubes buy time

Resolution is mostly determined by lung healing Resolution is mostly determined by lung healing Small bore: placed via small incision in second Small bore: placed via small incision in second

intercostal space (ICS), midclavicular line or intercostal space (ICS), midclavicular line or laterally, fifth–seventh ICSlaterally, fifth–seventh ICS• Connected to underwater seal or Heimlich valveConnected to underwater seal or Heimlich valve

Large bore: placed via blunt dissection, usually Large bore: placed via blunt dissection, usually connected to “three-bottle” chest drainage systemconnected to “three-bottle” chest drainage system

Chest tubes are sutured in placeChest tubes are sutured in place

Pleurodesis: consider with recurrent pneumothoracesPleurodesis: consider with recurrent pneumothoraces

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Pneumothorax (cont.)Pneumothorax (cont.)ComplicationsComplications Tension pneumothoraxTension pneumothorax

Pleural air pressure exceeds atmospheric pressurePleural air pressure exceeds atmospheric pressure Radiographic appearanceRadiographic appearance

• Mediastinal shift, diaphragmatic depression, flattened ribsMediastinal shift, diaphragmatic depression, flattened ribs

Clinical presentationClinical presentation• Venous return and cardiac output decrease with Venous return and cardiac output decrease with

hypotension and tachycardiahypotension and tachycardia

• Hypoxemia due to alveolar collapseHypoxemia due to alveolar collapse

Treatment: emergency needle decompression Treatment: emergency needle decompression

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Pneumothorax (cont.)Pneumothorax (cont.)

TherapyTherapy 100% Oxygen100% Oxygen

Should be administered to all patientsShould be administered to all patients Supplemental OSupplemental O22 speeds absorption of air from speeds absorption of air from

pleural spacepleural space

Observation of stable patientsObservation of stable patients Primary: observe 4 hours, if no enlargement: homePrimary: observe 4 hours, if no enlargement: home Secondary and iatrogenic: hospitalize and observe Secondary and iatrogenic: hospitalize and observe

carefully, carefully, • If there is any deterioration (SpOIf there is any deterioration (SpO22, RR, etc) - drain , RR, etc) - drain

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Pneumothorax (cont.)Pneumothorax (cont.)

DiagnosisDiagnosis Chest radiographyChest radiography

Requires good quality film Requires good quality film In ICU, 30% of pneumothoraces are missed due In ICU, 30% of pneumothoraces are missed due

to:to:• Low-quality filmLow-quality film

• Supine position of patient on AP filmSupine position of patient on AP film• Air hidden behind thoracic or mediastinal structuresAir hidden behind thoracic or mediastinal structures

CT may be used to confirm size and CT may be used to confirm size and presence of pneumothorax.presence of pneumothorax.

atelectasisatelectasis

aa- without- without

tel/o:tel/o: complete complete

-ectasis-ectasis: stretching, : stretching, dilation, expansiondilation, expansion

Without complete Without complete expansion of a lungexpansion of a lung collapsed lungcollapsed lung

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hemothoraxhemothorax

hem/ohem/o bloodblood

-thorax: -thorax: chest, pleural cavitychest, pleural cavity

Blood in the pleural cavityBlood in the pleural cavity

pyothoraxpyothorax

py/opy/o

-thorax-thorax

Pus in the chestPus in the chest

empyema of the chestempyema of the chest