pleuralkbk18juli2011

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Kelainan Pleura

Dr. Sanarko Lukman Halim,

SpPK

Bagian Patologi Klinik

F.K. UKRIDA

Juli 2011


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Outline

Physiology of the pleura

Pleural effusions

Neoplastic disease of the pleura

Pneumothorax

Chylothorax, and hemothorax


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Analisis Cairan Pleura 1/2 Torasentesis/Thoracentesis kecuali

Cairan tidak cukup

Ada Gagal jantung, efusi bilateral, tidak panasefusi hilang setelah 3 hari Transudat atau Eksudat?

Transdat: Gagal Jantung,sirosis hepatis (hepatichydrothorax), emboli paru, sindroma nefrotik,

Eksudat: Infeksi, kanker, penyakit jaringanikat/connective tissue disease,chylothorax, reaksiobat.

Kriteria Light/Lights criteria(salah satu)

Total protein cairan pleura/ Total protein > 0.5LDH c pleura / LDH serum >0.6LDH c pleura > 2/3 batas atas nilai normal LDH serum


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Analisis Cairan Pleura 2/22 Bila Eksudatif

PMN > 50%Parapneumonic, emboli paru, pankreatitis

Limfo > 50%Keganasan,TBC, jamur, pasca pembedahanEos > 10%reaksi obat, asbestos, infeksi parasit

Kultur/ pewarn Gram: BTA (bila limfo>50%), Jamur

Glukosa: < 60 mg%:keganasan, hemotoraks,Tb

RA, SLE, infeksi parasitTes Adenosine Deaminase (ADA) untuk Tuberkulosa

ADA > 40-60 U/L dengan limfo >50%TBC

3. Bila diagnosa tidak jelas

Emboli paru. Thorascopy, biopsi


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Pleu ral effus ion


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Definisi Efusi Pleura Increased amount of fluid within the pleural

cavity Stedmans Medical Dictionary

Accumulation of fluid between the layers of the membranethat lines the lungs and the chest cavity

Medline PlusUrgent pleural disorders

Pleural emergencies:

haemorrhage - haemothoraxelevated pleural pressure

- tensionpneumothorax

- massive pleural effusion


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Key PointsDifferentiation between transudates and

exudates.

The characteristic pleural findings for specificdiseases (i.e. CHF, SLE, RA, tuberculosis,)

Differentiation and management of

parapneumonic effusions . Causes and diagnosis of neoplastic disease of the

pleura

Causes and management of the various types of

pneumothorax Causes and management of chylothorax

Causes and management of hemothorax


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Tipe

Hydrothorax

Hemothorax

Chylothorax

Pyothorax / Empyema

Etiologi

Paru

Bukan Paru

Asites (sirosis)

Sindroma nefrotik/

Meigs syndrome

Efusi Pleura

Klasifikasia. Transudate

Ultrafiltrate of plasma

Small group ofetiologies

b. Exudate Produced by host of

inflammatory conditions

Large group ofetiologies


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Causes of Pleural Effusion Congestive heart failure 500,000

Pneumonia 300,000 Malignancy 200,000

Pulmonary embolism 150,000

Viral 100,000

Cirrhosis with ascites 50,000 GI disease 25,000

Collagen-vascular disease 6,000

Tuberculosis 2,500

Asbestos 2,000 Mesothelioma 1,500

Light,RW: Pleural Diseases (3rd) edition, Philadelphia: Lea & Febiger, 1995, p 76


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Diagnostic evaluation of the pleura Radiography

Thoracentesis

Video-assisted thoracic surgery

(thoracoscopy) Thoracotomy


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Differentiation of transudates & exudates

Transudates

< 0.5

< 0.6

< 2/3 the upper

limit for serum

Exudates

> 0.5

> 0.6

>2/3 the upper

limit for serum

Pleural F luid

Pleural/serumProtein

Pleural/serum

LDH

Pleural

LDH


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Transudative Pleural Effusions Congestive heart failure

Pericardial disease

Hepatic hydrothorax

Nephrotic syndrome Urinothorax

Myxedema

Pulmonary embolism (sometimes)


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Exudative Pleural Effusions4 Parapneumonic effusions

Tuberculous

Fungal

Viral

Parasitic

Pulmonary embolism

Abdominal disease Collagen vascular disease

Post cardiac injury

Asbestos


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Hemotorak

pleural fluid with Ht > 50%blood Ht

CAUSES: chest trauma:penetrating / nonpenetrating

(lung blood vessels, chest wall, diaphragm, pleural

adhesions, mediastinum, large vessels, abdomen)

iatrogenic

(pleural biopsy, subclavian or jugular CVC placement,

thoracentesis, transthoracic or transbronchial NA,

esophageal variceal TH,...)

nonthraumatic(pleural malignancy, anticoagulant TH, spontaneous

rupture of vessel (AO aneurism), bleeding disorder,

thoracic endometriosis)


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haracteristics of a Complicated Parapneumonic Effusion

Glucose < 60 mg/dL

pH < 7.2

Positive culture

Pleural LDH > 3x the upper limit for serum

Pleural fluid is loculated

Empyema

Pus in pleura space

Positive gram stain


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Tuberculous Pleuritis

Acute illness 2/3 of cases; chronic illness in 1/3

Unilateral effusion

1/3 will have parenchymal disease

Exudative, lymphocytepredominant effusion


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Diagnosis of Tuberculous Pleuritis

PPD may be negative in up to 30%

Culture

Pleural fluid for

Adenosine deaminase Interferon-gamma

Polymerase chain reaction (PCR) for tuberculous DNA

Biopsy


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Neoplastic disease of the pleura

Lung 36%

Breast 25%

Lymphoma 10%

Ovary 5%

Stomach 2% Unknown 7%

Sahn, SA: In Fishman, JA 9ed): Fishmans Pulmonary Diseases

and Disorders, 3rded. McGraw Hill, NY, 1998


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Clinical Manifestations of Plural

Metastasis

Dyspnea 57Cough 43

Weight loss 32

Chest pain 26

Malaise 22Fever 8

Chills 5

Asymptomatic 23

Symptom Patients with

symptom (%)

Chernow, B., Sahn, SA., Am J Med, 1977


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Characteristics of MalignantPleural Effusion

Usually exudative(though occasionally

transudative)

Mononuclear cell predominant(lymphocytes,macrophages, and

mesothelial cells)

1/3 will have low pH (less than 7.3)

Sahn, SA, Clin Chest Med, 1998

Good, TJ, et al: American Review of Respiratory Disease, 1985


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Secondary Spontaneous Pneumothorax

Etiology COPD

Cystic fibrosis

Interstitial lung disease such as sarcoidosis oreosinophilic granuloma

Pneumocystis

Recurrence rates higher that for primaryspontaneous pneumothorax

Ch l Pl l Eff i


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Chylous Pleural Effusion Defined by the presence of chyle (lymph) in the

pleural space.

Diagnosis Appearance often milky. Must differentiate

chylous from chyliform effusion

Chemical confirmation

Triglyceride > 110 mg/dL

If triglyceride is between 50-110 mg/dL,send fluid for lipoprotein electrophoresis.

Chylomicrons confirms a chylothorax If triglyceride is < 50, it is not chylous

Chyliform effusion has elevated cholesteroland occurs in long standing effusions.


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Causes of Chylous Effusion

Tumor 54% Lymphoma

Trauma 25%

Surgical Other

Idiopathic 15%

Miscellaneous 6%


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Chyliform EffusionsMilky pleural fluid due to elevated

cholesterol of lecithin-globulin complexesMost commonly associated with

tuberculosis, rheumatoid arthritis,

therapeutic pneumothorax

H th


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Hemothorax Pleural fluid hematocrit greater that 50% that of

peripheral blood Causes

Traumatic (penetrating or non-penetrating)

Iatrogenic (thoracic surgery or line placement)Non traumatic (from metastatic pleural disease),

spontaneous rupture of an intrathoracic vessel, bleeding

disorders

Complication of anticoagulant therapy

Treatment is immediate chest tube (both to evacuate

the fluid and monitor for additional bleeding)

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